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1. NEPHROTIC AND NEPHRITIC
SYNDROME
PRESENTER: UNISA A. KANU
SUPERVISOR: DR IRENE

2. LEARNING OBJECTIVES
 Understand and define nephrotic and nephritic
syndromes.
 Describe the initial investigations and management
of nephrotic and nephritic syndromes.
 Describe the complications of nephrotic and
nephritic syndromes.

4. GLOMERULONEPHRITIS
 Glomerulus – capillary loop with basement
membrane which allows passage of specific
molecules into the nephron
 Glomerulonephritis – inflammation/damage of the
glomerular basement membrane resulting in altered
function. Relatively uncommon cause of kidney
injury.
 Can present as nephrotic and/or nephritic
syndrome.

5. What is nephrotic syndrome?
• Increased permeability of the glomerulus leading to loss of
proteins into the tubules.
• Triad of:
 MASSIVE Proteinuria >3g/24hours
 Or spot urine protein: creatinine ratio >300-350mg/mmol
 Hypoalbuminaema <25g/L
 Oedema
• And often:
 Hypercholesterolemia/dyslipidaemia (total cholesterol
>10mmol/L)

6. PRESENTATION
 New-onset oedema
 Initially periorbital or peripheral
 Later genitals, ascites, anasarca
 Frothy urine
 Generalised symptoms – lethargy, fatigue, reduced
appetite

7. FURTHER POSSIBLE PRESENTATIONS...
 Oedema
 BP normal/raised
 Leukonychia
 Breathlessness:
 Pleural effusion, fluid overload, AKI
 DVT/PE/MI
 Eruptive xanthomata/ xanthalosmata

8. CAUSES OF NEPHROTIC SYNDROME
 Primary glomerulonephritis
 Minimal change disease (80% paeds cases)
 Focal segmental glomerulosclerosis (most common cause
in adults)
 Membranous glomerulonephritis

9. Systemic Causes
 Secondary glomerulonephritis
 Diabetic nephropathy
 Sarcoidosis
 Autoimmune: SLE, Sjogrens
 Infection: Syphilis, hepatitis B, HIV
 Amyloidosis
 Multiple myeloma
 Vasculitis
 Cancer
 Drugs: gold, penicillamine, captopril, NSAIDs

10. INVESTIGATIONS
 Urine dipstick and send to lab
 Urine microscopy
 Bloods – the usual ones, plus renal screen
 Immunoglobulins, electrophoresis (myeloma screen),
complement (C3, C4) autoantibodies (ANA, ANCA,
anti-dsDNA, anti-GBM)
 Renal ultrasound
 Renal biopsy (all adults)
 Children generally trial of steroids first

11. MANAGEMENT
 Conservative
 Monitor U&E, BP, fluid balance, weight
 Salt and fluid restriction
 Treat underlying cause
 Medical
 Diuretics
 ACE-inhibitors/ARBs
 Corticosteroids/immunosuppression
 Dialysis
 Anticoagulation
 Surgical
 Renal transplant

12. COMPLICATIONS
 Increased susceptibility to infection
 20% adult cases
 Due to reduced serum IgG, reduced complement activity,
reduced T cell function
 Thromboembolism
 40% adult cases
 Partly due to increased clotting factors and platelet
abnormalities
 Hyperlipidaemia
 due to hepatic lipoprotein synthesis to restore osmotic
pressure

13. Prognosis
 Varies
 With treatment, generally good prognosis
 Especially minimal change disease (1% progress to
ESRF)
 Without treatment, very poor prognosis
 Children under 5 or adults older than 30 = worse
prognosis

14. DIFFERENTIAL DIAGNOSIS FOR OEDEMA
 Congestive Cardiac Failure
 Raised JVP, pulmonary oedema, mild proteinuria
 Liver disease
 Hypoalbuminaemia, ascites/oedema
 What investigations can you do?
 You decide to send your patient to the renal clinic...

15. WHAT IS NEPHRITIC SYNDROME?

16. PATHOPHYSIOLOGY
 Thin glomerular basement membrane with pores that
allow protein and blood into the tubule.
 Clinical syndrome defined by:
 Haematuria/ red cell casts
 Hypertension (mild)
 Oliguria
 Uraemia
 Proteinuria (<3g/24 hours)

17. SIGNS AND SYMPTOMS
 Haematuria (E.g. cola coloured)
 Proteinuria
 Hypertension
 Oliguria
 Flank pain
 General systemic symptoms
 Post-infectious = 2-3 weeks after strep-throat/URTI

18. What are your differentials?
 Malignancy (older patients)
 UTI
 Trauma
 What bedside investigation would you like to do?
 You decide to refer to the renal clinic...

19. Causes
 Post-infectious glomerulonephritis
 Primary
 IgA Nephropathy (Berger's disease)
 Rapidly progressive glomerulonephritis
 Proliferative glomerulonephritis
 Secondary glomerulonephritis
 Henoch-Schonlein purpura
 Vasculitis

20. INVESTIGATIONS
 Urine dipstick and send sample to lab
 Urine microscopy – red cell casts
 Bloods – the usual plus renal screen
 Immunoglobulins, electrophoresis, complement (C3, C4)
autoantibodies (ANA, ANCA, anti-dsDNA, anti-GBM);
blood culture; ASOT (anti-streptolysin O titre)
 Renal ultrasound
 Renal biopsy

21. Red Cell Casts

22. Management
 Conservative
 Monitor U&E, BP, fluid balance, weight
 Salt and fluid restriction
 Treat underlying cause
 Medical
 Diuretics
 Treat hypertension
 Corticosteroids/immunosuppression
 Dialysis
 Surgical
 Renal transplant

23. PROGNOSIS
 Varies
 Post-infectious usually self-resolving (95% recover
renal function)
 Others are a bit more nasty

24. EXAMPLE CASE

25. ANY QUESTIONS?

26. SUMMARY
 Nephrotic syndrome = MASSIVE proteinuria
 Nephritic syndrome = haematuria/red cell casts
 May be a mixed presentation
 New oedema? Dipstick that urine!
 Haematuria? Exclude malignancy!

27. THANK YOU