Nephrotic syndrome is characterized by proteinuria (>3.5g/24hr), hypoalbuminemia, edema, and other issues. The proteinuria is caused by damage to the glomerular filtration barrier, and the other symptoms are secondary effects of protein loss in the urine. Nephrotic syndrome has potential complications including edema, hyperlipidemia, hypercoagulability, and infection risk. Management involves identifying the underlying cause, treating that cause if possible, controlling proteinuria with ACE inhibitors, and managing complications like edema and hyperlipidemia. Steroids are often used but renal biopsy is usually needed first in adults to guide treatment.

1. Nephrotic syndrome

2. Nephrotic syndrome
Nephrotic syndrome is a clinical complex
charecterized by a number of renal and extrarenal
features :
1- protien urea of > 3.5 gram /24 hr.
2- hypoalbominaemia (usually <30 gm/L ).
3- oedema .
4- hyperlipidemia , hyperlipiduria .
5- hypercoagulability .

3.  The key point for nephrotic syndrom is proteinuria
(>3.5 gm/24 hr ) .
 The proteinuria result from altered permiability of
the glumerular filtration barrier for protein (namely
the GBM & podocytes )
 The other components & metabolic complications of
nephrotic syndrome are all secondary to protein loss
in urine .

4. Consequences & Complications of NS :
1- edema
NS. Cause Hypoalbominaemia , & this results in
decrease intravascular oncotic pressure, leading
to leakage of extracellular fluid from the blood to
the interstitium .
The oedema accumulate predominantely in the
lower limbs in adults. Extending to the genitalia
& lower abdomen as it becomes more sever .
In the morning the upper limbs & face may be
more affected .
In children : ascitis occurs early & the oedema is
often seen in the face .

5. 2-Hyperlipidemia
– It is due to the increased hepatic lipoprotein
synthesis that is triggered by reduced oncotic
pressure .
– LDL & cholestrol are increase in majority of
patiens .
– VLDL & triglyceride are increase in patients with
sever disease .
– Hyperlipidemia may accelerate atherosclerosis &
progression of renal disease .

6. 3-hypercoagulability
 It is multifactorial in origin & caused by :
1-Increased urinary loss of antithrombin 3 .
2-Altered level &lor activity of protein C & S .
3-Hyperfibrinogenemia (due to increased hepatic
synthesis ) .
4-Impaired fibrinolysis .
5-Increased platelet aggregability .
The patient may develop peripheral arterial or
venous thrombosis , renal vein thrombosis or
pulmonary embolism .
Venous thrombosis is common & some time fatal.

7. 4-Increased susceptability to Infection
It is due to the low level of IgG ( due to the
urinary loss of IgG ) .
Usually susceptable to infection by Pneumococci .

8. 5-Other metabolic complications of
nephrotic syndrome
A- Protien malnutrition .
B- Iron resistance hypochromic microcytic anaemia
due to transferrin loss.
C-Hypocalcaemia & secondary hyperparathyroidism
as a consequence of Vitamine D deficiency due to
the increased urinary excreation of cholecalciferol
– binding protein .
D- Depressed thyroxine level .
due to the loss of thyroxine – binding globulin .

9. Causes of nephrotic syndrome(types)
A- Nephrotic range proteinuria(NS.) with
bland urine sidement (non-inflammatory)
(Pure nephrotic )
1- Primary glomerular disease :
- minimal change NS.
- membranous glomerulopathy.
- focal glomerulosclerosis .
2- Secondary glomerular disease :
- diabetic nephropathy .
- amyloidosis .

10. B- Nephrotic range proteinuria with active
urine sidement
(inflammatory,proliferative)
(mixed nephrotic / nephritic
1- Primary glomerular disease :
- membranoproliferative glomerulopathy.
2- Secondary glomerular disease :
- membranoproliferative glomerulopathy.
- SLE .
- Henoch-Schonlein purpara .
- Mixed essential cryoglobulinemia .

11. Management of nephrotic syndrome
Management of NS. Has 4 elements :
1- Establish the cause .
2- Treat the cause (if possible ) .
3- Measures to control proteinuria &
treatment of complications.
4- Prevent complications.

12. Renal biopsy
Renal biopsy in adults with NS. Is a valuable tool
for establishing definitive diagnosis , guiding
therapy & estimating prognosis .
Renal biopsy is not required in the majority of
children with NS. As most cases are due to
minimal change disease &respond to emperic
treatment with glucocorticoid .
In NS. Renal biopsy is indicated in :
1- adult patient .
2-children not respond to steroid .

13. Lines of management of NS
A- Treatment of proteinuria:
non specific measure that may reduce
proteinuria is Angiotensin-converting enzyme
inhibitors like lisinopril .
ACE-inhibitors reduce proteinuria & slow the rate
of progression of renal failure by lowering
intraglomerular pressure & preventing the
development of hemodynamically mediated focal
segmental glomerulosclerosis .
ACE-inhibitors are renoprotective in diabetic
nephropathy.

14. B-Treatment of complications of NS
1-Oedema
-Moderate salt restriction ( 1-2 g/day)
-Diuretics : usually we use loop diuretic (frusemide) . But
in sever NS & sever oedema combination of diuretics can
be used acting on different parts of the nephron
(frusemide , thiazide , amiloride )
We should not remove > 1 Kg. of the oedema per day ,
as more aggressive diuretics may precipitate
intravascular volume depletion & pre-renal azotemia .

15. If the patient have sever hypoalbuminaemia , the
oedema may be resistant to diuretics & may
need to give IV albumine by infusion.
Giving albumine in NS. Is some times harmful ,
because the more albumine you give the more
will be loss in the urine & this may cause more
glomerular damage .

16. 2-Hypercholestrolemia
Treated by lipid lowering drugs ( statin
group ) to prevent accelerated
atherosclerosis & slow the decline in GFR.

17. 3- Thromboembolism
Anticoagulation is indicated for patients with
NS. developed DVT , arterial thrombosis or
pulmonary embolism.
Also anticoagulation indicated routinly in
all patients with chronic or sever NS.
There may be a resistance to heparin
because of antithrombine III deficiency .

18. 4-Infection
Risk of infection can be reduced by immunization
( particularly pneumococci).

19. 5- Vit. D deficiency
Vitamin D supplementation is advisable in
patients with clinical or biochemical
evidence of vit. D deficiency .

20. C-Steroid & other immunosupressant
drugs
In adults :
renal biopsy should be done before giving steroid &
other immunosupressant drugs ( as cyclophosphamide ).
giving steroid & other immunosupressant drugs depend
on the result of renal biopsy
In children :
we can start steroid without renal biops because most
cases are minimal change type which have a good
response to steroid .
renal biopsy is indicated if the child with NS. have no
response to steroid.