Transcript Nephrotic/itic syndrome

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)
• 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 +++
Scenario
1. 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
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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
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Alport's syndrome
Amyloidosis
Sarcoidosis
Drugs (eg non-steroidal antiinflammatory
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
Causes
Primary
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:
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Haematuria & red cell casts
Proteinuria
Hypertension
Uraemia
Oliguria
Nephritic syndrome
• Collection of findings associated with glomerular
inflammation and glomerulonephritis
• Features:
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Haematuria & red cell casts
Proteinuria
Hypertension
Uraemia
Oliguria
Causes
1. Post-streptococcal
2. Primary:
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Membranous glomerulonephritis
Rapidly progressive glomerulonephritis
IgA nephropathy (Berger’s disease)
3. Secondary
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HSP
Vasculitis
Symptoms & signs
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Classically 2-3 weeks after URTI
Oedema
Oliguria
Haematuria
Flank pain
General symptoms
Investigations
• Urine dip
• Urine microscopy
• Bloods – FBC, U&E, ESR, complement, autoantibodies, myeloma screen, ASOT
• Renal Ultrasound
• Renal biopsy
Investigations
• Urine dipstick
• Urine microscopy
• Bloods – FBC, U&E, ESR, complement, autoantibodies, myeloma screen, ASOT
• Renal Ultrasound
• Renal biopsy
Management
Nephrotic syn.
Nephritis
• Conservative
▫ Salt & fluid restriction
• Medical
▫ Diuretics
▫ ACE-inhibitors/ARB
▫ Steroids/Immunosuppressi
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• Surgical
• Conservative
▫ Salt & fluid restriction
• Medical
▫ Diuretics
▫ Steroids/immunosuppressi
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• Surgical
• Dialysis
Management
Nephrotic syn.
Nephritis
• Conservative
▫ Salt & fluid restriction
• Medical
▫ Diuretics
▫ ACE-inhibitors/ARB
▫ Steroids/Immunosuppressi
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• Surgical
• Conservative
▫ Salt & fluid restriction
• Medical
▫ Diuretics
▫ Steroids/immunosuppressi
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• Surgical
• Dialysis
Complications
Complications 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
casts
FBC & 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
Scenario
1. 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?