Cardiovascular · Year 1 · from Cardiovascular
Case 3: Nephrotic Syndrome with Anasarca
Patient Presentation
Demographics: 45-year-old male
Chief Complaint: Generalized swelling and foamy urine
History of Present Illness: A 45-year-old male with no significant past medical history presents with 4 weeks of progressive generalized swelling. He first noticed puffy eyelids in the morning, then ankle swelling, and now has abdominal distension and scrotal swelling. He reports foamy urine for the past 2 months. He denies shortness of breath, chest pain, or fever. He has had a 20-pound weight gain.
Physical Examination:
- Vital Signs: BP 135/88 mmHg, HR 78 bpm, RR 16/min, SpO2 98% on room air
- General: Facial puffiness, periorbital edema (worse in morning)
- Cardiovascular: Normal S1/S2, no S3, JVP normal
- Lungs: Clear to auscultation
- Abdomen: Distended with shifting dullness (ascites), no hepatomegaly
- Extremities: 3+ pitting edema bilateral lower extremities
- Genitalia: Scrotal edema
- Skin: White bands on nails (Muehrcke's lines - hypoalbuminemia)
Workup
- Urinalysis:
- Protein: 4+ (dipstick)
- Lipid droplets ("Maltese crosses" under polarized light)
- Oval fat bodies
- 24-hour urine protein: 8.5 g/day (nephrotic range >3.5 g/day)
- Labs:
- Albumin: 1.8 g/dL (severely low, normal 3.5-5.0)
- Total protein: 4.2 g/dL
- Cholesterol: 385 mg/dL, Triglycerides: 310 mg/dL
- Creatinine: 1.1 mg/dL (normal)
- Complement C3, C4: Normal
- Renal biopsy: Minimal change disease on light microscopy, foot process effacement on electron microscopy
Diagnosis
Nephrotic syndrome (minimal change disease) with anasarca due to hypoalbuminemia
Starling Forces Correlation:
Nephrotic syndrome hallmarks:
- Proteinuria >3.5 g/day
- Hypoalbuminemia (<3.0 g/dL)
- Edema
- Hyperlipidemia
Edema mechanism (underfill hypothesis):
- Massive proteinuria → loss of albumin
- ↓ Plasma oncotic pressure (πc)
- Starling equation: ↓ πc → favors filtration out of capillaries
- Fluid moves from intravascular → interstitial space
- ↓ Effective circulating volume
- RAAS and ADH activation → Na+/H2O retention → worsens edema
Starling forces in nephrotic syndrome:
| Factor | Effect |
|---|---|
| πc (plasma oncotic) | ↓↓ (hypoalbuminemia) |
| Pc (capillary) | May ↑ with Na retention |
| Net filtration | ↑↑ |
Why facial/periorbital edema in morning?
- Low tissue resistance around eyes
- Dependent edema redistributes with recumbency
- Gravitational effect on low-oncotic pressure fluid
Anasarca distribution:
- Dependent areas (legs when upright)
- Periorbital (loose tissue, recumbency)
- Scrotum/labia (dependent, loose tissue)
- Ascites (serosal surfaces)
Treatment
- Treat underlying disease:
- Minimal change disease responds to corticosteroids
- Prednisone 1 mg/kg/day for 4-8 weeks, then taper
- Diuretics for edema:
- Loop diuretics (furosemide) ± thiazide
- Caution: May worsen hypovolemia
- Salt restriction: <2 g sodium/day
- ACE inhibitor/ARB: Reduce proteinuria
- Statins: For hyperlipidemia
- Anticoagulation consideration: Increased DVT/PE risk (loss of antithrombin III)
- Albumin infusion: Only for severe symptomatic hypoalbuminemia (temporary effect)
Clinical Image
Image Description: Photograph showing periorbital edema characteristic of nephrotic syndrome. The puffiness around the eyes is due to fluid accumulation from decreased plasma oncotic pressure secondary to hypoalbuminemia.
Source: Wikimedia Commons - Periorbital edema License: CC BY-SA 4.0 URL: https://commons.wikimedia.org/wiki/File:Periorbital_edema.jpg