questions 8

Primary Nephrotic Syndrome

Topic updated on 09/26/16 2:58pm

  • A 3-year-old boy presents with puffy eyes to the ER. His physician had treated him for allergies but the symptoms did not improve. On PE the patient is noted to have lower extremity edema. He has a serum albumin of 2.5 g/dL, and 4+ proteinuria on urinalysis. (Minimal Change Disease)
  • Primary nephrotic syndrome refers to disease limited to kidney
  • Secondary nephrotic syndrome is a multisystem disease
  • Generalized edema (anasarca)
    • caused by loss of albumin / decreased oncotic pressure
  • Labs show
    • hypoalbuminemia (serum albumin of <3.0 g/dL)
    • proteinuria > 3.5 g/day
    • hyperlipidemia with lipiduria
      • low albumin stimulates liver to produce cholesterol
  • Diagnosis made by renal biopsy

Nephrotic Syndrome
"o for protein"
Nephritic Syndrome
Chronic Disease
+ + +
+ / -
+ / -
+ / _
+ + +
+ / -
+ / _
+ RBCs / + WBCs
+ / -
Fatty Casts
RBC and granular casts
Waxy/pigmented/granular casts
Free fat droplets
Oval fat bodies

Generalized treatment
  • Protein restriction
  • Salt restriction
  • Diuretic therapy for edema
  • HMG-CoA reductase inhibitor for hyperlipidema
Minimal Change Disease (MCD)
  • Most common cause of nephrotic syndrome in young children 
  • Results from loss of polyanions (neg charge) in the GBM
  • Associated with allergic diseases
    • treating allergy often improves nephrotic syndrome
    • also the most common manifestation of nephrotic syndrome in Hodgkin's lymphoma
    • electron microscopy findings show effacement of podocytes 
  • Treatment  
    • prednisone
      • disease very responsive with excellent prognosis
  • Complications
    • at risk for encapsulated organism infection especially strep. pneumonia
Focal Segmental Glomerulonephritis
  • Clinically similar to MCD, but occurs in adults with refractory HTN
  • Usually idiopathic
  • Can be associated with:
    • heroin
    • HIV   
    • DM
    • Sickle cell anemia
    • Most common cause of proteinuria in adults
  • Typical presentation of idiopathic type is young, black, hypertensive male 
  • Treatment
    • prednisone
    • cyclophosphamide
  • Prognosis very poor due to refractory disease
Membraneous Glomerulonephritis
  • Most common cause of nephrotic syndrome in adults
  • Causes include
    • infection (HBV, HCV, syphilis, malaria) 
    • drugs (gold, penicillamine)
    • occult malignancy
    • SLE (found in 10% of patients)
  • Treatment
    • prednisone
    • +/- cyclophosphamide
  • Slowly progressive disorder with decreasing response to steroids
Membranoproliferative Glomerulonephritis
  • Two forms
    • Type I is slowly proliferative 
    • Type II more aggressive
      • have autoantibody against C3
      • leads to decreased serum C3 levels
  • Treatment
    • prednisone
    • +/- plasmapheresis or interferon-alpha
  • Prognosis very poor


Qbank (7 Questions)

(M2.RL.7) A seven-year-old girl presents to general pediatrics condition with swelling as shown in Figure A. She has never had symptoms like this before. She has no significant past medical history. Her vital signs are stable. Her physical examination is notable for 2+ pitting edema of the bilateral lower extremities. The remainder of her physical examination is within normal limits. She has no costovertebral angle tenderness. A dipstick urinalysis is significant for 3+ proteinuria. On renal biopsy and on microscopic urinalysis, what would one likely expect to find in this patient? Topic Review Topic
FIGURES: A          

1. Apple-green birefringence and no casts
2. Podocyte effacement and fatty casts
3. Spike and dome appearance with subepithelial deposits and red blood cell casts
4. Positive Congo red stain and waxy casts
5. Kimmelstiel-Wilson lesions and waxy casts

(M2.RL.50) A 37-year-old male with HIV presents to infectious disease clinic for follow-up. He contracted HIV 15 years ago and has been compliant with his anti-viral medications. His viral load is undetectable and CD4 count is within normal limits. He has no other comorbidities and no complaints at today's visit. Vital signs are BP 150/95 mmHg, HR 75 bpm, RR 12, SpO2 99% on room air and T 37 C. Physical examination is unremarkable. A urinalysis reveals proteinuria. Given this patient's illness, what is the most likely glomerulopathy causing this finding? Topic Review Topic

1. A highly corticosteroid responsive disease that is also the most common cause of nephrotic syndrome in children
2. A cause of nephropathy that is likely to be found in patients with multiple myeloma and rheumatoid arthritis
3. A glomerulopathy that is secondary to nonenzymatic glycosylation of the glomerular basement membrane resulting in Kimmelstiel-Wilson lesions
4. A glomerulopathy that is also found in patients with Goodpasture syndrome, Wegener's granulomatosis, and microscopic polyangiitis
5. A disease that is the most common cause of nephrotic syndrome in adults and African American patients

(M2.RL.54) A 38-year-old female presents to emergency department with "swollen eyes and feet." The patient states that she was in her normal state of health until one week ago when she noticed that her shoes and rings were not fitting. In the ED the patient is afebrile with vitals HR 75, BP168/83. The patient cannot comment on her baseline blood pressure. Physical exam is otherwise notable for 2+ pitting edema at the ankles and periorbital edema. In the ED, urinalysis is positive for protein. The patient is admitted, and her kidney disease is further work-up, ultimately revealing low serum C3 and "tram-tracking" on kidney biopsy (Figure A). Which of the following, if part of the patient's medical history, would be a potential etiology for the her kidney disease? Topic Review Topic
FIGURES: A          

1. 8 years of HAART for HIV
2. Chronic hepatitis C without interferon therapy
3. Diagnosis of rheumaoid arthritis (RA) at the age of 28, managed with herbal medicine
4. Untreated syphilis
5. Diagnosis of type 1 diabetes at the age of 16 with intermittant periods of poor control

(M2.RL.58) An asymptomatic 15-year-old high school wrestler with no family history of renal disease is completing his preseason physical exam. He submits a urine sample for a dipstick examination, which tests positive for protein. What is the next appropriate step in management? Topic Review Topic

1. Repeat dipstick on a separate occasion
2. Urine culture
3. Renal ultrasound
4. 24 hour urine collection
5. Spot urine-protein-to-creatinine ratio

(M2.RL.64) A 3-year-old girl is brought to her pediatrician by her mother, who is concerned that her daughter has developed puffy eyes and swelling in her feet. Physical examination confirms bilateral lower extermity edema to the mid-calf. The patient's medical history is significant for acute hepatitis B infection at the age of 9 months that was acquired through perinatal transmission. Laboratory studies are obtained and show a serum albumin level of 2.2 g/dL and 4+ protein and no blood on urinalysis. Hepatitis B serologies are also obtained and show positive HBsAg and positive anti-HBc IgM antibodies. Which of the following is the most likely diagnosis in this patient? Topic Review Topic

1. Minimal change disease
2. Focal segmental glomerulosclerosis
3. Membranous glomerulonephritis
4. IgA nephropathy
5. Poststreptococcal glomerulonephritis

(M2.RL.168) A concerned mother brings her previously healthy 5 year child to the family care physician after 3 mornings of significant swelling around the child's eyes and feet. The mother is concerned since she feels that the child has not been urinating at his normal frequency, and that his urine has been "thick and frothy." The physician requests a 24hr urine protein collection which reveals nephrotic range proteinuria. What is the next step in the management of this patient? Topic Review Topic

1. Echocardiogram
2. Abdominal X-Ray
3. Empiric Steroid Therapy
4. Renal Biopsy
5. Renal Ultrasound

(M2.RL.3966) A 25-year-old female with Hodgkin's lymphoma presents with a several day history of edema. Lab studies show:

Serum Na+: 140 mmol/L
Serum K+: 3.5 mmol/L
Serum albumin: 1.9 g/dL
Total serum bilirubin: 1.0 mg/dL
Serum creatinine: 1.2 mg/dL

Urinalysis shows 4+ proteinuria and fatty casts. What is the most likely diagnosis? Topic Review Topic

1. Focal segmental glomerulosclerosis
2. Membranous nephropathy
3. Minimal change disease
4. Amyloidosis
5. Membranoproliferative glomerulonephritis


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