Q&A Medicine>>>>>Nephrology
Question 3#

A 43-year-old Caucasian man comes to the physician because of fatigue and body swelling that has developed over the last few weeks. He has no significant medical history, and takes no medications. He does not smoke or drink alcohol, and exercises 3 times weekly. He is afebrile with a blood pressure of 128/86 mmHg, heart rate of 88 beats per minute, and respiratory rate of 16 breaths per minute. On physical examination, there is noticeable periorbital edema with diffuse edema of the extremities. His laboratory values are shown below.

Which of the following is also likely to be present in this patient?

A) HIV infection
B) Hypercholesterolemia
C) S3 on cardiac auscultation
D) Hematuria

Correct Answer is B

Comment:

Hypercholesterolemia. This patient has three characteristics of nephrotic syndrome: proteinuria, hypoalbuminemia, and generalized edema. Nephrotic range proteinuria must be confirmed with a 24-hour urine sample and is defined as >3.5 g/d. Another important characteristic of nephrotic syndrome is hyperlipidemia. In response to the reduction in plasma oncotic pressure due to the loss of albumin and other plasma proteins in the urine, the liver increases synthesis of lipoproteins resulting in hypercholesterolemia. In addition, there is impaired liver metabolism that often results in hypertriglyceridemia. Finally, lipiduria may also be present and is manifested as urine fatty casts with a “Maltese cross” appearance. (A) FSGS is the most common glomerulopathy in the setting of HIV infection. However, this patient does not have apparent risk factors for HIV infection and he better fits the epidemiologic profile of membranous nephropathy (middle-aged Caucasian). FSGS is seen more commonly in African American and Hispanic patients. (C) This patient has characteristics of nephrotic syndrome and therefore heart failure is not the correct diagnosis. (D) Though there is some overlap of nephrotic and nephritic syndromes, as well as the causes of each, hematuria is typically a feature of nephritic syndrome. There are typically few or no cells in the urine of nephrotic patients.