Nephrotic Syndrome

Question 1

What is nephrotic syndrome?

Answer 1

It is the quadrad of signs and symptoms:
Heavy proteinuria
Hypoalbuminaemia
Generalised oedema (due to oncotic pressure)
Hypercholestrolaemia 

nephrOtic think Oedema

Question 2

What is nephritic syndrome?

Answer 2

In lay terms represents worse damage

Proteinuria
Haematauria and urinary red cell casts
High BP
Oliguria

Question 3

What is the aetiology of the symptoms in nephrotic syndrome?

Answer 3

Increased glomerular permeability to large molecules: (proteins and albumin)

This causes proteinuria and hypoalbuminaemia.

The oedema is a result of oncotic pressures due to the low albumin.

Question 4

What are the primary causes of nephrotic syndrome?

Answer 4

Idiopathic membranous nephropathy (most common cause in adults)

Focal segmental glomerulosclerosis (most common cause in black races)

Minimal change disease (most common cause in children)

Question 5

What are the causes the pathophysiology in idiopathic membranous nephropathy?

Answer 5

Inflammation of the glomeular arterioles associated with protein leakage.

Can be caused by: 
– Malignancy
– Drugs (Gold, Penicillamine,
Captopril)
– Autoimmune (RA, SLE)
– Infections

Question 6

What is the pathophysiology in focal segmental glomerulosclerosis?

Answer 6

Scarring of certain sections of glomerulus seen on renal biopsy. Leads to protein leakage which can lead to nephrotic syndrome.

In 30-50% of cases the patient will develop end stage renal failure in 10 years.

Question 7

What are the causes of focal segmental glomerulosclerosis?

Answer 7

Vesicoureteric reflux

IgA Nephropathy

Vasculitis

Sickle Cell

Heroin use

Alport’s syndrome (congenital syndrome)

Question 8

What occurs in minimal change disease?

Answer 8

There is a diffuse loss of podocyte processes leading to leakage of albumin.

It is an autoimmune T-lymphocyte mediated condition.

It is called minimal change disease as historically on microscopy there was minimal change that could be seen.

Question 9

What are the causative associations with minimal change disease?

Answer 9

Hodgkin’s Lymphoma

Drugs (NSAIDs)

Question 10

What are the secondary causes of nephrotic syndrome?

Answer 10

Main secondary causes are:

Diabetic nephropathy
Drugs
SLE

Other causes are:

Secondary:

Vascular: Pre eclampsia, Vasculitis, HSP

Infection: HIV, Hep B & C, Malaria, Schistosomiasis, Syphilis, Toxoplasmosis

Autoimmune: Transplant rejection

Metabolic: DM, Amyloid

Inflammatory: SLE, rheumatoid arthiritis

Neoplasm: Myeloma, lymphoma, leukemia

Drugs: NSAIDs, Lithium, Dimorphine

Question 11

How should nephrotic syndrome be investigated?

Answer 11

Bedside:
Urinalysis (expect to see proteinuria)

Bloods:

• FBC, LFTs, U&E’s
• Lipid profile, Coagulation screen, Bone profile
• Infection screen if suspected

Imaging:
USS
CXR (if sob think pulmonary oedema)

Renal Biopsy (needed to find underlying cause and guide treatment)

Question 12

How should nephrotic syndrome be treated?

Answer 12

Reduce oedema

– Limit dietary sodium (