CASE PRESENTATION
A middle-aged male in his early 50s, presented to the ED after a fall. He had a past medical history that was significant for nephrotic syndrome secondary to focal segmental glomerulosclerosis (FSGS), on cyclosporine therapy with partial response, chronic kidney disease (CKD) stage-3a, hypoalbuminemia, hypothyroidism, hyperlipidemia, epilepsy, disorganized schizophrenia, and bipolar disorder. He reported that he had chronic bilateral lower extremity swelling due to his kidney disease, which had been worsening for the last 2 weeks, leading to difficulty with ambulation. He said that he was going to the hospital and fell while going past the door. The ambulance was called and he was brought to the ED. He was conscious and moving at that time. There was no major injury, head-strike, tongue-biting or urinary incontinence. His last reported seizure was 2-3 years ago, and he endorsed taking all medications as prescribed. He denied any dark urine or decreased urine output. He denied fever, chills, night sweats, cough, sore throat, chest pain or myalgia. There was no history of smoking, alcohol consumption and intravenous drug use. The patient had a family history of cardiovascular disease.
The patient’s home medications included atorvastatin for hyperlipidemia, cyclosporine for steroid & cyclophosphamide-resistant nephrotic syndrome secondary to FSGS, antiepileptics (Divalproex, levetiracetam, lacosamide, and lamotrigine), levothyroxine for hypothyroidism, psychiatric medications for schizophrenia (aripiprazole, risperidone, and benztropine), and enalapril for proteinuria. He was last seen in the renal clinic more than a month ago, when his latest urine protein/creatinine ratio was 2758, which had fallen significantly from 4237 about 9 months ago. Of note, his cyclosporine dose was increased by 25% a month before admission, due to sub-therapeutic levels in the blood, after which it had attained therapeutic levels for a while.
On arrival at the emergency department, the patient was afebrile and hemodynamically stable, with a physical exam notable for 3+ pitting edema of bilateral lower extremities up to the hip with mild tenderness, chronic scrotal edema, flat abdomen and chest clear to auscultation. Other systemic examinations were within normal limits.