Updated: 3/23/2020

Nephrotic Syndrome

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Snapshot
  • 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.
Introduction
  • 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
        • most common cause of nephrotic syndrome in adults
      • 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
    • HBV
      • membranous nephropathy
  • Prognosis
    • depends on the underlying cause
      • e.g., patients with minimal change disease typically respond well to steroid therapy
Presentation
  • 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
Studies
  • Labs
    • hypoalbuminemia (serum albumin of < 2.5 g/dL)
    • hyperlipidemia
  • Urine studies
    • rule out transient / orthostatic proteinuria if no symptoms or signs are present other than proteinuria
    • 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
Type
Pathophysiology
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
Amyloidosis
  • Amyloid deposits in the mesangium
  • Electron microscopy 
    • apple-green birefringence on Congo red stain under polarized light 
  • Associated with multiple myeloma and chronic inflammatory conditions (i.e., rheumatoid arthritis)
  • Treatment involves addressing the plasma cell dyscrasia or management of the underlying inflammatory condition
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
 
 

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Questions (7)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.RL.17.80) A 23-year-old male presents with enlarged cervical nodes. The nodes are non-erythematous, non-tender, mobile, and have a rubbery consistency. He notes recurrent night sweats that soak through his clothes and nightly fevers. A lymph-node biopsy is performed, and is shown in Figure A. The patient also mentions that his urine is “frothy”. A urine dipstick is positive for albumin (3+). If a renal biopsy were to be performed, which of the following would most likely be found in this patient? Review Topic | Tested Concept

QID: 104622
FIGURES:
1

Normal glomerulus on light microscopy

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Eosinophilic nodular glomerulosclerosis

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Hypercellular glomeruli with many neutrophils

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Mesangial proliferation

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5

Red-green birefringence under polarized light on congo red stain

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(M2.RL.15.58) 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? Review Topic | Tested Concept

QID: 104600
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Repeat dipstick on a separate occasion

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2

Urine culture

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Renal ultrasound

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24 hour urine collection

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Spot urine-protein-to-creatinine ratio

13%

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(M2.RL.15.3966) 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?
Review Topic | Tested Concept

QID: 106281
1

Focal segmental glomerulosclerosis

4%

(1/25)

2

Membranous nephropathy

8%

(2/25)

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Minimal change disease

68%

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4

Amyloidosis

12%

(3/25)

5

Membranoproliferative glomerulonephritis

4%

(1/25)

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