10-07-2007, 04:16 PM
NEPHROTIC SYNDROME (NS) is characterized by the
N = Na + water retention
This occurs due to several factors, including compensatory secretion of
aldosterone in response to hypovolemia-mediated release of ADH.
E = Edema
Due to hypoproteinemia + Na, water retention. Edema is soft, pitting
and starts in the periorbital region.
P = Proteinuria >3.5gm/1.74sq. ml/24hrs
H = Hypertension + hyperlipidemia (due to increased lipoprotein
synthesis in liver , abnormal transport of circulating lipoproteins, decreased
catabolism.)
R = Renal vein thrombosis
O = "Oval fat bodies" in the urine. Lipiduria follows hyperlipidemia.
Albumin as well as lipoproteins are lost. Lipoproteins are reabsorbed by
tubular epithelial cells and they shed along with degenerated cells-
this appears as "oval fat bodies" in urine.
T = Thrombotic + thromboembolic complications owing to loss of
anticoagulant factors (eg. anti-thrombin III )
I = Infection. These patients are prone to infection, especially with
staphylococci and pneumococci. Vulnerability is due to loss of
immunoglobulins.
C = hyperCoagulable state
Nephritic S
PHAROH =
Proteinuria,
Hematuria,
Azotemia,
RBC casts,
Oliguria, low urine output <400 mL/day)
Hypertension
1. Distinguish nephrotic syndrome (bland sediment, isolated heavy proteinuria, > 3.5 g/day) from nephritic
syndrome (dysmorphic RBCs, RBC casts, active sediment, proteinuria < 3 g/day).
2. The spot urine protein:creatinine ratio can be a quick tool to look for nephrotic range proteinuria.
3. The secondary causes of nephrotic range proteinuria: think of tumor, drugs, infections, and systemic
causes
Step 1: establish the diagnosis of nephrotic syndrome vs. nephrotic range proteinuria
¢ Check the urinalysis “ cases of nephrotic syndrome should have a bland sediment except for heavy
proteinuria. In nephrotic syndrome, look for lipiduria (maltese cross). If you see red cells, think of
membranoproliferative GN (MPGN) or lupus-induced membranous nephropathy. Note that the
dipstick only checks for albumin; you will want a formal U/A (with the sulfosalicylic acid (SSA) prep to
look for other proteins like light chains in myeloma).
¢ Check the urine spot protein:creatinine ratio. This roughly correlates to the amount of protein/day
excretion.
¢
Check a 24 hour urine for protein and creatinine. Nephrotic-range proteinuria > 3.5 g/day proteinuria.
¢
Check renal ultrasound. Large kidneys “ think of diabetes, HIV nephropathy, and infiltrative disorders
such as amyloidosis. Caveat: acute GN can present with large kidneys.
¢ Nephrotic syndrome means that there is associated hypoalbuminemia, hyperlipidemia, lipiduria and edema.
Syndromes (like diabetes, myeloma) associated with nephrotic-range proteinuria may not be associated
with these findings.
¢ Hypercoagulability in nephrotic syndrome is most commonly seen in membranous nephropathy and
MPGN.
Step 2: figure out the cause of the underlying nephrotic-range proteinuria
¢ First think of secondary causes: below is just a partial list using the mnmonic œTHIS LAD HAS “ Cause
Tumor carcinomas “ MN; lymphoma “ MCD
Heroin, drugs heroin “ FSGS; gold, penicillamine “ MN/FSGS
Infectious (see œHAS below)
Systemic (see œLAD below)
Lupus MN
Amyloidosis, myeloma variable
Diabetes mellitus Kimmelsteil-Wilson lesions
Hepatitis B, C Hep B “ MN; Hep C “ MPGN
AIDS FSGS collapsing variant
Syphilis MN
¢ When secondary causes are ruled out, think of the primary (idiopathic) causes of nephrotic syndrome:
− FSGS: increasing and most common cause in urban settings and in patients of African descent
− Membranous (MN): most common cause overall; more prominent in elderly patients
− Minimal change disease (MCD): most common in children, #3 in adults
−
Membranoproliferative glomerulonephritis (MPGN): can present as nephritic or nephrotic syndrome
N = Na + water retention
This occurs due to several factors, including compensatory secretion of
aldosterone in response to hypovolemia-mediated release of ADH.
E = Edema
Due to hypoproteinemia + Na, water retention. Edema is soft, pitting
and starts in the periorbital region.
P = Proteinuria >3.5gm/1.74sq. ml/24hrs
H = Hypertension + hyperlipidemia (due to increased lipoprotein
synthesis in liver , abnormal transport of circulating lipoproteins, decreased
catabolism.)
R = Renal vein thrombosis
O = "Oval fat bodies" in the urine. Lipiduria follows hyperlipidemia.
Albumin as well as lipoproteins are lost. Lipoproteins are reabsorbed by
tubular epithelial cells and they shed along with degenerated cells-
this appears as "oval fat bodies" in urine.
T = Thrombotic + thromboembolic complications owing to loss of
anticoagulant factors (eg. anti-thrombin III )
I = Infection. These patients are prone to infection, especially with
staphylococci and pneumococci. Vulnerability is due to loss of
immunoglobulins.
C = hyperCoagulable state
Nephritic S
PHAROH =
Proteinuria,
Hematuria,
Azotemia,
RBC casts,
Oliguria, low urine output <400 mL/day)
Hypertension
1. Distinguish nephrotic syndrome (bland sediment, isolated heavy proteinuria, > 3.5 g/day) from nephritic
syndrome (dysmorphic RBCs, RBC casts, active sediment, proteinuria < 3 g/day).
2. The spot urine protein:creatinine ratio can be a quick tool to look for nephrotic range proteinuria.
3. The secondary causes of nephrotic range proteinuria: think of tumor, drugs, infections, and systemic
causes
Step 1: establish the diagnosis of nephrotic syndrome vs. nephrotic range proteinuria
¢ Check the urinalysis “ cases of nephrotic syndrome should have a bland sediment except for heavy
proteinuria. In nephrotic syndrome, look for lipiduria (maltese cross). If you see red cells, think of
membranoproliferative GN (MPGN) or lupus-induced membranous nephropathy. Note that the
dipstick only checks for albumin; you will want a formal U/A (with the sulfosalicylic acid (SSA) prep to
look for other proteins like light chains in myeloma).
¢ Check the urine spot protein:creatinine ratio. This roughly correlates to the amount of protein/day
excretion.
¢
Check a 24 hour urine for protein and creatinine. Nephrotic-range proteinuria > 3.5 g/day proteinuria.
¢
Check renal ultrasound. Large kidneys “ think of diabetes, HIV nephropathy, and infiltrative disorders
such as amyloidosis. Caveat: acute GN can present with large kidneys.
¢ Nephrotic syndrome means that there is associated hypoalbuminemia, hyperlipidemia, lipiduria and edema.
Syndromes (like diabetes, myeloma) associated with nephrotic-range proteinuria may not be associated
with these findings.
¢ Hypercoagulability in nephrotic syndrome is most commonly seen in membranous nephropathy and
MPGN.
Step 2: figure out the cause of the underlying nephrotic-range proteinuria
¢ First think of secondary causes: below is just a partial list using the mnmonic œTHIS LAD HAS “ Cause
Tumor carcinomas “ MN; lymphoma “ MCD
Heroin, drugs heroin “ FSGS; gold, penicillamine “ MN/FSGS
Infectious (see œHAS below)
Systemic (see œLAD below)
Lupus MN
Amyloidosis, myeloma variable
Diabetes mellitus Kimmelsteil-Wilson lesions
Hepatitis B, C Hep B “ MN; Hep C “ MPGN
AIDS FSGS collapsing variant
Syphilis MN
¢ When secondary causes are ruled out, think of the primary (idiopathic) causes of nephrotic syndrome:
− FSGS: increasing and most common cause in urban settings and in patients of African descent
− Membranous (MN): most common cause overall; more prominent in elderly patients
− Minimal change disease (MCD): most common in children, #3 in adults
−
Membranoproliferative glomerulonephritis (MPGN): can present as nephritic or nephrotic syndrome