Nephrotic Syndrome

Department of Internal
Medicine
Christian University of
Indonesia

Definition
Proteinuria
3 gr / day
2 gr / gr creatinine

Edema
Hypoalbuminemia
Hypercholesterolemia

Etiologies
Renal

Systemic

Minimal change
nephropathy
Focal
glomerulosclerosis
Membranous
nephropathy

Diabetes Mellitus Type

2
SLE
Amyloidosis
Viral infection ( hep B /
C)
Precalmpsia
Drug abuse (heroin)

Etiologies
Congenital

Medications

Mutations of genes
that code for
podocytes proteins

NSAID
Gold & penicillamin
Lithium
Interferon
Bevacizumab
Biphosphonat

Pathophysiology

Pathophysiology

Pathophysiology
Hypercoagulability
urinary loss of AT III and plasminogen
increase clotting factors I, VII, VIII and X

Hypovolemia
occurs when albumin < 1.5 g / Dl

Hyperlipidemia
low serum oncotic pressure leads to
hepatic protein synthesis including
lipoprotein

Pathophysiology
infection
due to : S. Pneumoniae, H. Influenzae, E. Coli
Cellulitis, pneumonia, peritonitis

Prone to infection because :

urinary immunoglobulin losses
edema fluit as culture medium
protein deficiency
decreased bactericid activity of leukocytes
immunosuppresive therapy
decreased perfusion of spleen due to hypovolemia

Clinical Presentations
History

Physical Examination

Swelling of the face

Foamy urine

Edema
Hematuria (rare)
Hypertension (rare)

Work Up
Urinalysis
Nephrotic range proteinuria +3 /+4 on
dipstick test
Semiquantitative testing by sulfosalycil
acid

Urine sediment examination

Cells and / or cast
Oval fat bodies and fatty cast (microscope)
Microhematuria

Work Up
Urinary protein measurement
Single spot urine collection > 2 g/ g
creatinine
Timed collection (24 hours) > 150 mg
Urinary electrophoresis

Renal biopsy
Not indicated in patient with obvious
cause
Indicated in childhood nephrotic
syndrome

Work Up
Albumin < 3 gr / dl
Serologic studies
Hep B
Hep C
HIV
Syphilis
Lupus (ANA, anti-dsDNA and
complement)

Work Up
Ultrasonography
Determine wether the patient has 1 or 2
kidney
Only 1 kidney
contraindication for biopsy
prone to developing focal glomerulosclerosis

Increased renal echogenicity

Intrarenal fibrosis

Treatment
Drugs

Dose

ACE Inhibitor or A2RB

Captopril

reduce proteinuria
reduce systemic blood
pressure
reduce intraglomerular
pressure
Direct action on
podocyte

3 x 25 mg

Enalapril
1 x 2.5 mg

Lisinopril
1 x 5 mg

Valsartan
1 x 40 - 80 mg

Treatment
Drugs

Dose

Diuretics

Furosemid

Increases urine output

Administer at
increments 20 40 mg
No sooner than 6 8
hours after previous
dose

Hypolipidemic agent

2 x 40 mg

Spironolactone
1 x 100 mg

Simvastatin 1 x 20 mg

THANK YOU