Nephrotic syndrome: Difference between revisions
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*Classical characteristics/risk factors: | *Classical characteristics/risk factors: | ||
**Minimal change disease - children, preceded by [[URI]] | **Minimal change disease - children, preceded by [[URI]] | ||
**Focal segmental glomerulosclerosis - Black patients, [[HIV]]/[[IVDA]] | **Focal segmental glomerulosclerosis - Black patients, [[HIV]]/[[IVDA]], specific anabolic steroids | ||
**Membranous nephropathy - | **Membranous nephropathy - Caucasian patients - primary etiology, [[HBV]], [[hepatitis C|HCV]], [[SLE]], gold, [[penicillamine]], malignancy | ||
**Type 1 MPGN - [[HBV]], [[hepatitis C|HCV]] | **Type 1 MPGN - [[HBV]], [[hepatitis C|HCV]] | ||
**Type 2 MPGN - ↓ C3 | **Type 2 MPGN - ↓ C3 | ||
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**Serum albumin < 25 g/L | **Serum albumin < 25 g/L | ||
*Lipid panel, with total cholesterol > 380mg/dL (10 mmol/L) | *Lipid panel, with total cholesterol > 380mg/dL (10 mmol/L) | ||
*ANA, C3, C4, [[viral hepatitis]] panel | *ANA, C3, C4, [[viral hepatitis]] panel, HIV, SPEP, SIFE, UPEP, ANCA, free light chains, PLA2R | ||
*[[CXR]] (only if suspect pleural effusion / pulmonary edema) | *[[CXR]] (only if suspect pleural effusion / pulmonary edema) | ||
*[[Renal ultrasound]] | *[[Renal ultrasound]] | ||
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*[[fluid overload|Volume overload]] | *[[fluid overload|Volume overload]] | ||
**Treat with [[furosemide]] 1-2mg/kg | **Treat with [[furosemide]] 1-2mg/kg | ||
**May require correction of [[hypoalbuminemia | **May require correction of [[hypoalbuminemia]] first; 0.5-1gm/kg | ||
*[[Steroids]] | *[[Steroids]] | ||
**Effective for minimal-change disease | **Effective for minimal-change disease | ||
Latest revision as of 07:22, 18 August 2022
Background
- Increased permeability of glomerular capillary wall
- Proteinuria, hypoproteinemia (albumin <3), edema, hyperlipidemia
- Life-threatening complications are infection and thromboembolic events
Clinical Features
- Edema (face, periphery)
- Shortness of breath, cough (pleural effusion, pulmonary edema)
- Oliguria
Complications[1]
- Chronic high dose steroid adverse effects
- Pulmonary embolism
- Renal vein thrombosis
- Hypovolemic crisis
- Acute kidney injury
- Infection
- Cardiovascular issues (hyperlipidemia)
- Anemia
- Hypocalcemia
- Hypothyroidism
- Intussusception
Differential Diagnosis
- Primary nephrotic syndrome
- Minimal-change, membranoproliferative
- Secondary nephrotic syndrome
- Classical characteristics/risk factors:
Periorbital swelling
Proptosis
- Normal IOP
- Orbital cellulitis
- Orbital pseudotumor
- Orbital tumor
- Increased IOP
- Retrobulbar abscess
- Retrobulbar emphysema
- Retrobulbar hemorrhage
- Ocular compartment syndrome
- Orbital tumor
No proptosis
- Periorbital cellulitis/erysipelas
- Dacryocystitis (lacrimal duct)
- Dacryocele/Dacryocystocele
- Dacryostenosis
- Dacryoadenitis (lacrimal gland)
- Allergic reaction
- Nephrotic Syndrome (pediatrics)
Lid Complications
- Blepharitis (crusts)
- Chalazion (meibomian gland)
- Stye (hordeolum) (eyelash folicle)
Other
- Subperiosteal abscess
- Orbital abscess
- Cavernous sinus thrombosis
- Conjunctivitis
- Contact dermatitis
- Herpes zoster
- Herpes simplex
- Sarcoidosis
- Granulomatosis with polyangiitis
Evaluation
- Urinalysis
- Proteinuria > 3.5 g/24 hr, no hematuria
- Spot urine protein : urine creatinine ratio of > 3 - 3.5mg/mg (300 - 350mg/mmol)
- CBC
- CMP
- Pseudohyponatremia due to elevated triglycerides
- Serum albumin < 25 g/L
- Lipid panel, with total cholesterol > 380mg/dL (10 mmol/L)
- ANA, C3, C4, viral hepatitis panel, HIV, SPEP, SIFE, UPEP, ANCA, free light chains, PLA2R
- CXR (only if suspect pleural effusion / pulmonary edema)
- Renal ultrasound
- Only if suspect renal vein thrombosis - hematuria, flank pain, AKI
Management
- Give IV fluids if evidence of hypovolemic shock (even if edema is severe)
- Volume overload
- Treat with furosemide 1-2mg/kg
- May require correction of hypoalbuminemia first; 0.5-1gm/kg
- Steroids
- Effective for minimal-change disease
- Prednisone 2mg/kg/d in 2-3 divided doses x 6 weeks
- Low-salt diet
- Prophylactic anticoagulation for thromboembolic events not recommended, unless patient had previous thrombotic events
Disposition
Admit
- Severe edema
- Pulmonary effusion or respiratory symptoms
- Infection or thrombotic complications
Outpatient nephrology follow up
- Mild-moderate edema
References
- Kodner C. Nephrotic Syndrome in Adults: Diagnosis and Management. Am Fam Physician. 2009 Nov 15;80(10):1129-1134.
- ↑ Park SJ and Shin JI. Complications of nephrotic syndrome. Korean J Pediatr. 2011 Aug; 54(8): 322–328.