Nephrotic syndrome

Nephrotic syndrome is the combination of: 
  • Proteinuria (>3-3.5g/24 hrs or urine protein:creatinine ratio >300-350m/mmol) 
  • Hypoalbuminaemia (serum albumin <25g/l) 
  • Peripheral oedema 

There is also often severe hyperlipidaemia 

Causes of nephrotic syndrome include 
  • Primary glomerular diseases – accounts for the majority of cases
    • Focal segmental glomerulosclerosis – commonest primary cause in black paients; accounts for around a third of primary cases 
    • Membranous glomerular disease –commonest primary cause in white patients; also accounts for around a third of primary cases 
    • Minimal change disease – 15%
    • Membranoproliferative glomerular disease – 14% 
  • Secondary causes

Presentation of nephrotic syndrome includes 
  • Oedema 
    • Often initially periorbital 
  • Tiredness 
  • Breathlessness 

Clinical signs which may be present include:
  • Oedema 
  • Leuconychia (due to the low albumin) 
  • Signs of pleural effusion 
  • Raised JVP 
  • Ascites 
  • Eruptive xanthomata 
  • Xanthalasmata 
  • Frothy urine 

  • Urine dipstick (Protein +++, haematuria) 
  • Early morning urinary protein:creatinine ratio 
  • Bloods – UEs, LFTs, FBC, clotting 
  • Investigations looking for causes of nephrotic syndrome 
    • Glucose 
    • CRP 
    • Immunoglobulins 
    • ?autoimmune screen 
  • CXR 
  • Renal ultrasound 
  • Renal biopsy 

  • Refer to renal team 
  • Fluid restrict – 1.5l 
  • Restrict sodium 
  • Furosemide 
  • ACE-i 
  • ? prophylactic anticoagulation 

  • Thromboembolism 
    • DVT 
    • PE 
    • Renal vein thrombosis 
  • Infection (20%) 
  • Acute renal failure 

Small print gem: Membranous glomerular disease has an association with cancer, especially lung and bowel.

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