A 54-year-old man with a 10-year history of diabetes and hypertension, with complications of diabetic retinopathy and peripheral neuropathy, presents to his primary care physician with complaints of fatigue and weight gain of 4.5 kg over the past 3 months. He denies any changes in his diet or glycemic control but does state that he has some intermittent nausea and anorexia. He states that he has noticed that his legs are more swollen at the end of the day but improve with elevation and rest. Physical exam reveals an obese man with a sitting blood pressure of 158/92 mmHg. The only pertinent physical exam findings are cotton wool patches and microaneurysms bilaterally on fundoscopic exam and pitting, bilateral lower-extremity edema.
The disease presents insidiously over months with vague complaints of fatigue, mild reduction in appetite, and, at more advanced stages, nausea and anorexia. Edema is a common presentation - as the glomerular filtration rate declines, there is an inability to effectively excrete salt and water to remain in metabolic balance with dietary intake. Additionally, proteinuria with a decrease in serum albumin may contribute to the development of peripheral edema.
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