questions 6

Nephrotic Syndrome

Topic updated on 08/29/17 7:09pm

  • A 6-year-old boy is brought to the emergency department by his mother due to swelling around his eyes and legs. The mother reports that the patient recently recovered from an upper respiratory tract infection. Physical exam is significant for periorbital and lower extremity edema. Laboratory testing is significant for hypoalbuminemia and normal complement levels. Urinalysis demonstrates 4+ protein. A presumptive diagnosis of minimal change disease is made and the patient is started on steroid therapy.
  • Clinical definition
    • a type of kidney disease that results in proteinuria, peripheral edema, hyperlipidemia, and hypoalbuminemia
  • Epidemiology
    • incidence
      • annually there are 3 cases per 100,000 adults
  • Etiology
    • primary glomerular disease
      • focal segmental glomerulosclerosis
      • membranous nephropathy
      • minimal change disease
    • secondary causes
      • diabetic nephropathy
      • systemic lupus erythematosus
      • amyloidosis
  • Pathogenesis
    • the glomerulus becomes permeable to large molecules (e.g., albumin)
      • this loss of albumin (proteinuria) results in hypoalbuminemia and edema
      • associated with a hypercoagulable state
        • pathophysiology unclear but may be due to loss of antithrombin and plasminogen proteins
      • increased lipid synthesis secondary to proteinuria
        • this in turn results in hypercholesterolemia and hyperlipidemia
  • Associated conditions
    • chronic kidney disease
  • Prognosis
    • depends on the underlying cause
      • e.g., patients with minimal change disease typically respond well to steroid therapy
  • Symptoms
    • edema
      • periorbital, lower extremity, and genital edema
    • frothy urine
    • ascites
    • weight gain
    • fatigue
    • shortness of breath
  • Physical exam
    • hypertension
    • edema
    • leukonychia
      • suggestive of a low albumin state and presents as white streaking on the fingernails
  • Labs
    • hypoalbuminemia (serum albumin of < 2.5 g/dL)
    • hyperlipidemia
  • Urine studies
    • proteinuria > 3-3.5 g/day 
      • or > 300-350 mg/mmol on spot urine protein to creatinine ratio
    • fatty casts with "maltese cross" sign

Nephrotic Syndrome
Renal Biopsy
Treatment and Notes
Focal segmental glomerulosclerosis
  • Podocyte injury or decreased glomerular filtration barrier integrity
  • Light microscopy 
    • segmental scarring
  • Treat underlying etiology in secondary causes
  • Steroid therapy
  • Can be secondary to 
    • HIV
    • sickle cell disease
    • heroin abuse
    • interferon treatment
Minimal change disease 
  • Unclear but may be due to an immune-related mechanism 
  • Light microscopy
    • normal appearing
  • Electron microscopy
    • effacement of the foot processes  
  • Steroid therapy
  • Most common in children
  • May follow recent infection, immunizations, or may be idiopathic
  • Can be associated with Hodgkin lymphoma
Membranous nephropathy
  • Antibody-immune complex deposition
    • IgG antibodies target podocyte antigens
      • or antigens in close proximity to the podocytes
  • Complement-mediated podocyte injury
  • Light microscopy
    • glomerular basement membrane thickening
  • Immunofluoresence
    • immune complex deposition leading to granular appearance
  • Electron microscopy
    • "spike and dome" 
    • subepithelial deposits
  • Immunosuppressive therapy in primary cases
    • steroids and cyclophosphamide
  • Most common cause of primary nephrotic syndrome in Caucasian adults
  • Primary causes
    • antibodies targeting phospholipase A2 receptors
  • Secondary causes
    • medications
    • systemic lupus erythematosus
    • nonsteroidal anti-inflammatory drugs
    • gold
    • penicillamine
    • hepatitis B and C infection
  • Amyloid deposits in the mesangium
  • Electron microscopy 
    • apple-green birefringence on Congo red stain under polarized light
  • Treatment involves addressing the plasma cell dyscrasia
Diabetic glomerulonephropathy
  • Glomerular hyperperfusion and hyperfiltration result in albumin leaking
    • under these conditions the glomerulus responds via
      • glomerular basement membrane thickening
        • due to non-enzymetic glycosylation
      • hypertrophy
      • sclerosing
      • podocyte injury
  • Light microscopy 
    • expansion of the mesangium
    • Kimmelstiel-Wilson lesions
  • Angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)
  • Adequately controlling diabetes


Qbank (3 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.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

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