Nephrotic Syndrome

Aka: Nephrotic Syndrome, Nephrosis

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II. Definition

  1. Conditions causing Proteinuria, edema, hypoalbuminemia and Hyperlipidemia

III. Epidemiology

  1. Incidence: 3 per 100,000 per year in U.S.

IV. Pathophysiology: Edema in Nephrotic Syndrome

  1. Underfill mechanism (children)
    1. Significant Proteinuria results in hypoalbuminemia
    2. Decreased oncotic pressure results in edema
  2. Overfill mechanism (adults)
    1. Glomerulus becomes more permeable to albumin and other Proteins
    2. Proteinuria Causes tubulointerstitial inflammation
    3. Hypoalbuminemia also occurs and results in decreased oncotic pressure
    4. Sodium retention leads to edema

V. Types: Histologic

  1. Primary glomerulonephropathy progresses to Nephrosis
    1. Occurs in 20% of cases
  2. Children
    1. Minimal Change Disease (NIL Lesion)
  3. Adults
    1. Membranous Nephropathy (33%)
      1. Most common in white patients
    2. Focal Segmental Glomerulosclerosis (33%)
      1. Most common in black patients
    3. Minimal Change Disease (15%)
    4. Immunoglobulin A Nephropathy (15%)

VI. Causes: Secondary

  1. Idiopathic (80-90% of cases)
  2. Most common
    1. Systemic Lupus Erythematosus
    2. Diabetic glomerulosclerosis in Diabetes Mellitus
  3. Immunologic and metabolic
    1. Cryoglobulinemia
    2. Goodpasture's Syndrome (anti-Glomerular Basement Membrane Disease)
    3. Henoch Schonlein Purpura
    4. Polyarteritis Nodosa
    5. Sjogren Syndrome
    6. Membranoproliferative Glomerulonephritis (MPGN)
    7. IgA Nephropathy
    8. Amyloidosis
    9. Erythema Multiforme
    10. Microscopic polyangitis
  4. Viral Infection
    1. Hepatitis B Infection
    2. Hepatitis C Infection
    3. HIV Infection
    4. Epstein-Barr Virus (Mononucleosis)
    5. Herpes Zoster (Shingles)
  5. Bacterial Infection
    1. Infective Endocarditis
    2. Syphilis
    3. Leposy
  6. Protozoa Infection
    1. Filariasis
    2. Helminthiasis
    3. Malaria
    4. Schistosomiasis
  7. Malignancy
    1. Multiple Myeloma
    2. Melanoma
    3. Leukemia or Lymphoma (e.g. Hodgkin's Lymphoma)
    4. Other cancers (e.g. Lung Cancer, Breast Cancer, Colon Cancer, Renal Cell Carcinoma)
  8. Medications and drugs
    1. NSAIDs
    2. Penicillamine
    3. Gold
    4. Lithium
    5. Heroin
    6. Pamidronate
    7. Interferon alfa
    8. Mercury Poisoning
  9. Miscellaneous
    1. Preeclampsia or Eclampsia
    2. Alport Syndrome
    3. Allergic Reaction (e.g. Insect stings, Snake Bite, anti-toxins, Poison Ivy)
    4. Malignant Hypertension
    5. Sarcoidosis
    6. Castleman Disease

VII. Symptoms

  1. Edema (see signs below) with secondary weight gain
  2. Foamy urine
  3. Exertional Dyspnea
  4. Fatigue

VIII. Signs

  1. Hypertension
  2. Edema (most common presenting complaint)
    1. Initial: Progressive Lower Extremity Edema
    2. Later: Periorbital edema, Scrotal Edema, Pleural Effusion, Ascites
    3. May present with acute Congestive Heart Failure

IX. Labs: Diagnosis

  1. Diagnostic criteria (in combination with edema)
    1. Hypoalbuminemia (Serum Albumin <2.5 g/dl)
    2. Hyperalbuminuria (Proteinuria >3.0 to 3.5 grams per day)
    3. Other associated lab findings (supportive, but not required for diagnosis)
      1. Hyperlipidemia (Total Cholesterol often >300 to 350 mg/dl)
  2. Urinalysis
    1. Urine Dipstick with 3+ Protein suggests nephrotic range Proteinuria
    2. Use only for initial screening and then confirm with Urine Protein to Creatinine Ratio
    3. Hematuria or casts suggests Glomerulonephritis
  3. Urine Protein to Creatinine Ratio
    1. Ratio >3 to 3.5 suggests nephrotic range Proteinuria
      1. Correlates with 3 to 3.5 grams Protein in 24 Hour Urine Protein
    2. Efficacy is equivalent to a 24 Hour Urine Protein collection
  4. Lipid profile
    1. Total Cholesterol >300 mg/dl (>50% of patients with Nephrotic Syndrome)
  5. Comprehensive metabolic panel
    1. Serum Albumin <2.5 g/dl
    2. Serum Creatinine increase and GFR reduced in some cases
      1. However Acute Kidney Injury from Nephrotic Syndrome is uncommon
    3. Other findings
      1. Increased serum transaminases may suggest underlying Viral Hepatitis
  6. Renal Biopsy
    1. Defer decision to biopsy to nephrology
    2. Indications
      1. Often not needed if controlled disease or secondary cause is known
      2. Useful in cases in which biopsy would direct treatment or inform prognosis
      3. Idiopathic cases or unknown histologic type
      4. Renal disorders (e.g. SLE)
      5. Severe disease or Corticosteroid refractory

X. Labs: Initial Evaluation of Causes to consider

  1. HIV Test
  2. Hepatitis B Serology (HBsAg)
  3. Hepatitis C Serology (Hepatitis C Antibiody, xHCV)
  4. Serum Protein Electrophoresis or Urine Protein electrophoresis (Multiple Myeloma, Amyloidosis)
  5. Rapid Plasma Reagin (Syphilis)
  6. Connective tissue labs
    1. Antinuclear Antibody
    2. Anti-dsDNA
    3. Complement C3
    4. Complement C4

XI. Imaging

  1. Renal Ultrasound
    1. Indicated in reduced GFR
  2. Other imaging to consider in evaluation of complications or differential diagnosis of edema
    1. Chest XRay
    2. Echocardiogram
    3. Abdominal Ultrasound

XII. Differential Diagnosis

  1. See Edema
  2. See Glomerulonephritis
  3. See Acute Kidney Injury
    1. Acute Interstitial Nephritis
    2. Acute Tubular Necrosis
    3. Renal Vein Thrombosis

XIII. Management

  1. Consult with nephrology
  2. Test for underlying cause (often idiopathic)
  3. Fluids and Electrolytes
    1. Limit daily Sodium intake to 3 grams/day
    2. Consider limiting oral fluids to <1.5 Liters daily
  4. Diuretics
    1. Precautions
      1. Initial goal weight loss: 2-4 lb (1 to 2 kg) per day
      2. Later goal weight loss: 1-2 lb (0.5 to 1 kg) per day (risk of Acute Renal Failure if excessive)
    2. Loop Diuretics (e.g. Furosemide)
      1. Diuretic resistance is typical (due to Protein-bound nature of Diuretics and hypoalbuminemia)
        1. Often requires high dose (e.g. Furosemide 80 to 120 mg)
        2. May require IV dosing as oral absorption may be reduced due to intestinal edema
        3. Consider human albumin 20% IV before IV Diuretic dose (acute cases only)
      2. Starting doses
        1. Furosemide 40 mg orally twice daily OR
        2. Bumetanide 1 mg twice daily
      3. Dose titration
        1. Double dose every 1-3 days until adequate effect
    3. Adjunctive Diuretics
      1. Thiazide Diuretics
      2. Spironolactone
      3. Metolazone (Zaroxolyn)
  5. ACE Inhibitor (or Angiotensin Receptor Blocker if ACE Inhibitor intolerant)
    1. Typically recommended to reduce Proteinuria even if normotensive
    2. Enalapril (Vasotec) 2.5 to 20 mg per day (dosing used in studies)
    3. Lisinopril
  6. Corticosteroids
    1. Example protocol (adult dosing)
      1. Prednisone 60 mg daily for 4 weeks, then 40 mg every other day for 4 weeks
      2. Hahn (2015) Cochrane Database Syst Rev (3):CD001533 [PubMed]
    2. Minimal Change Disease (especially in children)
      1. Corticosteroid responsive
    3. Focal Glomerulosclerosis and Membranous Nephropathy
      1. Variable response to Corticosteroids
      2. Management per local consultant recommendations
  7. Immunosuppressants (e.g. Cyclophosphamide, Chlorambucil, Cyclosporine, Rituximab)
    1. Used alone or in combination with Corticosteroids in some cases (steroids ineffective, intolerable)
    2. Immunosuppressants may be very effective in some secondary causes (e.g. SLE)
  8. Other measures
    1. Avoid Nephrotoxins (e.g. NSAIDs)
    2. Maintain Blood Pressure less than 130/80
    3. Control Hyperlipidemia
      1. Also improves as Proteinuria resolves and underlying secondary cause improves
    4. Other measures that may be considered in specific cases
      1. Prophylactic Anticoagulation
        1. Consider in superimposed Hypercoagulable states (but not used in most cases)
    5. Avoid unproven strategies
      1. Avoid intravenous albumin
      2. Avoid prophylactic Antibiotics

XIV. Complications

  1. Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism)
    1. Relative Risk of 1.4 to 1.7
      1. Deep Vein Thrombosis (occurs in 1.5% of adult Nephrotic Syndrome)
      2. Renal vein thrombosis (occurs in 0.5% of adult Nephrotic Syndrome)
    2. Results in part from loss of coagulation regulatory Proteins (Protein C and Protein S)
    3. Risk factors
      1. Age 18 to 39 years
      2. Nephrotic Syndrome onset in last 6 months
      3. Membranous Nephropathy as the cause of Nephrotic Syndrome (occurs in 7% of cases)
      4. Serum Albumin <2.0 to 2.5 g/dl
  2. Infection and Immunodeficiency
    1. Mechanism
      1. Serum IgG and complement loss (Proteinuria)
      2. Nephrotic Syndrome management (Corticosteroids)
    2. Risk factors
      1. Children
      2. Nephrotic Syndrome relapse
      3. Corticosteroid use
    3. Most common infections
      1. Cellulitis
      2. Peritonitis
      3. Sepsis
  3. Acute Renal Failure
    1. Rare complication
    2. Appears to be multifactorial
      1. Sepsis
      2. Excessive diuresis
      3. Renal vein thrombosis
      4. Renal Interstitial Edema

XV. Prognosis

  1. Variable based on histology and secondary cause
  2. Idiopathic Membranous Nephropathy
    1. One third with benign course
    2. One third with persistent Proteinuria or edema but normal Renal Function
    3. One third with progression to End Stage Renal Disease (ESRD) within 10 day
    4. Chen (2014) Cochrane Database Syst Rev (10):CD004293 [PubMed]
  3. Primary focal segmental sclerosis
    1. Moderate Proteinuria (3 g/day): ESRD develops in 50% over 5-10 years
    2. Severe Proteinuria (>10 g/day): ESRD develops within 3-5 years
    3. Korbet (2012) J Am Soc Nephrol 23(11): 1769-76 [PubMed]

XVI. References

  1. Hull (2008) BMJ 336(7654): 1185-9 [PubMed]
  2. Karnath (2007) Hosp Physician 43(10): 25-30 [PubMed]
  3. Kodner (2009) Am Fam Physician 80(10): 1129-36 [PubMed]
  4. Kodner (2016) Am Fam Physician 93(6):479-85 [PubMed]

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Related Studies

Ontology: Nephrosis (C0027720)

Definition (CSP) diseases of the kidney characterized by purely degenerative lesions of the renal tubules without an inflammatory component.
Definition (MSH) Pathological processes of the KIDNEY without inflammatory or neoplastic components. Nephrosis may be a primary disorder or secondary complication of other diseases. It is characterized by the NEPHROTIC SYNDROME indicating the presence of PROTEINURIA and HYPOALBUMINEMIA with accompanying EDEMA.
Concepts Disease or Syndrome (T047)
MSH D009401
SnomedCT 90708001
LNC LA10567-8
English Nephroses, Nephrosis, NEPHROSIS, Nephrosis [Disease/Finding], nephroses, nephrosis, -- Nephrosis, Nephrosis, NOS, Nephrosis NOS
French NEPHROSE, Néphrose
Portuguese NEFROSE, Nefrose
Spanish NEFROSIS, nefrosis, Nefrosis
German NEPHROSE, Nephrose
Dutch nefrose, Nefrose
Japanese ネフローゼ, ﾈﾌﾛｰｾﾞ
Swedish Nefros
Czech nefróza, Nefróza
Finnish Nefroosi
Russian NEFROZ, НЕФРОЗ
Polish Nerczyca
Hungarian Nephrosis
Croatian NEFROZA
Norwegian Nefrose
Italian Nefrosi
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Nephrotic Syndrome (C0027726)

Definition (CHV) a kidney disease characterized by a high protein level in urine
Definition (NCI) A collection of symptoms that include severe edema, proteinuria, and hypoalbuminemia; it is indicative of renal dysfunction.
Definition (CSP) diseases involving defective kidney glomeruli, characterized by massive proteinuria and lipiduria with varying degrees of edema, hypoalbuminemia, and hyperlipidemia.
Definition (MSH) A condition characterized by severe PROTEINURIA, greater than 3.5 g/day in an average adult. The substantial loss of protein in the urine results in complications such as HYPOPROTEINEMIA; generalized EDEMA; HYPERTENSION; and HYPERLIPIDEMIAS. Diseases associated with nephrotic syndrome generally cause chronic kidney dysfunction.
Concepts Disease or Syndrome (T047)
MSH D009404
ICD9 581
ICD10 N04 , N04.9
SnomedCT 155851004, 197611005, 52254009
LNC LA10569-4
English Nephrotic Syndromes, Syndromes, Nephrotic, NEPHROTIC SYNDROME, Syndrome, Nephrotic, Nephrotic syndrome NOS, Nephrotic syndrome, unspecified, Nephrotic Syndrome, nephrotic syndrome (diagnosis), nephrotic syndrome, Syndrome nephrotic, Nephrotic Syndrome [Disease/Finding], Nephrotic syndrome NOS (disorder), -- Nephrotic Syndrome, Nephrotic syndrome, NS - Nephrotic syndrome, Nephrotic syndrome (disorder), nephrotic; syndrome, syndrome; nephrotic, Nephrotic syndrome, NOS
French SYNDROME NEPHROTIQUE, Syndrome néphrotique
Spanish SINDROME NEFROTICO, síndrome nefrótico, SAI (trastorno), síndrome nefrótico, SAI, síndrome nefrótico (trastorno), síndrome nefrótico, Síndrome nefrótico, Síndrome Nefrótico
German NEPHROTISCHES SYNDROM, Syndrom nephrotisch, Nephrotisches Syndrom: Art der morphologischen Veraenderung nicht naeher bezeichnet, nephrotisches Syndrom, Nephrotisches Syndrom
Dutch syndroom nefrotisch, nefrotisch; syndroom, syndroom; nefrotisch, Nefrotisch syndroom; Niet gespecificeerd, nefrotisch syndroom, Nefrotisch syndroom, Syndroom, nefrotisch
Japanese ネフローゼ症候群, ﾈﾌﾛｰｾﾞｼｮｳｺｳｸﾞﾝ
Swedish Nefrotiskt syndrom
Czech nefrotický syndrom, Nefrotický syndrom, nefronoftíza
Finnish Nefroottinen oireyhtymä
Russian NEFROTICHESKII SINDROM, НЕФРОТИЧЕСКИЙ СИНДРОМ
Portuguese SINDROME NEFROTICO, Síndrome nefrótica, Síndrome Nefrótica
Korean 신 증후군
Croatian NEFROTSKI SINDROM
Polish Zespół nerczycowy
Hungarian Nephrosis syndroma, nephrosis syndroma
Norwegian Nefrotisk syndrom
Italian Sindrome nefrosica
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Renal Glomerular Disorders

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