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Proteinuria and the Nephrotic Syndrome
William Primack MDUNC Division of Nephrology and Hypertension
October 4, 2006
No relevant financial disclosures
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“When bubbles settle on the surface of the urine, it indicates disease of the kidneys and that
the complaint will be protracted”
Hippocrates
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CASE 1
• 5 y.o. girl
• CC: eye swelling
• Dx: Allergic conjunctivitis
• Rx given without improvement
• About 1 week later abdominal distension noted and brought in for further evaluation.
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BP=95/58 mmHg
T=37 C
RR=26/min
P=97/min
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Case 1Labs
• U/A 4+ protein, trace heme
micro: 1-3 rbc/hpf, 0-1 wbc/hpf
• BUN 26 mg/dl, creat 0.5 mg/dl
• S albumin<1 g/l, cholesterol 568 mg/dl
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NEPHROTIC SYNDROME
PROTEINURIA
HYPOALBUMINEMIA
HYPERLIPIDEMIA
+/- EDEMA
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Nephrotic Syndrome in Children
• CONGENITAL• PRIMARY• SECONDARY
– Systemic Illness• SLE, HSP, IDDM, obesity
– Infections• Hep B, C; HIV, malaria, syphilis, schistosomiasis, parvo B19
– Allergy• Bee stings, milk, pork
– Exposures• NSAID’s, Penicillamine, gold, ampicillin, heavy metals
– Lymphomas, S-S disease
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Case 1Labs
• U/A 4+ protein, trace hememicro: bland
• BUN 26 mg/dl, creat 0.5 mg/dl• S albumin<1 g/l, cholesterol 568 mg/dl
• C3 complement nl, ANA neg, HbsAg neg, HIV neg
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Nephrotic Syndrome--Etiology vs. Age
Cameron et al. Am J Kidney Dis 1987; 10:157
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Case 1Clinical Course
• Prednisone 2 mg/kg/day
• On day 12 of therapy, urine protein decreased to trace-negative with a prompt vigorous diuresis
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Nephrotic Syndrome in ChildrenHistory 1
• 1484—Roelans – swelling of the whole body of the child
• Rx—’Take the tops of the elder plant, and danewort, cook in white wine and wrap the child in hot cloths by applying a poultice…and so cure him.’
• 1722—Zwinger – Associated generalized edema and kidney
• 1770—Cotugno – Associated edema and proteinuria
Adapted from: Cameron J, Ulster Med J 54:S5,1985
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Nephrotic Syndrome in ChildrenHistory 2
• 1827 Bright and Bostock– Edema, proteinuria, kidney disease
• 1940 Introduction antibiotics• 1950 Steroids first used
– ACTH and later cortisone
• 1954 Percutaneous renal biopsy• 1970 ISKDC
– First prospective study of treatment and developed current pathological classification
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Nephrotic syndrome in children5 year status in various eras
Pre
antibiotic
Post
antibiotic
Early
steroid
Current
Survival 51% 62% 78% >95%
Persistent proteinuria
11% 23% 46% 20%
Remission 38% 39% 39% 71%
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Incidence of Nephrosis in Children
• 0.8 new cases per year/100,000
• 6.9 new cases per year/100,000– Children aged 1-9 years
• 6-15 cases/100,000 ages 1-16– Possibly more frequent in Southern Asians
Rothenberg et al. Pediatrics 1957; 19:446
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PROTEINURIA
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PROTEINURIA
• 24 HOUR URINE– Normal
• <4 mg/M2/hr or <100 mg/M2/day• <150 mg/24 hours (adult)
– Nephrotic range• > 40 mg/M2/hr or >1000 mg/M2/day• >2 grams/24 hours (adult)
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PROTEINURIA
• 24 HOUR URINE COLLECTION– Sources of error
• incomplete/inaccurate collection • posture/exercise/intercurrent illness
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PROTEINURIA
• URINE PROTEIN TO CREATININE RATIO
• UProt/UCreat
– normal• <0.2 mg protein/mg creatinine
– nephrotic• >2 mg protein/mg creatinine
– some labs report urine protein in micrograms (mcg)
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Correlation between UProt/UCr and quantitative protein excretion
100 1000 10,000 Up/Ucr (g/mg)
To
tal
Pro
tein
Exc
reti
on
(m
g/m
2 /d
ay)
10,000
1000
100R = .93
n = 20
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Orthostatic proteinuria
• Proteinuria present only in up-right but not recumbent position
• Felt to be benign process
• 42-50 year follow-up--no increased risk renal disease (Rytand NEJM 305:618,1981)
• Measure carefully collected first morning Uprot/creat
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Nephrotic syndrome in childhoodInitial Therapy
• 2 mg/kg/day prednisone– Controversies
• Single or divided dose• Duration of initial therapy
• My approach--b.i.d. for 8 weeks
• Taper– 60% of daily dose q.o.d. x 4 weeks and
then fairly rapid taper
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Nephrotic syndrome in childhoodDefinitions
• Remission– Neg or tr urine protein for 3 consecutive days
• Relapse– 2 + or > urine protein for 3 consecutive days
• Frequent relapser (FRNS)– 2 or more relapses in 6 months
• Steroid dependent (SDNS)– In remission only when on steroids
• Primary non-responder
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Nephrotic syndrome in childhood Response to 4 weeks of daily steroids
ISKDC
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Nephrotic syndrome in childhood
• 10-15% of children < 10 years will be steroid resistant
• This percentage increases with age and A.A. ethnicity
• About half of those who respond to steroids are FRNS or SDNS
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Nephrotic Syndrome in ChildhoodComplications (if not in remission)
• Infection– Spontaneous bacterial peritonitis– cellulitis
• Edema– Subpulmonic effusion, gut wall edema
genital edema
• Thombosis• Hyperlipidemia
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Nephrotic syndrome in childhood
• 10-15% of children < 10 years will be steroid resistant
• This percentage increases with age and A.A. ethnicity
• About half of those who respond to steroids are FRNS or SDNS
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Nephrotic Syndrome in ChildhoodComplications of Steroid Therapy
• Behavior/sleep changes• Weight gain & distribution• “Cushingoid facies”• Striae• Growth arrest• Osteoporosis• Hyperglycemia• Hypertension• Risk of ulcer• Hyperlipidemia
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Nephrotic Syndrome in Childhood“Steroid Sparing” Medications
• If a child with FRNS/SDNS remains steroid responsive, e.g. urine becomes neg or tr with therapy, a biopsy will nearly always show MCNS, indicating good prognosis.
• If unacceptable steroid side effects:– Alkylating drugs
• Cyclophosphamide, chlorambucil
– Calcineurin inhibitors • cyclosporin, tacrolimus
– Cell cycle inhibitors• Mycophenolate mofetil (MMF), immuran
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Nephrotic Syndrome in ChildhoodIndications for Renal Biopsy
• Steroid non-responsive– Primary or secondary
• Lower likelihood of MCNS at onset– Older age, A.A., HTN, rbc casts, low C3– Suspicion that NS is secondary
• Parental needs– Reticence to use steroids– Need to know before (during) treatment
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SSNS—Long term
Median 22 y f/u
More relapses=more likely adult relapse
No ESRD
Ruth. J Pediatr 2005;147:202-7
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Nephrotic Syndrome in Childhood
Cameron et al. Am J Kidney Dis 1987; 10:157
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FSGSFSGS FOCALFOCAL
andand
SEGMENTALSEGMENTAL
GLOMERULO-GLOMERULO- SCLEROSISSCLEROSIS
Part of glomerulus Part of glomerulus damageddamaged
Some glomeruli Some glomeruli involved, others involved, others “minimal change”“minimal change”
Interstitium WNL earlyInterstitium WNL early ScarringScarring
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FOCAL SEGMENTAL FOCAL SEGMENTAL GLOMERULOSCLEROSIS (FSGS)GLOMERULOSCLEROSIS (FSGS)
Most common non-urologic cause ESRD Most common non-urologic cause ESRD ages 5-20.ages 5-20.More common in Blacks and Hispanics More common in Blacks and Hispanics than Caucasiansthan CaucasiansMay recur post-transplantationMay recur post-transplantationMost pediatric cases are “idiopathic”Most pediatric cases are “idiopathic”
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FSGSFSGS
Crossover between MCNS and FSGSCrossover between MCNS and FSGSSteroid responsive patients with FSGS Steroid responsive patients with FSGS have much lower incidence of renal have much lower incidence of renal insufficiency than steroid resistant patientsinsufficiency than steroid resistant patients
Common pathologic end-point for many Common pathologic end-point for many processes—”secondary FSFS”processes—”secondary FSFS”– Obesity, HIV, V-U reflux, decreased nephron Obesity, HIV, V-U reflux, decreased nephron
massmass
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PRIMARY FSGSPRIMARY FSGSTHERAPYTHERAPY
Steroid responsive--?continuum with MCNSSteroid responsive--?continuum with MCNSLong term q.o.d. steroids—adultsLong term q.o.d. steroids—adults““Mendoza Protocol”Mendoza Protocol”– ‘‘Pulse’ steroids + cyclophosphamidePulse’ steroids + cyclophosphamideCyclosporineCyclosporineTacrolimus?Tacrolimus?MMF?MMF?
ACE and/or ARB to diminish proteinuriaACE and/or ARB to diminish proteinuriaFor recurrence post-transplantationFor recurrence post-transplantation– Plasmapheresis + CyA or cyclophosphamidePlasmapheresis + CyA or cyclophosphamide
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NEPHROTIC SYNDROMEPRESENTATION
STEROIDS
RESPONSE
Good prognosisRelapses likely
NO RESPONSE
BIOPSY
FSGSMCNS
OTHER
IMMUNOSUPPRESSION
LateNon-resp
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?
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CASE 2--Jessica• 7 y.o. girl with 4+ proteinuria at routine PE. No
edema. Neg PMH, normal G & D
• BUN=14 mg/dl, S cr=0.5 mg/dl
• S alb=3.5 g/dl, chol=301 mg/dl
• 24 hour urine protein=4.6 grams
• Normal C3, neg ANA
• Prednisone 4 weeks at 2 mg/kg/day, no response
• Renal biopsy=FSGS
• Cyclophosphamide non-responsive
• No further treatment except ACE inhibitor
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Case 3--The sister, Julie• 3-4+ proteinuria found at age 5 (by her mother) with
dip sticks given test her sister, Jessica’s, urine
• Normal PE, BP 92/58
• U/A=3+ protein, occasional rbc
• 24 hr U protein= 1.7 g
• S creat=0.5 mg/dl, S alb=3.9 g/dl
• Biopsy=FSGS
• Therapy--ACE inhibitor only
• Menarche age 11
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Jessica (cont)
• Primary amenorrhea age 16
• Urine prot/cr=6.7, s cr=1.0 mg/dl
• Tanner 2 breasts, unambiguous female Tanner III genitalia
• Very high gonadotropins
• Karyotype 46 XY
• SRY present by FISH
• Surgical evaluation showed streak gonads with several adenomas, small uterus
• No evidence of kidney tumor
• Begun on replacement estrogen/progestin
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FRASIER SYNDOME• Proteinuria in a phenotypically normal
female, FSGS, renal insufficiency by adolescence or young adulthood
• Normal female external genitalia, primary amennorhea
• Streak gonads, XY karyotype (with normal sex determining gene, SRY)
• gonadoblastoma, but no reported Wilm’s tumor
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Wilms Tumor Suppressor Gene--WT1
• Chromosome 11p13
• Expression peaks during embryogenesis, especially in meso- and metanephros.
• Persistent expression in mature podocytes suggests WT1 necessary for terminal differentiation and proper function
• WT1 knock out mice lack kidneys or gonads
• Both girls have a mutation at exon 9 of WT1
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Normal Glomerular Capillary
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Glomerular Barriers to Proteinuria
Glomerular basement membrane (GBM)
Epithelial cell foot processes
Endothelial cell with fenestrations
Protein
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The glomerular Podocyte
Direction of filtration
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Copyright ©2005 American Physiological Society
Tryggvason, K. et al. Physiology 2005;20:96-101
FIGURE 1. Renal glomerular filtration system Each human kidney contains ~1,000,000 glomeruli
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Minimal Change Glomerulopathy Electron Microscopy
Normal Foot process effacement
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Modified from: Curr Opin Genet Dev 2001; 11:322
Podocyte foot process
Endothelial cell
Direction offiltration
CD2AP-actinin-4
GBM
Urinary space
Slit diaphragm made of nephrin molecules from two opposite foot processes
F-actin Podocin Nephrin
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GENETIC ETIOLOGIES GENETIC ETIOLOGIES Nephrotic syndromeNephrotic syndrome
CHILDHOOD ONSETCHILDHOOD ONSET– WT1WT1 Frasier syndrome—AD Frasier syndrome—AD
Denys-Drash SyndromeDenys-Drash Syndrome– PAX-2 PAX-2 (Renal Coloboma syndrome--AR) (Renal Coloboma syndrome--AR)– NPHS1NPHS1 (nephrin--congenital nephrotic syndrome (nephrin--congenital nephrotic syndrome
Finnish type--AR)Finnish type--AR)– NPHS2NPHS2 (podocin--AR) (podocin--AR)
ADULT ONSETADULT ONSET– 19q1319q13 (alpha-actinin--AD) (alpha-actinin--AD)– TRPC-6TRPC-6--AD--AD
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Podocin—NPHS-2Podocin—NPHS-2
In Europe, accounts for ~ 50% familial NS In Europe, accounts for ~ 50% familial NS and 8-20% sporadic SRNSand 8-20% sporadic SRNS
Most patients have FSGSMost patients have FSGS
Most present first decadeMost present first decade
More than 50 mutations identifiedMore than 50 mutations identified
Most do not respond to immunosuppressivesMost do not respond to immunosuppressives
Heterozygote carriers generally unaffectedHeterozygote carriers generally unaffected
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NEPHROTIC SYNDROMEPRESENTATION
STEROIDS
RESPONSE
Good prognosisRelapses likely
NO RESPONSE
BIOPSY
FSGSMCNS
OTHER
?GENETIC SCREENING?
IMMUNOSUPPRESSION
neg
LateNon-resp
SYMPTOMATIC Rx ONLY
NPHS2Wt-1