This document discusses complications of nephrotic syndrome, including hypovolemia, acute kidney injury, infection, thyroid dysfunction, thrombo-embolic complications such as deep vein thrombosis and pulmonary embolism, and renal vein thrombosis. It provides details on the indications for IV albumin treatment for hypovolemia. It also notes that low serum albumin levels can affect warfarin dosing and discusses screening, diagnosis, and treatment of renal vein thrombosis in nephrotic syndrome patients.

1. COMPLICATIONS OF
NEPHROTIC SYNDROME
AMIR EL OKELY
MRCP, MD

2. Questions
 What is the definition of NS?
 What are the complications of NS?
 What are the indications of IV
albumin?
 What is the effect of serum albumin
on warfarin dosing?

3. Nephrotic syndrome
 Proteinuria
 Hypoalbuminemia
 Edema
 Hyperlipidaemia
 Lipiduria

4. .

6. Hypovolemia
 Excessive diuresis.
 Severe hypoalbuminemia cause fluid
movement into the interstitum and
hypovolemia.
 When to give IV albumin?

7. Acute kidney injury
 Excessive diuresis.
 ATIN.
 Superimposed crescentic GN.

8. Infection
 Reduced serum concentration of IG.
 Impaired ability to make specific AB.
 Decreased level of the complement.
 Immunosuppressive therapy.

9. Thyroid Dysfunction
 A decrease in TBG can cause marked changes in
various thyroid function tests.
 When renal failure complicates the nephrotic
syndrome, the thyroid function abnormalities
are often more severe.{TSH}
 Steroids can cause small reduction in TSH
secretion inhibit peripheral conversion of T4 to
T3.{FT4}

10. Thrombo-embolic
Complications
 DVT is the most common.
 PE has been described with or
without evident DVT or RVT.
 The prevalence of a symptomatic
PE in patients with NS range from
12-30%.
 The risk of PE increase in NS by 39
time compared to non NS patients.

11. Pathogenesis
 Increase platelet aggregation.
 Activation of the coagulation
system.
 Decrease endogenous anti-
coagulant.

12. Venous Thrombo-embolism and
Membranous Nephropathy
Clin J Am Soc Nephrol 7: 43–51, 2012.

13. Renal Vein Thrombosis
 RVT may be unilateral or bilateral
and may extend into the inferior
vena cava.
 RVT most often has an insidious
onset and produces no symptoms
referable to the kidney.

14. Renal Vein Thrombosis
 It typically presents with symptoms of
renal infarction, including flank pain,
microscopic or gross hematuria, a marked
elevation in serum LDH, and an increase
in renal size on radiographic study.
 Bilateral RVT may present with acute
renal failure.

15. Screening
Routine screening for RVT is not
recommended in patients with
nephrotic syndrome:
No proven benefit to diagnose occult
disease.
A patient with a negative study may
develop RVT at a later time.

16. Screening
It is also not useful to evaluate for RVT in a
patient who experiences an overt embolic
event such as PE.
It cannot be proven that the pulmonary
embolus originated in the renal veins.
In situ pulmonary thrombosis may occur.
Patients will be treated with anticoagulants
whether or not RVT is present.

17. Diagnosis of RVT
Sensitivity % Specificity %
CT angiography 92.3 100
Doppler US 85 56
IVU 34 87
 Selective renal venography is the standard
diagnostic test for RVT

18. Renal Biopsy

19. Treatment of RVT
 There are no definitive studies that
have evaluated the role of
anticoagulation in patients with an
asymptomatic RVT, but case series
report treating such patients.

20. Treatment of RVT
 Patients with a symptomatic RVT or a
thromboembolic event in the absence of
RVT are treated with low molecular
weight heparin and then warfarin.
 Some patients are partially resistant to
heparin therapy due to severe
antithrombin deficiency.
.

21. Treatment of RVT
 Warfarin therapy is given for a minimum of 6 to
12 months and some people recommend
continuing treatment for as long as the patient
remains nephrotic.
 Local thrombolytic therapy with or without
thrombectomy in patients who have signs of
acute RVT has been successfully performed in
small numbers of patients.

22. Warfarin Induced
Nephropathy
J Am Soc Nephrol 22: 1856–1862, 2011.

23. Warfarin Induced
Nephropathy
Nephrol Dial Transplant (2012) 27: 475–477

24. Behavioural Abnormalities

25. Aspirin Resistance

26. Headache and Visual
Disturbance

27. Questions

28. Thank You