A 55-year-old man is evaluated for puffiness of the face and abdominal distension over the past 4 weeks. He has hypertension and type 2 diabetes mellitus. The patient does not use alcohol, tobacco, or illicit drugs. His temperature is 37.1 C (98.8 F), blood pressure is 133/75 mm Hg, pulse is 82/min, and respirations are 14/min. He also has periorbital edema, moderate ascites, and 1+ bilateral pitting pedal edema. Twenty-four-hour urinary protein excretion is 5 g/day. This patient is at increased risk for developing which of the following?

Question

A 55-year-old man is evaluated for puffiness of the face and abdominal distension over the past 4 weeks.  He has hypertension and type 2 diabetes mellitus.  The patient does not use alcohol, tobacco, or illicit drugs.  His temperature is 37.1 C (98.8 F), blood pressure is 133/75 mm Hg, pulse is 82/min, and respirations are 14/min.  He also has periorbital edema, moderate ascites, and 1+ bilateral pitting pedal edema.  Twenty-four-hour urinary protein excretion is 5 g/day.  This patient is at increased risk for developing which of the following?

Quizplus · Accepted Answer

11ec25c8_d4dc_0ae7_bc81_7b3d0a6f625f_MD0003_00 This patient with peripheral edema, hypoalbuminemia, and urinary protein excretion of >3.5 g/day meets all of the major criteria for nephrotic syndrome. Although some patients with nephrotic syndrome may develop acute renal failure, a normal creatinine level does not rule out the diagnosis. Low plasma oncotic pressure (due to hypoalbuminemia) increases hepatic lipoprotein synthesis. The result is an increase in serum cholesterol and triglyceride levels, which increases the risk for atherosclerotic disease, particularly in individuals with comorbid conditions for atherosclerosis (eg, hypertension, diabetes). Patients with nephrotic syndrome are also hypercoagulable, possibly due to loss of antithrombin III in urine. This hypercoagulability tends to affect the venous more than the arterial system, particularly the renal veins. Atherosclerosis and hypercoagulability put affected patients at increased risk for stroke or myocardial infarction. Aggressive management with statins or other medications to lower cholesterol levels is indicated. (Choices B and D) Significant cobalamin (vitamin B₁₂) deficiency occurs most commonly due to intestinal malabsorption (eg, pernicious anemia) or in those with dietary restrictions (eg, vegans). Anemia in nephrotic syndrome is more likely due to a combination of erythropoietin and iron deficiencies. Iron overload, as seen in hemochromatosis, is not generally associated with nephrotic syndrome. (Choice C) Patients with nephrotic syndrome can lose vitamin D into the urine, leading to a compensatory increase in parathyroid hormone. Hypoparathyroidism is not typically seen with nephrotic syndrome. (Choice E) Monoclonal gammopathy can lead to amyloidosis, which can be a cause of nephrotic syndrome. However, nephrotic syndrome itself does not lead to monoclonal gammopathy. Educational objective: Patients with nephrotic syndrome have increased risk for atherosclerosis (due to hyperlipidemia) and arteriovenous thrombosis (due to loss of antithrombin III). Atherosclerosis and hypercoagulability increase the risk for stroke and myocardial infarction.

A 55-Year-Old Man Is Evaluated for Puffiness of the Face