Nephrotic syndrome notes

1. NEPHROTIC SYNDROME
Ndayambaje Israel

2. Introduction
• Nephrotic syndrome isn't a disease but is a
condition Cxtxd by marked proteinuria,
hypoalbuminemia, hyperlipidemia, lipiduria,
increased coagulation, & edema.
• It results from a glomerular defect that affects
the vessels' permeability & indicates renal
damage.
• Some forms of nephrotic syndrome may
eventually progress to end-stage renal failure.

3. Anatomy

4. Nephrotic Syndrome
Nephrotic Syndrome
• Chronic renal
disorder in
which the
basement
membrane
surfaces of the
glomeruli are
affected, cause
loss of protein
in the urine.

5. Nephrotic criteria
1. Massive proteinuria:
• Qualitative proteinuria: 3+ or 4+,
• Quantitative proteinuria : more than 40
mg/m2/hr in children (selective).
2. Hypo-proteinemia : total plasma proteins <
5.5g/dl & serum albumin : < 2.5g/dl.
3. Hyperlipidemia: Serum cholesterol : >
5.7mmol/L
4. Edema: pitting edema in different degree

6. Causes
• Glomerulonephritis
• Metabolic diseases: diabetes mellitus
• Collagen-vascular disorders: systemic lupus
erythematosus,periarteritis nodosa.
• Circulatory diseases: heart failure, sickle cell
anemia, and renal vein thrombosis.
• Nephrotoxins: mercury, gold, and bismuth.
• Infections: tuberculosis, enteritis; allergic
reactions; pregnancy; hereditary nephritis
• Neoplastic: multiple myeloma

7. Types
1. Idiopathic nephritic syndrome
– The most common in children for about
90%
2. Congenital Nephrotic Syndrome
– Rare in children & congenital
– It is inherited by an autosomal recessive
gene, meaning that males & females are
equally affected

8. Pathophysiology
I. Proteinuria :Increase glomerular permeability for
proteins due to loss of negative charged
glycoprotein
• Degree of protineuria:-
– Mild: less than 0.5g/m2/day
– Moderate: 0.5 – 2g/m2/day
– Severe: more than 2g/m2/day
• Type of proteinuria:-
A-Selective proteinuria: where proteins of low
molecular weight, such as albumin, are excreted
more readily than protein of HMW
B-Non selective : LMW+HMW are lost in urine

9. Pathophysiology /2
II. Hypoalbinaemia
Due to hyperproteinuria----- Loss of plasma
protein in urine mainly the albumin.
Increased catabolism of protein during acute
phase.

10. Pathophysiology /3
III. Edema
• Reduction plasma colloid osmotic pressure↓
secondary to hypoalbuminemia Edema &
hypovolemia
• *Intravascular volume↓ antidiuretic hormone
(ADH ) & aldosterone(ALD)  water & sodium
retention Edema
• *Intravascular volume↓ glomerular filtration
rate
(GFR)↓ water & sodium retention  Edema

13. Signs & symptoms
1.Main manifestations:
Edema (varying degrees) is the common
symptom
Local edema: edema in face , around
eyes( Periorbital swelling) , in lower
extremities.
Generalized edema (anasarca), edema
in penis and scrotum.

14. The symptoms of nephrotic syndrome
• Fatigue & malaise . Decreased appetite
• Weight gain from excess fluid
• Dull hair
• Foamy urine, decrease in frequency of urination
• Pale fingernail beds .
• Ears cartilage may feel less firm
• Food intolerances or allergies
• Proteinuria, high levels
• Low levels of proteinemia due to its loss in the
urine
• High cholesterol levels in the blood

16. 1.Massive proteinuria
2.Hypoalbuminemia (K+
normal &
BP normal)
3.Edema – usually starts in
periorbital area & dependent areas
of the body and progresses to
generalized, massive edema.
Pitting edema of 4+. Caused by
hypo albumin which causes shift of
fluids to extracellular space. There
is an insidious weight gain- shoes
don't fit, etc..
4.Hyperlipidemia
* NB: there is no hematuria or
hypertension
! Four most common characteristics:

17. Diagnosis
• Urine tests (to check for protein)
>40mg/m2/hr
• Blood tests for levels of cholesterol & albumin
• Renal ultrasound.
• Renal biopsy

18. Blood specimen
• Serum protein: decrease >5.5gm/dL ,
Albumin levels are low ( ＜ 2.5gm/dL).
• Serum cholesterol & triglycerides:
Cholesterol ＞ 5.7mmol/L (220mg/dl).
• ESR↑ ＞ 100mm/hr during activity phase
• Serum complement: Vary with clinical type.
• Renal function

19. Medications
• Corticosteroids
• Immunosuppressive drug therapy
• Diuretics (to reduce the edema)
• Restriction to fluids intake
• IV albumin
• Special diet that restricts salt intake

20. Nrsg care
1. Assess and Document the location and
character of the patient's edema.
2. Vital signs: BP, Pulse
3. Monitor & record intake and output & weigh
the patient accurately each morning after s/he
voids & before S/he eats. Make sure S/he's
wearing the same amount of clothing each time
you weigh him/her.
4. Careful monitoring of IV fluids
5. Plan a low-sodium diet with moderate amounts
of protein.
6. Frequently check urine for protein.

21. Nrsg care
7. Monitor plasma albumin & transferrin
concentrations to evaluate overall nutritional
status.
8. Provide meticulous skin care
9. Use a reduced-pressure mattress or padding to
help prevent pressure ulcers.
10. To prevent the occurrence of thrombophlebitis,
encourage activity & exercise
11. Psychological care - Give the patient & family
reassurance & support
12. Provide appropriate provisions corticosteroids
13. Give diuretic if prescribed

22. Complications
1. Infections: Infections is a major complication in
children with NS. It frequently trigger relapses.
Common infections: URI, peritonitis, cellulitis &UTI
2. Hypercoagulability (Thrombosis)
3. Cardiovascular disease :-Hyperlipidemia, may
be a risk factor for cardiovascular disease.
4. Hypovolemic shock
5. Others: growth retardation, malnutrition, adrenal
cortical insufficiency