Hrishi Narayanan Learning Outcomes Understand the key differences between nephrotic and nephritic syndrome nephritis Describe initial investigations and management of nephrotic and nephritic syndrome nephritis ID: 775043
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Slide1
Nephrotic/nephritic syndrome
Hrishi Narayanan
Slide2Learning Outcomes
Understand the key differences between
nephrotic
and nephritic syndrome (nephritis)
Describe initial investigations and management of
nephrotic
and nephritic syndrome (nephritis)
Describe the possible complications of
nephrotic
syndrome
Slide3Scenario
24 year old man
Feeling more tired recently
No systemic symptoms on questioning
Frothy urine, no urinary symptoms, no blood
No past medical history, no medications
Non-smoker, social alcohol use
Examination is unremarkable
Urine dipstick - protein +++
Slide4Scenario
What are your main differential diagnoses for this gentleman?
What are the features of
nephrotic
syndrome and nephritic syndrome?
How would you investigate this gentleman?
What would your management plan be for this gentleman?
What are the complications of
nephrotic
syndrome?
Slide5Differentials
Emotional stressExerciseFeverUTIOrthostaticSeizuresFocal segmental glomerulonephritisIgA nephropathy (ie Berger's disease)IgM nephropathyMembranoproliferative glomerulonephritisMembranous nephropathyMinimal change diseaseHaemoglobinuriaMultiple myelomaMyoglobinuriaPre-eclampsia/eclampsia
Alport's
syndrome
Amyloidosis
Sarcoidosis
Drugs (
eg
non-steroidal anti-inflammatory drugs (NSAIDs), penicillamine,
gold, angiotensin-converting enzyme (ACE) inhibitors)
Anderson-
Fabry
disease
Sickle cell disease
Malignancies (
eg
lymphoma, solid tumours)
Infections (
eg
HIV, syphilis, hepatitis, post-streptococcal infection)
Aminoaciduria
Drugs (
eg
NSAIDs, antibiotics)
Fanconi's
syndrome
Heavy metal ingestion
Slide6Differentials
Transient – exercise, stress, UTI
Primary glomerular disease – minimal change, FSGS
Secondary glomerular disease – drugs (e.g. NSAIDS), infx (e.g. HIV/hepatitis),
sarcoid
Tubular – drugs
Serum excess – multiple myeloma
Other – pre-eclampsia
Slide7Nephrotic syndrome
Kidney disease leading to proteinuria,
hypoalbuminaemia
, oedema &
lipiduria
Proteinuria - >3g per day
Damage to glomerular basement membrane causes increased permeability
This causes proteinuria →
hypoalbuminaemia
→oedema
Slide8Nephrotic syndrome
Kidney disease leading to proteinuria,
hypoalbuminaemia
, oedema & hyperlipidaemia
Proteinuria - >3g per day
Damage to glomerular basement membrane causes increased permeability
This causes proteinuria →
hypoalbuminaemia
→oedema
Slide9Causes
Primary
Secondary
Minimal change diseaseFocal glomerulosclerosisMembranous nephropathy
Diabetes
SLE
Amyloidosis
Slide10Symptoms
Oedema
Foamy urine
Complications
Slide11Nephritic syndrome
Collection of findings associated with glomerular inflammation and
glomerulonephritis
Features:
Haematuria & red cell casts
Proteinuria
Hypertension
Uraemia
Oliguria
Slide12Nephritic syndrome
Collection of findings associated with glomerular inflammation and
glomerulonephritis
Features:
Haematuria & red cell casts
Proteinuria
Hypertension
Uraemia
Oliguria
Slide13Causes
Post-streptococcal
Primary:
Membranous glomerulonephritis
Rapidly progressive glomerulonephritis
IgA
nephropathy (Berger’s disease)
Secondary
HSP
Vasculitis
Slide14Symptoms & signs
Classically 2-3 weeks after URTI
Oedema
Oliguria
Haematuria
Flank pain
General symptoms
Slide15Investigations
Urine dip
Urine microscopy
Bloods – FBC, U&E, ESR, complement, auto-antibodies, myeloma screen, ASOT
Renal Ultrasound
Renal biopsy
Slide16Investigations
Urine dipstick
Urine microscopy
Bloods – FBC, U&E, ESR, complement, auto-antibodies, myeloma screen, ASOT
Renal Ultrasound
Renal biopsy
Slide17Management
Nephrotic syn.
Nephritis
ConservativeSalt & fluid restrictionMedicalDiureticsACE-inhibitors/ARBSteroids/ImmunosuppressionSurgical
Conservative
Salt & fluid restriction
Medical
Diuretics
Steroids/immunosuppression
Surgical
Dialysis
Slide18Management
Nephrotic syn.
Nephritis
ConservativeSalt & fluid restrictionMedicalDiureticsACE-inhibitors/ARBSteroids/ImmunosuppressionSurgical
Conservative
Salt & fluid restriction
Medical
Diuretics
Steroids/immunosuppression
Surgical
Dialysis
Slide19Complications
Complications of
nephrotic
syndrome:
Infection
Hyperlipidaemia
Hypocalcaemia
Hypercoagulability
Hypovolaemia
Slide20Scenario
A 12 year old male with dark "cola coloured" urine for 2 days
Well until 14 days ago - had a sore throat and fever – resolved without medical input
Now facial puffiness and nonspecific abdominal pain.
Dark brown urine, voiding less, normal smell
Reduced appetite, lethargy, back pain
Normally fit & well, no other symptoms
Examination reveals only mild
periorbital
oedema
Urine dip: blood +++, protein +
Urine microscopy - RBCs are too numerous to count, RBC casts
FBC & U&E normal, ASO titre high, complement C3 low
Slide21Scenario
A 12 year old male with dark "cola coloured" urine for 2 days
Well until 14 days ago - had a sore throat and fever – resolved without medical input
Now facial puffiness and nonspecific abdominal pain.
Dark brown urine, voiding less, normal smell
Reduced appetite, lethargy, back pain
Normally fit & well, no other symptoms
Examination reveals only mild
periorbital
oedema
Urine dip: blood +++, protein +
Urine microscopy - RBCs are too numerous to count, RBC casts
FBC & U&E normal, ASO titre high, complement C3 low
Slide22Scenario
What are your main differential diagnoses for this patient?
How would you investigate this patient?
What would your management plan be for this patient?
Slide23Key points
Nephrotic
syndrome – heavy proteinuria, nephritis (nephritic syndrome) – haematuria
Always do a urine dip for patients with oedema
Important complications include infection and
hypoercoagulability
Slide24Questions?