2Edema:Palpable swelling produced by expansion of the interstitial fluid volumeGeneralized edema = anasarca
3Example 1:Young female broke her calf. She received a plaster fixation for 4 weeks. After 3 weeks she observed pain in the involved leg. Following the removal of the fixation, her right leg became swallen, her calf muscles became tender, she developped mild fever. Her left leg was normal.
4Example 1 – diagnosis: Localised edema of the right leg. Local reason for oedema is likely.Deep venous thrombosis.Diagnosis?Doppler ultrasoundPhlebography (isotope, X-ray)Treatment?Heparin
5Localised edema – treatment: No diuretics!Treatment depends on the cause.
6Example 2:Male with the history of MI followed by exertional dyspnea. 2 weeks ago he had a respiratory infection with cough. Since then his dyspnea worsened and he developed edema of the legs.
7Example 2 – physical examination (1): Symmetrical edema of the legsNot tenderNormal skin colourHepatomegalyDistended jugular veins
8Example 2 – physical examination (2): Patient becomes dyspneic in recumbent position, prefers sitting.Symmetrical inspiratory rales over the lung base.GallopCyanosisImpaired mental status
9Example 2 – physical examination (3): Dull percussion and decreased breathing sounds over the base of the right lung.
16Example 3 – physical examination (2): Symmetrical swelling of the legsNot tenderUnaltered colour of the swollen area.Signs of hypovolemiaCollapsed jugular veinsHypotensionTachycardiaDupuytren´s contractureGynecomastiaFoetor hepaticusEncephalopathyflapping tremor
17Example 3 – diagnosis? Liver cirrhosis. History of liver disease or ethanol abuse.Predominating ascites.Other signs of cirrhosis.Dyspnea is uncommon (large ascites).
18Example 4: Female suddenly developed large swelling of both legs. No pain, no considerable history, no other symptoms.Physical examinationSymmetrical swelling, non-tenderNo other remarkable abnormalities
19Example 4 – diagnosis? Edema of renal origin. Lack of symptoms of cardiac edema and liver cirrhosis makes renal edema likely.
20Edema in renal disorders - history: No specific symptomsSymptoms of particular renal disorderUremic symptoms may be presentFatigue, malaise, weight lossDyspepsia, vomiting, diarrheaDyspneaItchingConfusion
21Edema in renal disorders – phys.exam: Hypertension may occurDiabetic or hypertonic vascular eye abnormalities may be presentUremic foetor may be presentEyelid edema may predominatePericardial friction rub in advanced uremiaCheck the kidneysFlank percussionBimanual palpationCheck the urinary bladderDistended?Tenderness above the symphysis or in the ureteric points?
22Edema in renal disorders – tests: Positive urinary sedimentHematuriaProteinuriaAbnormalities in serum commonLow albuminHigh cholesterolHigh ureaHigh creatinineUltrasonographyKidneys enlarged, reduced size, abnormal echogenityDilatation of the pelvis, calyces, ureterMany other tests...
23General edema and fluid overload: Edema of a systemic originSymmetricalGravity – dependentMostly unpainfulAccumulation of fluidPleural effusionPericardial effusionAscitesTranscutaneous fluid leakage
24Clinically important evaluation of edema: Physical examination.Blood pressureHypertension in renal related edema is commonBody weight.X-rayPleural effusionPulmonary congestionUltrasonographyAscitesDiameter of vena cava and hepatic veinsEchocardiographyCTBioimpedance measurementCentral venous pressure
25General edema – reason?Retention of dietary or intravenously administered sodium and water by the kidneys.Primary (renal edema)Secondary (cardiac edema, liver cirrhosis)Combination (impaired cardiorenal axis)2,5-3 liters before it becomes apparentVascular reasonsIncreased capillary leakIncreased oncotic pressure of the interstitiumMyxedema … accumulation of proteins
26EDEMA IN RENAL DISEASES: Nephrotic syndrome.ProteinuriaHypoalbuminemiaHyperlipoproteinemiaEdemaAcute nephritic syndrome.Acute poststreptococcal glomerulonephritisLoss of GFR.Abnormal Na+ excretion
27Nephrotic syndrome: Proteinuria > 3,5 g/24h Hypoalbuminemia Reabsorption in tubules, toxic effect.HypoalbuminemiaLoss of albumin in the urine ≈ increased albumin synthesis in the liver.HyperlipoproteinemiaDecreased catabolism of lipoproteinsCardiovascular risk, progression of renal disease (capture of lipoproteins by mesangial cells)EdemaPrimary renal Na+ retention („overflow“ theory)Leakage of the fluid to the interstitium → hypovolemia („undefilling“ theory)
28Complications of the nephrotic syndrome: Loss of proteins in the urineHypoalbuminemia, catabolism, malnutrition.Deficit of IgG → risk of infection (pneumococcal).Loss of binders (TBG, vit.D binding glob., Ca).Loss of antithrombin III.Increased concentration of plasma macromoleculesFibrinogen.IgM.
29Disorders causing nephrotic syndrome: Idiopathic (primary) nephrotic syndrome.Minimal change disease.Focal and segmental glomerulosclerosis.Membranous nephropathy.Secondary nephrotic syndrome.Diabetic nephropathy.Myeloma kidney.Amyloidosis.Many other disorders…
30Glomerulonephritis = nephritic syndrome HematuriaProteinuriaHypertensionEdemaLoss of GFRMostly unpainful
33Conclusions: Nephritic syndrome Localised edema General edema Types of general edemaCardiacLiver cirrhosisRenalNephrotic syndromeNephritic syndromLoss of GFROther (myxedema, allergic...)Nephritic syndrome