Revision - Nephrotic Syndrome & Nephritis Flashcards
What triad is seen in nephrotic syndrome?
1) Oedema
2) Hypoalbuminaemia (<30 g/l)
3) Proteinuria (+++ on dipstick)
What albumin level defines hypoalbuminaemia in nephrotic syndrome?
<30g/L
What proteinuria level is seen in nephrotic syndrome?
≥3.5g/day
What 3 other features are seen in nephrotic syndrome?
1) HTN
2) Raised cholesterol
3) Hypercoagulability
Symptoms of nephrotic syndrome?
1) Peripheral oedema (more common in adults)
2) Facial oedema (more common in children)
3) Frothy urine
4) Fatigue
5) Poor appetite
6) Recurrent infection (due to immune dysfunction)
7) Venous or arterial thrombosis (e.g. MI, DVT) due to hypercoagulability
Clinical signs of nephrotic syndrome?
1) Oedema (e.g. peri-orbital, lower limb, ascites)
2) Xanthelasma and/or xanthoma
3) Leukonychia
4) SOB (with associated chest signs of pleural effusion – e.g. stony dullness in lung bases)
Typical urinalysis findings in nephrotic syndrome?
1) Proteinuria +++
2) Frothy urine
Cause of hypercoagulability in nephrotic syndrome?
Loss of antithrombin-III, proteins C and S and an associated rise in fibrinogen levels predispose to thrombosis
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
What will urinalysis show in minimal change disease?
(2)
1) hyaline casts
2) small molecular weight proteins
What are some 2ary causes of nephrotic syndrome?
1) Diabetes mellitus
2) SLE
3) Amyloidosis
4) Infections (HIV, Hep B and C)
5) Drugs (NSAIDs, gold therapy)
What are 3 primary causes of nephrotic syndrome?
1) minimal change disease
2) focal segmental glomerulosclerosis
3) membranous nephropathy
How long are high dose steroids given for in nephrotic syndrome?
4 weeks, and then gradually weaned over the next 8 weeks.
What % of patients will have a relapse in nephrotic syndrome?
80%
what age group is nephrotic syndrome most common in?
2-5 y/o
BP in nephrotic syndrome?
Hypotension
What causes thrombosis in nephrotic syndrome?
1) Proteins that normally prevent blood clotting are lost in the kidneys
2) The liver responds to the low albumin by producing pro-thrombotic proteins
What causes a predisposition to infections in nephrotic syndrome?
The kidneys leak immunoglobulins, weakening the capacity of the immune system to respond.
This is exacerbated by treatment with medications that suppress the immune system, such as steroids.
BP in nephrotic vs nephritic syndrome?
Nephrotic –> hypotension
Nephritic –> HTN
What 5 classic signs are seen in nephritic syndrome?
1) Haematuria
2) Mild proteinuria
3) HTN
4) Oliguria (<300 mls/day)
5) Oedema
What 3 things are seen on urinalysis in nephritic syndrome/nephritis?
1) Haematuria (+++)
2) Proteinuria
3) Red cell casts (distinguishing feature)
What are the 2 most common causes of nephritis in children?
1) Post-strep glomerulonephritis
2) IgA nephropathy (Berger’s disease)
What infection does post-strep glomerulonephritis follow?
GAS
What is the most commonly recognised clinical presentation of post-strep glomerulonephritis?
Nephritic syndrome
What causes HTN in nephritic syndrome?
Caused by water and salt retention due to renal insufficiency.
What colour does urine typically appear in nephritic syndrome?
Urine looks tea or cola-coloured due to haematuria.
What is the Streptozyme test?
A combined test measuring the levels of the 5 antibodies that can be produced in response to a recent GAS infection e.g. Anti-streptolysin (ASO).
What are some potential short-term complications of post-strep glomerulonephritis?
1) pulmonary oedema
2) hypertensive encephalopathy
3) severe AKI requiring dialysis
What drugs can cause haematuria?
1) Cause tubular necrosis or interstitial nephritis –> aminoglycosides, chemotherapy
2) Cause interstitial nephritis –> penicillin, sulphonamides, and NSAIDs
3) Anticoagulants
Investigation for definitive diagnosis in MCD?
Renal biopsy (note - in children, this is generally avoided)
What is 2nd line for MCD (in steroid-resistant cases)?
Cyclophosphamide
What is the most common cause of nephrotic syndrome in adults?
Focal segmental glomerulosclerosis (FSGS)
Focal segmental glomerulosclerosis is noted for having a high recurrence rate in who?
Renal transplant
Management of FSGS?
High-dose prednisolone +/- immunosuppressants (e.g. cyclophosphamide or ciclosporin)
What is IgA nephropathy also known as?
Berger’s
What is the commonest cause of glomerulonephritis worldwide?
IgA nephropathy (also known as Berger’s disease)
How does IgA nephropathy classically present?
As MACROscopic haematuria in young people 24-48 hours after an URTI.
What is the key differential for IgA nephropathy?
Post-streptococcal glomerulonephritis
What is the main symptom in post-streptococcal glomerulonephritis?
Proteinuria (although haematuria can occur)
What is the main symptom in IgA nephropathy?
Haematuria
Key differences between IgA nephropathy and post-strep glomerulonephritis? (3)
1) Longer latency period between URTI and PSGN than IgA nephropathy.
2) Proteinuria dominates in PSGN, haematuria dominates in IgA nephropathy.
3) PSGN typically doesn’t recur, IgA nephropathy can
Markers of GOOD prognosis in IgA nepropathy? (1)
Frank haematuria
What serology test can be done in post-strep glomerulonephritis?
The Streptozyme test
Complement levels in post-strep glomerulonephritis?
Low C3 levels found during intitial 2 weeks
What is the key differential for post-strep glomerulonephritis?
IgA nephropathy
What can reduce the incidence and severity of PSGN?
Early Abx therapy
What is one of the main complications of anti-GBM disease?
Pulmonary haemorrhage
