Nephrotic Syndrome

GROUPARELLANO, Tristan Jay I.

BAUTISTA, Mark Christian C.

DAVID, John Aufer D.GUTIERREZ, Algene C.

KIM, Hyun Oae

OLALIA, Jayson S.MARTIN, Eleanor D.

Ventura, Nikki Jireh F.PEREZ, Jaramie O.

VILLAFUERTE, Karla Lizette M.

9thNEPHROTIC

syndrome

Clinical CasePRESENTATION

MRS. RAMEDIO, 66 YEARS OLD

After her menarche at the age of 13, Mrs. Ramedios has had experienced pain during urination, especially during her monthly period. If this happens, all she would do is to perform vaginal douche and just drink plenty of fluids, coconut juice in order to relieve her pain by increasing the flow of urine and increasing its frequency.

Mrs. Remedio during her teenage years already went in to farming, in order to aid her parents to bring home money for the family. It was also during this time that she started to smoke. Her work as a planter is very exhausting as she exerted so many efforts under the scorching heat of the sun. With that, she really perspires a lot, however, when asked as to how many glasses of water she consumed during those very strenuous days at the field, she replied that she can finish only 2 medium glasses a day.

Aside from the dysuria, she had a high-grade fever, which was accompanied by chills. When Mrs. Ramedio felt that there is pain during urination and at the onset of mild fever, she would buy from the nearest drug store the same antibiotics, which is Bactrim and will take this until dysuria will be alleviated.

When asked what does she do after voiding, she revealed that she seldom washes and wipes her vagina after voiding. She noticed that whenever she voids, her urine is very cloudy and seemingly thick and very concentrated, and is very few, bit frequency increased in number. At exactly 12:45 am of March 30, 2013, Mrs. Ramedio shouted at the top of her lungs because of severe suprapubic pain that radiates to the flank area.

When her daughter went to Mrs. Ramedio’s room, she saw her mother curled into a fetal position and was already suffering from high-grade fever. This led to Mrs. Ramedio’s confinement in one of the Secondary Hospitals in Angeles City. CBC revealed an elevation in the WBC count and Urinalysis revealed presence of +4 Albumin in the urine. Puffiness of the eyes and edema on all extremities was noted.

Let’s Have ADEEPER LOOK

justKIDNEY ing

justKIDNEY ing

The renal glomerulus filters the blood that arrives at the kidney.

It is formed of capillaries with small pores that allow small molecules to pass through that have a molecular weight of less than 40,000 Daltons, but not larger macromolecules such

as proteins.

GLOMERULUS

NEPHROTIC SYNDROMEPathophysiolo

gy

Primary Lesions- Membranous Glomerulopathy- Minimal Change Nephrotic Syndrome- Focal Segmental Gromerulosclerosis- Membranoprolirative Glomerulonephritides

Systemic Diseases- Diabetes Insipidus- Amyloidosis- Systemic Lupus Erythematosus- Drugs- Severe Infections- Malignancies

Increased GlomerularCapillary Permeability

Massive Proteinuria [3.5g]

Hypoalbuminemia

Specific Renal EffectsSystemic Effects

Altered Coagulation Factors

Loss of Proteins Carrying Hormones

and Vitamins

Thromboembolism

Depletion of Serum Albumin Levels, Below

Compensatory Synthesis Levels

Parallel to Liver Ability

Decreased Cellular Immunity

Reversed Albumin-

Globulin Ratio

Increased Risk for Infections

SYSTEMIC EFFECTS

Increased Turnover Rate of Immunoglobulins



and Vitamins

Thromboembolism





Reversed Albumin-

Globulin Ratio


SYSTEMIC EFFECTS






Hypoalbuminemia


Albuminuria

Increased Tubular Reabsorption of Filtered Proteins

Increased Catabolism of Albumin

Tubulointerstitial Inflammatory

Infiltrate Induction with Stimulation of Angiotensin II and Inhibition of Nitric

Oxide

Increased Sodium Reabsorption

Primary Retention of Sodium

Increased Capillary Hydrostatic Pressure

SPECIFIC RENAL EFFECTS

Albuminuria





Oxide





Hypoalbuminemia











Hypoalbuminemia



and Vitamins

Thromboembolism





Reversed Albumin-

Globulin Ratio


SYSTEMIC EFFECTS




and Vitamins

Thromboembolism





Reversed Albumin-

Globulin Ratio


SYSTEMIC EFFECTS


Hypoalbuminemia

Hypoalbuminemia

Decreased Plasma Oncotic Pressure

DIFFUSION OF WATER AND ELECTROLYTES TOWARDS INTERSTITIUM

Decreased Plasma Volume

Decreased Venous Return

Increased Production and Secretion of

Vasopressin

Increased Retention of Water and

SodiumDecreased Renal Blood Flow

Variuos Systemic Manifestations Decreased Cardiac Output

Albuminuria





Oxide





Albuminuria





Oxide





Hypoalbuminemia






Vasopressin




Decreased Functional

Capability to Filter Sodium

and Water

Stimulation of R.A.A.S

Increased A-II

Increased Aldosterone

Increased Sodium

Reabsorption

Peripheral Vasoconstriction

Increased Cardiac Workload

Hypertension

Edema

Decreased Functional

Capability to Filter Sodium

and Water

Stimulation of R.A.A.S

Increased A-II

Increased Aldosterone

Increased Sodium

Reabsorption

Peripheral Vasoconstriction

Increased Cardiac Workload

Hypertension

Edema

Hypoalbuminemia






Vasopressin




Increased Synthesis of

Lipoproteins by the Liver

Hyperlipoproteinemiaand Hyperlipidemia

Lipiduria

Presence of either Free Fats or Oval Fat

Bodies in Urine

NEXT

NEPHROTIC SYNDROMESigns & Symptoms

1. Nonspecific symptoms include weakness, fever, abdominal pain, and malaise2. Edema/ Swelling

Puffiness of the eyelids and facial edema In the arms and legs, especially in the feet and ankles

3. Urine is cloudy in appearance.4. Diminished urine output (Oliguria)5. Weight gain from fluid retention6. Proteinuria7. Blood pressure may be elevated8. Hyperlipidemia9. Pale skin color10.Possible flank pain secondary to stretching of the renal capsule

(IN GENERAL)

1.Dysuria2.High grade fever3.Urine is cloudy and turbid in appearance

4.Scanty and diminished urine volume (oliguria)

5.Proteinuria6.Grade ++ edema (moderate edema: both feet plus lower legs, hands or lower arms

7.Suprapubic pain that radiates to the flank area

8.Tachycardia

(PATIENT CENTERED)

NEPHROTIC SYNDROMEDiagnostics

• URINALYSIS• URINE SEDIMENT EXAMINATION• URINARY PROTEIN MEASUREMENT• SERUM ALBUMIN• SEROLOGIC TESTS/STUDIES FOR IMMUNE AND

INFECTION ABNORMALITIES• RENAL ULTRASONOGRAPHY• RENAL BIOPSY

(IN GENERAL)

TESTS RESULTS NORMAL VALUES

CBC:• Hgb 125g/dL 120-160g/dL• Hct 0.26g/L 0.37 – 0.47 g/L

• WBC NEUTROPHILS LYMPHOCYTES MONOCYTES

19.1x10^9/L0.40.2

0.01

5 x 109/L 0.5 – 0.7 g/L0.1 –0.4 g/L0 – 0.04 g/L

• RBC Count 3.04 4.2 – 5.4 x 109/L

SODIUM (Na) 139.8 135 – 145 mEq/L

POTASSIUM (K) 5.1 3.5 – 5.2 mEq/L

RBS 107 up to 140

CREATININE 2.3 0.5 –1.7 mg/dL

(PATIENT CENTERED)

NEPHROTIC SYNDROMEManagement

• Diuretics• Anti -hypertensives• Anti -hyperlipidemics• Anticoagulants• Albumin Replacement• Antibiotics• Corticosteroids• Fluid and Nutrition• Skin Care

NEPHRITIC SYNDROME

NEPHROTIC SYNDROME

ACUTE GLOMERULONEPHRITIS

CAUSEIt is immunologically

mediated, and are characterized by

proliferative changes and inflammation in the

glomeruli

There are many specific reasons, these include kidney

diseases such as minimal-change nephropathy and

systemic diseases such as DM and SLE. All of these diseases are characterized by a loss of

foot processes.

Inflammation of the glomeruli usually due to bacterial infection

SIGNS AND SYMPTOMS

Hematuria (usually with dysmorphic rbcs)

RBC casts on microscopic examination of urinary sediment

Often one or more elements: Mild to moderate

proteinuria (subnephrotic proteinuria of < 3.0 g per 24 h),

Edema, Hypertension, Elevated serum creatinine,

and Oliguria (400 ml/day of

urine)

Proteinuria of >3.5 g per 1.73 m2 per 24 h,

HypoalbuminemiaEdemaHyperlipidemia LipiduriaHypercoagulability

BLOOD in the urineEdema (general) “Foamy urine”Hypertension Low urine outputHyperlipidemiaNausea/vomitingFeverRash

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Nephrotic Syndrome