Nephrotic syndrome: Difference between revisions
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==Background==
==Background==
*Increased permeability of glomerular capillary wall
*Increased permeability of glomerular capillary wall
**Proteinuria, hypoproteinemia (alb <3), edema, hyperlipidemia
**[[Proteinuria]], [[hypoalbuminemia|hypoproteinemia]] (albumin <3), edema, hyperlipidemia
*Life-threatening complications are infection and thromboembolic events
*Life-threatening complications are [[infection]] and [[thromboembolism|thromboembolic events]]


==Clinical Features==
==Clinical Features==
*Edema (face, periphery)
*Edema (face, periphery)
*[[SOB]], cough ([[pleural effusion]], [[pulmonary edema]])
*[[Shortness of breath]], cough ([[pleural effusion]], [[pulmonary edema]])
*Oliguria
*Oliguria
===Complications<ref>Park SJ and Shin JI. Complications of nephrotic syndrome. Korean J Pediatr. 2011 Aug; 54(8): 322–328.</ref>===
*Chronic high dose steroid adverse effects
*[[Pulmonary embolism]]
*[[Renal vein thrombosis]]
*[[hypovolemia|Hypovolemic]] crisis
*[[Acute kidney injury]]
*[[Infection]]
*Cardiovascular issues (hyperlipidemia)
*[[Anemia]]
*[[Hypocalcemia]]
*[[Hypothyroidism]]
*[[Intussusception]]


==Differential Diagnosis==
==Differential Diagnosis==
*Primary nephrotic syndrome
*Primary nephrotic syndrome
**Minimal-change, Membranoproliferative
**Minimal-change, membranoproliferative
*Secondary nephrotic syndrome
*Secondary nephrotic syndrome
**SLE, HSP, SCD
**[[SLE]], [[HSP]], [[sickle cell|SCD]]
*Classical characteristics/risk factors:
**Minimal change disease - children, preceded by [[URI]]
**Focal segmental glomerulosclerosis - Black patients, [[HIV]]/[[IVDA]]
**Membranous nephropathy - White patients, [[HBV]], [[hepatitis C|HCV]], [[SLE]], gold, [[penicillamine]], malignancy
**Type 1 MPGN - [[HBV]], [[HCV]]
**Type 2 MPGN - ↓ C3 


{{Periorbital swelling DDX}}
{{Periorbital swelling DDX}}


==Diagnosis==
==Evaluation==
*UA
*[[Urinalysis]]
**Proteinuria > 3.5 g/24 hr, no hematuria
**[[Proteinuria]] > 3.5 g/24 hr, no hematuria
**Protein:Cr ratio of > 3 - 3.5 mg/mg (300 - 350 mg/mmol)
**Spot urine protein : urine creatinine ratio of > 3 - 3.5mg/mg (300 - 350mg/mmol)
*CBC
*CBC
*Chemistry
*CMP
**Pseudohyponatremia due to elevated triglycerides
**Pseudohyponatremia due to elevated triglycerides
**Serum albumin < 25 g/L
**Serum albumin < 25 g/L
*Lipid panel, with total cholesterol > 380 mg/dL (10 mmol/L)
*Lipid panel, with total cholesterol > 380mg/dL (10 mmol/L)
*ANA, C3, C4, Hep panel
*ANA, C3, C4, [[viral hepatitis]] panel
*CXR (only if suspect pleural effusion / pulm edema)
*[[CXR]] (only if suspect pleural effusion / pulmonary edema)
*Ultrasound
*[[Renal ultrasound]]
**Only if suspect renal vein thrombosis - hematuria, flank pain, ARF
**Only if suspect renal vein thrombosis - [[hematuria]], [[flank pain]], [[AKI]]


==Treatment==
==Management==
*Give IV fluids if evidence of hypovolemic shock (even if edema is severe)
*Give [[IV fluids]] if evidence of [[hypovolemic]] [[shock]] (even if edema is severe)
*Volume overload
*[[fluid overload|Volume overload]]
**Treat with [[furosemide]] 1-2mg/kg
**Treat with [[furosemide]] 1-2mg/kg
**May require correction of hypoalbuminemia first; 0.5-1gm/kg
**May require correction of [[hypoalbuminemia first]]; 0.5-1gm/kg
*Steroids
*[[Steroids]]
**Effective for minimal-change disease
**Effective for minimal-change disease
**[[Prednisone]] 2mg/kg/d in 2-3 divided doses x 6 weeks
**[[Prednisone]] 2mg/kg/d in 2-3 divided doses x 6 weeks
*Low-salt diet
*Low-salt diet
*Prophylactic anticoagulation for thromboembolic events not recommended, unless patient had previous thrombotic events


==Disposition==
==Disposition==
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*Infection or thrombotic complications
*Infection or thrombotic complications


===Outpt nephrology follow up===
===Outpatient nephrology follow up===
*Mild-moderate edema
*Mild-moderate edema


==References==
==References==
*Kodner C. Nephrotic Syndrome in Adults: Diagnosis and Management. Am Fam Physician. 2009 Nov 15;80(10):1129-1134.


[[Category:Peds]]
[[Category:Pediatrics]]
[[Category:Renal]]

Revision as of 15:07, 21 May 2020

Background

Clinical Features

Complications[1]

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, viral hepatitis panel
  • CXR (only if suspect pleural effusion / pulmonary edema)
  • Renal ultrasound

Management

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.
  1. ↑ Park SJ and Shin JI. Complications of nephrotic syndrome. Korean J Pediatr. 2011 Aug; 54(8): 322–328.
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