Nephrotic Syndrome

Introduction –The syndrome is apparent in any condition that seriously damages the glomerular
capillary membrane that results in increase glomerular capillary permeability to plasma proteins.
Although liver is capable of increasing the production of protein. It can’t keep up with the daily loss of
albumin through the kidney. Thus hypoalbuminemia results.

Definition

It is a clinical disorder that is characterized by proteinuria, hypoalbuminemia, edema and

hyperlipidemia. This occurs due to excessive leakage of plasma proteins in urine because of increase
capillary permeability of the glomerulus.

Etiology

1. Primary renal cause

• Minimal change nephropathy

• Glomerulosclerosis
• Acute post streptococcal glomerulonephritis
• Immune complex glomerulonephritis.

2. Systemic cause

• Infections
• Toxins – mercury, bismuth, gold
• Allergic – bee sting, inhaled pollen, food allergy
• Cardiovascular – sickle cell disease, renal vein thrombosis, congestive heartfailure
• Malignancies – leukemia
• Others – systemic lupus erythematous, anaphylactic

TYPES

1. Idiopathic NS:

In childhood, the vast majority belongs to category it is regarded as a sort of autoimmune phenomenon,
especially since it responds well to immunosuppressive therapy. It is two types:

a) Minimal change NS – this predominant type, seen 86% of the cases.

b) Significant change NS – this is infrequent. Mesangial proliferation is seen in 5% cases and focal
sclerosis in 10% of cases.

2. Secondary NS:
• It occurs in children (about 10%) of all cases.
 • This condition may occur due to some form of chronic glomerulonephritis, or due to diabetes
mellitus, SLE, malaria, malignant hypertension, hepatitis B, infective endocarditic, HIV/AIDS,
drug toxicity, lymphomas syphilis etc.

3. Congenital NS:
• It is rare but a serious and fetal problem usually associated with other congenital anomalies of
kidney.
• It is inherited as autosomal recessive disease.
• Severe renal insufficiency & urinary infections along with this condition result is poor prognosis.

4. Infantile NS:
• The term is applied to NS occurring in infants between 4 – 12months of age.

Pathophysiology

Due to E/F

Glomerular damage

Increased permeability of glomerulus capsule to protein

Proteinuria (3.5 gm/24 hours)

Increase renal catabolism albumin

Hypoalbuminemia (less then 3.4 mg/DL)

Decrease plasma oncotic pressure Compensatory synthesis of protein

including lipoprotein by liver

Fluid escape into Decrease plasma Decrease lipid catabolism due to low level
the tissue volume of protein

Edema Decrease GFR Hyperlipidemia

Increase Aldosterone

Sodium and water Retention

Generalized edema
(Anasarca or dropsy)
CLINICAL MANIFESTATION

Four main symptoms of nephritic symptoms:-

• Protein urea
• Hypoalbuminemia
• Hyperlipidemia
• Edema

OTHERS:
• SOB (Shortness of breath)
• Mild headache
• Fever, rash, joint pain
• Weakness
• Malaise
• Anorexia
• Weight gain
• Periorbital edema
• Irritability
• Ascites
• HTN
• Anemia due to loss of RBCs
• Flank pain
• Fatigue.

DIAGNOSIS
 PALPATION: Due to edema and ascites kidney cannot be palpable.
 Urine analysis
• Haematuria
• 24 hour urinary total protein estimation – urine sample shows proteinuria (>3.5 g per liter
per 24 hours)
 Blood test
• BUN
• S.creatinine
• S.protein Desreases
• Lipid profile shows high level of S. cholesterol- 200mg.
• Comprehensive metabolic panel(CMP) shows hypoalbuminemia, albumin level is <2.5g/dl
• Needle biopsy of kidney
• ECG
• KUB – X.ray
• Renal ultrasound
• Renal scan
• Intravenous urogram (IVU).
Treatment:

 Blood pressure medications: These can help to lower blood pressure and reduce the amount of
protein lost in the urine. These medications include angiotensin-converting enzyme (ACE)
inhibitors and angiotensin II receptor blockers (ARBs).
 Diuretics. Diuretics cause your kidneys to release extra fluid, which brings down swelling. These
medications include things like furosemide (Lasix) and spironolactone (Aldactone).
 Statins. These drugs lower cholesterol levels. Some examples of stains include atorvastatin
calcium (Lipitor) and lovastatin (Altoprev, Mevacor).
 Blood thinners. These medications reduce your blood’s ability to clot and may be prescribed if
you’ve had a blood clot in your kidney. Examples include heparin and warfarin (Coumadin,
Jantoven).
 Immune system suppressants. These drugs help keep the immune system under control and
can be helpful for treating an underlying condition like lupus. An example of an immune-
suppressing medication is corticosteroids.

Complication

• Infection
• Thromboembolic complication
• Pulmonary edema
• Hypovolemia
• Growth retardation
• Altered drug metabolism
• ESRD

NURSING MANAGEMENT

NURSING DIAGNOSIS:
• Risk for infection related to immunosuppressive drugs.
• Fluid and electrolyte imbalanced related to edema.
• Impaired skin integrity related to disease process.
• Altered nutrition related to Anorexia.
• Altered kidney function related to disease condition.
• Knowledge deficit related to disease process.