Nephrotic Syndrome

Triad of

·         Proteinuria >3g/day

·         Hypoalbuminaemia <30g/l

·         Anasarca (generalized Oedema)

Anasarca

Also seen in

1.       CCF

2.       liver failure

3.       protein losing enteropathy

4.       Fetal hydrops

5.       Capillary leak syndrome with monoclonal gammmopathy

Aetiology

Primary

         i.            Minimal change disease

       ii.            Focal segmental glomerulosclerosis (FSGS)

      iii.            Membranous nephropathy (*commones on adults)

     iv.            Mesangiocapillary GN

       v.            Proliferative GN

Secondary

         i.            Diabetic  nephropathy

       ii.            SLE

      iii.            Drugs - NSAIDS, captopril, gold, penicillamine

     iv.            Allergies- bee sting

       v.            Infections- Hep B, Malaria, leprosy

     vi.             Malignancy- M. myeloma, Ca lungs, Hodgkin’s lymphoma

    vii.            Hereditary- Alport’s syndrome

  viii.            Amyloidosis

Symptoms & Signs

SOB

Periorbital oedema

Ascites

Genital oedema

Leg swelling

Anasarca

Normal blood pressure

I(x)

FBC – Hct, ↑WCC

24h urine protein + dipstick (2+)

RFT – urea/creat, electrolyte imbalance

C3,C4 normal

ASOT normal

Complication

Features	Mechanisms	Consequences	Managements
Hypoalbuminaemia	Urinary protein lossess exceed synthetic capacity of liver	↓oncotic pressure àoedema	Diuretics, low Na diet, albumin infusion
↑ susceptibility to infection	Hypogammaglobulinaemia (urinary loss)	Cellulitis, Strep, bacterila peritonitis	Pneumococcal Vaccination esp children
Hyper coagulability (~40%)	Loss of inhibitors of coagulation (e.g. Anti-thrombin III, protein C,S), ↑ synthesis of pro-coagulant in liver	Venous thromboembolism e.g. DVT/PE	Routine anti-coagulant
Hypercholestrolaemia	↑lipoprotein synthesis 20 ↓ oncotic pressure	High rate of atherosclerosis	Lipid lowering drugs esp. HMG CoA reductase inhibitor

Managements

1.       Monitor U&E, BP, fluid balance, weight

2.       Restricted salt intake. Normal protein diet

3.       Diuretics e.g frusemide 80-250mg/24h PO ± metolazone or spironolactone, with monitoring U&E

4.       Albumin infusion

5.       High-dose corticosteroid (in children)

6.       Prophylactic heparin if immobile e.g. SC enoxaparin 20mg daily. Avoid prolonged bed rest

7.       Treat infection. Pneumococcal vaccination advised.

SE steroid – Cushing’s syndrome

Central obesity, comedone (acne)

Unusual bruising

Striae

HTN, hyperglycaemia, hirsutism, hump

 I  nfection, impotence, immunospression

MooN face

Growth retardation

Osteoporosis

Immunosuppresion

Depression