Nephrotic syndrome is a primary glomerular disease characterized by

proteinuria, hypoalbuminemia, edema, and hyperlipidemia. It is seen in any

condition that seriously damages the glomerular capillary membrane, causing
increased glomerular permeability with loss of protein in the urine. Generally a
disorder of childhood, it does occur in adults, including the elderly. Causes in
clued chronic glomerulonephritis and diabetes mellitus, among other conditions.

CLINICAL MANIFESTATIONS

• Major manifestation is edema (usually periorbital, in dependent areas [sacrum,

ankles, and hands], and ascites).

• Malaise, headache, irritability and fatigue

• Protein electrophoresis and immunoelectrophoresis to determine type of

proteinuria

• Serum markers (Anti-C1q)

ASSESSMENT AND DIAGNOSTIC METHODS

• Proteinuria (exceeding 3 to 3.5 g/day_

• Microscopic hematuria, urinary casts

• Needle biopsy of the kidney for histology examination to confirm diagnosis

MEDICAL MANAGEMENT

Objective of management is to preserve renal function.

• Bed rest for a few days to promote diuresis and reduce edema

• Diet with high biologic protein (0.8 g/kg/day) to replenish urinary losses

• Low sodium, low saturated fat, liberal potassium

Pharmacologic Therapy

• Diuretics for severe edema, in combination with angiotensin-converting enzyme

(ACE) inhibitors

• Adrenocorticosteroids to reduce proteinuria

• Antineoplastic agents Cytoxan) or immunosuppressive agents (Imuran,
Leukeran, or cyclosporine)

NURSING MANAGEMENT

• In the early stages, nursing management is similar to that of acute

glomerulonephritis.

• As the disease worsens, management is similar to that of chronic renal failure.

• Monitor intake and output; note sings of low plasma volume and impaired
circulation with prerenal acute renal failure.

• Instruct patient receiving steroids or cyclosporine regarding medication and

signs and symptoms that must be reported to physician.

• Instruct patient in selecting a high-protein diet while restricting cholesterol and

fat intake.

Symptoms
Early symptoms include loss of appetite, a general feeling of illness (malaise),
puffy eyelids and tissue swelling from excess sodium and water retention,
abdominal pain, wasting of muscles (atrophy), and frothy urine. The abdomen
may be swollen because of a large accumulation of fluid in the abdominal cavity
(ascites). Shortness of breath may develop because fluid accumulates in the
space surrounding the lungs (pleural effusion). Other symptoms may include
swelling of the knees and, in men, the scrotum. Most often, the fluid that causes
tissue swelling is affected by gravity and therefore moves around. During the
night, fluid accumulates in the upper parts of the body, such as the eyelids.
During the day, when the person is sitting or standing, fluid accumulates in the
lower parts of the body, such as the ankles. Swelling may hide the muscle
wasting that is progressing at the same time.

In children, blood pressure is generally low, and blood pressure may fall when
the child stands up (orthostatic hypotension). Shock occasionally develops.
Adults may have low, normal, or high blood pressure. Urine production may
decrease, and kidney failure may develop if the leakage of fluid from blood
vessels into tissues depletes the liquid component of blood and the blood supply
to the kidney is diminished. Occasionally, kidney failure with low urine output
occurs suddenly.
Nutritional deficiencies may result because nutrients are excreted in the urine. In
children, growth may be stunted. Calcium may be lost from bones. The hair and
nails may become brittle, and some hair may fall out. Horizontal white lines may
develop in fingernail beds for unknown reasons.

The membrane that lines the abdominal cavity and abdominal organs
(peritoneum) may become inflamed and infected. Opportunistic infections—
infections caused by normally harmless bacteria—are common. The higher
likelihood of infection is thought to occur because the antibodies that normally
combat infections are excreted in the urine or not produced in normal amounts.
The tendency for blood clotting (thrombosis) increases, particularly inside the
main vein from the kidney. Less commonly, the blood may not clot when clotting
is needed, generally leading to excessive bleeding. High blood pressure
accompanied by complications affecting the heart and brain is most likely to
occur in people who have diabetes or systemic lupus erythematosus.

Diagnosis
A doctor bases the diagnosis of nephrotic syndrome on the symptoms, physical
examination findings, and laboratory findings. Sometimes nephrotic syndrome is
at first mistaken for heart failure in older adults because swelling occurs in both
disorders and heart failure is common in older people. A laboratory test of urine
collected over a 24-hour period is useful for measuring the degree of protein loss,
but collection of urine over such a long period is difficult for many people to
accomplish. Alternatively, to estimate protein loss, a randomly collected urine
specimen can be tested to measure the ratio of the level of protein to that of
creatinine (a waste product). Blood tests and other urine tests detect additional
characteristics of the syndrome. The level of albumin in the blood is low because
this vital protein is excreted in the urine and its production is impaired. The urine
often contains clumps of cells that may be combined with protein and fat (casts).
The urine contains low levels of sodium and high levels of potassium.

Concentrations of lipid in the blood are high, sometimes exceeding 10 times that
of a normal concentration. Levels of lipid in the urine are also high. Anemia may
be present. Levels of blood clotting proteins may be increased or decreased.

The doctor investigates possible causes of nephrotic syndrome, including drugs.

Analysis of the urine and blood may reveal an underlying disorder. An imaging
test of the kidney, such as ultrasound, computed tomography (CT), or magnetic
resonance imaging (MRI), is usually done. If the person has lost weight or is
older, a search for cancer is undertaken. A kidney biopsy is especially useful in
determining the cause and extent of kidney damage.

Causes
Nephrotic syndrome can be primary, affecting only the kidneys, or secondary,
caused by a vast array of disorders that affect other parts of the body, most
commonly diabetes mellitus, systemic lupus erythematosus, and certain viral
infections. Nephrotic syndrome can also result from glomerulonephritis. A
number of drugs that are toxic to the kidneys can also cause nephrotic
syndrome, especially nonsteroidal anti-inflammatory drugs (NSAIDs). The
syndrome may be caused by certain allergies, including allergies to insect bites
and to poison ivy or poison oak. Some types of nephrotic syndrome are
hereditary.