Nephrotic Syndrome Complications of Nephrotic Syndrome 1. Susceptibility to UTI, peritonitis, septicaemiaDefinition infections Due to:- Loss of IgG Hypoalbuminaemia <30g/L Immunosuppression by steroids or immunosuppressants Proteinuria >3.5g/day Lost of factor B of the alternate complement activation Oedema pathway Loss of transferrinCauses T cell abnormalities 2. Thrombosis & DIVC, pulmonary embolism, renal vein thrombosis Primary Glomerular diseases embolism Hypercoagulability due to 1. Minimal Change Nephropathy Commonest dx in children ↓ plasma antithrombin III (urinary loss) 2. Focal Segmental Glomerulosclerosis Commoner dx in middle-aged & ↑ plasma fibrinogen & clotting factors V & VIII 3. Membranous GN elderly Haemoconcentration 4. Mesangioproliferative GN 3. ↓ volaemia Shock 5. Membranoproliferative GN Acute Tubular Necrosis / Acute renal failure Secondary Glomerular diseases 4. ↑lipidaemia ↓ apolipoprotein (urinary loss) 1. Diabetic nephropathy increased risk of CHD & atherosclerosis 2. Autoimmune – SLE, HSP 5. ↓calcaemia Urinary loss of Vit D binding proteins 3. Infections – Post-streptococcal infection Bone demineralization in the long term 4. Drugs – TCM, gold 6. Negative Due to Proteinuria, LOA & nausea 5. Amyloidosis nitrogen balance 6. Metabolic diseases 7. ESRF 7. Vascular diseases 8. Steroid toxicity 8. Hereditary nephritis – eg Alport’s InvestigationsPresentation Bloods Dx and Cx:General condition Anorexia, wt gain, lethargy, xanthomata, xanthelasma FBC & ESR – haemoconcentration, infections, hypoCa, inflammationOedema Periorbital, pedal, sacral, scrotal, ascites U/E/CrPleural effusion SOB Albumin – assess severityUrinary Oliguria, haematuria, concentrated urine Lipid profile – assess hyperlipidaemiaOthers Infections, HPT, abdominal pain, hepatomegaly Immunoglobulins & serum electrophoresis Causes:Other things to note in Long case Serum C3 & C4 – in MCGN & SLEPast History to note AutoAbs – ANA, ANCA, anti-dsDNA, anti-GBM 1. Initial diagnosis – date, symptoms, investigations, aetiology identified, Rx ASOT – in post-strep. GN 2. No. of episodes / year – precipitants, usual Rx Hep B serology – associated with membranous nephritits 3. No. of hospitalizations Hep C serology – associated with MCGN 4. Cxs & Mx Urine Dipstick – proteinuria, haematuriaManagement Urinalysis – microscopic haematuria & casts 1. Diet C/S – UTI 2. Medication & compliance 24hr UTP & CCT 3. Management problems Albumin:creatinine ration - > 200mg/mmol 4. Present Rx for current admission Na Concentration - <20mmol/L if hypovolaemic 5. Previous drugs used Throat swab For microscopy, C/S. 6. Drug side effects For post-strep GN 7. Home urine testing and nephrotic diary Imaging CXR 8. F/U Renal U/S Renal biopsy
Management1. Bed rest, monitoring U/E, BP, fluid I/O charting, weight2. Fluid restriction 1-1.5L/day salt restriction high protein diet3. Diuretics Frusemide 80-250 mg PO ± spironolactone Aim for loss of 1kg/day Occasionally high dose frusemide + IV salt-poor albumin to promote diuresis. However, risk of renal failure secondary to hypovolaemia with over diuresis4. Chronic nephrotic Consider reducing proteinuria with ACEI or cyclosporine syndrome5. Hyperlipidaemia Consider statin. Usually improves with resolution of nephrotic syndrome6. Hypertension Conventional regimens7. Anticoagulation Prophylactic heparin for immobile PTs Warfarin for symptomatic thrombosis8. Infections Prophylactic ABx Pneumococcal vaccination during remission9. Mx of minimal change High dose corticosteroids nephropathy in ± cyclophosphamide / cyclosporine in steroid dependant NS children Digitally signed by DR WANA HLA SHWE DN: cn=DR WANA HLA SHWE, c=MY, o=UCSI University, School of Medicine, KT- Campus, Terengganu, ou=Internal Medicine Group, firstname.lastname@example.org Reason: This document is for UCSI year 4 students. Date: 2009.02.24 10:17:10 +0800
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