nephrotic /nephritic syndrome
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Nephrotic /nephritic syndrome. Hrishi Narayanan. Learning Outcomes. Understand the key differences between nephrotic and nephritic syndrome (nephritis) Describe initial investigations and management of nephrotic and nephritic syndrome (nephritis) - PowerPoint PPT PresentationTRANSCRIPT
Nephrotic/nephritic syndromeHrishi Narayanan
Learning Outcomes•Understand the key differences between
nephrotic and nephritic syndrome (nephritis)
•Describe initial investigations and management of nephrotic and nephritic syndrome (nephritis)
•Describe the possible complications of nephrotic syndrome
Scenario•24 year old man •Feeling more tired recently •No systemic symptoms on questioning•Frothy urine, no urinary symptoms, no blood•No past medical history, no medications•Non-smoker, social alcohol use•Examination is unremarkable•Urine dipstick - protein +++
Scenario1. What are your main differential diagnoses
for this gentleman?2. What are the features of nephrotic
syndrome and nephritic syndrome?3. How would you investigate this gentleman?4. What would your management plan be for
this gentleman?5. What are the complications of nephrotic
syndrome?
Differentials• Emotional stress• Exercise• Fever• UTI• Orthostatic• Seizures• Focal
segmental glomerulonephritis• IgA nephropathy (ie Berger's
disease)• IgM nephropathy• Membranoproliferative
glomerulonephritis• Membranous nephropathy• Minimal change disease• Haemoglobinuria• Multiple myeloma• Myoglobinuria• Pre-eclampsia/eclampsia
• Alport's syndrome• Amyloidosis• Sarcoidosis• Drugs (eg non-steroidal anti-
inflammatory drugs (NSAIDs), penicillamine,gold, angiotensin-converting enzyme (ACE) inhibitors)
• Anderson-Fabry disease• Sickle cell disease• Malignancies (eg lymphoma,
solid tumours)• Infections
(eg HIV, syphilis, hepatitis, post-streptococcal infection)
• Aminoaciduria• Drugs (eg NSAIDs, antibiotics)• Fanconi's syndrome• Heavy metal ingestion
Differentials•Transient – exercise, stress, UTI•Primary glomerular disease – minimal
change, FSGS•Secondary glomerular disease – drugs
(e.g. NSAIDS), infx (e.g. HIV/hepatitis), sarcoid
•Tubular – drugs•Serum excess – multiple myeloma•Other – pre-eclampsia
Nephrotic syndrome•Kidney disease leading to proteinuria,
hypoalbuminaemia, oedema & lipiduria•Proteinuria - >3g per day•Damage to glomerular basement
membrane causes increased permeability•This causes proteinuria →
hypoalbuminaemia →oedema
Nephrotic syndrome•Kidney disease leading to proteinuria,
hypoalbuminaemia, oedema & hyperlipidaemia
•Proteinuria - >3g per day•Damage to glomerular basement
membrane causes increased permeability•This causes proteinuria →
hypoalbuminaemia →oedema
CausesPrimary Secondary• Minimal change disease• Focal glomerulosclerosis• Membranous nephropathy
• Diabetes• SLE• Amyloidosis
Symptoms•Oedema•Foamy urine•Complications
Nephritic syndrome•Collection of findings associated with
glomerular inflammation and glomerulonephritis
•Features:▫Haematuria & red cell casts▫Proteinuria▫Hypertension▫Uraemia▫Oliguria
Nephritic syndrome•Collection of findings associated with
glomerular inflammation and glomerulonephritis
•Features:▫Haematuria & red cell casts▫Proteinuria▫Hypertension▫Uraemia▫Oliguria
Causes1. Post-streptococcal2. Primary:
▫ Membranous glomerulonephritis▫ Rapidly progressive glomerulonephritis▫ IgA nephropathy (Berger’s disease)
3. Secondary▫ HSP▫ Vasculitis
Symptoms & signs•Classically 2-3 weeks after URTI•Oedema•Oliguria•Haematuria•Flank pain•General symptoms
Investigations•Urine dip•Urine microscopy•Bloods – FBC, U&E, ESR, complement,
auto-antibodies, myeloma screen, ASOT•Renal Ultrasound•Renal biopsy
Investigations•Urine dipstick•Urine microscopy•Bloods – FBC, U&E, ESR, complement,
auto-antibodies, myeloma screen, ASOT•Renal Ultrasound•Renal biopsy
ManagementNephrotic syn. Nephritis• Conservative
▫ Salt & fluid restriction• Medical
▫ Diuretics▫ ACE-inhibitors/ARB▫ Steroids/
Immunosuppression• Surgical
• Conservative▫ Salt & fluid restriction
• Medical▫ Diuretics▫ Steroids/
immunosuppression• Surgical• Dialysis
ManagementNephrotic syn. Nephritis• Conservative
▫ Salt & fluid restriction• Medical
▫ Diuretics▫ ACE-inhibitors/ARB▫ Steroids/
Immunosuppression• Surgical
• Conservative▫ Salt & fluid restriction
• Medical▫ Diuretics▫ Steroids/
immunosuppression• Surgical• Dialysis
ComplicationsComplications of nephrotic syndrome:•Infection•Hyperlipidaemia•Hypocalcaemia•Hypercoagulability•Hypovolaemia
Scenario• A 12 year old male with dark "cola coloured" urine for 2
days• Well until 14 days ago - had a sore throat and fever –
resolved without medical input • Now facial puffiness and nonspecific abdominal pain.• Dark brown urine, voiding less, normal smell• Reduced appetite, lethargy, back pain• Normally fit & well, no other symptoms• Examination reveals only mild periorbital oedema Urine dip: blood +++, protein +Urine microscopy - RBCs are too numerous to count, RBC
castsFBC & U&E normal, ASO titre high, complement C3 low
Scenario• A 12 year old male with dark "cola coloured" urine for 2
days• Well until 14 days ago - had a sore throat and fever –
resolved without medical input • Now facial puffiness and nonspecific abdominal pain.• Dark brown urine, voiding less, normal smell• Reduced appetite, lethargy, back pain• Normally fit & well, no other symptoms• Examination reveals only mild periorbital oedema • Urine dip: blood +++, protein +• Urine microscopy - RBCs are too numerous to count, RBC
casts• FBC & U&E normal, ASO titre high, complement C3 low
Scenario1. What are your main differential
diagnoses for this patient?2. How would you investigate this patient?3. What would your management plan be
for this patient?
Key points•Nephrotic syndrome – heavy proteinuria,
nephritis (nephritic syndrome) – haematuria
•Always do a urine dip for patients with oedema
•Important complications include infection and hypoercoagulability
Questions?