1. Nephrotic and Nephritic Syndrome
Dr Claire Gibbons
FY2

2. Learning Objectives
Understand and define nephrotic and nephritic syndromes.
Describe the initial investigations and management of nephrotic and nephritic syndromes.
Describe the complications of nephrotic and nephritic syndromes.

3. Draw a nephron!

5. Glomerulonephritis
Glomerulus – capillary loop with basement membrane which allows passage of specific molecules into the nephron
Glomerulonephritis – inflammation/damage of the glomerular basement membrane resulting in altered function. Relatively uncommon cause of kidney injury.
Can present as nephrotic and/or nephritic syndrome.

6. What is nephrotic syndrome?
Increased permeability of the glomerulus leading to loss of proteins into the tubules.

7. Nephrotic Syndrome Triad of: And often:
MASSIVE Proteinuria >3g/24hours
Or spot urine protein:creatinine ratio > mg/mmol
Hypoalbuminaema <25g/L
Oedema
And often:
Hypercholesterolaemia/dyslipidaemia (total cholesterol >10mmol/L)

8. Presentation New-onset oedema Frothy urine
Initially periorbital or peripheral
Later genitals, ascites, anasarca
Frothy urine
Generalised symptoms – lethargy, fatigue, reduced appetite

9. Further possible presentations...
Oedema
BP normal/raised
Leukonychia
Breathlessness:
Pleural effusion, fluid overload, AKI
DVT/PE/MI
Eruptive xanthomata/ xanthalosmata

10. You are a GP with the following patients...
Young, fit 24 year old male complaining of frothy urine.
10 year old boy with puffy eyes.
74 year old female with multiple co-morbidities and swollen ankles.

11. Differential Diagnosis for Oedema
Congestive Cardiac Failure
Raised JVP, pulmonary oedema, mild proteinuria
Liver disease
Hypoalbuminaemia, ascites/oedema
What investigations can you do?
You decide to send your patient to the renal clinic...

12. Causes of Nephrotic Syndrome
Primary glomerulonephritis
Minimal change disease (80% paeds cases)
Focal segmental glomerulosclerosis (most common cause in adults)
Membranous glomerulonephritis

13. Systemic Causes Secondary glomerulonephritis Diabetic nephropathy
Sarcoidosis
Autoimmune: SLE, Sjogrens
Infection: Syphilis, hepatitis B, HIV
Amyloidosis
Multiple myeloma
Vasculitis
Cancer
Drugs: gold, penicillamine, captopril, NSAIDs

14. Investigations Urine dipstick and send to lab Urine microscopy
Bloods – the usual ones, plus renal screen
Immunoglobulins, electrophoresis (myeloma screen), complement (C3, C4) autoantibodies (ANA, ANCA, anti-dsDNA, anti-GBM)
Renal ultrasound
Renal biopsy (all adults)
Children generally trial of steroids first

15. Management Conservative Medical Surgical
Monitor U&E, BP, fluid balance, weight
Salt and fluid restriction
Treat underlying cause
Medical
Diuretics
ACE-inhibitors/ARBs
Corticosteroids/immunosuppression
Dialysis
Anticoagulation
Surgical
Renal transplant

16. Complications Increased susceptibility to infection Thromboembolism
20% adult cases
Due to reduced serum IgG, reduced complement activity, reduced T cell function
Thromboembolism
40% adult cases
Partly due to increased clotting factors and platelet abnormalities
Hyperlipidaemia
due to hepatic lipoprotein synthesis to restore osmotic pressure

17. Prognosis Varies With treatment, generally good prognosis
Especially minimal change disease (1% progress to ESRF)
Without treatment, very poor prognosis
Children under 5 or adults older than 30 = worse prognosis

18. What is nephritic syndrome?

19. Pathophysiology
Thin glomerular basement membrane with pores that allow protein and blood into the tubule.

20. Nephritic Syndrome Clinical syndrome defined by:
Haematuria/ red cell casts
Hypertension (mild)
Oliguria
Uraemia
Proteinuria (<3g/24 hours)

21. Signs and Symptoms Haematuria (E.g. cola coloured) Proteinuria
Hypertension
Oliguria
Flank pain
General systemic symptoms
Post-infectious = 2-3 weeks after strep- throat/URTI

22. What are your differentials?
Malignancy (older patients)
UTI
Trauma
What bedside investigation would you like to do?
You decide to refer to the renal clinic...

23. Causes Post-infectious glomerulonephritis Primary
IgA Nephropathy (Berger's disease)
Rapidly progressive glomerulonephritis
Proliferative glomerulonephritis
Secondary glomerulonephritis
Henoch-Schonlein purpura
Vasculitis

24. Investigations Urine dipstick and send sample to lab
Urine microscopy – red cell casts
Bloods – the usual plus renal screen
Immunoglobulins, electrophoresis, complement (C3, C4) autoantibodies (ANA, ANCA, anti-dsDNA, anti-GBM); blood culture; ASOT (anti-streptolysin O titre)
Renal ultrasound
Renal biopsy

25. Red Cell Casts

26. Management Conservative Medical Surgical
Monitor U&E, BP, fluid balance, weight
Salt and fluid restriction
Treat underlying cause
Medical
Diuretics
Treat hypertension
Corticosteroids/immunosuppression
Dialysis
Surgical
Renal transplant

27. Prognosis
Varies
Post-infectious usually self-resolving (95% recover renal function)
Others are a bit more nasty

28. Example Case

29. Summary Nephrotic syndrome = MASSIVE proteinuria
Nephritic syndrome = haematuria/red cell casts
May be a mixed presentation
New oedema? Dipstick that urine!
Haematuria? Exclude malignancy!

30. Any Questions?

31. Sources Oxford Handbook of Clinical Medicine
Oxford Handbook for the Foundation Programme
Essential Revision Notes for the MRCP