nephrotic syndrome
TRANSCRIPT
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Hematuria,Proteinuria AND
Nephrotic Syndrome
By:Dr.Leena Hafeez
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HEMATURIA
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DefinitionMore than 3 red blood cells present in the
centrifuged urine per high power field microscopy (>3 RBCs/HPF ).
It indicates bleeding from anywhere in the renal tract.
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ClassificationOn the basis of amount of RBCs in the urine Hematuria can be classified into two categories
Macroscopic Hematuria: Hematuria visible to the naked eyeMicroscopic Hematuria: Invisible and detected on dipstick tests
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EtiologyDiseases of Urinary system-most common
cause
Glomerular: IgA nephropathy Glomerulonephritis
Interstitial: Renal cystic disease Tuberculosis Acute pyelonephritis
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Etiology Uroepithelium:• Malignancy• Trauma• Papillary necrosis• Cystitis/prostatitis/Urethritis• Stone Vascular:• Renal vein thrombosis• Arterial Emboli or thrombosis
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EtiologySystemic Causes-Less common Diabetes Mellitus Hypertensive Nephropathy Hematological Disorders
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InvestigationComplete urine examinationRenal Parameters-urea and creatinineUltrasoundIVUCystoscopyRenal Biopsy
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Approach to the patient with Hematuria
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Interpretation of Dipstick positive hematuria
Hematuria with WBCs-Infection
Hematuria with Abnormal epithelial cells-Tumor
Hematuria with RBC casts-Glomerular bleeding
Hemoglobinuria-Intravascular Hemolysis
Myoglobinuria-Rhabdomyolysis
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TreatmentManagement of hematuria involves the
treatment of underlying cause.
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Polyuria
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DefinitionPassing large volume of urine (>3L per day )
is called polyuria.
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Causes of PolyuriaExcessive fluid intake
Osmotic:Hyperglycemia,Hypercalcemia
Cranial diabetes insipidus:Reduced ADH secreation,secondary to trauma,tumor,or idiopathic.
Nephrogenic diabetes insipidus: Genetic tubular defects Drugs/toxins-Lithium, Diuretics Interstitial renal disease Hypokalemia,Hypercalcemia
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Investigations24 hour urinary collectionSerum electrolytesSerum calciumSerum glucose levelsRenal parameters
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Proteinuria
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DefinitionThe presence of abnormal quantities of
protein in the urine is called proteinuria.
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Causes Transient proteinuria
UTIFeverHeavy exercisePregnancyOrthostatic proteinuria - not found in early
morning sample, uncommon over age of 30 years
Vaginal mucus
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CausesPersistent Proteinuria: Primary renal disease
Glomerular – GNTubular
Secondary renal diseaseDMCTDVasculitisAmyloidosisMyelomaCCFHypertension
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Evaluation of ProteinuriaHistory:• Symptoms of renal Failure• Arthralgia, Mouth ulcers, Rashes indicating
connective tissue disease• Past History of DM,HTN,CCF• Drug History-NSAIDs,Captopril• Family History of Polycystic kidney disease,
Reflux nephropathy
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Examination• Look for signs of Nephrotic syndrome• Signs of multisystem disease – rashes,
splinter hemorrhage, bruits.• B.P• Urine dipstick test to check for microscopic
hematuria – if + go for urine microscopy.• Rule out Diabetes and UTI
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Quantification of Proteinuria24 hour urine
collectionSpot urine protein to
creatinine ratio(PCR)Albumin to creatinine
ratio(ACR)More than 150 mg in
24h or PCR of 15 mg/mmol is abnormal
Nephrotic range - >3.5 g/24h or a ratio > 3500 - check for serum albumin and cholesterol.
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Approach to a patient with proteinuria
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Microalbuminuria
Microalbuminuria describes the urinary excretion of small amounts of albumin.
Microalbuminuria indicates glomerular disease e.g diabetic nephropathy
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Bence Jones proteinuria
Patients with a clone of B lymphocytes secreting free immunoglobulin light chains filter these freely into the urine, and this can be identified as ‘Bence Jones protein.
• A feature of multiple myeloma and amyloidosis
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Nephrotic Syndrome
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Definition• Nephrotic syndrome is a condition
characterized by
• Nephrotic range proteinuria• Hypoalbuminemia• Hyperlipidemia • Edema
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Clinical FeaturesClinical features of Nephrotic syndrome include:
Edema: Dependent edema of lower limbs,Genitalia,acities and facial edema more prominent in children.Hypercholesterolemia: Increased incidence of atherosclerosisHypercoagulability: Leading to venous thromboembolismInfections: pneumococcal Infections
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Pathogenesis Edema:• Urinary protein losses exceeds synthetic capacity of liver Reduced oncotic pressure edema • Secondary hypoaldosteronism Sodium Retention Edema Hypercholesterolemia: Non-specific increase in lipoprotein synthesis by liver in response to low oncotic pressure
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Pathogenesis Hypercoagulability:Relative loss of inhibitors of coagulation (e.g. antithrombin III,protein C and S)and increase in liver synthesis of procoagulant factors.
Infections:Hypogammaglobulinaemia due to urinary losses.
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Management• High dose steroids in children with nephrotic
syndrome sec.to minimal change glomerulonephritis
• Diuretics• Low sodium diet• Lipid Lowering drugs(HMG CoA reducatase
Inhibitors)• Anticoagulation prophylaxis for
thromboembolism• Consider vaccination for Pneumococcal
Infections
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Thank You