Nephrotic syndrome

Question 1

Presentation of periorbital swelling

Answer 1

Seasonal Allergies: pruritis, discharge, sneezing, itchy, rhinorrhea
URI: concurrent findings of congestion, cough and pharyngitis
Cellulitis: swelling from inflammatory edema (unilateral and erythematous), history of trauma, bite, infection
- pneumococci, moraxella, H. flu nontypeable

Question 2

Question to ask if presented with periorbital swelling

Answer 2

have they been sick recently? - gives a source of inflammation

Question 3

Physical signs of heart failure

Answer 3

edema, S3 gallop (overloaded LV)

Question 4

Nephrotic Syndrome Symptoms

Answer 4

Edema - most prominent symptom (periorbital often first to show up)
Weight Gain - edema becomes more generalized, ascites,
*edema from interstitial fluid accumulation rather than intravascular overload (no HTN)
Tiredness

Question 5

Minimal change disease

Answer 5

most common cause of nephrotic syndrome

- fusion and diffuse effacement of epithelial foot processes on electron microscopy

Question 6

Benign causes of proteinuria

Answer 6

Children may have 1+ to 2+ proteinuria during fever or significant exertion which resolves

Question 7

Pathogenesis of proteinuria in nephrotic syndrome

Answer 7

Increased filtration of large proteins (albumin) throught glomerular capillary membrane

• loss of polyanion charge (normally negative from proteoglycans)
• shift in capillary wall pore size
• change in hemodynamic capillary flow

Question 8

Causes of proteinuria

Answer 8

Pyleonephritis - (+) leukocyte esterase test on dipstick
Acute Glomerulonephritis
Interstitial Nephritis - NSAIDs, ABx

Question 9

Hypoalbuminemia in nephrotic syndrome

Answer 9

major loss of albumin due to leaking through defective capillary basement membrane

Question 10

Hyperlipidemia in nephrotic syndrome

Answer 10

in response to hypoalbuminemia, liver is stimulated to make lipoproteins which leads to hyperlipidemia

Question 11

Edema pathophys

Answer 11

Fall in serum albumin –> lower plasma colloid osmotic pressure

• -> fluid moves out of vascular component into interstitial space –> intravascular hypovolemia
• -> stimulates kidney’s renin-angiotensin system –> sodium and water retention –> edema

Question 12

Venous thrombus in nephrotic syndrome

Answer 12

Higher risk because of:

• urinary loss of proteins (ATIII) that inhibit coagulation
• destabilization of platelets by hyperlipidemia
• increased fibrinogen levels
• increased blood viscosity

Question 13

Steroid responsiveness of nephrotic syndrome

Answer 13

1. Steroid responsive
2. Relapsing/steroid dependent
3. Steroid-resistant (usually need renal biopsy)

Question 14

Where can you typically see edema?

Answer 14

Male - scrotal area

Female - labia

Question 15

Assessing for fluid wave

Answer 15

patient supine –> assistant places hand firmly on vertical midline of abdomen
place hands on side of abdomen
tap one side firmly with fingertips
if ascites present, fluid wave will hit hand or see it

Question 16

DDx for fatigue, periorbital edema, and abdominal distention

Answer 16

Nephrotic Syndrome
Allergic Reaction
Acute Glomerulonephritis
CHF
Sinusitis
Hepatic Failure

Question 17

Nephrotic Syndrome

Answer 17

periorbital edema is first sign of hypoalbuminemia
abdominal distentionfrom ascites and hypoalbuminemia
- fatigue and poor appetite

Question 18

Allergic Reaction

Answer 18

periorbital swelling possible, usually abrupt in onset and accompanied by rash

Question 19

Acute Glomerulonephritis

Answer 19

periorbital swelling, abdominal distention from hypoalbuminemia
fatigue and poor appetite

Question 20

CHF

Answer 20

edema common, hepatomegaly, abnormal cardiac exam, tachycardia, SOB

Question 21

Sinusitis

Answer 21

periorbital swelling and redness can result from inflammatory edema

Question 22

Hepatic Failure

Answer 22

liver failure can lead to abdominal distention and decreased production of albumin
fatigue, jaundice

Question 23

DDx for ankle swelling

Answer 23

arthritis - localized swelling
Systemic allergic reaction - associated with rash
Serum sickness
Henoch-Schonlein Purpura

Question 24

Evaluating generalized edema

Answer 24

Determine whether it is loss of albumin in urine or lack of production by liver
Electrolytes, BUN and Cr - indication of renal function
LFTs and albumin - hepatic fxn and inflammation
Complement levels - associated with other disease
Streptozyme - PSGN

Question 25

Treatment of nephrotic syndrome

Answer 25

Corticosteroids (ages 1-10) - if normal serum complement
Sodium restriction - limit edema accumulation
Furosemide and Albumin - only for symptomatic edema, DON’T use furosemide alone

Question 26

Infectious complication of nephrotic syndrome

Answer 26

during nephrotic syndrome or relapse when using steroids, patients are at higher risks of infection
- if they get a fever or feel ill => prompt evaluation is necessary and early tx with broad spectrum Abx is necessary