Heart Failure and Renal Interactions, Heart Failure Management, Cardiovascular Medicine - Full Vigne

Описание: A 60-year-old woman with stable HIV, diabetic retinopathy, and chronic heart failure presents with progressive evening leg swelling, abdominal bloating, early satiety, and exertional dyspnea. Exam findings include elevated jugular venous pressure, bibasilar crackles, mild ascites, and worsening edema. Laboratory tests show declining kidney function and mild proteinuria. What pathophysiological renal mechanisms connect heart failure to her deteriorating kidney status and sodium retention in this scenario? How should a clinician approach this complex interplay?

VIDEO INFO
Category: Heart Failure and Renal Interactions, Heart Failure Management, Cardiovascular Medicine
Difficulty: Moderate - Intermediate level - Requires solid foundational knowledge
Question Type: Pathology
Case Type: Routine Visit - Standard clinical encounter in outpatient setting

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QUESTION
A 60-year-old woman with HIV on stable antiretroviral therapy and long-standing diabetic retinopathy attends a routine heart failure follow-up visit. She reports progressive evening leg swelling and abdominal bloating over 2 months, early satiety, and exertional dyspnea after climbing one flight of stairs. She denies chest pain or fever. She quit smoking 15 years ago after 10 pack-years. She has never used NSAIDs chronically....

OPTIONS
A. Elevated renal venous pressure with interstitial edema compressing tubules and reducing net filtration pressure, leading to sodium retention and progressive fall in GFR.
B. Primary podocyte injury with subepithelial immune complex deposits, effacement on electron microscopy, heavy albuminuria, and secondary hyperlipidemia leading to edema and nephrotic syndrome.
C. Direct tubular cytotoxicity from loop diuretics causing diffuse acute tubular necrosis with granular casts, abrupt oliguria, and persistent intrinsic renal failure.
D. Ischemic infarction of renal cortex from cholesterol emboli producing abrupt anuria, livedo reticularis, eosinophilia, and flank pain.

CORRECT ANSWER
A. Elevated renal venous pressure with interstitial edema compressing tubules and reducing net filtration pressure, leading to sodium retention and progressive fall in GFR.

EXPLANATION
The patient s chronic HFrEF with progressive systemic congestion, modest albuminuria (ACR 80 mg/g), bland urine, and eGFR ~31.9 mL/min/1.73 m2 suggests cardiorenal syndrome where renal venous congestion is central. Elevated renal venous pressure transmits to the interstitium, compresses tubules, and lowers net filtration pressure, driving sodium retention and gradual GFR decline despite absence of heavy albuminuria or active sediment.

Primary podocyte injury with subepithelial immune complex deposits... implies nephrotic syndrome with heavy albuminuria and hyperlipidemia, which is not present. Direct tubular cytotoxicity from loop diuretics... would present as ATN with granular casts and abrupt oliguric failure, inconsistent with her chronic bland urinalysis and progressive course....


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