L4: Nephrotic Syndrome Flashcards
Def of Nephrotic Syndrome
Classification of Nephrotic Syndrome
Clinical & Pathological
Secondary of Nephrotic Syndrome
Clinical Classification of Nephrotic Syndrome
- NS is classified based upon whether or not there are signs of systemic disease into 1ry & 2ry
Primary Nephrotic Syndrome
- 90% of childhood cases.
- It refers to NS in the absence of an identifiable systemic disease.
Disorders Causing Nephrotic Syndrome
Disorders Causing Nephrotic Syndrome
- Infections
HBV - HCV - HIV & Strept - syphilis & bilharziasis - malaria.
Disorders Causing Nephrotic Syndrome
- Immune
SLE - anaphylactoid purpura.
Disorders Causing Nephrotic Syndrome
- Iatrogenic
NSAIDs - penicillamine - gold - Heroin.
Disorders Causing Nephrotic Syndrome
- Metabolic
DM - amyloidosis.
Disorders Causing Nephrotic Syndrome
- Metals
Lead - mercury
Disorders Causing Nephrotic Syndrome
- Others
Sickle cell anemia - alport syndrome - HUS - lymphoma.
Types of Nephrotic syndrome during the 1st year of life
- Congenital NS: in 1st 3 months of life.
- Infantie NS: in infants 1 year.
Etiology of Nephrotic syndrome during the 1st year of life
Pathological Classification of Nephrotic syndrome
Characters of Minimal change disease (MCD)
- %
- LM
- IF
- EM
- Response to Steroids
- Illustration
Characters of FSGS
- %
- LM
- IF
- EM
- Response to Steroids
- Illustration
Characters of DMP
- %
- LM
- IF
- EM
- Response to Steroids
- Illustration
Characters of Membranous Glumeronephritis
- %
- LM
- IF
- EM
- Response to Steroids
- Illustration
Characters of MPGN
- %
- LM
- IF
- EM
- Response to Steroids
- Illustration
Def of Idiopathic Nephrotic Syndrome
Incidence of Idiopathic Nephrotic Syndrome
- It is the most common form of childhood NS.
- Representing more than 90 percent of cases between 1 and 10 years of age and 50 percent after 10 years of age.
Pathogenesis of Idiopathic Nephrotic Syndrome
- Mechanisms of glomerular injury
- Mechanisms of edema
- Mechanism of hypoalbuminemia
- Mechanism of proteinuria
- Mechanism of hyperlipidemia
Age in Idiopathic Nephrotic Syndrome
2:8 years
Sex in Idiopathic Nephrotic Syndrome
Male 2 : Female 1
Pathogenesis of Idiopathic Nephrotic Syndrome
- Mechanism of Glomerular Injury
- Circulating non-immune Factors
- Circulating immune Factors
- Mutations in podocyte or slit diaphragm proteins
Mechanism of Glomerular Injury in Nephrotic Syndrome
- Circulating non-immune factors:
Mechanism of Glomerular Injury in Nephrotic Syndrome
- Circulating immune factors:
Mechanism of Glomerular Injury in Nephrotic Syndrome
- Mutations in podocyte or slit diaphragm proteins
The occurrence of prolonged remissions following measles, which down regulates CMI further endorses this hypothesis.
โฆ
Abnormalities of T cell subsets and/or function have been variably reported in a number of patients with MCD.
โฆ
Pathogenesis of Idiopathic Nephrotic Syndrome
- Mechanism of Edema
Mechanism of Edema in Nephrotic Syndrome
- Arterial Underfiling
- A reduction in plasma oncotic pressure induced by hypoalbuminemia would seem to favor the movement of fluid out of the vascular space into the interstitium and produce arterial underfilling.
Mechanism of Edema in Nephrotic Syndrome
- Sodium retention
- Sodium retention is due to increased reabsorption in the collecting tubules mainly due to increased activity of the Na-K-ATPase pump in the cortical collecting tubule and relative resistance to atrial natriuretic peptide.
Pathogenesis of Nephrotic Syndrome
- Mechanism of hypoalbuminemia
Pathogenesis of Nephrotic Syndrome
- Mechanism of Proteinurea
The filtration of macromolecules across the glomerular capillary wall is normally restricted by two mechanisms:
- charge-selectivity
- size-selectivity
The pores between feet processes are closed by a thin membrane called the โฆ..
slit diaphragm.
In comparison: circulating IgG is predominantly neutral or cationic, and its filtration is not limited by charge.
โฆ
โฆ
The glomerular capillary wall is size-selective; having functional pores of an approximate radius of 40 to 45 A (the radius of albumin is roughly 36 A).
โฆ
Pathogenesis of Idiopathic Nephrotic Syndrome
- Mechanism of Hyperlipidemia
CP of Nephrotic Syndrome
CP of Nephrotic Syndrome
- Edema
What is the major Presenting Symptom of Nephrotic Syndrome?
Edema
Edema in Nephrotic Syndrome
- Manifestation
It becomes clinically detectable when fluid retention exceeds 3-5% of body weight.
Edema in Nephrotic Syndrome
- Sites
- Periorbital edema frequently misdiagnosed as allergy is often the initial symptom.
- Edema is gravity dependent, localized to the lower extremities in the upright position, and to the dorsal part of the body in reclining position.
Edema in Nephrotic Syndrome
- Characters
- This edema is soft and pitting, keeping the marks of clothes or finger pressure.
Edema in Nephrotic Syndrome
- Severity
- Anasarca may develop with ascites, and pleural and pericardial effusions. (If anasarca occurred canโt be AGN)
- Edema of the scrotum and penis, or labia, may be seen.
CP of Nephrotic Syndrome
- Abdominal Pain
- It may be related to rapid formation of ascites or concomitant hypovolemia.
- It is occasionally due to a complication such as peritonitis, thrombosis or rarely, pancreatitis.
CP of Nephrotic Syndrome
- HTN
- Mild in 95% of cases.
- Blood pressure is usually normal but sometimes elevated.
CP of Nephrotic Syndrome
- Macroscopic Hematuria
It is observed in 3% of cases.
CP of Nephrotic Syndrome
- Complications
The disease may also be revealed by a complication
CP of Nephrotic Syndrome
- Asymptomatic
NS is occasionally discovered during a routine urine analysis.
Urine Analysis in Nephrotic Syndrome
- Volume
- Color
- Casts
- Specific Gravity
Investigations for Nephrotic Syndrome
- Urine Analysis
Investigations for Nephrotic Syndrome
- Urine & Blood
Urine Analysis in Nephrotic Syndrome
- Proteinuria
Qualitative Evaluation of Proteinuria in Nehrotic Syndrome
Quantitative Evaluation of Proteinuria in Nehrotic Syndrome
What is the screening test for Proteinuria in Nephrotic Syndrome?
Using urine dipstick
Urine Analysis in Nephrotic Syndrome
- Urine Protein Selectivity
Investigations for Nephrotic Syndrome
- Blood Tests
What is the Confirmatory test for Proteinuria in Nephrotic Syndrome?
- Using 24-hour urine protein
- Using Spot urine protein / creatinine ratio
Blood Tests for Nephrotic Syndrome
- CBC
- PTN
- Lipids
- C3
- Ck
Pathological Dx of Nephrotic Syndrome
Etiological Dx of Nephrotic Syndrome
When is Renal Bx Indicated in children in Nephrotic Syndrome?
Nephrotic sydrome not fulfilling criteria of Finnish type
Complications of Nephrotic Syndrome
- Infections
- Thromboembolism
- Hypovolemia
- Renal Insufficiency
- Corticosteroids SE
Most Common Complications of Nephrotic Syndrome
Infections
Infections in Nephrotic Syndrome
- Types
Bacterial & Viral
Bacterial Infections in Nephrotic Syndrome
- most Common Site
- The most common infection is peritonitis.
- Patients may also develop meningitis, pneumonia, UTI and cellulitis.
Bacterial Infections in Nephrotic Syndrome
- Organism
- Streptococcus pneumoniae โmost commonโ
- Others: E. coli, streptococcus B, Haemophilus influenzae & other G-ve organisms
Bacterial Infections in Nephrotic Syndrome
- Predisposing Factors
Cofactor of Cb of the alternative pathway of complement which has an important role in opsonization of encapsulated bacteria as Streptococcus pneumoniae.
โฆ
Viral Infections in Nephrotic Syndrome
- RF
- Viral infections may be observed in patients receiving steroids or immunosuppressive agents.
Viral Infections in Nephrotic Syndrome
- Organisms
Chickenpox is often observed in these young children and may be life threatening.
Complication of Nephrotic Syndrome
- Hypovolemia
Hypovolemia in Nephrotic Syndrome
- When does it happen?
This complication is observed typically early during a relapse or in acute phase of NS.
Hypovolemia in Nephrotic Syndrome
- Predisposing Factors
Sepsis, diarrhea or diuretics may precipitate hypovolemia.
Hypovolemia in Nephrotic Syndrome
- Complaint
Complications in Nephrotic Syndrome
- Thromboembolism
Most Dangerous Complication in Nephrotic Syndrome
Thromboembolism
Thromboembolism in Nephrotic Syndrome
- Incidence
- 2-3%
- However, this may underestimate the true incidence since many thromboembolic events are asymptomatic.
Thromboembolism in Nephrotic Syndrome
- RF
Thromboembolism in Nephrotic Syndrome
- Sites
- Both arterial and venous thromboses have been reported.
- Most common: pulmonary artery, renal vein, deep leg veins, inferior vena cava, and femoral/iliac artery.
- Others: cerebral and meningeal arteries, mesenteric and hepatic veins.
Complications in Nephrotic Syndrome
- Renal Insufficiency
Complications in Nephrotic Syndrome
- Corticosteroids SE
TTT Aspects of Nephrotic Syndrome
- General
- Specific
General TTT of Nephrotic Syndrome
- Diet
General TTT of Nephrotic Syndrome
- Bed Rest
Noooo โcause thrombosisโ
General TTT of Nephrotic Syndrome
- Edema
General TTT of Nephrotic Syndrome
- Hypovolemia
General TTT of Nephrotic Syndrome
- Prevention of Complications
Prevention of Complications in Nephrotic Syndrome
- Infections
- S pneumonia: Oral penicillin + Pneumococcal vaccine
- Varicella: Acyclovir + Varicella vaccine
Prevention of Complications in Nephrotic Syndrome
- Thromboembolism
Prevention of Complications in Nephrotic Syndrome
- Hyperlipidemia
It is reasonable to consider a lipid lowering regimen in children with a persistent NS
Specific TTT of Nephrotic Syndrome
- DOC
- Oral steroids: Corner stone
- The commonly used preparation is prednisone.
Specific TTT of Nephrotic Syndrome
- TTT of First Episode
Indications of Empiric TTT of Nephrotic Syndrome with Corticosteroids
TTT of First Episode in Nephrotic Syndrome
- Induction of Steroid Dose
TTT of First Episode in Nephrotic Syndrome
- Maintenaince of Steroid Dose
TTT of First Episode in Nephrotic Syndrome
- Monitoring
Once a patient responds to steroid therapy, monitoring for proteinuria is required to detect relapses early.
Def of Relapse in Nephrotic Syndrome
Appearance of significant proteinuria (>40 mg/h/ m2 or >50 mg/kg/day or Albustix +++) for 3 consecutive days after having been in remission.
Patients who respond to steroid have one of the following courses:
Non relapsers (36%)
No relapses within the six-month period.
Infrequent relapsers (18%)
A single relapse within the six-month period.
Frequent relapsers
- โฅ 2 relapses within the six-months of end of therapy or
- โฅ 4 relapses within 1 year of end of therapy.
Steroid dependence
2 consecutive relapses during steroid therapy or within 14 days after cessation of therapy.
Steroid resistance
Failure to induce remission in 4 weeks using conventional doses of corticosteroid
Late non-responders (3%)
steroid resistance in a patient who had previously responded to corticosteroid therapy.
TTT of Relapses in Nephrotic Syndome
Treatment of frequent relapsing/ steroid dependent NS:
Steroid-sparing agents should be considered in children โฆโฆ.
- Who have significant steroid toxicity and those requiring prednisone at doses exceeding 1 mg/kg on alternate days to maintain remission.
Treatment of steroid resistant NS (SRNS)
- First Step
- A renal biopsy and screening for genetic disorders should be performed in this setting, as the underlying pathology or a detection of a genetic disorder may affect therapeutic choices.
- Mutations in the genes that encode for podocyte proteins (NPHS1, NPHS2 and WT1) are detected in 20% of children with non-familial SRNS.
Treatment of steroid resistant NS (SRNS)
- Due to Genetic Disorder
Treatment of steroid resistant NS (SRNS)
- Not Due to Gentic Disorder
- ACEI and ARB are used.
- Immunosuppressive therapy depends on the underlying pathology.
What are Examples of Steroid Sparing Agents?
- Levamisole
- Cyclophosphamide
- Cyclosporine
- Myco-phenolate mofetil
Dose of Levamisole
2.5 mg/kg on alternate days for 6-31 months.
Dose of Cyclophosphamide
2 - 3 mg/kg/day for 8 - 12 weeks Oral
SE of Levamisole
Rare like:
Leukopenia - Vasculitic rash - Liver toxicity.
SE of Cyclophosphamide
- Bone marrow suppression
- Alopecia
- Infection
- Hemorrhagic cystitis
- Gonadal toxicity
The development of gonadal toxicity resulting in infertility generally requires a total dose > 200 to 300 mg/kg which exceeds the recommended cumulative dose {168 mg/kg}.
โฆ
SE of Cyclosporine (CsA)
- Prolonged TTT with CA exposes patients to nephrotoxicity.
- It mandates careful monitoring of renal functions and renal biopsy to assess for evidence of CA induced vasculopathy
Dose of Cyclosporine (CsA)
4 - 5 mg/kg (100 - 150 mg/m2) for 1 - 3 days
Dose of Myco-phenolate mofetil
1200 mg/m2 daily for at least 6 months
SE of Myco-phenolate mofetil
Abdominal pain - Diarrhea - Hematological abnormalities.
Prognosis of Nephrotic Syndrome
Compare between Nephrotic & Nephritic Syndrome in terms of
- Strept inf
Compare between Nephrotic & Nephritic Syndrome in terms of
- Edema
Compare between Nephrotic & Nephritic Syndrome in terms of
- Oliguria
Compare between Nephrotic & Nephritic Syndrome in terms of
- HTN
Compare between Nephrotic & Nephritic Syndrome in terms of
- Hematuria
Compare between Nephrotic & Nephritic Syndrome in terms of
- Serum Albumin
Compare between Nephrotic & Nephritic Syndrome in terms of
- Serum Cholesterol
Compare between Nephrotic & Nephritic Syndrome in terms of
- C3 & C4
Compare between Nephrotic & Nephritic Syndrome in terms of
- ASO
Compare between Nephrotic & Nephritic Syndrome in terms of
- Proyeinuria
Compare between Nephrotic & Nephritic Syndrome in terms of
- Casts
Compare between Nephrotic & Nephritic Syndrome in terms of
- Renal Function