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Abstract: When there is increased foam in the urine, decreased urine volume, and edema in both lower extremities, glomerular disease should be alerted. The etiology and type of pathology should be actively defined in the clinic and reasonable treatment should be given, which facilitates disease control. The patient in this case was seen for the above symptoms, and the examination revealed the presence of massive proteinuria and decreased blood albumin, which was later diagnosed as microscopic lesions in nephrotic syndrome. Glucocorticoid therapy was given clinically, and the patient’s condition was subsequently controlled with good recovery of all indicators.
Basic information】Male, 60 years old
Type of disease】Nephrotic syndrome
Hospital】People’s Hospital of Peking University
Time of consultation】September 2018
Treatment plan】Medication (closartan potassium tablets + metformin hydrochloride extended-release tablets + reglanet tablets + furosemide tablets + spironolactone tablets + prednisone acetate tablets + methylprednisolone sodium succinate for injection + oseltriol soft capsules + calcium carbonate tablets + low-molecular-weight heparin calcium injection + aspirin enteric-coated tablets + cyclosporine soft capsules)
Treatment Period】Hospitalization 14 days, outpatient follow-up 4 years
Treatment effect】The disease is under control and all indicators are recovering well
I. Initial consultation
A 60-year-old grandfather came to our hospital 1 week ago with an increase in foam in urine without any cause and a daily urine volume of about 1000ml, which was less than before. 5 days ago, after exertion, he felt a significant decrease in urine volume, only 400-500ml per day, and an increase in foam in urine, edema in both lower limbs, no hematuria and discomfort in urination. Routine urinalysis was performed on the patient and revealed that he had urine protein (++++), urine occult blood (++), blood albumin was 23.2 g/L, creatinine was 89.5 μmol/L, and blood routine was normal. After diuretic treatment was given in the outpatient clinic, the patient’s edema was relieved, but the blood albumin was still 21.2 g/L, creatinine was 90.9 μmol/L, and elevated lipids were present. For further clarification of the cause, the patient was admitted to the hospital for treatment. During communication with the patient, we learned that the patient had no rash, photosensitivity, or arthralgia, and had a past history of diabetes mellitus for 3 years, but no special personal history, marital history, or family history of nephropathy. The results showed that the patient’s blood pressure was 130/80 mmHg, and there were no special findings after cardiac, pulmonary and abdominal examinations, but the patient had facial edema and severe edema in both lower limbs. The patient’s urine protein and blood protein were checked, and the patient was found to have 7.5g/day of proteinuria and 21.2g/L of albumin in blood, so the patient was initially considered to have nephrotic syndrome, which is a type of glomerular disease.
II. Treatment history
In response to the patient’s clinical manifestations such as edema, proteinuria, and history of diabetes mellitus, it was decided to give the patient the appropriate symptomatic treatment as a priority, which mainly included the following.
1. edema: restriction of water and salt intake, diuretic treatment with furosemide tablets and spironolactone tablets.
2, proteinuria: oral cloxacin potassium tablets to reduce protein in the urine.
3, diabetes mellitus: oral treatment with metformin hydrochloride extended-release tablets and Repaglinide tablets.
To further clarify the diagnosis of the disease, the patient was given a renal puncture biopsy to determine the next treatment plan by the pathological type of the kidney. The results of renal puncture pathology showed that the patient had microscopic glomerular lesions. The patient was given treatment with injectable methylprednisolone sodium succinate, which was changed to oral prednisone acetate tablets after 1 week, and supplemented with calcium carbonate tablets and osteoporotic triol soft capsules to prevent osteoporosis. In addition, because of the patient’s low blood albumin and high blood viscosity, anticoagulation and antiplatelet therapy were given, i.e., low-molecular-weight heparin calcium injection was given during hospitalization to prevent thrombosis, and later changed to oral aspirin enteric-coated tablets for antiplatelet therapy.
III. Treatment effect
The patient in this case responded well to the treatment of glucocorticoid-like drug prednisone acetate tablets, which started to take effect after 1 week of application of the drug, and was seen to increase the patient’s urine volume, and after 2 weeks, the protein in the urine decreased significantly, and the 24-hour urine protein quantification was 0.3 g/d, and the urine volume increased to about 2000 ml/day, and the patient’s blood albumin increased to 35.3 g/L, and the blood creatinine was 80-90 μmol/L. During the subsequent hormone reduction treatment, the patient had 4 relapses due to exertion and infection. Prednisone acetate tablet + cyclosporine soft capsule was given, and the patient is now recovering well, with urine protein of 0.14g/d, blood creatinine stable at about 80μmol/L and blood albumin at 38-43g/L, and the disease is under control. After 14 days of treatment, the patient recovered relatively well and was discharged from the hospital. Up to now, the patient has been followed up continuously for 4 years in the outpatient clinic.
IV. Notes
We are glad that the patient’s condition was controlled after a series of treatments and the indicators recovered well, but the patient still has the following points to note after discharge.
1. Relax, ensure sleep, maintain a regular life, and eat a low-salt, low-fat, high-quality protein diet. In addition, as the disease is prone to recurrence, patients should try to avoid strain and infection to reduce the risk of recurrence.
2. Regular outpatient follow-up examinations, including blood routine, urine routine, 24-hour urine protein quantification, renal function, blood albumin, blood lipids, blood glucose and other examination items, to understand the recovery of kidney disease. Reduce the dose of glucocorticoids or adjust the treatment plan according to the treatment effect.
3. During the application of glucocorticosteroids, patients should pay attention to monitoring blood sugar and blood pressure. If uncomfortable symptoms appear, they should go to the hospital promptly and inform the doctor of the monitoring situation truthfully so as to adjust the treatment subsequently.
V. Personal insight
Glomerular diseases contain many types, such as various nephritis and nephrotic syndrome. Nephrotic syndrome is a common condition in nephrology and belongs to the category of glomerular lesions. The disease can be classified into different causes according to the etiology, including primary, secondary and hereditary. The patient in this case belongs to the microscopic lesions in primary nephrotic syndrome, which is the type of pathology with the best treatment effect, and the patient can obtain clinical remission within a short period of time. However, the disease is prone to recurrence, and it is important to adhere to regular follow-up examinations and avoid factors that induce disease recurrence, such as infection and exertion.