Lady with a hidden kidney

Hello everyone. I'm currently posted in Medicine and we get to see interesting cases everyday and we daily have an opportunity to learn from new cases.So here is my case which i followed.

A 40 year old woman, farmer by occupation from Miryalguda, Hypertensive since 1 month, non diabetic, non alcoholic and

Not a smoker presented to our Out Patient Department with the chief complaints of 

Reduced urine output since 2 months

Bilateral lower limbs swelling since 1 month

Lower back ache since 1 month

Facial puffiness since 15 days

The patient is attained her menarche at 13 years of age and had regular menstrual cycles every 30 days lasting for 3 - 4 days. She got married to her husband who is a farmer & even a landlord when she was 15 years old. She gave birth to her first child when she was 17 years of age. She has 3 male children, all the three deliveries were normal vaginal deliveries and she had no complications during their deliveries. She had a happy life with no health problems until 10 years back when she one day had severe abdominal pain which lasted for a couple of days after which she was rushed to the hospital where she was diagnosed with ? Fibroid uterus (no documentation, only orally described by the patient) after which she had to undergo a hysterectomy. The patient was even told that she had renal calculi at the point in one of her kidneys but patient is unable to recall which side. 

10 yrs later, now she has been having reduced urine output since 2 months, bilateral lower limb swelling since 2 months which are of pitting type and it slowly progressed over a couple of days from ankle to her knee joint. She also tells us she has been having on and off lower back ache, non radiating to her thighs. Along with facial puffiness since 15 days. Though, she doesn't give us any complains of hematuria, frothy urine, chest pain, dyspnea, cough, hemoptysis, palpitations, wheeze.

She was taken to a local hospital before presenting to us where she was told that she had no right kidney and was even diagnosed with hypertension.

During the course of her hospital stay, she was evaluated and her 24 hours urinary protein turned out to be more than 3grams per day which fits into the nephrotic range also keeping in mind her other symptoms fitting into nephrotic syndrome such as edema, hyperlipidaemia, proteinuria.We  got a CT KUB done in order to rule out presence of any ectopic kidney as there was no right kidney on ultrasonography of the abdomen. On CT KUB a right shrunken kidney was found with a midureteric calculus on the right side causing obstructive nephropathy which led to the shrunken right kidney.

However, Obstruction wouldn't lead to such high amount of proteinuria and even if it is the cause, the patient wouldn't have presented with such acute symptoms. Keeping this in mind , a left renal biopsy was planned.

PAST HISTORY:

    Not a k/c/o Diabetes, asthma, TB, CKD , CHF

   Past surgical:Hysterectomy done 10 years back.

PERSONAL HISTORY:

   Her diet is mixed

    Appetite is normal

    Sleep is adequate

    Bowel and bladder habits are regular

    No addictions

FAMILY HISTORY:

    No significant family history.

GENERAL PHYSICAL EXAMINATION:

   Patient was conscious, coherent, cooperative,  moderately built and moderately nourished. 

   Pallor:absent

   Icterus:no

   Cyanosis:no

   Clubbing:no

   Koilonychia:no

   Gerneralised lymphadenopathy:no

   Pedal edema:present

VITALS : she is a febrile

                BP-120/70 mm hg

                PR-78bpm

                RR-18cpm

                Spo2- 98%

                Grbs-105 mg%

 SYSTEMIC EXAMINATION:

       PER ABDOMEN: Soft , non tender, no organomegaly

                               Bowel sounds present

        CVS: s1 and s2 heard , no murmurs

        RESPIRATORY SYSTEM: BAE present, NVBS heard

        CNS:Higher mental functions- intact

                Cranial nerves- normal

                 Motor system-normal

                 Sensory system- normal 

                 Cerebellum- intact

                 No signs of meningeal irritation 

The following investigations were done:

Urine for culture & sensitivity.

Ultrasound abdomen

CT KUB 

PROVISIONAL DIAGNOSIS: 

Nephrotic syndrome

Obstructive nephropathy

 K/c/o HTN since 1 month

Treatment :

1)Tab. LASIX 40 mg PO/BD

2)Tab.PANTOP 40mg PO/OD/BBF

3)Fluid Restriction <1L/day.

    Salt Restriction<2g/day

4)Wysolone 30mg OD

       

She was advised for the left Renal biopsy.

Usually in these kind of cases a renal biopsy would be advisable, but considering their financial status and their short need of well-being, it was decided that renal biopsy may not be that effective in changing the course of treatment. However we would like to perform a biopsy in case she complains of similar complaints in the future.