James Cole Case wrap up

 Upr/Cr = "spot" protein instead of 24 hour protein.


James had pitting edema


Non-pitting edema indicates hypothyroidism (myxedema) or lymphedema

oval fat bodies are proximal tubular cells filled with lipids

ultrasound normal size 11cm; not chronic condition; increased echogenicity increased density.

negative serologies rule out systemic diseases causing nephrotic syndrome.

foot process effacement in EM specific for minimal change disease.

Treatment

• furosemide
• lisinopril - to decrease proteinuria.  High Pcap causes increased GFR and increased protein loss.  protein in tubule lumen triggers inflammation.  lisinopril blocks AT2 and dilates efferent arteriole = decreased Pcap and decreased proteinuria.  risk-benefit analysis = decreased GFR vs. protein inflammation.
• prednisone - decreased IL-1,3; decreased TH2 cells
• simvastatin - low albumin = increased liver synthesis of lipoproteins.
• heparin - risk of thrombosis due to loss of plasminogen, antithrombin, plus liver produces more fibrinogen. 

Glomerular filtration barrier

Mechanism of Edema in Nephrotic Syndrome

• Underfill hypothesis
• low protein in plasma = fluid shift to interstitial space = underfill = stimulation of RAS = Na retention and H2O 

 

• Overfill hypothesis
• low albumin doesn't always cause edema
• animals with no adrenal glands develop edema
• new theory = filtration of plasminogen.  converted to plasmin by urokinase.  Plasmin activates Na channels causing Na and H2O retention.