Nephrotic Syndrome

Nephrotic syndrome is characterized by pro­teinuria > 3 to 3.5 g / 24 hrs., Associated with many types of kidney disease hypoalbumin­emia, edema, hyperlipidemia, Iipiduria, and hy­percoagulability. Nephrotic syndrome is a dis­ease of glomerular basement membrane, . podocyte-slit diaphragm. A condition marked by increased glomerular permeability to proteins, resulting in massive loss of proteins in the urine, edema, hypoalbuminemia, hyperlipidemia, and hypercoagulability.

Causes of nephrotic syndrome

• are minimal change disease, focal and segmental glomerular sclerosis,
• · membranous glomerulopathy, membrano-proliferative glomerulonephritis, diabetic nephropathy, and amy­loidosis.
• Nephrotic syndr.ome responds well to glucocorticoids. The chief feature of nephrotic syndrome is proteinuria. Hypoalbuminemia is due to loss of protein in urine, increased renal ca.tabolism, increased hepatic syn­thesis of albumin. ,
• Edema is due to hypoalbuminemia, decreased intra­vascular oncotic pressure, leakage of extra cellular fluid (ECF) to interstitial spaces, decrease of intra­vascular volume, activation of renin- angiotensin-al­dosterone axis and the sympathetic nervous system, and release of vasopressin, and suppression of atrial natriuretic peptide release, renal salt and water re­tention.
• Hyperlipidemia is due to increased hepatic lipopro­tein synthesis, leading to atherosclerosis and wors­ening of renal disease.
• Hypercoagulability is due to increased urinary loss of antithrombin III, protein C and 5, hyper­fibrinogenemia, increased platelet aggregation. This leads to peripheral arterial and venous thrombosis, renal vein thrombosis, pulmonary thromboembolism.
• Renal vein thrombosis occurs in nephrotic syndrome if it is due to membranous glomerulopathy, mem­branoproliferative glomerulopathy, amyloidosis.
• There is protein malnutrition.
• There is macrocytic hypochromic anaemia .
• There is hypocalcemia and vitamin D deficiency and secondary hyperparathyroidism. There is also in­creased incidence of infections.

Physical Exam in Nephrotic Syndrome

• A complete physical exam may discover clues to systemic disease as a potential cause and/or may suggest the severity of disease:
• Fluid retention: Abdominal distention, abdominal fluid shift, extremity edema, puffy eyelids, scrotal swelling, weight gain, shortness of breath:
• Pericardial rub and decreased breath sounds with pleural effusions may develop.
• Hypertension
• Orthostatic hypotension

History of Nephrotic Syndrome

• Look for signs or symptoms of systemic disease:
• Joint complaint, rash, edema, infectious complaint, fevers, anorexia, oliguria, foamy urine, acute flank pain, hematuria, etc.
• Look for a recent drug history that may be causative, especially nonsteroidal anti-inflammatory drugs (NSAIDs).
• Assess for risk factors.

Nephrotic Syndrome Risk Factors

• Drug addiction (e.g., heroin [FSGS])
• Hepatitis B and C, HIV, other infections
• Cancer (usually MGN, may be MCD)
• Chronic analgesic use/abuse
• Preeclampsia
• Immunosuppression
• Nephrotoxic drugs
• Vesicoureteral reflux (FSGS)

Symptoms :

• Patients with nephrotic syndrome may initially present with fluid retention in the legs or symptoms caused by blood clotting (e.g., in the renal vein).
• The hyperlipidemia that often accompanies the syndrome may lead to symptoms caused by atherosclerosis.

Treatment of Nephrotic Syndrome

• Treat the etiology.
• General measures for proteinuria. Control of complications
• For proteinuria – ACE inhibitors, ARBs (Angio­tensin Receptor Blockers), NSAIDs.
• These drugs lower the intraglomerular pressure and prevent glomerulosclerosis and also de­creased protein loss.
• ACE (Angiotensin converting enzyme) inhibitors and ARBs (Angiotensin receptor blockers) are also very useful in diabetic nephropathy.
• NSAIDs can however cause hyperkalemia, salt water retention, acute renal failure.
• Salt restriction 1 – 2 g/day, loop diuretics (weight reduction should not be > 1 kg/day by removal of edema fluid).
• Lipid-lowering drugs.
• Anticoagulation in patients with thrombosis. Diet: moderate amounts of proteLrYi~e. 0.8 g/ kg/day plus 1 g for each grafT. protein lost in urine, vitamin D supplements.
• Many of the nephrotic diseases will require escalation in therapy above steroids.
• These include rapidly relapsing forms as well as MGN, LN, and IgA nephropathy:
• Bolus steroids and other immunosuppressives are required in this circumstance (cyclophosphamide, mycophenolate mofetil, chlorambucil, cyclosporine).

Admission Criteria

• Respiratory distress, sepsis/severe infection, thromboses, renal failure, hypertension, or other complications

Discharge Criteria

• Hemodynamically stable patients without complications may be managed as outpatients.