PROTEINURIA, NEPHROTIC AND NEPHRITIC SYNDROME
Beata Mladosievičová
Institute of Pathophysiology
Medical Faculty, Bratislava
The kidneys play a major role
in regulating
fluids, electrolytes, acids and bases,
osmolality
Imbalances occur as the kidneys
• increase the ability to excrete proteins
or
• decrease the ability to excrete (water,
electrolytes, wastes and acid-base
products) .
The daily excretion of protein into the urine of normal subjects rarely exceeds 150 mg... the small quantity of protein: High molecular weight glycoproteins from the distal tubular epithelium
PROTEINURIA
daily urinary excretion of
protein>150 mg/ day
Unrelated to renal disease
Pathological
Pathological proteinuria
1. Overflow of plasma proteins in excessive concentration – Ig light chains
2. Increased glomerular permeability – abnormalities of GFB 1-40 g of protein/d
3. Tubular damage < 2 g/d
4. Disease of the lower urinary tract
Glomerular permeability to proteins:
the nature of the glomerular filter – Endo, GBM, Epi
(pores in layers,
charge-selective filter,
blood flow)
the properties of the proteins (size, shape, charge)
Bacterial, viral Ag(Ab)
components of complement
attraction of the Leu
lysosomal enzymes, free oxygen radicals
filter damage
Increased glomerular permeability:
congenital NS
minimal change disease (most common in children)
glomerulosclerosis (hypertension, diabetes mellitus)
glomerulonephritis (membranous common in adults)
IK deposits*
postinfectious – bacterial endocarditis, hepatitis, TBC
malignancy – Ca lung, breast, cervix. colon, kidney,
ovary, leukaemias, lymphomas
renal transplant rejection
Glomerulosclerosis
THE NEPHROTIC SYNDROME
Heavy proteinuria > 3.5 g/day/1.73 m2 highly or poorly selective increased glomerular permeability*
decreased tubular reabsorbtion
Hypoproteinaemia (esp.hypoalbuminaemia)
Edema (increased ECF in the interstitium)
decreased oncotic pressure,
increased aldosterone and ADH, sodium and water retention
Hyperlipidaemia increased hepatic synthesis of
lipoproteins
Lipiduria - oval fat bodies, granular casts
Oval fat bodies
Complications of NS
• Infection – skin, lungs, peritoneum
• Premature atherosclerosis
• Impaired coagulation – increased circulating
levels fibrinogen, factors V and VIII, decreased
antithrombin III, haemoconcentration
• Disorders in vitamins, hormones and elements
bound to plasma proteins
Clinical presentation of the NS:
•anorexia
•edema - ankles, periorbital region, anasarca, pleural effusion
• may be hypertension
• thrombotic complications (renal vein!)
• frothy urine (proteinuria), nocturia
Laboratory findings:
Urine: heavy proteinuria, protein ++ or greater in
the urine for 2 consecutive days
casts: granular, hyaline, epithelial
Blood: hypoalbuminemia
globulines, hormones adrenocortical or
thyroid may be low
lipemia (elevated cholesterol, Tg)
anemia (loss of transferrin, poor
production of erythropoetin)
increased levels of fVIII, fibrinogen, Tr, Er
Hematuria
Generally, hematuria is defined as the presence of 5 or more red blood cells (RBCs) per high-power field in 3 of 3 consecutive centrifuged specimens obtained at least 1 week apart.
Hematuria can be either gross - visible(ie, overtly bloody, smoky, or tea-colored urine) or
microscopic.
Hematuria
• Renal
• Postrenal - cystitis, stone, tumor,
accident
• Other – drugs, infections
Hematuria – renal causes
Renal GLOMERULAR
-postinf. GN, RPGN,
glomerulosclerosis...
Renal NONGLOMERULAR–
interstitial, Tu, accident, cystic,
hydronephrosis...
PHARAOH Nephritic sy
Proteinuria
Hematuria
Azotemia
RBC casts
Antistreptolysin O titres
Oliguria
Hypertension
Nephritic sy in adults
Abdominal abscess
Hepatitis B or C
Infective endocarditis
Membranoproliferative GN
Rapidly progressive glomerulonephritis
SLE
Vasculitis
Viral diseases: measles, mononucleosis,
mumps
Case
• 40 yrs old patient. 5 months ago both leg
edema slowly progressive, phlebography
without thrombosis, fatigue 3 months, no
drugs, general practitioner found
hypoproteinemia
• History: alcohol abusus successfully treated
3 yrs ago
• Physical exam: leg edema, back edema, soft
pitting edema
Causes of generalized edema?
• Hypoproteinemia (low intake, enteropathies,
liver damage, nephrotic sy)
• Heart failure (RAA)
• Electrolyte and water dysbalance (primary
hyperaldosteronism, renal failure,...
• Acute GN
• Hypothyreosis
• Drugs
Causes of localized edema?
• Flebotrombosis
• Leg ischemia
• Trauma
• Inflammation
• Lymphedema
• Allergy
Case II cont
• Clinical signs and symptoms of heart
failure, liver damage, myxedema and GIT
damage are not present
• Drugs potentially associated with edema,
such as corticoids, calcium antagonist and
others were not given
Which examinations are
suggested?
• complete blood count,
• proteins,
• electrolytes (Na, K, Cl, Ca),
• creatinín, urea,
• glycemia,
• lipids,
• markers of inflammation
Which next exams?
• Liver test (AST,ALT, bilirubín...),
• urine test,
• X ray chest (pulmonary edema),
• Sonography (ascites, kidneys, liver),
• EKG
Results
• ERY a Hb decreased,
• FW a CRP mild increase,
• Total proteins in blood and albumins
decreased
• cholesterol and TG increased
• liver test normal
• creatinin, urea normal
• EKG, X ray, abdominal and heart
sonography normal
Conclusion
• Low probability of heart, liver and
kidney failure
Next exams?
• Quantitative and qualitative exam of
proteins during 24 hours, electrophoresis
• Systemic disorders (ASLO, RF, antinuclear
faktors)
• Renal biopsy
Results
• IgG low (excluded myeloma and systemic
diseases),
• ASLO,RF, antinuclear ff negat. excluded
systemic disorders
• Proteinuria 36g/day • Histology on biopsy: focal segmental
glomerulosclerosis
Therapy
• Diuretics,
• Corticoids
• ACE inhibitors
Later after 6 months- worsening
• Dialysis and planned transplantation
Hematuria could also be
attributed to
- non-nephrologic bleeding (e.g. menstruation),
• But many are false positive findings due to the
use of certain drugs or consumption of certain
foods (e.g. mangold).
• Transient hematuria is common (40% in the
general population)
• Persistent hematuria (defined as urine
positive in two out of three consecutive
dipsticks, e.g. over a one to two weeks
period) in just 2.5–4.3%