This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision of Prof. Jamal Al Wakeel. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Nephrotic syndrome is kidney disease with proteinuria, hypoalbuminemia, and edema. Nephrotic-range proteinuria is 3 grams per day or more. With Hyperlipidemia and thrombotic diseases. Nephrotic syndrome may affect adults and children, of both sexes and of any race.

Pathogenesis Structural damage to the glomerular basement membrane leads to loss of electrostatic and physical barriers, which normally prevent the passage of large molecular weight proteins into the glomerular infiltrate. Increase protein loss, in addition to increased catabolism of protein in the kidney, leads to hypoalbuminaemia.

Etiology Primary causes of nephrotic syndrome include the following: Minimal-change nephropathy. Focal glomerulosclerosis. Membranous nephropathy. Hereditary nephropathies.

Secondary causes include the following: Diabetes mellitus. Lupus erythematosus. Amyloidosis and paraproteinemias. Viral infections (eg, hepatitis B, hepatitis C, human immunodeficiency virus [HIV]. Preeclampsia.

From a therapeutic perspective, nephrotic syndrome may be classified as steroid sensitive, steroid resistant, steroid dependent, or frequently relapsing.

Clinical features The first sign of nephrotic syndrome in children is usually swelling of the face (periorbital edema) ; this is followed by swelling of the entire body. Adults can present with dependent edema. Foamy urine may be a presenting feature.

Differential Diagnoses Heart failure and liver disease Diabetic Nephropathy Focal Segmental Glomerulosclerosis Glomerulonephritis, Chronic Glomerulonephritis, Membranous HIV Nephropathy IgA Nephropathy Light Chain-Associated Renal Disorders Minimal-Change Disease Nephritis, Radiation Sickle Cell Nephropathy

Diagnostic studies for nephrotic syndrome may include: Urinalysis Urinary protein measurement Serum albumin Serologic studies for infection and immune abnormalities Renal ultrasonography Renal biopsy

Heavy proteinuria ( >3.5 g/24 h in adults ) Hypoalbuminaemia (serum albumin <30 g/l) Hyperlipidemia as a result of increase hepatic synthesis of cholesterol and triglycerides.

Non-Specific Treatment Treatment of oedema Low Na diet Diuretics Loop Thiazide ACEI Treatment of hyperlipidemia Prophylaxis and treatment of Thrombo-embolism

Specific Treatment Prednisolone ( effective in children ) Cyclophosphamide, Chlorambucil ( un responsisive to steroids ) Cyclosporine A

Complications 1- venous thrombosis : hypovolaemia and hypercoagulable state predispose to renal vein thrombosis. 2- sepsis ( infections ): loss of immunoglobulins in the urine increases the susceptibility to infections and death. 3- Acute renal failure : May be a result of hypovolaemia ( after diuratics therapy) or with renal vein thrombosis.

Clinical medicine by Kumar and clark. Medscape.com