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Approach to nephrotic syndrome

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Approach to nephrotic syndrome

  1. 1. Approach to Nephrotic Syndrome Dr Abhay Mange
  2. 2.  15 yrs old Male, Surendra Upwanshi r/o Bitoli , Balaghat (mp) admitted on 7/2/14 with c/o  Swelling over face and lower limbs since 15 days  Decreased urine out put since 10 days  No h/o fever, sore throat, skin infection, rash, joint pain  No h/o Jaundice / hemoptysis  No h/o DM
  3. 3. On examination  Conscious / oriented  Afebrile  Pulse -90 /min , all pulsation +  Resp- 18/min  Bp -180/100 mmhg  Edema feet +  Periorbital edema +  Jvp –nr  No pallor, icterus  P/A – ff +  RS –wnl  CVS –wnl  CNS –wnl
  4. 4. Investigations  Hb -10.2 gm %  TLC – 8400/cumm T- 71, L-27, E-2 , M-2 %  PS  RBCS-Normocytic,normochromic  WBCS- WNL,PLATELETS –adequate  No prasite seen  URINE EXAM  Protein = ++++  Sugar = negative  RBCS = 25-30/hpf  pus cells = 4-5/hpf  No cast seen  24 hr urine protein = 7930 gm  KFT-  BUL=130 mg/dl ,  SC = 1.6 mg/dl  Na + = 136 meq/l  K + =5.6 meq/l  LFT  TP = 5 gm  Total Cholesterol = 264 mg/dl  ECG- WNL  X-RAY CHEST –WNL  USG KUB  Rt. = 9.4 X 4.3 cm, Lt.=9.9 x 4.4 cm  Diffuse increase in echo texture ,maintained CMD
  5. 5. Provisional Diagnosis  Nephrotic syndrome  Renal biopsy planned
  6. 6. Investigations  ASO = 58 IU/L (Negative)  C3 = 0.3 gm/l (0.9 -1.8)  ANA = Negative  HBsAg = Negative  HCV = Negative  HIV = Negative  INR =1.2
  7. 7. Treatment  Inj Cefotaxime 0.5 gm tds  Inj lasix 80 mg bd  Tab cilnidepine 20 mg tds  Tab prazocin 5 mg od  Tab calcium lactate 1 tds  Tab atorvaststin 10 mg  Human albumin  BIOPSY TAKEN  Inj Methylprednisolone 750 mg od 3 day  Tab prednisolone 50 mg od ct…
  8. 8. Renal biopsy Microscopy : -  Glomeruli are enlarged in size and shows diffuse segmental areas of increase in mesangial matrix and hypercellularity and occasional infiltrating polymorph.  Focal areas of endocapillary hypercellularity are noted.  Focal areas of glomerular basement membrane thickening are noted.  Lobular accentuation is noted in 05 – 06 glomeruli.  Silver stain shows tram tracking.  The interstitium show mild mononuclear cell inflammatory infiltrate.  The blood vessels are unremarkable.
  9. 9. Immunofluorescence Study  IgG : Positive (++) coarsely granular diffuse mesangial deposits are seen.  IgM : Negative  IgA : Negative  C3 : Positive (++) coarsely granular diffuse mesangial deposits are seen.  Impression :- Membranoproliferative Glomerulonephritis with IgG and C3 positivity.
  10. 10. Final diagnosis  Idiopathtic Membranoproliferative glomerulonephritis Nephrotic syndrome
  11. 11. Approach to acute Glomerulonephritis
  12. 12. DISCUSSION
  13. 13. Definition Nephrotic syndrome is a clinical complex characterized by a number of renal and extrarenal features, most prominent of which are  Proteinuria (in practice > 3.0 to 3.5gm/24hrs),  Hypoalbuminemia,  Edema,  Hypertension,  Hyperlipidemia,  Lipiduria and  Hypercoagulabilty.
  14. 14. Classification Nephrotic syndrome can be  Primary, being a disease specific to the kidneys,  Secondary, being a renal manifestation of a systemic general illness
  15. 15. Primary causes Primary causes include-  Minimal-change nephropathy(70-90% in children and 10- 15% in adult)  Focal glomerulosclerosis (15% in adult)  Membranous nephropathy (30% in adult)  Membranoproliferative glomerulonephritis .
  16. 16. Secondary causes Secondary causes include-  Diabetes mellitus  Lupus erythematosus  Amyloidosis and paraproteinemias  Viral infections (eg, hepatitis B, hepatitis C, HIV )  Preeclampsia
  17. 17. Workup Diagnostic studies for nephrotic syndrome may include the following:  Urinalysis  Urine sediment examination  Urinary protein measurement (24-hr)  Serum albumin  Serologic studies for infection and immune abnormalities  Renal ultrasonography  Renal biopsy
  18. 18. Renal biopsy Indications  Unexplained renal failure  Acute nephritic syndrome  Nephrotic syndrome  Isolated nonnephrotic proteinuria  Isolated glomerular hematuria  Renal masses (primary or secondary)  Renal transplant rejection  Connective-tissue diseases ( SLE)
  19. 19. Renal biopsy  2 biopsy cylinders  • minimal length 1 cm  • diameter 1.2 mm  # isotonic saline – fast local transport  • cryopreservation of one piece for immunefluorescence  • fixation with paraformaldehyde or buffered (4%)  formaldehyde for paraffin embedding  • fixation with 3% glutaraldehyde for electron microscopy  or  # direct fixation with paraformaldehyde or formaldehyde and  shipping (indirect immunehistology by APAAP (alkaline  phosphatase) or others
  20. 20. Renal biopsy Absolute Contraindications  Uncorrectable bleeding diathesis  Uncontrollable severe hypertension  Active renal or perirenal infection  Skin infection at biopsy site Relative contraindications  Uncooperative patient  Anatomic abnormalities of the kidney which may increase risk  Small kidneys  Solitary kidney
  21. 21. Renal biopsy Complications  Bleeding- may occur in 3 distinct locations  Collecting system -blood is seen in the urine,Obstuction  Under the renal capsule-cause increase in the release of renin-hypertension  Into the perinephric space-Hematoma  The injured kidney can also undergo fibrosis-chronic hypertension and perhaps even renal failure can result if the contralateral kidney is compromised – “page kidney effect”  AV fistules
  22. 22. THANK YOU

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