Young Man with Edema and Decreased Urine Output

H. William Schnaper

A 19-year-old man presented to the hospital complaining of swelling of his ankles, abdomen, and eyelids for the past 4 days. He had been in good health until several months ago when he noted a "bloated" sensation after eating. He also thought that he had gained weight recently, noting that his jeans seemed tighter. Four days before presentation, he experienced headaches and mild abdominal pain. At bedtime, there were depressions in his legs from the elastic in his socks. In the morning his legs were less swollen, but his eyes appeared "puffy." These symptoms abated somewhat by evening, but lower extremity swelling recurred. He noticed that his urine appeared a bit darker than usual, and he thought that he might be urinating less frequently. Except for some mild upper respiratory congestion, which he had attributed (along with the initial eye "puffiness") to allergies, he reported no other symptoms. He denied blurred vision, rashes, joint pains, fevers, or grossly bloody urine. The past medical history and the rest of the review of systems were noncontributory.

Physical examination revealed a muscular, well-nourished, 185-lb (84-kg) black male in no acute distress. Temperature was 99°F (37.2°C), heart rate was 78 bpm, respiratory rate was 28/min, and blood pressure was 110/68 mm Hg. There was mild edema of the eyelids. The head, eyes, ears, nose, and throat were all normal. The thyroid was not enlarged. There was a 4-cm span of shifting dullness appreciated on percussion of the posterior thorax. No rales or rhonchi were noted on auscultation of the lungs. Cardiac examination was unremarkable. The abdomen was soft without organomegaly; there was a sense of "fullness" to the abdomen, although no fluid wave could be observed. The genitalia showed mild, nontender scrotal swelling. There was 2-3+ pitting edema two-thirds of the way from the ankle to the knee. The ankles were markedly edematous, with depressions in the edema made by the tops of the patient's shoes. The nailbeds were pale, but edema of the hands was minimal. A chest film was obtained and showed bilateral pleural effusions. There was no evidence of infiltration, consolidation, or pulmonary overcirculation.

The following laboratory studies were obtained:

Value,

Reference Interval,

Reference

Conventional

Conventional

Value,

Interval,

Analyte

Units

Units

SI Units

SI Units

Sodium

135 mmol/L

136-145

Same

Potassium

4.5 mmol/L

3.5-5.0

Same

Chloride

97 mmol/L

96-106

Same

CO2, total

24 mmol/L

24-30

Same

Urea nitrogen

25 mg/dL

11-23

8.9 mmol urea/L

3.9-8.2

Creatinine

1.0 mg/dL

0.6-1.2

88 mmol/L

53-106

Glucose

87 mg/dL

70-105

4.8 mmol/L

3.9-5.8

Calcium

7.9 mg/dL

8.4-10.2

1.98 mmol/L

2.10-2.54

Protein, total

4.6 g/dL

6.0-8.0

46 g/L

60-80

Albumin

1.2 g/dL

3.5-5.5

12 g/L

35-55

Urate

4.2 mg/dL

1.5-7.0

250 mmol/L

89-416

Cholesterol, total

322 mg/dL

<200

8.34 mmol/L

<5.18

Triglyceride

270 mg/dL

40-150

3.05 mmol/L

0.45-1.69

Urinalysis

PH

6.0

4.6-8.0

Same

Specific gravity

1.050

1.001-1.036

Same

Protein

3+ (confirmed by

Negative

sulfosalicylic acid

precipitation)

Glucose

Negative

Negative

Ketones

Negative

Negative

Microscopic

Erythrocytes

0-2/hpf

Rare

Hyaline casts

1-2/hpf

Rare

Granular casts

None

None

Erythrocyte casts

None

None

Amorphous crystals

None

Rare

Urine protein:

5.6

creatinine ratio creatinine ratio

These data indicated that the patient had urinary protein loss, with decreased serum albumin concentration, peripheral edema, and elevated serum cholesterol concentration. This tetrad of findings defines the nephrotic syndrome. Additional tests were performed to help elucidate the etiology of the nephrosis:

Analyte

C3 complement C4 complement Antinuclear antibody titer Anti-DNA titer IgM IgG IgA

Urine protein

Value, Conventional Units

Negative 230 mg/dL 320 mg/dL 127 mg/dL 5.3 g/day

Reference Interval, Conventional Units

Negative 45-145 550-1900 60-333 100 mg/day

Value, SI Units

2.30

Reference Interval, SI Units

870-1500 138 - 270

5.50-19.00

The absence of values indicating inflammation strongly suggested that the patient did not have an underlying nephritic lesion. Percutaneous renal biopsy was performed, showing moderate glomerular enlargement and mild mesangial expansion with increased extracellular matrix. The tubules and interstitium were unremarkable in appearance. Immunofluorescence microscopy showed trace mesangial staining for IgM but was negative for IgG, IgA, C3, or fibrin. Electron microscopy showed patchy effacement of the glomerular epithelial podocytes but no electron-dense deposits. A diagnosis of early focal segmental glomerulosclerosis (FSGS) was made.

The patient was started on oral prednisone, 80 mg/day. A sodium-restricted diet with mild fluid restriction and treatment with furosemide, 60 mg daily, were instituted. After 3 days, the patient's edema had decreased significantly, although the urine albumin remained 4+. Five weeks after initiating treatment, a urine dipstick reading was 2+ and his urine protein: creatinine ratio was 2.1. His weight was 5 lb (2.3 kg) less than when he was first seen. Prednisone was continued.

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