claire nephroticandnephritic syndrome

7/21/2019 Claire Nephroticandnephritic Syndrome

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Nephrotic and Nephritic Syndrome

Dr Claire GibbonsFY2

[email protected]


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Learning b!ecti"es

#nderstand and de$ine nephrotic and nephriticsyndromes.

Describe the initial in"estigations and

management o$ nephrotic and nephriticsyndromes.

Describe the complications o$ nephrotic and

nephritic syndromes.


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Dra% a nephron&


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Glomerulonephritis

Glomerulus' capillary loop %ith basementmembrane %hich allo%s passage o$ speci$icmolecules into the nephron

Glomerulonephritis' in$lammation(damage o$the glomerular basement membrane resultingin altered $unction. )elati"ely uncommon causeo$ kidney in!ury.

Can present as nephrotic and/or nephriticsyndrome.


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*hat is nephrotic syndrome+

,ncreased permeability o$ the glomerulusleading to loss o$ proteins into the tubules.


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Nephrotic Syndrome

-riad o$

MASSIVE Proteinuria >3g/24hours r spot urine proteincreatinine ratio /011031mg(mmol

Hpoal!uminaema "2#g/$

%edema

4nd o$ten 5ypercholesterolaemia(dyslipidaemia 6total

cholesterol /71mmol(L8


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9resentation

Ne%onset oedema

,nitially periorbital or peripheral

Later genitals: ascites: anasarca

Frothy urine

Generalised symptoms ' lethargy: $atigue:reduced appetite


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Further possible presentations...

edema

;9 normal(raised

Leukonychia

;reathlessness

9leural e$$usion: $luid o"erload: 4(?, >rupti"e anthomata( anthalosmata


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You are a G9 %ith the $ollo%ingpatients...

Young: $it 2A year old male complaining o$$rothy urine.

71 year old boy %ith pu$$y eyes.

BA year old $emale %ith multiple comorbiditiesand s%ollen ankles.


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Di$$erential Diagnosis $or edema

Congesti"e Cardiac Failure

)aised =9: pulmonary oedema: mild proteinuria

Li"er disease

5ypoalbuminaemia: ascites(oedema

*hat in"estigations can you do+

You decide to send your patient to the renalclinic...


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Causes o$ Nephrotic Syndrome

9rimary glomerulonephritis

?inimal change disease 61E paeds cases8

Focal segmental glomerulosclerosis 6most commoncause in adults8

?embranous glomerulonephritis


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Systemic Causes

Secondary glomerulonephritis

Diabetic nephropathy

Sarcoidosis

4utoimmune SLE, Sjogrens

,n$ection Syphilis, hepatitis B, HIV

4myloidosis

?ultiple myeloma =asculitis

Cancer

Drugs gold, penicillamine, captopril, NSAIDs


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,n"estigations

#rine dipstick and send to lab

#rine microscopy

;loods ' the usual ones: plus renal screen

,mmunoglobulins: electrophoresis 6myelomascreen8: complement 6C0: CA8 autoantibodies64N4: 4NC4: antidsDN4: antiG;?8

)enal ultrasound )enal biopsy 6all adults8

Children generally trial o$ steroids $irst


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?anagement &onser'ati'e

?onitor #>: ;9: $luid balance: %eight Salt and $luid restriction

-reat underlying cause

Medical Diuretics

4C>inhibitors(4);s

Corticosteroids(immunosuppression

Dialysis

4nticoagulation

Surgical

)enal transplant


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Complications

,ncreased susceptibility to in$ection

21E adult cases

Due to reduced serum ,gG: reduced complement

acti"ity: reduced - cell $unction -hromboembolism

A1E adult cases

9artly due to increased clotting $actors and plateletabnormalities

5yperlipidaemia

due to hepatic lipoprotein synthesis to restore

osmotic pressure


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9rognosis

=aries

*ith treatment: generally good prognosis

>specially minimal change disease 67E progress to

>S)F8

*ithout treatment: "ery poor prognosis

Children under 3 or adults older than 01 %orse

prognosis


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*hat is nephritic syndrome+


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9athophysiology

-hin glomerular basement membrane %ithpores that allo% protein and blood into thetubule.


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Nephritic Syndrome

Clinical syndrome de$ined by

Haematuria/ red cell casts

Hpertension (mild)

%liguria

*raemia

Proteinuria ("3g/24 hours)


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Signs and Symptoms

5aematuria 6>.g. cola coloured8

9roteinuria

5ypertension

liguria

Flank pain

General systemic symptoms 9ostin$ectious 20 %eeks a$ter strep

throat(#)-,


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*hat are your di$$erentials+

?alignancy 6older patients8

#-,

-rauma

*hat bedside in"estigation %ould you like todo+

You decide to re$er to the renal clinic...


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Causes

Post+in,ectious glomerulonephritis

Primar

,g4 Nephropathy 6;ergerHs disease8

)apidly progressi"e glomerulonephritis

9roli$erati"e glomerulonephritis

Secondar glomerulonephritis

5enochSchonlein purpura

=asculitis


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,n"estigations

#rine dipstick and send sample to lab

#rine microscopy ' red cell casts

;loods ' the usual plus renal screen

,mmunoglobulins: electrophoresis: complement6C0: CA8 autoantibodies 64N4: 4NC4: antidsDN4:antiG;?8I blood cultureI 4S- 6antistreptolysin titre8

)enal ultrasound

)enal biopsy


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)ed Cell Casts


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?anagement &onser'ati'e

?onitor #>: ;9: $luid balance: %eight

Salt and $luid restriction

-reat underlying cause

Medical

Diuretics

-reat hypertension

Corticosteroids(immunosuppression Dialysis

Surgical

)enal transplant


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9rognosis

=aries

9ostin$ectious usually sel$resol"ing 6J3Ereco"er renal $unction8

thers are a bit more nasty


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>ample Case


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Summary

Nephrotic syndrome ?4SS,=> proteinuria

Nephritic syndrome haematuria(red cell casts

?ay be a mied presentation

Ne% oedema+ Dipstick that urine&

5aematuria+ >clude malignancy&


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4ny Kuestions+

[email protected]


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Sources

$ord 5andbook o$ Clinical ?edicine

$ord 5andbook $or the Foundation9rogramme

>ssential )e"ision Notes $or the ?)C9

*%%.almostadoctor.com

*%%.pathologystudent.com
http://www.almostadoctor.com/http://www.almostadoctor.com/

claire nephroticandnephritic syndrome

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