Diabetic patients can't lower their urine protein, what's wrong?

*For medical professionals to read and reference the diagnosis only Ah, I have to ask you about some new situations recently
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" I nodded and said with a smile, "Sit down, wait a moment
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" After sending the patient in front away, I asked Lao Liu to sit over and asked with concern Said: "Lao Liu, what's wrong with you? You went out to eat and drink again?" (Prospect summary: Lao Liu is a friend of my classmates.
It's been five or six years since he was diagnosed with diabetes, but he always doesn't take it seriously.
He usually does not pay attention to moderation because there are a lot of wine bars, and his blood sugar control is very poor
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He always likes to consult me ​​about some physical conditions.
I persuade him many times to let him control his blood sugar, but he always smiles and doesn't take it seriously
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This time Seeing that his face is not good, it is estimated that it is a physical problem)
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Lao Liu hurriedly replied: "Brother, this time I encountered a big problem
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One night two months ago, when I was soaking my feet, I found that there was always a hole on the back of my foot, and I felt a little better in the morning after sleeping.
, it was serious in the last day and night, and it was limited to the instep at first, and then gradually spread upward, and now the eyelids are a little swollen
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" I looked up at Lao Liu's eyelids, and hurriedly said: "Brother, put your shoes on.
Take it off, roll up the trouser legs, I'll take a look
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" I pressed the left ankle, at least moderate edema
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"Brother, have you checked your blood sugar during this time? How is your blood sugar control?" I asked again
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While discussing the condition with Lao Liu, I carefully checked Lao Liu's body, but no other positive signs were found
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"It's not that you don't know, when did I care about blood sugar," Lao Liu replied
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"Brother, this time you need to be hospitalized for an examination.
Only after passing the examination can you find out the reason," I said
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"I always feel weak this time.
You don't want me to live here, and I have to be hospitalized," Lao Liu said dejectedly
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What is the cause of moderate edema of bare feet? After arranging hospitalization for Lao Liu, I carefully analyzed his condition.
Except for a history of diabetes for five or six years, Lao Liu had no other conditions
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Regarding edema, a detailed classification is given in the "Diagnostics" of the ninth edition of the People's Medical Publishing House
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▌First of all, according to the distribution range, edema can be manifested as localized and generalized edema
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Systemic edema is often accompanied by serous effusion
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Judging from the distribution of Lao Liu's edema, it is obviously systemic edema
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▌The degree of edema can be divided into mild, moderate and severe edema
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Patients with moderate edema have visible edema in the loose tissues of the whole body.
After acupressure, obvious or deep tissue depressions may appear, and the recovery is slow
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At present, Lao Liu should belong to moderate edema
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▌ Edema is divided into cardiogenic edema, renal edema, hepatic edema, malnutrition edema, edema caused by endocrine diseases, idiopathic edema, drug-induced edema, and senile edema according to the cause
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Combining the patient's symptoms and signs: Cardiogenic edema is not consistent; the patient is a middle-aged male, obviously senile edema is excluded; except for metformin, no other drugs have been taken, obviously drug-induced edema is excluded; diet is normal, and he often goes out Hu eats Hesai, malnutrition edema is excluded; there is no history of liver disease, liver-derived edema is not suitable, but the possibility of occult liver disease cannot be ruled out; the rest are nephrotic edema, idiopathic edema and endocrine diseases The edema caused by these items is not easy to identify, and we have to wait for the detailed examination results after hospitalization
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In order to find out the essence of the phenomenon as soon as possible, I also tried my best to consider it thoroughly, and gave him a comprehensive examination.
Enzyme spectrum, heart failure index, five items of thyroid function, cortisol rhythm and other indicators that can be thought of
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The next day I went to work, and I kept refreshing the test results
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The first to come back is the venous ultrasound of both lower extremities, urinary ultrasound and abdominal ultrasound
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In the color Doppler ultrasound of the lower extremity, varicose veins and valve insufficiency of the left lower extremity were found, and the subcutaneous soft tissue of both lower extremities was edema
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Figure 1: Color Doppler ultrasonography of lower extremity veins showed that the kidneys were enlarged in size by color Doppler ultrasonography of the urinary system; there was no obvious abnormality in the color Doppler ultrasonography of the abdomen
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Figure 2: Urinary Department Color Doppler Ultrasound Results Subsequently, the laboratory test results came out one after another
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Blood routine, stool routine + OB, ion analysis were normal, five hepatitis B antibodies, five thyroid function, myocardial enzyme spectrum, brain natriuretic peptide (BNP), 8am cortisol and adrenocorticotropic hormone were normal
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Urine routine urine sugar (+), urine protein (3+); urine trace protein 2190mg/L↑ (0-25); fasting blood glucose 11.
9mmol/L↑ (3.
9-6.
4); glycosylated hemoglobin 9.
5%↑ (3.
8 -5.
8); triglycerides in blood lipids 1.
74mmol/L (0.
4-1.
86), total cholesterol 8.
41mmol/L (0-5.
2), low density lipoprotein 6.
31mmol/L↑ (2.
07-3.
1); Protein 22.
5g/L (35-54), serum total protein 42.
2g/L (62-88); urea nitrogen in renal function 8.
53mmol/L↑ (2.
86-8.
2), cystatin C1.
18mg/L↑ ( 0.
56-1.
15); fasting C-peptide 1.
18ng/ml and fasting insulin 13.
1μU/ml in the two items of glucose metabolism
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D-dimer 0.
70μg/ml↑(0-0.
5) in the five items of coagulation
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All the evidence obtained so far basically points to nephrotic syndrome (NS)
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Let's review the diagnostic criteria of NS sign: ①urinary protein greater than 3.
5g/d; ②plasma albumin less than 30g/L; ③edema; ④hyperlipidemia
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Among them, two of ① and ② are necessary for diagnosis
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Although we did not measure 24-hour urine protein, we can basically diagnose nephrotic syndrome.
With the direction, the treatment is logical
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▌The first is a low-salt and high-quality protein diet and intravenous protein supplementation.
At the same time, diuretics are used to reduce swelling, blood lipids, anticoagulation to prevent thrombosis, and hormones and tacrolimus capsules are used to suppress immune and inflammatory reactions
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Due to the use of hormones, in order to control blood sugar more conveniently, protamine human insulin mixed injection (30R) was given subcutaneously before breakfast and dinner
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Since our hospital is temporarily unable to perform kidney puncture, we can only treat it empirically
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According to past experience, after 2 weeks, the patient's edema will gradually reduce, blood lipids will drop, and urinary microprotein will gradually drop
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However, although Lao Liu was hospitalized for 2 weeks, although the edema was significantly relieved, the re-examination of albumin 24.
6g/L (35-54) and urine microprotein 2580mg/L↑ (0-25) still did not improve
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Empirical treatment has not improved, what should I do next? In view of the fact that Lao Liu’s test indicators were still not good, I explained to Lao Liu during my ward round the next day: “Brother, after 2 weeks of treatment, the urine protein still does not go down.
It is best to go to a higher-level hospital for a kidney puncture to clarify the pathology.
Classification, with pathological classification, treatment can be targeted, and the treatment plan can be more clear
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” Lao Liu still trusts me, and immediately went to the higher-level hospital (Shandong Qianfoshan Hospital) after being discharged from the hospital for inpatient treatment
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A week after Lao Liu was discharged from the hospital, he wanted to call to ask how Lao Liu was being treated in a higher-level hospital, but Ke Li was very busy recently, and he wanted to make a phone call several times and was delayed by other things
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But Lao Liu called me, and after connecting the phone, Lao Liu said, "Brother, I should have listened to your words earlier and controlled my blood sugar
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I came here, and they did a kidney puncture for me first.
The type has also come out, and diabetic nephrotic syndrome is considered
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” Lao Liu paused for a while, and then said, “They stopped the hormones and tacrolimus capsules for me, so that I can control my blood sugar and monitor my blood pressure
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” “What are you using? A hypoglycemic plan?" I asked hurriedly
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"Four times a day, three short-acting insulins, and one long-acting insulin before going to bed," Lao Liu replied
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After the phone call with Lao Liu, I quickly fell into reflection.
Although I often read the relevant guidelines for diabetic nephropathy, I ignored the nephrotic syndrome secondary to diabetic nephropathy
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After I finished the phone call with Lao Liu, I quickly fell into reflection.
Although I often read the relevant guidelines for diabetic nephropathy, and usually deal with patients with diabetic nephropathy, I still ignored diabetes secondary nephrotic syndrome when reading the guidelines.
paragraph
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Among the patients with diabetic nephropathy treated, it is basically in the early stage, so that the secondary nephrotic syndrome is ignored when encountering a large amount of urine protein
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Nephrotic syndrome can be divided into primary nephrotic syndrome, secondary nephrotic syndrome and hereditary nephrotic syndrome according to the etiology
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Secondary nephrotic syndrome is a nephrotic syndrome caused by clear etiologies such as immune diseases, diabetes, and secondary infections, circulatory system diseases, and drug poisoning
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Among them, diabetes secondary to nephrotic syndrome accounts for less than 10% of diabetes
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According to statistics [1], only 30%-40% of patients with type 2 diabetes suffer from diabetic nephropathy
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In diabetic patients with proteinuria or decreased glomerular filtration rate, renal biopsy should be used to differentiate the diagnosis
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In terms of treatment, diabetic nephrotic syndrome is also different from primary nephrotic syndrome
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Primary nephrotic syndrome can be treated with hormones and immunosuppressive agents, while diabetic nephrotic syndrome can only be treated with strict control of blood sugar, blood pressure, blood lipids and uric acid, using renin-angiotensin system inhibitors and improving renal function.
Microcirculation drugs
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Summarizing the diagnosis and treatment of this patient, it can be said to be full of harvest.
Diabetic nephropathy and nephrotic syndrome cannot be blindly diagnosed, and we need to assist us in diagnosis and treatment on the basis of renal biopsy pathology
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References: [1] Endocrinology Branch of Chinese Medical Association.
Expert consensus on clinical diagnosis of diabetic nephropathy in Chinese adults [J].
Chinese Journal of Endocrinology and Metabolism, 2015, 31(5): 379-385.