Proteinuria is one of several markers of kidney damage in diabetes. The excretion of specific types of protein, such as albumin or low molecular weight globulins, depends on the type of kidney disease that is present.1 One of the earliest changes in diabetes is an increase in glomerular filtration rate (GFR), or hyperfiltration, which is observed in patients with type 1 as well as many with type 2 diabetes and is accompanied by an increase in renal size.2 The next observable change is the development of albuminuria, and current UK guidance recommends annual screening with the albumin creatinine ratio (ACR) to identify early kidney disease in patients with diabetes.3 Patients with diabetes with persistent microalbuminuria are at greatly increased risk for development of proteinuria (albuminuria >300 mg/day). However, it is important to exclude other causes of proteinuria in patients with diabetes, especially if there is no associated retinopathy. We report a case of an 81-year-old man with type 2 diabetes mellitus who presented with lower back pain and proteinuria but who had had normal/minimal microalbuminuria on his annual screening. He was diagnosed with multiple myeloma. The case highlights the importance of proteinuria in diagnosing multiple myeloma and the distinction between proteinuria in diabetic nephropathy and in multiple myeloma.
A 49-year-old woman presented with severe abdominal pain and per rectal bleed, 13 days after receiving the first dose of the AstraZeneca vaccine. Blood tests showed remarkably low platelet count, unmeasurable D-dimer levels and low fibrinogen levels, consistent with a diagnosis of vaccine-induced thrombotic thrombocytopaenia and disseminated intravascular coagulation. CT mesenteric angiogram revealed massive portosplenic mesenteric vein thrombosis. CT head also noted non-occlusive thrombosis at several sites. She was treated with intravenous immunoglobulins, plasma exchange, anticoagulants and transjugular intrahepatic portosystemic shunt procedure. Following a prolonged inpatient stay, she was discharged with subsequent short bowel syndrome and long-term parenteral nutrition. This particular clinical scenario aims to highlight the importance for clinicians to remain vigilant for rare complications associated with the AstraZeneca vaccine and the subsequent management involved, at a time where it is vital to vaccinate globally in order to control the spread of the COVID-19 pandemic.
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