Diabetic With Exertional Dyspnea and Anasarca: Case Study

Diabetic With Exertional Dyspnea and Anasarca: Case Study A fifty year old gentleman, a known diabetic and hypertensive presented with exertional dyspnea and fluid overload. He was detected to have renal failure and associated evidence of cardiac disease, cardiorenal syndrome Type 4. He improved with decongestive therapy and conservative management. In view of the presence of microvascular complications of diabetes, he was diagnosed as diabetic nephropathy stage 5 and initiated on maintenance haemodialysis. The approach to diabetics with renal involvement and the issues in their management is discussed. Case summary A fifty year old gentleman a known diabetic and hypertensive for eight years presented with exertional dyspnea of one month duration. Dyspnoea on exertion had been progressively worsening for one month with orthopnea for one day. He complained of cough accompanied with  ½ a cup per day of mucoid non foul smelling, non blood stained sputum for last one month. He complained of swelling feet with worsening of dyspnoea for last four days. No h/o chest pain, PND, syncope, wheeze or fever. He was a chronic smoker (25 pack yrs) and a reformed alcohol consumer 240 gms/day for 15yrs. What would be your analysis of symptoms? The exertional dyspnea is suggestive of cardiovascular system involvement. In a diabetic, hypertensive and chronic smoker, coronary artery disease or hypertensive heart disease would be common possibilities. Cough with wheeze in a smoker could be COPD in exacerbation with cor pulmonale accounting for the exertional dyspnea and swelling feet, however orthopnea, a sign of left sided cardiac involvement would be uncommon. Additionally, the duration of cough is too short to qualify for COPD. Infective causes of cough like tuberculosis need to be excluded although they cannot account for all symptoms. He also complained of decreased urine output and puffiness of face for last four days. There is no history of altered behaviour, haematuria, smoky urine, nocturia, dysuria, hesitancy or precipitancy. Two years ago patient during evaluation prior to surgery for prolapsed disc was found a creatinine of 1.5mg%. Does the differential diagnosis change in the light of the additional information? The complaints of oliguria and puffiness of face suggests renal failure with fluid overload state. It is common for Type 2 diabetics, especially with accompanying hypertension to present with early renal involvement. Therefore, although the duration of diabetes is only eight years, the cause of renal failure could still be diabetic nephropathy. The presence of renal involvement two years ago is a clue to the chronic nature of renal involvement. An acute on chronic renal failure due to respiratory tract infection could account for the sudden worsening over one month. On examination, pulse 84 / min, regular, BP 190/110 mm Hg, respiratory rate 28/min, thoraco abdominal , JVP 8 cm above sternal angle, Facial puffiness, pallor and pitting edema in upper and lower limbs noted. Trophic skin changes in lower limb were present. No asterixis, Icterus, clubbing, cyanosis or lymphadenopathy seen. Respiratory system examination revealed extensive wheeze and coarse crackles. The heart sounds were normal with no pericardial rub. Liver was enlarged, span 15cm,soft, nontender and ascites was not elicitable. Fundoscopy revealed early nonproliferative diabetic retinopathy. Rest of neurological examination was normal. What is your analysis with the given clinical findings? The patient has anasarca with pallor and hypertension. The presence of diabetic retinopathy also suggests microvascular complications have set in. Diabetic nephropathy with fluid overload state can explain most of the signs and symptoms. An associated cardiac disease like coronary artery disease may be present. Diastolic heart failure is common accompaniment that may be contributing the signs of right heart failure. Cardiac asthma can account for the new onset wheeze in a diabetic. Diabetic nephropathy with a possible cardiac pathology, cardiorenal syndrome is the most likely diagnosis. What is cardiorenal syndrome? Cardiorenal syndrome (CRS) is a pathophysiologic entity involving the heart and kidneys where acute or chronic dysfunction of one organ may result in acute or chronic dysfunction of the other. CRS Type 1 reflects an abrupt worsening of cardiac function as is seen in acute cardiogenic shock or in a patient of congestive heart failure who has decompensated leading to acute kidney injury. CRS Type 2 comprises the group of patient with chronic congestive heart failure resulting in progressive chronic renal failure. CRS Type 3 consists of an abrupt worsening of kidney function (e.g., acute renal failure or glomerulonephritis) causing acute cardiac dysfunction (e.g., arrhythmia, ischemia, heart failure). CRS Type 4 refers to a state of chronic kidney disease (e.g., chronic interstitial nephritis, chronic glomerulonephritis) contributing to left ventricular hypertrophy and poor cardiac function. CRS Type 5 reflects a systemic condition like sepsis resulting in simultaneous cardiac and renal dysfunction. Our patient seems to have Cardiorenal syndrome Type 4. The biochemical parameters, ECG and echocardiography will be needed to make a firm diagnosis. Investigations revealed Hb 10.5g/dl, TLC 13300/cumm, DLC P91L7, platelets 2.78lac/cumm, Urine albumin 4+, granular casts+, blood urea 89mg/dL, serum creatinine 5.8mg/dL, serum Na 115mmol/L, serum K 3.1mmol/L, blood sugar fasting 102mg/dL, postprandial 156mg/dL,HbA1C 6.6%, serum bilirubin 0.5mg/dL, calcium 8.4mg/dL, phosphate 3.2mg/dL, iPTH 6.9pg/ml, CKMB 19mg/dL, serum iron 48  µg /dL, serum TIBC 243 µg/dL, transferrin saturation 19.7%, HBsAg negative, Anti HCV Negative, HIV Negative. Ultrasound revealed medical renal Disease with bilateral renal cysts, size of right kidney 8.5 cms left kidney 9.5 cms. Chest radiograph showed cardiomegaly with prominent hilar markings. ECG showed T wave inversion in I, aVL,V4- V6 suggestive of strain pattern and left ventricular hypertrophy by voltage criteria. 2-D ECHO showed concentric LVH, No RWMA, EF 0.65,diastolic dysfunction, trivial TR and no AS/AR. Could this patient have nondiabetic renal disease? Is there an indication for kidney biopsy to confirm renal diagnosis in this patient? In a diabetic with kidney disease, it would be presumed that the proteinuria and azotemia is due to diabetic nephropathy especially if there is associated retinopathy and normal sized kidneys. There is no necessity to perform a kidney biopsy to confirm diabetic nephropathy as it would make no difference in the management. However, a diabetic is also prone to other nondiabetic renal diseases as in the general population that may need histopathological examination and warrant specific therapy. The clues that the renal failure is due to nondiabetic renal disease requiring a biopsy are summarised. Asymmetric kidneys or small sized kidneys are also clues to a nondiabetic renal disease but donot warrant biopsy. Our patient has near normal sized kidneys (right kidney small) with proteinuria and nonproliferative retinopathy, hence there is no requirement to biopsy. Retinopathy is present in 65% of cases of DMType2 with nephropathy, hence absence of retinopathy doesnot rule out nephropathy. Biopsy not indicated when Typical evolution of renal disease Concomitant retinopathy Biopsy should be considered when Renal manifestations are seen atypically (5-8 g/day) persists despite lowering of blood pressure * Only for Type 1 diabetes What are the stages of diabetic nephropathy? What stage is the patient in? The stages of diabetic nephropathy are as summarised in the table. Microalbuminuria is the earliest clinically detectable evidence of onset of nephropathy in a diabetic. About 20-25% of diabetics develop nephropathy in their lifetimes. The time after diagnosis has been validated after followup of Type1 diabetics and doesnot hold true for type 2 diabetics because the the time of onset of diabetes is not clearcut ina given case. It is not uncommon for clinically evident nephropathy to be present when type 2 diabetes is detected. Our patient has established renal failure, hence is in stage 5 diabetic nephropathy. Stage Glomerular filtration Albuminuria Blood pressure Time interval 1 Renal hyperfunction Elevated Absent Normal At diagnosis 2 Clinical latency High normal Absent 3Microalbuminuria Within the normal range 20-200 ÃŽ ¼g/min (30-300 mg/day) Rising within or above the normal range 5-15 years 4 Proteinuria (overt nephropathy) Decreasing 200 ÃŽ ¼g/min (300 mg/day) Increased 10-15 years 5 Renal failure Diminished Massive Increased 15-30 years What is the difference in nephropathy in Type 1 diabetes and type2 diabetes? Type 1 Diabetes with nephropathy Type 2 Diabetes with nephropathy Follows classical stages Hypertension is usually due to renoparenchymal aetiology Retinopathy 90-100 % concordance Non diabetic renal disease rare Less consistent Primary hypertension commoner (metabolic syndrome) Retinopathy 60% concordance Non diabetic renal disease 20-30% Define microalbuminuria. What is the relevance of finding microalbuminuria in a diabetic? Microabuminuria is defined as the presence of 30-300 mg albumin/24 hrs urine collection or 20-200microgm/mt in a timed urine sample in atleast 2/3 samples over 6 months in the absence of fever, infection, physical exercise, uncontrolled blood pressure or sugar, cardiac failure or haematuria. The importance of the finding is that it indicates endothelial dysfunction and is a predictor of diabetic nephropathy in 80% and 40% Type1 and Type2 diabetics. It is also is a predictor of cardiovascular mortality and is strongly associated with insulin resistance and hypertension. In a given patient it is a clue to the clinician to institute aggressive control of blood pressure and hyperglycemia to prevent progression of diabetic nephropathy. The patient was managed with loop diuretics, plain insulin, inhaled bronchodilators, nitroglycerine drip and oxygen therapy. After initial stabilisation, he continued to have raised serum creatinine, hence was initiated on maintenance haemodialysis as a case of diabetic nephropathy with ESRD. What happens to the hyperglycemia with the onset of diabetic nephropathy? What treatment modifications are required to be made for glycemic control? With the onset of nephropathy, the insulin requirement decreases and patient becomes more prone to hypoglycaemia because the half life of insulin is prolonged, renal gluconeogenesis decreases, food intake is decreased, half life of oral hypoglycemics is prolonged, diabetic gastropathy delays gastric emptying and patient frequently vomits food due to uraemia. Infact if a well controlled diabetic develops episodes of unexplained hypoglycaemia, then one needs to look for evidence of nephropathy. Biguanides and long acting sulfonylureas are contraindicated in the presence of renal failure. Glimepride and glipizide may be used if serum creatinine is less than 2mg/dL. With more advanced renal failure, patient should be shifted to insulin therapy. What are the measures that can prevent the progression of diabetic nephropathy? Large randomised control trials like IDNT and RENAAL have provided clear evidence that angiotensin receptor blockers help to prevent progression of diabetic nephropathy. The ADVANCE trial provided similar evidence for angiotensin converting enzyme inhibitors. A target blood pressure of 130/80 mmof Hg is recommended for diabetics with proteinuria. Intensive treatment of hyperglycemia with tight blood sugar control has shown to reduce the incidence of micovascular complications including nephropatrhy in multiple studies like DCCT, UKPDS and ADVANCE. Cessation of smoking, avoidance of high protein diet and control of hyperlipidemia also seem to be beneficial. Once overt renal failure has set in then tight blood sugar control may not prevent further progression of nephropathy and the risk of hypoglycaemia increases, hence the physician should use discretion in prescribing antidiabetic therapy. What are the issues in dialysis of patients with diabetic nephropathy? Although diabetics with ESRD are candidates for all renal replacement therapy (RRT) options as nondiabetics, there are many factors that make it challenging to provide RRT in a diabetic. Associated coronary artery disease and diastolic dysfunction, high incidence of fistula failure due to atherosclerosed vessels, heparin (given during haemodialysis) related bleed due to associated retinopathy, decreased osmotic gradient and poor clearance in CAPD, poor tolerance to uraemic symptoms, diabetic cystopathy and gastroparesis, preponderance to low turnover bone disease, higher incidence of infections, autonomic neuropathy, elderly age group of patients with attendant social and logistic issues all contribute to poor survival in diabetics compared to nondiabetics. Final diagnosis Diabetic nephropathy in end stage renal disease with Cardiorenal syndrome Type 4 Commentary Diabetic nephropathy has become the commonest cause of chronic kidney disease in both the western world and developing countries. Classical stages of diabetic nephropathy described in Type 1 diabetics may not be evident in the progression of kidney disease associated with Type 2 diabetics. Measures to prevent progression of diabetic nephropathy should be aggressively instituted. Patients of diabetes Type2 with kidney disease additionally have associated cardiac disease making the management of such patients challenging. Cardiorenal syndromes encountered in various situations have been recently described that have improved our understanding of the complex pathophysiology and may open new avenues of treatment in the future. Take home message Diabetic nephropathy is the commonest cause of ESRD and developing countries are likely to face an epidemic in the next two decades. Cardiorenal syndrome (Types1-5) is a recently described pathophysiological condition that has furthered our understanding of the complex interrelation between heart failure and kidney failure in diverse clinical settings. Why Are Informal Networks Important? Why Are Informal Networks Important? Introduction Informal organizations affect decisions within the formal organization but either, are omitted from the formal scheme or are not consistent with it. They consist of interpersonal relationships that are not mandated by the rules of the formal organization but arise spontaneously in order to satisfy individual members needs Ever since the Hawthorne Studies (Mayo, 1949) and the development of the Human Relations school of thought, there has been a widespread tendency towards adopting a less scientific view of organisations. There has also been a relaxation of the assumption of rational behaviour by employees and behaviour that is strictly in tune with the goals of management and the rest of the organisation. As Mayo states: In every department that continues to operate, the workers have, whether aware of it or not, formed themselves into a group with appropriate customs, duties, routines, even rituals; and management succeeds (or fails) in proportion, as it is accepted without reservation by the group as authority and leader (Mayo, 1949) This indicates that individuals in organisations do not stop being social beings while at work. This in turn relates to the very core of the essential question of how to define an organisation. The underlying assumption in this paper will be that organisations are basically a web of coalitions and that coalition building is an important dimension of all organisational life (Morgan, 1997). In consequence, various approaches have been undertaken in order to try and understand organisations. By mainly focusing on communication as the vehicle of social structures, sociologists have described organisations as structures of social interactions in a specific organisational context or culture (White, 1970). Psychologists relaxed and redefined the assumption of rational behaviour in order to understand and describe the needs of individuals in organisations. This has led to a multitude of ways to describe organisational structures, often through metaphors (Morgan, 1997). There has been a shift in the traditional view of the role of the manager and his or her workday (Mintzberg, 1973). By not relying on the normative division of work into planning, organising, coordinating and controlling, Mintzberg suggested that the workday of a manager was much less structured and based on intuition rather than formal decision making processes. What becomes apparent regardless of the method of analysis of the underlying premise is that no organisation can be described or mapped in a satisfactory manner using just formal organisational methods, let alone be managed on that basis. The Structure of Informal Networks It is important to present the concepts associated with intra-organisational social networks. The optimal terminology to describe the informal organisation depends on the purpose of the analysis. There is no one best way to interpret informal networks (Mintzberg, 1989). Informal networks in organisations are likened with the nervous system of a living organism, whereas the bones represent the formal organisation (Krackhardt and Hanson, 1993). Staying with the analogy of the human body, a superficial comparison can be made between the skeleton and the nervous system, and informal/ formal networks within organisations to help understand the function of these networks. The formal organisation is compared to a skeleton which is a strong and rigid frame and the informal organisation is compared to the nervous system which is fragile yet flexible. The skeleton is visible, whereas the nervous system is an entity with no structure without definite subdivisions. Without determined, close obse rvation, it might be difficult to recognise (Han, 1983). Why do Informal Networks Exist? Informal networks exist in every organisation and are an inevitable function within them. Individuals do not stop being social beings when placed in a formal work setting. When highlighting some of the motives for the creation and maintenance of informal networks within organisations, it is important to distinguish between unconscious and conscious reasons for their existence. Affiliation needs: To satisfy the need for belonging to a group, individuals will tend to join networks of friendship and support. As a result, a part of ones individuality is sacrificed to conform to group norms. Identity and self-esteem: Belonging to a group or informal network can develop, enhance and confirm an individuals sense of identity as a result of the personal interaction. Social needs: Traditional formal networks within organisations often offer little room for emotions, feelings or sharing of personal thought, informal networks serve as an agent for structuring and supporting a shared social reality. By relying on this social reality, individuals can reduce uncertainty and stress. Informal groups also help members to compensate for feeling of dissatisfaction with the formal leader, organization or official communication system (Han, 1983). Defence mechanism: In the face of perceived threat or general uncertainty, group cohesion can act as a defence mechanism to reduce (perceived) uncertainty and strengthen each individuals ability to respond to the threat. Risk reduction: Through diluting blame and aggregating praise, a group of workers perceive risk to a lesser extent than they would as individuals. Thus unconscious efforts of individuals to control the conditions of their existence will lead to the creation of informal groups. In addition, often more practical and very clear unambiguous conscious reasons for the creation and development of informal networks also exist. The need to know: One of the primary characteristics of the informal structure within organisations is their communications network, often referred to as the grapevine. Studies have shown grapevine communication to be both fast and surprisingly accurate (Crampton et al., 1998). And in situations when information is critically needed by an individual to perform the task at hand, the grapevine can prove and efficient vehicle for news and information, thus bypassing the formal channels of communication (Mintzberg, 1973). Politics: One of the more conscious reasons for the use of informal networks within organisations is that employees might choose to use informal channels of communication to influence colleagues or superiors in order to gain an advantage in organisational politics. Politics refers to individual or group behaviour, that is informal, ostensibly parochial, typically divisive, and above all, in the technical sense, illegitimate, sanctioned neither by formal authority, accepted ideology, nor certified expertise (though it may exploit any one of these) (Mintzberg, 1983) What is the Informal Organisation? Chester Bernard, a pioneering management theorist who studying organisational behaviour, in the classic The Functions of the Executive, described the informal organisation as any joint personal activity without conscious joint purpose, even though it contributes to joint results. Thus, the informal relationships established between groups of colleagues going for a drink after work on a Friday may actually help in the achievement of reaching organisational goals (Barnard, 1938). More recently the informal organisation has been described as a network of personal and social relations not established or required by the formal organization but arising spontaneously as people associate with one another (Davis and Newstrom, 1985). Thus, informal relationships do not appear on the organisational chart but do include relationships such as chatting together, having lunch or even getting together outside of work hours to socialise together. Informal Group Dynamics at Work Managers are often not aware that within every organisation there are group pressures that influence and regulate employee behaviour, performance and motivation. Informal groups can form their own code of ethics and an unspoken set of standards in establishing acceptable behaviour. Manager needs to be aware of the power and influence informal groups have and that they will almost inevitably form if the opportunity arises. These groups can have an extremely powerful impact on the achievement of organisational effectiveness. However the influence of these groups can be controlled and resisted if handled efficiently. The impact of informal behaviour within the formal organisational setting depends on the norms that the group adheres to. As this is the case it can be surmised that the informal organisation can make the formal organisation either more or less effective depending on how it is managed and controlled and interacts within a company. References BARNARD, C. I. 1938. The functions of the executive, Cambridge, Harvard university press. CRAMPTON, S. M., HODGE, J. W. MISHRA, J. M. 1998. The Informal Communication Network: Factors Influencing Grapevine Activity. Public Personnel Management. DAVIS, K. NEWSTROM, J. 1985. Human Behavior at Work. New York: Mc Graw Hill. HAN, P. E. 1983. The Informal Organization Youve Got to Live With. Supervisory Management 28. KRACKHARDT, D. HANSON, J. R. 1993. Informal networks : the company behind the chart, Harvard Business Review. MAYO, E. 1949. The social problems of an industrial civilization. Routhledge. MINTZBERG, H. 1973. The nature of managerial work, New York ; London, Harper and Row. MINTZBERG, H. 1983. Power in and around organizations, Englewood Cliffs ; London, Prentice-Hall. MINTZBERG, H. 1989. Mintzberg on management : inside our strange world of organizations, New York London, Free Press ; Collier Macmillan. MORGAN, G. 1997. Images of Organization. Thousand Oaks: CA: Sage Publications. SIMON, H. A. 1976. Administrative Behavior. New York: The Free Press. WHITE, H. C. 1970. Chains of Opportunity: System Models of Mobility in Organizations. Cambridge: Harvard University Press.