NEPHROTIC SYNDROME

1. Prepared by: Dr. NEENUMOL K JOSE
ASSOCIATE PROFESSOR

2. Nephrotic syndrome is a kidney disorder characterized by a specific set
of symptoms that occur due to damage to the small blood vessels in the
kidneys, known as glomeruli.
These damaged glomeruli lead to abnormal filtration of blood and the
loss of essential proteins in the urine.
The syndrome primarily affects adults and children, though it can occur
at any age.

3. DEFINITION
“Nephrotic syndrome is a kidney disorder caused by glomerular damage
and characterized by a marked increase in protein (particularly albumin)
in the urine (proteinuria), a decrease in albumin in the blood
(hypoalbuminemia), diffuse edema, high serum cholesterol, and low-
density lipoproteins (hyperlipidemia)”.

4. CAUSES
Primary (Idiopathic) Nephrotic Syndrome:
• Minimal Change Disease: This is the most common cause of nephrotic syndrome
in children. It is called "minimal change" because the kidney tissue appears
normal under a microscope, but there are functional abnormalities.
• Focal Segmental Glomerulosclerosis (FSGS): This condition involves scarring
(sclerosis) of some glomeruli, and it can be primary or secondary to other
diseases.
• Membranous Nephropathy: This is characterized by thickening of the glomerular
basement membrane and is one of the common causes of nephrotic syndrome in
adults.

5. Secondary Nephrotic Syndrome:
• Nephrotic syndrome can also result from underlying medical conditions, infections,
or exposure to certain medications. Some common causes include:
• Systemic Lupus Erythematosus (SLE): An autoimmune disease that can affect
various organs, including the kidneys.
• Diabetes: Diabetic nephropathy is kidney damage caused by uncontrolled diabetes.
• Amyloidosis: Accumulation of abnormal proteins in the kidney tissue.
• Infections: Some infections like HIV, hepatitis B and C, and malaria can lead to
nephrotic syndrome.
• Medications: Certain medications, including non-steroidal anti-inflammatory drugs
(NSAIDs), some antibiotics, and certain blood pressure medications, can cause
nephrotic syndrome as a side effect.
• Allergies: Allergic reactions can occasionally lead to nephrotic syndrome.

6. Hereditary Causes:
• Rarely, nephrotic syndrome can be caused by genetic mutations that affect the
structure and function of the glomeruli.
Systemic Diseases:
• Certain systemic diseases, such as multiple myeloma and some types of cancer,
can affect the kidneys and lead to nephrotic syndrome.
Unknown Causes:
• In some cases, the exact cause of nephrotic syndrome remains unknown, and it
is classified as idiopathic.

7. PATHOPHYSIOLOGY

8. CLINICAL MANIFESTATIONS
Edema: The primary and hallmark symptom of nephrotic syndrome is the presence of
edema, which is swelling caused by the accumulation of excess fluid in the body tissues.
Soft and Pitting edema: The edema associated with nephrotic syndrome is typically soft and
pitting, meaning that when pressure is applied to the swollen area (e.g., by pressing with a
finger), it leaves an indentation that slowly resolves.
Distribution of Edema: Edema often occurs in specific areas of the body:
• Periorbital: Swelling around the eyes is common, giving a puffy appearance.
• Dependent Areas: Edema tends to accumulate in areas of the body that are dependent,
such as the sacrum (lower back), ankles, and hands.
• Abdomen (Ascites): In some cases, fluid buildup in the abdominal cavity can lead to
ascites, causing abdominal distension.

9. Systemic Symptoms: Patients with nephrotic syndrome may experience various
systemic symptoms, including:
• Irritability: Due to discomfort and the impact of edema on daily life.
• Headache: Often related to the increased fluid retention and changes in
blood volume.
• Malaise: A general feeling of discomfort or unease.

10. ASSESSMENT AND DIAGNOSTIC FINDINGS
Proteinuria:
• Proteinuria is a key diagnostic feature of nephrotic syndrome.
• In nephrotic syndrome, proteinuria involves the loss of predominantly albumin, and it
typically exceeds 3.5 grams per day.
Urine Analysis:
• Protein electrophoresis and immunoelectrophoresis may be performed on the urine to
categorize the type of proteinuria. This helps determine the specific proteins being lost in
the urine.
• Increased levels of white blood cells (WBCs) may be present in the urine, indicating
possible inflammation or infection in the urinary tract.
• Granular and epithelial casts may also be observed in the urine. Casts are cylindrical
structures formed in the renal tubules and can be indicative of kidney damage.

11. MEDICAL MANAGEMENT
• Corticosteroids: These are often the first-line treatment for nephrotic syndrome,
especially in cases of minimal change disease. Prednisone is a common corticosteroid
used to reduce proteinuria and suppress the immune system's abnormal response.
• Immunosuppressive Drugs: In some cases, when corticosteroids alone are not
effective, immunosuppressive medications like cyclophosphamide or cyclosporine
may be prescribed to further suppress the immune system's activity.
• Diuretics: Diuretics (water pills) may be used to manage edema and reduce fluid
retention. Common diuretics include furosemide and spironolactone.
• ACE Inhibitors or Angiotensin Receptor Blockers (ARBs): These medications help
control blood pressure and reduce proteinuria by dilating blood vessels within the
kidneys. They are often used to slow the progression of kidney damage.

12. Dietary Management:
Sodium Restriction: Reducing dietary sodium (salt) intake can help manage edema by
minimizing fluid retention.
Protein Intake: Protein intake may be adjusted to compensate for protein loss in the urine. In
some cases, a dietitian may recommend a higher protein intake to offset losses.
Fluid Management:
Monitoring Fluid Intake: Patients may need to monitor and limit their fluid intake to help
control edema.
Monitoring Weight: Regular monitoring of body weight is essential to track changes related to
fluid retention.

13. NURSING MANAGEMENT
Education and Communication:
• Provide comprehensive education to patients about their condition, its causes, and
potential complications.
• Emphasize the importance of adhering to prescribed medications, dietary restrictions,
and fluid management strategies.
• Encourage open communication with healthcare providers, particularly regarding any
changes in symptoms, medication side effects, or other health-related concerns.
Medication Management:
• Ensure that patients understand the purpose, dosage, and potential side effects of their
medications, including corticosteroids, immunosuppressive drugs, diuretics, and
antihypertensive medications.
• Monitor medication compliance and address any concerns or barriers to adherence that
patients may have.

14. Dietary Management:
• Collaborate with dietitians to develop and implement dietary plans that align with the patient's
specific needs and restrictions.
• Emphasize dietary measures, such as sodium and protein intake restrictions, as prescribed by
the healthcare team.
• Monitor and educate patients about fluid intake and output to manage edema and maintain
fluid balance.
Prevention of Complications:
• Implement measures to prevent complications, such as monitoring for signs of infection and
educating patients about infection prevention strategies.
• Provide guidance on measures to prevent thromboembolic events, such as the importance of
mobility and wearing compression stockings.
Psychosocial Support:
• Address the psychosocial aspects of living with a chronic condition, including the emotional
impact and potential lifestyle changes.
• Encourage patients to seek emotional support from family, friends, or support groups.