Nephrotic Syndrome

Complications of Nephrotic Syndrome

Definition 1. Susceptibility to UTI, peritonitis, septicaemia
infections Due to:-
Hypoalbuminaemia <30g/L Loss of IgG
Proteinuria >3.5g/day Immunosuppression by steroids or immunosuppressants
Oedema Lost of factor B of the alternate complement activation
pathway
Causes Loss of transferrin
T cell abnormalities
Primary Glomerular diseases
2. Thrombosis & DIVC, pulmonary embolism, renal vein thrombosis
1. Minimal Change Nephropathy Commonest dx in children embolism Hypercoagulability due to
2. Focal Segmental Glomerulosclerosis Commoner dx in middle-aged &
plasma antithrombin III (urinary loss)
3. Membranous GN elderly
plasma fibrinogen & clotting factors V & VIII
4. Mesangioproliferative GN
5. Membranoproliferative GN Haemoconcentration
3. volaemia Shock
Secondary Glomerular diseases
Acute Tubular Necrosis / Acute renal failure
1. Diabetic nephropathy
2. Autoimmune SLE, HSP 4. lipidaemia apolipoprotein (urinary loss)
3. Infections Post-streptococcal infection increased risk of CHD & atherosclerosis
4. Drugs TCM, gold 5. calcaemia Urinary loss of Vit D binding proteins
5. Amyloidosis Bone demineralization in the long term
6. Metabolic diseases 6. Negative Due to Proteinuria, LOA & nausea
7. Vascular diseases nitrogen balance
8. Hereditary nephritis eg Alports 7. ESRF
8. Steroid toxicity
Presentation
General condition Anorexia, wt gain, lethargy, xanthomata, xanthelasma Investigations
Oedema Periorbital, pedal, sacral, scrotal, ascites Bloods Dx and Cx:
Pleural effusion SOB FBC & ESR haemoconcentration, infections, hypoCa, inflammation
Urinary Oliguria, haematuria, concentrated urine U/E/Cr
Others Infections, HPT, abdominal pain, hepatomegaly Albumin assess severity
Lipid profile assess hyperlipidaemia
Other things to note in Long case
Immunoglobulins & serum electrophoresis
Past History to note
Causes:
1. Initial diagnosis date, symptoms, investigations, aetiology identified, Rx
Serum C3 & C4 in MCGN & SLE
2. No. of episodes / year precipitants, usual Rx
3. No. of hospitalizations AutoAbs ANA, ANCA, anti-dsDNA, anti-GBM
4. Cxs & Mx ASOT in post-strep. GN
Management Hep B serology associated with membranous nephritits
1. Diet Hep C serology associated with MCGN
2. Medication & compliance Urine Dipstick proteinuria, haematuria
3. Management problems Urinalysis microscopic haematuria & casts
4. Present Rx for current admission C/S UTI
5. Previous drugs used 24hr UTP & CCT
6. Drug side effects Albumin:creatinine ration - > 200mg/mmol
7. Home urine testing and nephrotic diary Na Concentration - <20mmol/L if hypovolaemic
8. F/U
Throat swab For microscopy, C/S.
 For post-strep GN
Imaging CXR
Renal U/S
Renal biopsy

DGIM Last updated March 2005

Management

1. Bed rest, monitoring U/E, BP, fluid I/O charting, weight

2. Fluid restriction 1-1.5L/day
salt restriction
high protein diet
3. Diuretics Frusemide 80-250 mg PO spironolactone
Aim for loss of 1kg/day
Occasionally high dose frusemide + IV salt-poor albumin to
promote diuresis. However, risk of renal failure secondary to
hypovolaemia with over diuresis
4. Chronic nephrotic Consider reducing proteinuria with ACEI or cyclosporine
syndrome
5. Hyperlipidaemia Consider statin.
Usually improves with resolution of nephrotic syndrome
6. Hypertension Conventional regimens
7. Anticoagulation Prophylactic heparin for immobile PTs
Warfarin for symptomatic thrombosis
8. Infections Prophylactic ABx
Pneumococcal vaccination during remission
9. Mx of minimal change High dose corticosteroids
nephropathy in cyclophosphamide / cyclosporine in steroid dependant NS
children

DGIM Last updated March 2005