2016年 · 第32卷第04期

A 65-year-old male was admitted to the hospital due to "polyuria, polydipsia, weight loss for more than 6 years, right toe ulceration for 4 months and fatigue for 3 months". The patient was found to have increased blood glucose 4 years ago (details unknown). One year ago, the fasting blood glucose was 8 mmol/L and the postprandial blood glucose was 18 mmol/L. He was given metformin hypoglycemic therapy, and then the patient stopped taking the drug on his own. Four months ago, after exercise, blisters appeared in the third toe of the right foot, which was then reddened, swollen, ulcerated, discharged pus, and gradually turned black. Three months ago, I felt fatigue, accompanied by foamy urine, with a daily urine volume of about 400 ml, numbness and hypoesthesia in both lower limbs, and intermittent pain in the third proximal interphalangeal joint of my left hand. Later, chest tightness, dyspnea and activity tolerance decreased. Admitted to the endocrinology department of our hospital. Since the onset of the disease, the patient has poor spirit, sleep and anorexia. Weight loss of 5 kg in the last 3 months. History of hypertension 11 years, untreated. Admission physical examination: blood pressure 182/120 mmHg, BMI 23.0 kg/m²。 Malnutrition, chronic disease, jugular distension. Wet rales could be heard at the floor of both lungs. Both lower limbs muscle strength grade 3, hypoesthesia. Mild depressed edema of both lower limbs. The skin of both feet was warm, the pulsation of bilateral dorsal pedis arteries was symmetrical and strong, the bilateral 10 g nylon wire test was positive, and the position sense and vibration sense of both lower limbs were reduced. Laboratory test: Blood WBC 9.10×10⁹/L, Hb 111 g/L, Plt 252×10⁹/L; Urinary routine RBC full visual field/HP, red blood cell deformation, red blood cell tubular type occasionally; Urinary protein amount 6.14 g/24 h; Alb 29.1 g/L, Scr 146 μ mol/L, eGFR 38.7 ml min^-1· (1.73 m²)^-1Blood glucose 5.15 mmol/L; Glycosylated hemoglobin 5.8%; ESR 105 mm/h; CRP 6.7 mg/L; RF 2230 IU/ml. Blood gas analysis : pH 7.396, PaO₂49.3 mmHg, PaCO₂35.1 mmHg. Fundus examination: retinal arteriosclerosis grade 1 in both eyes. After blood pressure control, blood glucose, oxygen inhalation, cardiotonic, diuretic, and vasodilator treatment, the symptoms of chest tightness improved compared with before, but there was still dyspnea, poor activity tolerance, numbness and joint pain of both lower limbs did not improve. At the same time, proteinuria, hematuria and serum creatinine increased to 342 μ mol/L, and he was transferred to the nephrology department.