ANASARCA

CASE OF ANASARCA

The following is a case of anasarca in a 45 year old female which we have been given to analyse and understand disease processes in various conditions.

https://alekyatummala.blogspot.com/2020/09/45-yr-female-with-anasarca.html?m=1

1) Anatomical and etiological diagnosis of the case:

Glomerularopathy, that is, nephrotic syndrome in a k/c/o DM and HTN.

2) Causes of azotemia, anemia, hypoalbuminemia, acidosis.

- Azotemia: Azotemia is the acumulation of nitrogenous wastes in the body due to damage to the glomerulus causing decreased excretion of the said products. Clinical signs that can occur due to azotemia:

• pitting edema
• ascites
• HTN/DM
• anuria

As we are considering nephrotic syndrome as the diagnosis, the azotemia can be due to improper filtration at the glomerular level.

Reference: https://emedicine.medscape.com/article/238545-overview

- Anemia: Anemia in this case could be due to inflammatory-mediated process or due to significant losses of erythropoietin and transferrin in nephrotic syndrome in diabetics.

reference: https://care.diabetesjournals.org/content/32/7/1320

- Hypoalbuminemia: Hypoalbuminemia occurs due to the excessive proteinuria as indicated in the urine examination of the patient (urine albumin ++++). Albumin gets filtered by the glomerulus and broken down to amino acids in the tubules which are reused. This can be corrected only when there is enough protein intake

- Acidosis: Acidosis could be due to decreased excretion of acids through the kidneys. As a result there is retention of H+ leading to fall in the pH blood.

Reference: https://www.uptodate.com/contents/pathogenesis-consequences-and-treatment-of-metabolic-acidosis-in-chronic-kidney-disease

3) Rationale for the treatment day wise

• Day 1: She was given NaHCO3, potassium chloride and all OHA, anti hypertensives were withheld. She was given NaHCO3 to control her acidosis, so as to decrease the pH by HCO3 ions. Potassium chloride for the low levels of potassium and withholding medication was to prevent further damage as they could be the reason for the renal problems.
• Day 2: She was given insulin, oral iron, tablet pan and furosemide. As she is a known diabetic and OHA cannot be given, insulin was given. She had microcytic hypochromic anemia which could be due to iron deficiency, so oral iron was given and tab pan to control any gastric irritation due to it. Furosemide was given to reduce the volume overload which caused high BP and edema.
• Day 3: Added another diuretic, potassium chloride, antacids, erythropoietin, nifedipine, calcium. erythropoietin was given for improving her anemia, nifedipine for hypertension, calcium as her calcium was low. Also dialysis was done 
• Day 4:  Dialysis was done
• Day 5: Diuretic furosemide, protein powder and a cephalosporin was given. Protein powder was given to increase the amount of protein in the body and for the synthesis of adequate albumin. Cephalosporin was probably given to prevent infections due to her diabetes or due to the dialysis she is undergoing.

Rationale and efficacy of bicarbonate:

Buffers like bicarbonate are used to control acidemia as in this case. It is used to reverse or control the effects of acidemia. In three studies conducting in patients with acidosis using normal saline, sodium chloride and sodium bicarbonate, bicarbonate showed the best results with improved hemodynamic parameters earlier than the other groups. In another study it was found that giving bicarbonate in stages was more beneficial than giving it continuously till desired pH is reached. 

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6538112/#:~:text=The%20main%20reason%20to%20commence,L%20to%2010%20mmol%2FL.

Indications for use of bicarbonate:

• metabolic acidosis
• cardiac arrest
• hyperkalemia.

Contraindications:

• metabolic or respiratory alkalosis
• hypercarbic acidosis
• hypersensitivity
• excessive Cl loss
• hypocalcemia.

Reference: https://reference.medscape.com/drug/sodium-bicarbonate-342305

4) Indication for dialysis for her could be refractory anuria, severe fluid overload or metabolic acidosis. Her refractory anuria could have been the most important reason for starting dialysis on the 3rd day of admission.

5)Conditions other than DM and HTN that led to her condition now?

• anemia
• tobacco chewing

6) Expected outcomes in this patient

• her edema should be reduced as she is on diuretics
• diabetes under control
• improvement in her renal function test results, that is, fall of creatinine and urea to normal levels and normalising of electrolytes as well
• improvement in anemia as she was given orl iron, erythropoietin and also blood transfusions.
• normalising of blood pH and reduced metabolic acidosis.
• normalising of albumin levels. 

7)Cardio-renal dysfunction: 

"The cardiorenal syndrome (CRS) is a complex disease in which heart and kidney are simultaneously affected and their deleterious effects are reinforced in a feedback cycle, with accelerated progression of renal and myocardial damage" https://www.hindawi.com/journals/ijn/2011/634903/ cardio renal syndrome:

“A pathophysiologic disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other organ”  https://www.hindawi.com/journals/ijn/2011/634903/

In HFpEF HTN nd DM are the risk factors in this case.

In HFPEF, because of the disproportionate increase in left ventricular diastolic pressure, there is an increase in left atrial and pulmonary venous pressure that may present as the signs and symptoms of pulmonary venous congestion that is breathlessness, chest pain, generalised edema, palpitations

As this case has the above features, evaluation for further cardiorenal HFpEF should be done once she is hemodynamically stable.

Mechanisms of HFpEF in diabetic renal failure patients:

Reference: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000691

In women, the major reasons for HFpEF are obesity, diastolic dysfunction, left ventricular hypertrophy and more often microvascular angina. in this case it appears to be diastolic dysfunction.

8) Efficacies over placebo for the available therapeutic options given to her for her anemia:

In studies done using erythropoietin and placebo for patients with diabetes and kidney failure, patients given erythropoietin had significant improvement in both renal and cardiac functions. It was found that early intervention to treat anemia delayed the progression of renal failure. The primary cardiac outcome was change in left ventricular mass index.

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699743/

9)  Utility of tools like the CKD-AQ :

CKD-AQ: Chronic Kidney Disease - Anemia Questionnaire. 

Below are the results of a study done with 36 patients with anemia and CKD.

effect	total mentions of concept
interference with daily activities	95%
physical impact	91%
emotional impact	63%
social impact	45%

Reference: https://jpro.springeropen.com/articles/10.1186/s41687-020-00215-8/tables/3; https://jpro.springeropen.com/articles/10.1186/s41687-020-00215-8

Is language telugu one of the language translations of CKD-AQ?

No.

reference: https://tools.ispor.org/research_pdfs/60/pdffiles/PRM203.pdf

10) PEM contribution to severe hypoalbuminemia: 

In PEM where there is adequate consumption of carbohydrates and decreased intake of proteins leads to hypoalbuminemia. she has decreased serum protein which could be due to decreased protein intake.

Reference: https://emedicine.medscape.com/article/1104623-overview#a5

Role of SGA in evaluation of malnutrition in CRF patients:

Subjective global assessment has 7 variables derived from history and physical examination of the patient. 

• weight change in preceding six months and two weeks, 
• change in dietary intake, 
• presence of gastrointestinal symptoms, 
• change in functional capacity, 
• loss of fat, 
• muscle wasting, and 
• edema

Additional biochemical aspects include hemoglobin, albumin, cholesterol, BUN, and creatinine were considered in the following study:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4090668/

  CASE 2:

Case 2 is a case of a 58 year old male. the case can be viewed from the following link:

https://bhavyayammanuru.blogspot.com/2020/09/aki-secondary-to-uti.html?m=1

	45 YEAR OLD FEMALE	58 YEAR OLD MALE
CHIEF COMPLAINTS ON PRESENTING	PROGRESSIVE PEDAL EDEMA, PITTING TYPE – 5 DAYS ABDOMINAL DISTENSION – 5 DAYS FACIAL PUFFINESS – 5 DAYS DECREASED URINE OUTPUT – 5 DAYS SOB AT REST ASS WITH RIGHT SIDED CHEST PAIN AND INTERMITTENT PALPITATIONS – 5 DAYS ANURIA – 3 DAYS	REDUCED URINE OUTPUT – 3 DAYS NO URINE OUTPUT – 1 DAY PAIN ABDOMEN – 1 DAY H/O COUGH WITHOUT EXPECTORATION, LOW GRADE CONTINUOUS FEVER, DRIBBLING OF URINE, REDUCED URINE OUTPUT WITH BURNING MICTURITION NON PITTING EDEMA
MEDICAL HISTORY	DM- 5 YEARS HTN – 1 YEAR	DM – 5 YEARS HTN – 8 MONTHS
DIAGNOSIS	NEPHROTIC SYNDROME WITH DIABETIC NEPHROPATHY WITH K/C/O DM AND HTN	PRERENAL AKI WITH K/C/O DM AND HTN
THERAPY	NaHCO3(METABOLIC ACIDOSIS), POTASSIUM CHLORIDE (LOW SERUM POTASSIUM) DIURETICS, ORAL IRON (IRON DEFICIENCY ANEMIA), INSULIN, ERYTHROPOIETIN (ANEMIA), CALCIUM SUPPLEMENTS, NIFEDIPINE (INSTEAD OF TELMISARTAN), DIALYSIS	PIPERACILLIN/TAZOBACTUM, PANTOPREZOLE, DIURETICS, INSULIN, AMLODIPINE
OUTCOMES	REDUCTION OF EDEMA, CONTROL OF SERUM UREA AND CREATININE, IMPROVED Hb,	INFECTION CONTROL, BLOOD GLUCOSE AND BLOOD PRESSURE CONTROL
COMMENT	IT APPEARS THE OUTCOMES ARE AS EXPECTED ON THE THERAPY THE PATIENT IS ON.	DIAGNOSIS DOES NOT APPEAR TO BE CONSISTENT WITH THE SYMPTOMS

 Diagnosis of the patient: satisfactory/ not satisfactory??

The patient presents with fever, burning micturition, incontinence and pain abdomen which are symptoms of UTI. The diagnosis does not seem satisfactory.

Ultrasound result of kidneys:

• Right kidney: 10.2 x 4.7 cm
• Left kidney: 7.6 x 3.6 cm

Normally the left kidney is bigger than the right kidney. here the left kidney is smaller than the right kidney. It is possible to lead a life without being affected much but there can problems later in life like HTN. This could explain the cause of renal failure in this patient who has both DM and HTN. 

Causes of smaller kidney:

• congenital dysplasia
• reflux nephropathy
• infection
• reduced blood supply
• glomerulonephritis

Reference: https://www.kidney.org.uk/small-or-single-kidney#:~:text=The%20kidney%20is%20small%20at,there%20may%20be%20kidney%20failure.