Nephrotic syndrome causes, clinical picture, DD, investigations, treatment

Here is a discussion of Nephrotic syndrome regarding its definition, causes, differential diagnosis, clinical presentation (manifestations), investigations and treatment .

Definition of Nephrotic syndrome

• It is a clinico-laboratory syndrome characterized by heavy proteinuria > 3.5 gm /24 hrs / 1.73m2 with hypoproteinemia, edema and hyperlipidemia.
• Usually hypercholesterolemia & Iipiduria are present due to increased lipoprotein production by hepatocytes.
• Edema is due to hypoalbuminemia and secondary hyperaldosteronism.

Causes of nephrotic syndrome

* Primary Glomerulonephritis GN
- Minimal lesion GN                   - Membranous GN 
- FSGS                                      - Membrano-proliferative GN
- Mesangio-proliferative GN

* Secondary Glomerulonephritis
a- Systemic disease 
  - Diabetec Nephropathy          - Rheumatoid disease 
  - SLE              - Amyloidosis   - Sarcoidosis
b- Infections
 - Bilharziasis    - Malaria   - HBV  -  HIV .
c- Drugs 
-Penicillamine   - Captopril .
d- Malignancy e.g Lymphomas, carcinomas
e- Heridofamilial e.g Alport's syndrome .
f- Miscellaneous 
 - Mexedema  -  Thyroiditis   - Renovascular disease .

Glomerulopathies presented with Nephrotic syndrome


Clinical picture of Nephrotic syndrome 

1. Edema (hypoalbuminemia + 2ry hyperaldostronism).
- Starts as puffiness then LL edema.
- Serous membranous trasudation e.g. pleural effusion, ascites, pericardial effusion.
- Gradual onset.
2. No hypertension or oliguria or azotemia except late in some types.
3. Manifestations of the cause as SLE, DM.

Differential diagnosis of nephrotic syndrome

• Other causes of generalized edema
• G.N presented by nephrotic syndrome (As above )

Investigations to diagnose nephrotic syndrome

1. Serum creatinine, blood urea, BUN  :  normal.
2. Late in some G.N : ++ serum creatinine and blood urea or BUN.
3. S. albumin : Decreased
4. Urine analysis : ++ protein > 3.5gm/24h urine.
                           - Cast (hyaline or fatty cast).
5. Biopsy (diagnosis - prognosis - response to ttt ) .
Light - E.M - immunofluorescence (see before in different types of G.N).

Treatment of Nephrotic syndrome

1) Diet
- Normal protein intake is advisable with proteins of high biologic values.
- Excessive protein intake ===> increases urinary protein excretion which may lead to glomerulosclerosis. With the development of renal impairment .
Modest protein restriction is advised.

2) Salt poor albumin should not be used except in cases of severe hypoalbuminemia with refractory anasarca as the albumin will be lost in urine within 24-48 hours.

3) Diuretics e.g loop diuretics can be used, also spironolactone can be added to correct hyperaldosteronism.
 Excessive diuresis should be avoided to prevent the occurrence of pre renal failure.

4) ACE inhibitor to decrease proteinuria .

5) Hypolipidemic drugs e.g. Atorvastatin 10-20 mg/D to decrease plasma cholesterol.
6) Specific therapy according to the type of glomerulopathy (see before).
7) Treatment of the cause.
Nephrotic syndrome causes, clinical picture, DD, investigations, treatment
Dr.Tamer Mobarak


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