"Doc! i can not see" ,the admitted patient suddenly cried in the ward.

 Clinical scenario :
                A 48-year-old, obese, non-diabetic male presented to our clinic with  history of abdominal distension and generalized edema  of 1-month duration.  He denied history of fever, jaundice, breathlessness or similar history in the past.
Examination:
             He was conscious, oriented, in time place  and person .He had puffy eyes and there was generalised edema . He had normal vital signs and his oxygen saturation on room air was normal .
Abdominal examination revealed gross  ascites, and no organomegaly could be demonstrated by dipping method.(Keeping in view massive ascites this method is used  ) He had no ballotable kidneys and there was no bruit on auscultation ( in the renal or in liver area). He had  no stigmata of chronic liver disease. His other systemic examination was normal.
Investigation :
             On evaluation, he had haemoglobin of 9.8 g/dl , white cell count and platelet count were normal . His blood urea was 38 g/dl (ref 26–40 mg/dl) and serum creatinine was 1.2 mg/dl (0.8–1.0 mg/dl). He had hypercholesterolaemia (408 mg/dl)
His 24-h urine collection revealed 6.7 g/l proteins.
Ultrasound showed gross ascites and no evidence of cirrhosis  The ascetic fluid was wide gradient and  no spontaneous bacterial peritonitis was found .
Doppler of renal veins revealed right renal vein thrombosis extending to inferior vena cava
CT scan showed no evidence of mesenteric vascular thrombosis or bowel ischaemia.
 Compression ultrasound  of leg veins revealed no thrombosis in leg veins.
Echocardiography revealed normal ejection fraction and all  valves were normal .
Hepatitis serology was negative , his antinuclear antibody and HIV serology were also negative.
Thus the cause of his generalized edema and ascites was due to kidney disease .
Management :
       Patient was put on low-protein, low-salt diet, tablet Enalapril 5 mg daily. Low molecular weight heparin was started in therapeutic doses keeping in view renal vein thrombosis.
On day 3, of admission he called the resident  on call,
Doctor I can not see properly I see  floating spots and flashing lights.
This was followed next day by progressive unilateral loss of vision. His visual acuity ranged from 20/20 to finger counting in subsequent 3 days and he was blind in right eye.
On indirect ophthalmoscopic examination, he had retinal oedema, superfi cial haemorrhages, diffuse  swelling, cotton wool spots and dilated retinal veins ( Figure 1 ).

Fig 1 Fundoscopic examination showing retinal vein thrombosis

Kidney biopsy showed features of membranous glomerulnephritis .
Patient never gained vision in his right eye unfortunately .

Fig 2 Kidney biopsy showing membranous glomerulonephritis 

Message :   "Puffy eyes, swollen limbs and the  patient says , doctor I pass frothy urine " ---friends think of  Nephrotic syndrome .

NEPHROTIC SYNDROME  MNEMONIC -----"NAPHROTIC "  

Na+Decrease (Hyponatremia) 

Albumin decrease(Hypoalbuminemia )

Proteinuria >3.5g/day

Hyperlipidemia 

Renal vein thrombosis 

Orbital edema

Thromboembolism

Infection(Due to loss of immunoglobulins in urine)

Coagulopathy (due to loss of antithrombin III in urine )

Fig 3 Classical look in a patient with Nephrotic syndrome .

This case was contributed By

Dr Imtiyaz Wani MD.DM (Nephrology)

Prof.  Dept.of Nephrology

 S K Institute of Medical sciences Srinagar, Kashmir