HDCN Mini Grand Rounds

Diabetes mellitus with unusual early complications and hypoalbuminemia

From: Eliahou HE, Matas Z, Zimlichman R
The Tel-Aviv University Sackler School of Medicine,
The Departments of Internal Medicine and Biochemistry
The Edith Wolfson Hospital
Holon, Israel

Case Report

A fifty year old man, an active food manufacturer, was admitted for severe swelling of legs up to the thighs, for the last week or so.

The patient claimed that he had been healthy until about a year ago when he suddenly had the classical polydipsia and polyuria of diabetes mellitus. The diagnosis was confirmed by high blood sugar levels reaching the range of 180-220 mg%. He also had very high cholesterol and triglyceride levels, which responded to dietary management and lovastatin. He had developed some vision problems for which he was treated with LASER. He progressively lost vision. He lost weight, from his usual body weight of 69 Kg to 64 Kg a few months ago.

Physical examination
He was lean, but with edema of the legs up to the mid-thigh region. There was (+) pitting edema at the sacrum. His body weight was now 74 Kg. Blood pressure was measured as 160/110 mmHg and was 151/96 later during the day. There was dullness at both bases of the lungs. The liver was not palpable. There were no murmurs over the heart or over the neck.

Laboratory values:

Blood hemoglobin 9.5 to 10.5 g%
Fasting blood glucoses 70-90 mg% (although they had been 74-140 mg% on repeated examination prior to admission as outpatient)
Glycosylated Hgb 9% (13.9% initially, decreasing to 11.2% after therapy as an outpatient prior to admission)
Serum creatinine 1.5 mg%
24-hour creatinine clearance 40ml/min
Blood urea 126 mg%
Serum albumin 2.6 g% (increasing to 3.2 g% after a few infusions of plasma)
Calcium 8.8 mg%
Inorganic phosphorus 4.0 mg%

Total cholesterol and triglycerides normal (However, prior to admission total cholesterol was 465 mg% and the triglycerides 329 mg% prior to admission. He was advised to take lovastatin 20mg every evening. Later total cholesterol levels decreased to 188-207 mg% and triglycerides 87 mg%.

24-hour urine protein 3.9 g/day, repeat 4.1 g/day
Urinalysis sediment unremarkable

SGOT, SGPT, gamma GT within normal limits
(In April 1995 the alkaline phosphatase was 817 U/L (normal 82-290)

Discussion questions

1. The cause of this patient's nephrotic syndrome can be assumed to be diabetes, despite the short antecedent history.

True
False

2. This patient has a worse prognosis than the usual diabetic patient with nephropathy.

True
False

3. The most important cause of this patient's marked hypoalbuminemia is

a. Poor dietary intake
b. Urinary losses
c. Decreased synthesis of albumin by the liver
d. Enhanced vascular permeability to albumin
e. Gastrointestinal losses

CONTINUE

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