Nephrotic syndrome

Background

  • Increased permeability of glomerular capillary wall
    • Proteinuria, hypoproteinemia (alb <3), edema, hyperlipidemia
  • Life-threatening complications are infection and thromboembolic events

Clinical Features

Differential Diagnosis

  • Primary nephrotic syndrome
    • Minimal-change, Membranoproliferative
  • Secondary nephrotic syndrome
  • Classical characteristics/risk factors:
    • Minimal change disease - children, preceded by URI
    • Focal segmental glomerulosclerosis - Black patients, HIV/IVDA
    • Membranous nephropathy - White patients, HBV, HCV, SLE, gold, penicillamine, malignancy
    • Type 1 MPGN - HBV, HCV
    • Type 2 MPGN - ↓ C3

Periorbital swelling

Proptosis

No proptosis

Lid Complications

Other

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, Hep panel
  • CXR (only if suspect pleural effusion / pulmonary edema)
  • Ultrasound
    • Only if suspect renal vein thrombosis - hematuria, flank pain, ARF

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.