1. Nephrotic and Nephritic Syndrome
Dr Claire Gibbons
FY2
Claire.gibbons@doctors.org.uk

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.

3. Draw a nephron!

5. 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.

6. What is nephrotic syndrome?

Increased permeability of the glomerulus
leading to loss of proteins into the tubules.

7. Nephrotic Syndrome

Triad of:
− MASSIVE Proteinuria >3g/24hours

Or spot urine protein:creatinine ratio >300-350mg/mmol
− Hypoalbuminaema <25g/L
− Oedema

And often:
− Hypercholesterolaemia/dyslipidaemia (total
cholesterol >10mmol/L)

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

9. Further possible presentations...

Oedema

BP normal/raised

Leukonychia

Breathlessness:
− Pleural effusion, fluid overload, AKI

DVT/PE/MI

Eruptive xanthomata/ xanthalosmata

10. You are a GP with the following
patients...

Young, fit 24 year old male complaining of
frothy urine.

10 year old boy with puffy eyes.

74 year old female with multiple co-morbidities
and swollen ankles.

11. 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...

12. Causes of Nephrotic Syndrome

Primary glomerulonephritis
− Minimal change disease (80% paeds cases)
− Focal segmental glomerulosclerosis (most common
cause in adults)
− Membranous glomerulonephritis

13. 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

14. 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

15. 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

16. 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

17. 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

18. What is nephritic syndrome?

19. Pathophysiology

Thin glomerular basement membrane with
pores that allow protein and blood into the
tubule.

20. Nephritic Syndrome

Clinical syndrome defined by:
− Haematuria/ red cell casts
− Hypertension (mild)
− Oliguria
− Uraemia
− Proteinuria (<3g/24 hours)

21. 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

22. 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...

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

24. 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

25. Red Cell Casts

26. 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

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

28. Example Case

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

30. Any Questions?
Claire.gibbons@doctors.org.uk

31. Sources

Oxford Handbook of Clinical Medicine

Oxford Handbook for the Foundation
Programme

Essential Revision Notes for the MRCP

Www.almostadoctor.com

Www.pathologystudent.com