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FZ is a 28 years old single Egyptian female housewife that was born and still living in New Valley governorate, Egypt. She was amenorrhoeic for the last 8 months before presentation. She presented to the outpatient clinic in August 2017 suffering ascites and lower limb edema for the last 2 years. Ascites was refractory to different diuretic combinations. Repeated therapeutic tapping of ascites confirmed the drained fluid as transudate. At the age of 16, she was investigated for systemic hypertension. Bilateral renal artery stenosis was discovered. In spite of right nephrectomy and left renal angioplasty, severe hypertension persisted. The patient, also, had experienced acute kidney injury following the procedure and underwent 2 sessions of hemodialysis. Since that time, she was kept on daily amlodipine 10 mg, carvedilol 25 mg twice, prazocin 2 mg twice, frusemide 40 mg twice, torsemide 20 mg twice, and omeprazole 20 mg once. On clinical examination, blood pressure was 140/80 mmHg, she had pitting edema up to the knees, congested neck veins with upper level 10 cm above the right clavicle while sitting, moderately enlarged tender liver, and moderate ascites. Apart from elevated kidney functions (Serum creatinine=1.7 mg/dL, serum urea=55 mg/dL), liver function tests, blood sugar, hemogram and serum electrolytes were unremarkable. Echo heart revealed restrictive cardiomyopathy with moderate pericardial effusion and ejection fraction 55%.
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