Nephrotic/Nephritic Syndromes

28/04/2013 by admin | Renal

Proteinuria and nephrotic syndrome:

  1. Normal protein in urine <150mg/day (normal physiological protein = ‘Tamm-Horsfall protein’).
    1. o Proteinuria = 300mg-4.5g urinary protein/day
    2. o Microalbuminaemia = 30-300mg urinary albumin /day
  2. Increased protein may = GN, if Bence-Jones (free light chains) = MM, if microalbuminaemia = diabetic nephropathy.
  3. Ix:
    1. o Assess renal function: serum creatinine and U&Es and 24h urine collection to determine creatinie and protein clearance.
    2. o If significant renal dysfunction/proteinuria – do further Ix = renal tract USS, BM, exclude MM, SLE, or systemic vasculitis.
    3. o If proteinuria >2g/d = renal biopsy
    4. o If proteinuria >4.4g/d – pt may show signs of the ‘nephrotic syndrome’ – as characterised by:
    5. Proteinuria +++ on dipstick
    6. 24h protein is >4g
    7. Hypoalbuminaemia <30g/dL
    8. Peripheral oedema
    9. No haematuria (unlike nephritic syndrome)! Normal BP.
  4. Caused by:
    1. o Glomerulonephritis: most common cause, types of GN include = minimal change disease, membranous nephropathy and focal segment glomerulosclerosis.
    2. o DM
    3.  
    1. o Renal amyloid (primary, MM)
    2. o Autoimmune disease (SLE)
    3. o Drugs (=gold, penicillamine, NSAIDs)
  1. Complications of nephrotic syndrome:
    1. o Oedema in dependant sites (=lower limbs, face, hands, scrotum)
    2. o Hypercoagulability = renal vein thrombosis/DVT
    3. o Hypercholesterolaemia = reasons unclear (?hypersynthesis of apolipoproteins resulting from general increase in protein synthesis sound in nephrotic patients)
    4. o Infections = nephrotic syndrome associated with hypogammaglobulinaemia and impaired immune function. Immunise against pneumonococcus.
  2. Tx:
    1. o Identify underlying cause and treat
    2. o Diuretics = reduce oedema (be cautious of diuretic-induced hypovolaemia and further renal damage).
    3. o ACEi = reduce proteinuria and Mx HTN – especially useful in diabetics
    4. o Anticoagulants = if thrombotic
    5. o Statins = If hypercholesterolaemia
    6. o Corticosteroids = if minimal change glomerulonephritis

 

Nephritic syndrome:

  1. p/c:
    1. o Haematuria (micro/macro)
    2. o Mild proteinuria – not significant enough to cause depression of serum albumin (no hypoalbuminaemia) unlike nephrotic syndrome.
    3. o Inability of kidney to excrete fluids = oedema, HTN, oliguria
    4. o Decreased GFR = uraemia (nitrogenous waste [urea] accumulates in blood due to renal inability to remove into urine).
    5. o Often occurs 2-3/52 after a group A haemolytic streptococcal throat infection
  2. Post-streptococcal GN prognosis is very good
  3. If no previous strep infection – careful work-up indicated.
  4. Tx:
    1. o In a similar way to nephrotic syndrome (=diuretics, ACEi)
    2. o Also remember penicillin if strep cause
    3. o Dialysis is more likely to be necessary in nephritic syndrome. 
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