This document discusses the approach to nephrotic syndrome. It describes the case of a 15-year old male patient presenting with swelling of the face and limbs and decreased urine output. Examinations and investigations revealed nephrotic syndrome. A renal biopsy showed membranoproliferative glomerulonephritis. The document then discusses nephrotic syndrome including definitions, classifications of primary and secondary causes, diagnostic workup including renal biopsy, complications of renal biopsy, and treatment approach.

1. Approach to Nephrotic Syndrome
Dr Abhay Mange

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. 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. 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. Provisional Diagnosis
 Nephrotic syndrome
 Renal biopsy planned

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. 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. 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. 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.

12. Final diagnosis
 Idiopathtic Membranoproliferative
glomerulonephritis
Nephrotic syndrome

13. Approach to acute Glomerulonephritis

14. DISCUSSION

15. 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.

16. Classification
Nephrotic syndrome can be
 Primary, being a disease specific to the kidneys,
 Secondary, being a renal manifestation of a systemic
general illness

17. 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 .

18. Secondary causes
Secondary causes include-
 Diabetes mellitus
 Lupus erythematosus
 Amyloidosis and paraproteinemias
 Viral infections (eg, hepatitis B, hepatitis C, HIV )
 Preeclampsia

19. 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

20. 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)

21. 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

22. 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

23. 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

24. THANK YOU