doc_clotaire
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A 61-year-old woman comes to the office because of lower and upper extremity swelling. She has a long history of hypertension, hyperlipidemia, and gout that have been very well controlled. She is an active woman who works as a fashion store manager. She takes thiazide, mevastatin, and allopurinol daily. Over the past few weeks, she has noticed increasing swelling of her feet and her hands. Her feet have gotten so swollen that this morning she was unable to put her shoes on. Her temperature is 37 C (98.6 F), blood pressure is 180/70 mm Hg, pulse is 72/min, and respirations are 12/min. Blood chemistries are remarkable for a BUN of 40 mg/dL and a creatinine of 1.8 mg/dL. A urine dipstick is positive for protein. A 24-hour urine test confirms 4gm of protein. The most important intervention at this time is to
A. add a loop diuretic
B. increase thiazide dosage
C. initiate ACE inhibitor therapy
D. recommend a high protein diet
E. start hemodialysis
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| farnsworth
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A
1) Treat the fluid overload (edematous swelling of the hands!) w/ loop diuretics
2) Add a ACE inhibitors to prevent the progression of the glomerulonephritis
3) dietary modifications (dietary sodium restriction)
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| doc_clotaire
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Explanation:
The correct answer is C. The nephrotic syndrome is defined by a urinary protein level exceeding 3.5 g per 1.73 m2 of body-surface area per day. Diabetic nephropathy is the most common cause of nephrotic proteinuria. Five primary glomerular diseases account for the great majority of cases of the nephrotic syndrome in persons who do not have diabetes. In adults, the most common cause is membranous glomerulonephropathy. A common clinical triad of the nephrotic syndrome is hypertension, hyperlipidemia, and proteinuria. Although the exact mechanism whereby edema formation occurs in these patients is uncertain, the loss of urinary protein leads to total body edema formation. Regardless of the magnitude of the urinary protein loss, initiating ACE inhibitor therapy has been shown to be beneficial in terms of both decreasing the urinary protein content and prolonging survival.
Adding a loop diuretic (choice A) or increasing the thiazide dosage (choice B) fails to address the etiology of the edema. This patient has new onset edema and simply trying to manage the symptom by increasing an existing diuretic dosage or adding a second diuretic class agent fails to address the underlying etiology of this patient's edema.
There is no role for a high-protein diet (choice D) in managing these patients. Contrary to previously held opinions that the protein needed to be replaced by high-protein diets, it is now clear that such diets exacerbate kidney damage and accelerate protein loss. Low-protein diets are recommended for these patients.
There is no indication for hemodialysis (choice E) at this time. The five indications for HD are refractory hyperkalemia, volume overload, acidosis, uremia, or uremic pericarditis.
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The elevator to succes is broke ,you must take the stairs
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