Nephrosis

Charu Choudhary
2406 2
Objective
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 Definition
Nephrosis (also called nephrotic syndrome) in medical terms refers to a
non-inflammatory kidney disorder characterized by damage to the renal
tubules or glomeruli, leading to excessive loss of protein in the urine
(proteinuria).
“Nephrosis is a degenerative disease of the renal
tubules or glomeruli causing proteinuria, hypoalbuminemia, hyperlipidemia,
and edema, without significant inflammation.”
Key features

• Proteinuria

• Hypoalbuminemia

• Edema

• Hyperlipidemia
Sign and symptoms
Four Hallmark signs
1. Proteinuria –

• Excess protein in urine (more than 3.5 g/day)

• Urine appears frothy or foamy

2. Hypoalbuminemia –

• Low level of albumin in blood due to protein loss i.e less than 3.5g/dl
. [Link] (Swelling) –

• Most prominent and early symptom

• Seen first around eyes (periorbital edema), then ankles, feet, abdomen

• Caused by loss of albumin from the blood

[Link] and Lipiduria –

• High cholesterol and triglycerides in blood

• Fat globules may appear in urine

Other sign and symptoms
Pallor (pale appearance) –

• Due to fluid retention and poor blood protein levels

Fatigue and Weakness –

• Result of loss of protein and poor nutrition

Weight Gain –

• Due to fluid accumulation (edema)

Nephrotic syndrome
Causes

• FSGS
• Membranous nephropathy
• Diabetes mellitus
• SLE
• Infections (Hep B/C, HIV)
• Drugs (NSAIDs)
• Amyloidosis
• Congenital genetic defects
Pathophysiology
Glomerular Damage

↑ Permeability of glomerular membrane

Protein loss in urine (Proteinuria)

↓ Blood albumin (Hypoalbuminemia)

↓ Oncotic pressure → Fluid moves into tissues → Edema

RAAS activation → Sodium & water retention → More edema

Liver compensation → ↑ Lipid synthesis → Hyperlipidemia & lipiduria

Loss of immune proteins → Infection risk

Loss of anticoagulant proteins → Thrombosis risk

Types of nephrosis
1. Minimal Change Disease (MCD)

•Most common in children

•Sudden onset edema

•Good response to steroids

2. Focal Segmental Glomerulosclerosis (FSGS)

•Common in adults

•Only some glomeruli affected, and segments of each

•Can lead to chronic kidney disease

•Poor response to steroids

3. Membranous Nephropathy

•Common in adults

•Thickening of glomerular basement membrane

•Causes include hepatitis B, autoimmune conditions, drugs

•Slow progression
4. Membranoproliferative Glomerulonephritis (MPGN)

•Also called mesangiocapillary GN

•Thickening + proliferation in glomerular cells

•Can be primary or secondary (Hepatitis C, autoimmune)

5. Congenital Nephrotic Syndrome

•Appears in infants

•Genetic mutations (NPHS1, NPHS2)

•Leads to severe protein loss early in life

6. Secondary Nephrotic Syndrome

Due to other diseases:

•Diabetes mellitus (diabetic nephropathy)

•Systemic lupus erythematosus (SLE)

•Amyloidosis

•Infections (HIV, hepatitis B/C)

•Drugs (NSAIDs, gold, penicillamine)

•Malignancies
 Diagnosis of nephrotic syndrome(nephrosis)

The diagnosis is based on clinical findings, laboratory tests, and sometimes kidney
biopsy.

🩺 1. Clinical Findings

• Generalized edema (face, legs, abdomen)

• Weight gain due to fluid retention

• Fatigue, pallor, and sometimes loss of appetite

🧪 2. Laboratory Investigations
[Link] Examination

•Proteinuria: Heavy protein loss in urine (>3.5 g/day).

•Frothy urine: Due to presence of protein.

•Microscopic findings: Fat globules and fatty casts (lipiduria).

•24-hour urine collection: Measures total protein loss.

[Link] Investigations

•Serum Albumin: Decreased (hypoalbuminemia).

•Total Serum Protein: Decreased due to protein loss.

•Serum Cholesterol and Triglycerides: Increased (hyperlipidemia).

•Blood Urea Nitrogen (BUN) & Serum Creatinine: Normal or slightly raised (to assess kidney function).

•Serum Electrolytes: May show hyponatremia due to fluid retention.

Medical management
A. Edema Control

•Salt restriction (2–3 g/day)

•Fluid restriction (in severe edema)

•Diuretics: Furosemide, Spironolactone

•Albumin infusion (20–25%) followed by diuretics in severe hypoalbuminemia

B. Proteinuria Reduction

•ACE inhibitors (e.g., Enalapril)

•ARBs (e.g., Losartan)

Reduce intraglomerular pressure → decreases protein loss.

C. Corticosteroids

Main treatment especially for Minimal Change Disease.

•Prednisolone: 1–2 mg/kg/day (as per protocol)

D. Immunosuppressants

Used when steroid-resistant or steroid-dependent.

•Cyclophosphamide

E. Hyperlipidemia Control

•Statins (Atorvastatin, Rosuvastatin)

F. Infection Prevention / Treatment

•Vaccination: pneumococcal & influenza

•Antibiotics if infection present

(Nephrotic patients are prone due to loss of immunoglobulins)

G. Anticoagulation (if thrombosis risk)

•Heparin / Warfarin

(For renal vein thrombosis, DVT)

Surgical management
Surgery is rare in nephrotic syndrome, but may be needed in:

1. Kidney Biopsy

(Not exactly surgery, but an interventional procedure)

•Indicated for adults or atypical cases to confirm diagnosis.

2. Management of Complications

•Surgical intervention for renal vein thrombosis

(thrombectomy) – rare

•Kidney transplant

•For end-stage kidney disease secondary to FSGS or MPGN

•Peritoneal dialysis catheter insertion (if renal failure develops)

[Link] Tests for Underlying Causes
•ANA Test: For systemic lupus erythematosus (SLE).
•HBsAg and Anti-HCV Test: For hepatitis B and C infections.
•HIV Test: To detect HIV-associated nephropathy.
•Complement Levels (C3, C4): Decreased in immune-related nephritis.
[Link] Biopsy
•Done to confirm the type and cause of nephrosis (e.g., minimal change disease,
FSGS, membranous nephropathy).
•Provides definitive diagnosis for treatment planning.
Complications of Nephrotic Syndrome
1.🫗 Edema and Ascites

•Due to low albumin levels and sodium retention.

•Can cause swelling of face, legs, and abdominal distension (ascites).

2.🦠 Infections

•Loss of immunoglobulins and complement proteins in urine weakens immunity.

•Increased risk of infections such as pneumonia, peritonitis, and cellulitis.

3.🩸 Thrombosis (Blood Clots)

•Loss of antithrombin III and other anticoagulant proteins causes hypercoagulability.

•May lead to renal vein thrombosis, deep vein thrombosis, or pulmonary embolism.
4.🧈 Hyperlipidemia and Atherosclerosis
•Liver increases lipid synthesis → high cholesterol and triglycerides.
•May cause early-onset cardiovascular disease.
5.💧 Hypovolemia (Low Blood Volume)
•Fluid shifts from intravascular to interstitial spaces → low circulating volume.
•Can cause shock, acute kidney injury, or hypotension.
6.⚡ Acute Kidney Injury (AKI)
•Due to severe hypovolemia, infection, or drug toxicity.
•May lead to temporary renal failure.
7.📉 Nutritional Deficiencies

•Continuous protein loss → muscle wasting, weakness, and poor growth

in children.

8.🧠 Drug Toxicity

•Altered protein binding increases free drug levels, enhancing toxicity (e.g.,
with diuretics, antibiotics).
Nursing interventions
•Monitor vital signs, daily weight, intake–output

•Assess degree of edema and urine protein

•Maintain low-sodium diet and fluid restriction (if ordered)

•Administer prescribed drugs: diuretics, steroids, albumin, ACE inhibitors

•Provide good skin care to prevent breakdown

•Prevent infection: hand hygiene, monitor temperature

•Educate patient/parents about medication compliance and signs of relapse

•Provide emotional support and encourage follow-up

Quizs
1. The hallmark feature of nephrotic syndrome is: 3. The main plasma protein lost in nephrosis is:

A. Hematuria A. Globulin

B. Proteinuria B. Albumin

C. Pyuria C. Fibrinogen

D. Glycosuria D. Hemoglobin

2. Proteinuria in nephrosis is usually more than: 4. The decreased plasma oncotic pressure in nephrosis leads to:

A. 1 g/day A. Dehydration

B. 10 g/day B. Edema

C. 3.5 g/day C. Fever

D. 5 g/day D. Hypotension
5. The most common type of nephrotic syndrome in children is:
7. Loss of which protein increases risk of thrombosis in nephrosis?

A. Focal segmental glomerulosclerosis

B. Minimal change disease A. Albumin

C. Membranous nephropathy B. Fibrinogen

C. Antithrombin III
D. Lupus nephritis
D. Immunoglobulin

6. Which laboratory finding is typical in nephrosis?

8. Which of the following is not a feature of nephrosis?

A. Hyperglycemia
A. Hypoalbuminemia

B. Hyperlipidemia B. Edema

C. Hypokalemia C. Proteinuria

D. Hypernatremia D. Hematuria