Nephrotic/nephritic syndromeHrishi Narayanan

Learning Outcomes•Understand the key differences between

nephrotic and nephritic syndrome (nephritis)

•Describe initial investigations and management of nephrotic and nephritic syndrome (nephritis)

•Describe the possible complications of nephrotic syndrome

Scenario•24 year old man •Feeling more tired recently •No systemic symptoms on questioning•Frothy urine, no urinary symptoms, no blood•No past medical history, no medications•Non-smoker, social alcohol use•Examination is unremarkable•Urine dipstick - protein +++

Scenario1. What are your main differential diagnoses

for this gentleman?2. What are the features of nephrotic

syndrome and nephritic syndrome?3. How would you investigate this gentleman?4. What would your management plan be for

this gentleman?5. What are the complications of nephrotic

syndrome?

Differentials• Emotional stress• Exercise• Fever• UTI• Orthostatic• Seizures• Focal

segmental glomerulonephritis• IgA nephropathy (ie Berger's

disease)• IgM nephropathy• Membranoproliferative

glomerulonephritis• Membranous nephropathy• Minimal change disease• Haemoglobinuria• Multiple myeloma• Myoglobinuria• Pre-eclampsia/eclampsia

• Alport's syndrome• Amyloidosis• Sarcoidosis• Drugs (eg non-steroidal anti-

inflammatory drugs (NSAIDs), penicillamine,gold, angiotensin-converting enzyme (ACE) inhibitors)

• Anderson-Fabry disease• Sickle cell disease• Malignancies (eg lymphoma,

solid tumours)• Infections

(eg HIV, syphilis, hepatitis, post-streptococcal infection)

• Aminoaciduria• Drugs (eg NSAIDs, antibiotics)• Fanconi's syndrome• Heavy metal ingestion

Differentials•Transient – exercise, stress, UTI•Primary glomerular disease – minimal

change, FSGS•Secondary glomerular disease – drugs

(e.g. NSAIDS), infx (e.g. HIV/hepatitis), sarcoid

•Tubular – drugs•Serum excess – multiple myeloma•Other – pre-eclampsia

Nephrotic syndrome•Kidney disease leading to proteinuria,

hypoalbuminaemia, oedema & lipiduria•Proteinuria - >3g per day•Damage to glomerular basement

membrane causes increased permeability•This causes proteinuria →

hypoalbuminaemia →oedema

Nephrotic syndrome•Kidney disease leading to proteinuria,

hypoalbuminaemia, oedema & hyperlipidaemia

•Proteinuria - >3g per day•Damage to glomerular basement

membrane causes increased permeability•This causes proteinuria →

hypoalbuminaemia →oedema

CausesPrimary Secondary• Minimal change disease• Focal glomerulosclerosis• Membranous nephropathy

• Diabetes• SLE• Amyloidosis

Symptoms•Oedema•Foamy urine•Complications

Nephritic syndrome•Collection of findings associated with

glomerular inflammation and glomerulonephritis

•Features:▫Haematuria & red cell casts▫Proteinuria▫Hypertension▫Uraemia▫Oliguria

Nephritic syndrome•Collection of findings associated with

glomerular inflammation and glomerulonephritis

•Features:▫Haematuria & red cell casts▫Proteinuria▫Hypertension▫Uraemia▫Oliguria

Causes1. Post-streptococcal2. Primary:

▫ Membranous glomerulonephritis▫ Rapidly progressive glomerulonephritis▫ IgA nephropathy (Berger’s disease)

3. Secondary▫ HSP▫ Vasculitis

Symptoms & signs•Classically 2-3 weeks after URTI•Oedema•Oliguria•Haematuria•Flank pain•General symptoms

Investigations•Urine dip•Urine microscopy•Bloods – FBC, U&E, ESR, complement,

auto-antibodies, myeloma screen, ASOT•Renal Ultrasound•Renal biopsy

Investigations•Urine dipstick•Urine microscopy•Bloods – FBC, U&E, ESR, complement,

auto-antibodies, myeloma screen, ASOT•Renal Ultrasound•Renal biopsy

ManagementNephrotic syn. Nephritis• Conservative

▫ Salt & fluid restriction• Medical

▫ Diuretics▫ ACE-inhibitors/ARB▫ Steroids/

Immunosuppression• Surgical

• Conservative▫ Salt & fluid restriction

• Medical▫ Diuretics▫ Steroids/

immunosuppression• Surgical• Dialysis

ManagementNephrotic syn. Nephritis• Conservative

▫ Salt & fluid restriction• Medical

▫ Diuretics▫ ACE-inhibitors/ARB▫ Steroids/

Immunosuppression• Surgical

• Conservative▫ Salt & fluid restriction

• Medical▫ Diuretics▫ Steroids/

immunosuppression• Surgical• Dialysis

ComplicationsComplications of nephrotic syndrome:•Infection•Hyperlipidaemia•Hypocalcaemia•Hypercoagulability•Hypovolaemia

Scenario• A 12 year old male with dark "cola coloured" urine for 2

days• Well until 14 days ago - had a sore throat and fever –

resolved without medical input • Now facial puffiness and nonspecific abdominal pain.• Dark brown urine, voiding less, normal smell• Reduced appetite, lethargy, back pain• Normally fit & well, no other symptoms• Examination reveals only mild periorbital oedema Urine dip: blood +++, protein +Urine microscopy - RBCs are too numerous to count, RBC

castsFBC & U&E normal, ASO titre high, complement C3 low

Scenario• A 12 year old male with dark "cola coloured" urine for 2

days• Well until 14 days ago - had a sore throat and fever –

resolved without medical input • Now facial puffiness and nonspecific abdominal pain.• Dark brown urine, voiding less, normal smell• Reduced appetite, lethargy, back pain• Normally fit & well, no other symptoms• Examination reveals only mild periorbital oedema • Urine dip: blood +++, protein +• Urine microscopy - RBCs are too numerous to count, RBC

casts• FBC & U&E normal, ASO titre high, complement C3 low

Scenario1. What are your main differential

diagnoses for this patient?2. How would you investigate this patient?3. What would your management plan be

for this patient?

Key points•Nephrotic syndrome – heavy proteinuria,

nephritis (nephritic syndrome) – haematuria

•Always do a urine dip for patients with oedema

•Important complications include infection and hypoercoagulability

Questions?