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.
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)
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
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
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...
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