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1. Approach to Nephrotic Syndrome
Dr Abhay Mange

2.  15 yrs old Male, Surendra Upwanshi
r/o Bitoli , Balaghat (mp) admitted on 7/2/14 with c/o
 Swelling over face and lower limbs since 15 days
 Decreased urine out put since 10 days
 No h/o fever, sore throat, skin infection, rash, joint pain
 No h/o Jaundice / hemoptysis
 No h/o DM

3. On examination
 Conscious / oriented
 Afebrile
 Pulse -90 /min , all pulsation +
 Resp- 18/min
 Bp -180/100 mmhg
 Edema feet +
 Periorbital edema +
 Jvp –nr
 No pallor, icterus
 P/A – ff +
 RS –wnl
 CVS –wnl
 CNS –wnl

4. Investigations
 Hb -10.2 gm %
 TLC – 8400/cumm
T- 71, L-27, E-2 , M-2 %
 PS
 RBCS-Normocytic,normochromic
 WBCS- WNL,PLATELETS –adequate
 No prasite seen
 URINE EXAM
 Protein = ++++
 Sugar = negative
 RBCS = 25-30/hpf
 pus cells = 4-5/hpf
 No cast seen
 24 hr urine protein = 7930 gm
 KFT-
 BUL=130 mg/dl ,
 SC = 1.6 mg/dl
 Na + = 136 meq/l
 K + =5.6 meq/l
 LFT
 TP = 5 gm
 Total Cholesterol = 264 mg/dl
 ECG- WNL
 X-RAY CHEST –WNL
 USG KUB
 Rt. = 9.4 X 4.3 cm, Lt.=9.9 x 4.4 cm
 Diffuse increase in echo texture ,maintained
CMD

5. Provisional Diagnosis
 Nephrotic syndrome
 Renal biopsy planned

6. Investigations
 ASO = 58 IU/L (Negative)
 C3 = 0.3 gm/l (0.9 -1.8)
 ANA = Negative
 HBsAg = Negative
 HCV = Negative
 HIV = Negative
 INR =1.2

7. Treatment
 Inj Cefotaxime 0.5 gm tds
 Inj lasix 80 mg bd
 Tab cilnidepine 20 mg tds
 Tab prazocin 5 mg od
 Tab calcium lactate 1 tds
 Tab atorvaststin 10 mg
 Human albumin
 BIOPSY TAKEN
 Inj Methylprednisolone 750
mg od 3 day
 Tab prednisolone 50 mg
od ct…

8. Renal biopsy
Microscopy : -
 Glomeruli are enlarged in size and shows diffuse segmental areas of
increase in mesangial matrix and hypercellularity and occasional
infiltrating polymorph.
 Focal areas of endocapillary hypercellularity are noted.
 Focal areas of glomerular basement membrane thickening are noted.
 Lobular accentuation is noted in 05 – 06 glomeruli.
 Silver stain shows tram tracking.
 The interstitium show mild mononuclear cell inflammatory infiltrate.
 The blood vessels are unremarkable.

9. Immunofluorescence Study
 IgG : Positive (++) coarsely granular diffuse
mesangial deposits are seen.
 IgM : Negative
 IgA : Negative
 C3 : Positive (++) coarsely granular diffuse
mesangial deposits are seen.
 Impression :- Membranoproliferative
Glomerulonephritis with IgG and C3 positivity.

12. Final diagnosis
 Idiopathtic Membranoproliferative
glomerulonephritis
Nephrotic syndrome

13. Approach to acute Glomerulonephritis

14. DISCUSSION

15. Definition
Nephrotic syndrome is a clinical complex characterized by a number
of renal and extrarenal features, most prominent of which are
 Proteinuria
(in practice > 3.0 to 3.5gm/24hrs),
 Hypoalbuminemia,
 Edema,
 Hypertension,
 Hyperlipidemia,
 Lipiduria and
 Hypercoagulabilty.

16. Classification
Nephrotic syndrome can be
 Primary, being a disease specific to the kidneys,
 Secondary, being a renal manifestation of a systemic
general illness

17. Primary causes
Primary causes include-
 Minimal-change nephropathy(70-90% in children and 10-
15% in adult)
 Focal glomerulosclerosis (15% in adult)
 Membranous nephropathy (30% in adult)
 Membranoproliferative glomerulonephritis .

18. Secondary causes
Secondary causes include-
 Diabetes mellitus
 Lupus erythematosus
 Amyloidosis and paraproteinemias
 Viral infections (eg, hepatitis B, hepatitis C, HIV )
 Preeclampsia

19. Workup
Diagnostic studies for nephrotic syndrome may include the
following:
 Urinalysis
 Urine sediment examination
 Urinary protein measurement (24-hr)
 Serum albumin
 Serologic studies for infection and immune abnormalities
 Renal ultrasonography
 Renal biopsy

20. Renal biopsy
Indications
 Unexplained renal failure
 Acute nephritic syndrome
 Nephrotic syndrome
 Isolated nonnephrotic proteinuria
 Isolated glomerular hematuria
 Renal masses (primary or secondary)
 Renal transplant rejection
 Connective-tissue diseases ( SLE)

21. Renal biopsy
 2 biopsy cylinders
 • minimal length 1 cm
 • diameter 1.2 mm
 # isotonic saline – fast local transport
 • cryopreservation of one piece for immunefluorescence
 • fixation with paraformaldehyde or buffered (4%)
 formaldehyde for paraffin embedding
 • fixation with 3% glutaraldehyde for electron microscopy
 or
 # direct fixation with paraformaldehyde or formaldehyde and
 shipping (indirect immunehistology by APAAP (alkaline
 phosphatase) or others

22. Renal biopsy
Absolute Contraindications
 Uncorrectable bleeding diathesis
 Uncontrollable severe hypertension
 Active renal or perirenal infection
 Skin infection at biopsy site
Relative contraindications
 Uncooperative patient
 Anatomic abnormalities of the kidney which may increase risk
 Small kidneys
 Solitary kidney

23. Renal biopsy
Complications
 Bleeding- may occur in 3 distinct locations
 Collecting system -blood is seen in the urine,Obstuction
 Under the renal capsule-cause increase in the release of renin-hypertension
 Into the perinephric space-Hematoma
 The injured kidney can also undergo fibrosis-chronic hypertension
and perhaps even renal failure can result if the contralateral kidney is
compromised – “page kidney effect”
 AV fistules

24. THANK YOU