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Nephrotic/nephritic syndrome Hrishi Narayanan. Learning Outcomes Understand the key differences between nephrotic and nephritic syndrome (nephritis) Describe.

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Presentation on theme: "Nephrotic/nephritic syndrome Hrishi Narayanan. Learning Outcomes Understand the key differences between nephrotic and nephritic syndrome (nephritis) Describe."— Presentation transcript:

1 Nephrotic/nephritic syndrome Hrishi Narayanan

2 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

3 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 +++

4 Scenario 1.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?

5 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

6 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

7 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

8 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

9 Causes PrimarySecondary Minimal change disease Focal glomerulosclerosis Membranous nephropathy Diabetes SLE Amyloidosis

10 Symptoms Oedema Foamy urine Complications

11 Nephritic syndrome Collection of findings associated with glomerular inflammation and glomerulonephritis Features: ▫Haematuria & red cell casts ▫Proteinuria ▫Hypertension ▫Uraemia ▫Oliguria

12 Nephritic syndrome Collection of findings associated with glomerular inflammation and glomerulonephritis Features: ▫Haematuria & red cell casts ▫Proteinuria ▫Hypertension ▫Uraemia ▫Oliguria

13 Causes 1.Post-streptococcal 2.Primary: ▫Membranous glomerulonephritis ▫Rapidly progressive glomerulonephritis ▫IgA nephropathy (Berger’s disease) 3.Secondary ▫HSP ▫Vasculitis

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

15 Investigations Urine dip Urine microscopy Bloods – FBC, U&E, ESR, complement, auto- antibodies, myeloma screen, ASOT Renal Ultrasound Renal biopsy

16 Investigations Urine dipstick Urine microscopy Bloods – FBC, U&E, ESR, complement, auto- antibodies, myeloma screen, ASOT Renal Ultrasound Renal biopsy

17 Management Nephrotic syn.Nephritis Conservative ▫Salt & fluid restriction Medical ▫Diuretics ▫ACE-inhibitors/ARB ▫Steroids/Immunosuppressi on Surgical Conservative ▫Salt & fluid restriction Medical ▫Diuretics ▫Steroids/immunosuppressi on Surgical Dialysis

18 Management Nephrotic syn.Nephritis Conservative ▫Salt & fluid restriction Medical ▫Diuretics ▫ACE-inhibitors/ARB ▫Steroids/Immunosuppressi on Surgical Conservative ▫Salt & fluid restriction Medical ▫Diuretics ▫Steroids/immunosuppressi on Surgical Dialysis

19 Complications Complications of nephrotic syndrome: Infection Hyperlipidaemia Hypocalcaemia Hypercoagulability Hypovolaemia

20 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

21 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

22 Scenario 1.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?

23 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

24 Questions?


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