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Prepared by
Dr Rajesh T Eapen
ATLAS HOSPITAL
RUWI
Introduction
• Nephrotic syndrome (NS)
– Commonest glomerular disease
affecting children
– Frequently encountered in general
paediatrics
– Characterised by
• Significant proteinuria (early morning urine
protein to creatinine ratio > 200mg/mmol)
leading to
– Hypoalbuminaemia (plasma albumin of < 25g/l)
Paediatrics and child health 2010;20(1):36-42
Definition
• Manifestation of glomerular disease,
characterized by nephrotic range
proteinuria and a triad of clinical findings
associated with large urinary losses of
protein : hypoalbuminaemia , edema and
hyperlipidemia
- Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1801
Nephrotic Syndrome
Why ‘nephrotic range’
• Defined as
– protein excretion of > 40 mg/m2/hr
– First morning protein : creatinine ratio of > 2-3 : 1
- Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1801
Incidence
(paediatric ) ?
• 2 – 7 cases per 100,000 children per year
• Higher in underdeveloped countries
(South east Asia )
• Occurs at all ages but is most prevalent in
children between the ages 1.5-6 years.
• It affects more boys than girls, 2:1 ratio
http://www.kidney.org/site/107/pdf/NephroticSyndrome.pdf
Etiology
• Genetic
• Secondary
• Idiopathic or Primary
Genetic causes
• Finnish type Congenital Nephrotic
Syndrome
• Focal Segmental Glomerulosclerosis
• Diffuse Mesangial Sclerosis
• Denys-Drash Syndrome
• Nail – Patella Syndrome
• Alport Syndrome
• Charcot-Marie-tooth disease
• Cockayne syndrome
• Laurence-Moon-Beidl-Bardet Syndrome
• Galloway-Mowat Syndrome
- Nelson Textbook of Paediatrics, Vol 2, 19th edition, page 1802, table 521-1
Secondary causes
• Congenital
– Oligomeganephronia
• Infectious
– Hepatitis (B,C) , HIV-1, Malaria, Syphilis, Toxoplasmosis
• Inflammatory
– Glomerulonephritis
• Immunological
– Castleman Disease, Kimura Disease, Bee sting, Food
allergens
• Neoplastic
– Lymphoma, Leukemia
• Traumatic ( Drug induced )
– Penicillamine, Gold, NSAIDS, Pamidronate, Mercury,
Lithium
- Nelson Textbook of Paediatrics, Vol 2,19th edition, page 1802, table 5
Idiopathic
• Minimal Change disease ( >80 % )
• Mesangial proliferation
• Focal segmental Glomerulosclerosis
• Membranous Nephropathy
• Membranoproliferative
glomerulonephritis
- Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1
Pathophysiology
Nephrotic Syndrome
Complex disturbances in
immune system
Genetic Mutations /
Mutations in proteins
Extensive effacement of podocyte foot processes
Increased permeability of the glomerular capillary wall
Massive proteinuria
Hypoalbuminaemia
Edema
Nephrotic Syndrome
PATHOPHYSIOLOGY
Clinical Features
Nephrotic Syndrome
alterations
CLINICAL
FEATURES
Minimal Change
Nephrotic
Syndrome
Focal
Segmental
Glomeruloscler
osis
Membranous
Nephropathy
Age ( yr ) 2 - 6 2 - 10 40 - 50
Sex ( M : F ) 2 : 1 1.3 : 1 2 : 1
Nephrotic
Syndrome
100 % 90 % 80 %
Asymptomatic
proteinuria
0 10 % 20 %
Hematuria 10 – 20 % 60 – 80 % 60 %
Hypertension 10 % 20 % early infrequent
Rate of
progression to
renal failure
Non progressive 10 yrs 50 % in 10 –
20 yrs
Associated
Conditions
Usually none None Renal vein
thrombosis,
SLE,
Hepatitis B
- Nelson Textbook of Paediatrics, Vol 2 : page 1803, table 521-2
Nephrotic Syndrome
Nephrotic Syndrome
Nephrotic Syndrome
DIFFERENTIAL
DIAGNOSIS
• Protein losing enteropathy
• Hepatic failure
• Heart failure
• Acute/Chronic Glomerulonephritis
• Protein Malnutrition
• < 1 year old
• Family history of nephrotic Syndrome
• Hypertension
• Pulmonary edema
• Gross hematuria
• Extrarenal findings
Lab Investigations
• Urine Examination
• Complete Blood Count & Blood
picture
• Renal parameters :
– Spot Urine Protein : Creatinine ratio
– Urinary protein excretion
– protein selectivity ratio
• Liver Function Test
• Renal Biopsy ???
• Urinalysis - 3+ to 4+ proteinuria
• Renal Function
–Spot UPC ratio > 2.0
–UPE > 40 mg/m2/hr
• Serum Creatinine – normal or elevated
• Serum albumin - < 2.5 gm/dl
• Serum Cholesterol/ TGA levels – elevated
• Serum Complement levels – Normal or
low
- Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1804
Additional Tests
• C3 and antistreptolysin O
• Chest X ray and tuberculin test
• ANA
• Hepatitis B surface antigen
Ghai Essential Paediatrics,8th edition, page 478
Indications for Biopsy
• Age below 12 months
• Gross or persistent microscopic hematuria
• Low blood C3
• Hypertension
• Impaired renal Function
• Failure of steroid therapy
Idiopathic Lab Findings
Minimal Change Nephrotic
Syndrome
Raised BUN in 15 – 30 %
Highly Selective proteinuria
Focal Segmental
Glomerulosclerosis
Raised BUN in 20 – 40 %
Membranous Nephropathy
Membranoproliferative
Glomerulonephritis
Type I Low C1, C4 , C3 – C9
Type II Normal C1, C4 , Low C3 –
C9
- Nelson Textbook of Paediatrics, Vol 2 : page 1803, table 521-2
Cause Light
microscopy
Immunoflorescence Electron Microscopy
Minimal Change
Nephrotic Syndrome
Normal Negative Foot process fusion
Focal Segmental
Glomerulosclerosis
Focal
sclerotic
lesions
IgM, C3 in lesions Foot process fusion
Membranous
Nephropathy
Thickened
GBM
Fine Granular IgG Sub epithelial deposits
Membranoproliferative
Glomerulonephritis
Type I Thickened
GBM,
proliferation
Granular IgG, C3 Mesangial and
subendothelial deposits
Type II Lobulation C3 only Dense deposits
- Nelson Textbook of Paediatrics, Vol 2 : page 1803, table 5
Management
Initial Episode
• High protein diet
• Salt moderation
• Treatment of infections
• If significant edema – diuretics
Aldosterone antagonist ( Furosemide,
spironolactone )
• Corticosteroid therapy with Prednisolone
or prednisone
– ( 2mg/kg per day for 6 weeks followed by
1.5 mg/kg single morning dose on
alternate days for 6 weeks )
Ghai Essential Paediatrics,8th edition, page 476, 477
Subsequent course
• Relapse
– Infrequent Relapsers : 3 or less
relapses per year
– Frequent Relapsers : 4 or more
relapses per year
• Steroid therapy
– Steroid dependant : relapse following
dose reduction or discontinuation
– Steroid resistant : Partial or no
response to initial treatment
Ghai Essential Paediatrics,8th edition, page 479
Management of Relapse
• Parent Education
• Symptomatic therapy for infections in
case of low grade proteinuria
• Persistent proteinuria ( 3 - 4+ ) –
– Prednisolone
( 2mg/kg/day until protein is negative for
3 days )
1.5 mg/kg on alternate days for 4
weeks )
Ghai Essential Paediatrics,8th edition, page 479
Frequent Relapses
• Alternate Day prednisolone
• Steroid sparing agents
– Levamisole ( 2 – 2.5 mg/kg )
– Cyclophosphamide ( 2 – 2.5 mg/kg/day)
– Mycophenolate Mofetil ( 20 – 25
mg/kg/day )
– Cyclosporin ( 4 – 5 mg/kg/day )
– Tacrolimus (0.1 – 0.2 mg/kg/day )
– Rituximab ( 375mg/m2 IV once a week )
Ghai Essential Paediatrics,8th edition, page 479, 480
Complications
• Edema
• Infections
• Thrombotic complications
• Hypovolaemia and Acute renal
Failure
• Steroid Toxicity
Ghai Essential Paediatrics,8th edition, page 480, 481
Steroid Resistant Nephrotic
Syndrome
• Diagnosis – Lack of response to prednisolone
therapy for 4 weeks
• Indication for renal biopsy , BBVS
• Etiology
– 10 – 20 % - Genetic ( Mutations in genes
encoding podocyte proteins )
• Indications for mutational analysis :
– Congenital Nephrotic Syndrome
– Family History of SRNS
– Sporadic resistance to steroids
– Girls with steroid resistant FSGS
Ghai Essential Paediatrics,8th edition, page 481
Management of SRNS
• Steroids + calcineurin inhibitors + ACE
inhibitors / ARBs’ + HMG coenzyme-A +
Diuretics
Ghai Essential Paediatrics,8th edition, page 481, 482
Prognosis
• Steroid Responsive NS : Good
prognosis ( MCNS )
• Steroid Resistant NS : Poor prognosis
( FSGS )
- Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1806
Congenital Nephrotic
Syndrome
• Presents in first 3 months of life
• Anasarca, hypoalbuminaemia, oliguria
‘Finnish’ Type Nephrotic Syndrome
• Antenatally detectable :
– Raised AFP in maternal serum and amniotic fluid
• Complications
– Failure o thrive
– Infections
– Hypothyroidism
– Renal Failure ( 2 – 3 yrs )
Ghai Essential Paediatrics,8th edition, page 4
Nephrotic Syndrome
Nephrotic Syndrome
Nephrotic Syndrome
Nephrotic Syndrome
Nephrotic Syndrome
Nephrotic Syndrome
Dietary management of ns
A balanced diet, adequate in
protein (1.5-2 g/kg) and calories
is recommended
Patients with persistent
proteinuria should receive 2-2.5
g/kg of protein daily
< 30% calories should be
derived from fat and saturated
fats avoided
• A ‘no added salt’ diet is advisable
in view of the salt and water
overload
• There is no evidence for use of a
high protein diet
• Children should be encouraged to
have a normal healthy diet
• Weight control
–In between meal snacks such
as biscuits, crisps, and fizzy
(high sugar) drinks should be
avoided with low energy
alternatives promoted
–Healthy eating advice should
again be reinforced
• Steroid resistant nephrotic
syndrome
–Vitamin supplementation and
iron treatment may also be
indicated
–Such children are often
hospitalised for long periods
and the clinical course may be
complicated by diarrhoea and
other nosocomial infections
from the ward
Nephrotic Syndrome
prognosis
Due to loss of
proteins in the urine
Due to ↓ oncotic
pressure
•Immunoglobulin
↑susceptibility to infection
•antithrombin III and proteins
C and S
Thromboembolism
•vit D–binding protein 
vit D deficiency
•Transferrin
Iron deficiency anemia
•Hyperlipidaemia
•Hypovolemia
Acute renal failure
•Anasarca
risk of cellulitis, bacterial
peritonitis with ascites
,large pleural effusions
or pulmonary edema
Nephrotic Syndrome

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Nephrotic Syndrome

  • 1. Prepared by Dr Rajesh T Eapen ATLAS HOSPITAL RUWI
  • 2. Introduction • Nephrotic syndrome (NS) – Commonest glomerular disease affecting children – Frequently encountered in general paediatrics – Characterised by • Significant proteinuria (early morning urine protein to creatinine ratio > 200mg/mmol) leading to – Hypoalbuminaemia (plasma albumin of < 25g/l) Paediatrics and child health 2010;20(1):36-42
  • 3. Definition • Manifestation of glomerular disease, characterized by nephrotic range proteinuria and a triad of clinical findings associated with large urinary losses of protein : hypoalbuminaemia , edema and hyperlipidemia - Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1801
  • 5. Why ‘nephrotic range’ • Defined as – protein excretion of > 40 mg/m2/hr – First morning protein : creatinine ratio of > 2-3 : 1 - Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1801
  • 6. Incidence (paediatric ) ? • 2 – 7 cases per 100,000 children per year • Higher in underdeveloped countries (South east Asia ) • Occurs at all ages but is most prevalent in children between the ages 1.5-6 years. • It affects more boys than girls, 2:1 ratio http://www.kidney.org/site/107/pdf/NephroticSyndrome.pdf
  • 8. Genetic causes • Finnish type Congenital Nephrotic Syndrome • Focal Segmental Glomerulosclerosis • Diffuse Mesangial Sclerosis • Denys-Drash Syndrome • Nail – Patella Syndrome • Alport Syndrome • Charcot-Marie-tooth disease • Cockayne syndrome • Laurence-Moon-Beidl-Bardet Syndrome • Galloway-Mowat Syndrome - Nelson Textbook of Paediatrics, Vol 2, 19th edition, page 1802, table 521-1
  • 9. Secondary causes • Congenital – Oligomeganephronia • Infectious – Hepatitis (B,C) , HIV-1, Malaria, Syphilis, Toxoplasmosis • Inflammatory – Glomerulonephritis • Immunological – Castleman Disease, Kimura Disease, Bee sting, Food allergens • Neoplastic – Lymphoma, Leukemia • Traumatic ( Drug induced ) – Penicillamine, Gold, NSAIDS, Pamidronate, Mercury, Lithium - Nelson Textbook of Paediatrics, Vol 2,19th edition, page 1802, table 5
  • 10. Idiopathic • Minimal Change disease ( >80 % ) • Mesangial proliferation • Focal segmental Glomerulosclerosis • Membranous Nephropathy • Membranoproliferative glomerulonephritis - Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1
  • 13. Complex disturbances in immune system Genetic Mutations / Mutations in proteins Extensive effacement of podocyte foot processes Increased permeability of the glomerular capillary wall Massive proteinuria Hypoalbuminaemia Edema
  • 19. CLINICAL FEATURES Minimal Change Nephrotic Syndrome Focal Segmental Glomeruloscler osis Membranous Nephropathy Age ( yr ) 2 - 6 2 - 10 40 - 50 Sex ( M : F ) 2 : 1 1.3 : 1 2 : 1 Nephrotic Syndrome 100 % 90 % 80 % Asymptomatic proteinuria 0 10 % 20 % Hematuria 10 – 20 % 60 – 80 % 60 % Hypertension 10 % 20 % early infrequent Rate of progression to renal failure Non progressive 10 yrs 50 % in 10 – 20 yrs Associated Conditions Usually none None Renal vein thrombosis, SLE, Hepatitis B - Nelson Textbook of Paediatrics, Vol 2 : page 1803, table 521-2
  • 23. DIFFERENTIAL DIAGNOSIS • Protein losing enteropathy • Hepatic failure • Heart failure • Acute/Chronic Glomerulonephritis • Protein Malnutrition • < 1 year old • Family history of nephrotic Syndrome • Hypertension • Pulmonary edema • Gross hematuria • Extrarenal findings
  • 24. Lab Investigations • Urine Examination • Complete Blood Count & Blood picture • Renal parameters : – Spot Urine Protein : Creatinine ratio – Urinary protein excretion – protein selectivity ratio • Liver Function Test • Renal Biopsy ???
  • 25. • Urinalysis - 3+ to 4+ proteinuria • Renal Function –Spot UPC ratio > 2.0 –UPE > 40 mg/m2/hr • Serum Creatinine – normal or elevated • Serum albumin - < 2.5 gm/dl • Serum Cholesterol/ TGA levels – elevated • Serum Complement levels – Normal or low - Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1804
  • 26. Additional Tests • C3 and antistreptolysin O • Chest X ray and tuberculin test • ANA • Hepatitis B surface antigen Ghai Essential Paediatrics,8th edition, page 478 Indications for Biopsy • Age below 12 months • Gross or persistent microscopic hematuria • Low blood C3 • Hypertension • Impaired renal Function • Failure of steroid therapy
  • 27. Idiopathic Lab Findings Minimal Change Nephrotic Syndrome Raised BUN in 15 – 30 % Highly Selective proteinuria Focal Segmental Glomerulosclerosis Raised BUN in 20 – 40 % Membranous Nephropathy Membranoproliferative Glomerulonephritis Type I Low C1, C4 , C3 – C9 Type II Normal C1, C4 , Low C3 – C9 - Nelson Textbook of Paediatrics, Vol 2 : page 1803, table 521-2
  • 28. Cause Light microscopy Immunoflorescence Electron Microscopy Minimal Change Nephrotic Syndrome Normal Negative Foot process fusion Focal Segmental Glomerulosclerosis Focal sclerotic lesions IgM, C3 in lesions Foot process fusion Membranous Nephropathy Thickened GBM Fine Granular IgG Sub epithelial deposits Membranoproliferative Glomerulonephritis Type I Thickened GBM, proliferation Granular IgG, C3 Mesangial and subendothelial deposits Type II Lobulation C3 only Dense deposits - Nelson Textbook of Paediatrics, Vol 2 : page 1803, table 5
  • 30. Initial Episode • High protein diet • Salt moderation • Treatment of infections • If significant edema – diuretics Aldosterone antagonist ( Furosemide, spironolactone ) • Corticosteroid therapy with Prednisolone or prednisone – ( 2mg/kg per day for 6 weeks followed by 1.5 mg/kg single morning dose on alternate days for 6 weeks ) Ghai Essential Paediatrics,8th edition, page 476, 477
  • 31. Subsequent course • Relapse – Infrequent Relapsers : 3 or less relapses per year – Frequent Relapsers : 4 or more relapses per year • Steroid therapy – Steroid dependant : relapse following dose reduction or discontinuation – Steroid resistant : Partial or no response to initial treatment Ghai Essential Paediatrics,8th edition, page 479
  • 32. Management of Relapse • Parent Education • Symptomatic therapy for infections in case of low grade proteinuria • Persistent proteinuria ( 3 - 4+ ) – – Prednisolone ( 2mg/kg/day until protein is negative for 3 days ) 1.5 mg/kg on alternate days for 4 weeks ) Ghai Essential Paediatrics,8th edition, page 479
  • 33. Frequent Relapses • Alternate Day prednisolone • Steroid sparing agents – Levamisole ( 2 – 2.5 mg/kg ) – Cyclophosphamide ( 2 – 2.5 mg/kg/day) – Mycophenolate Mofetil ( 20 – 25 mg/kg/day ) – Cyclosporin ( 4 – 5 mg/kg/day ) – Tacrolimus (0.1 – 0.2 mg/kg/day ) – Rituximab ( 375mg/m2 IV once a week ) Ghai Essential Paediatrics,8th edition, page 479, 480
  • 34. Complications • Edema • Infections • Thrombotic complications • Hypovolaemia and Acute renal Failure • Steroid Toxicity Ghai Essential Paediatrics,8th edition, page 480, 481
  • 35. Steroid Resistant Nephrotic Syndrome • Diagnosis – Lack of response to prednisolone therapy for 4 weeks • Indication for renal biopsy , BBVS • Etiology – 10 – 20 % - Genetic ( Mutations in genes encoding podocyte proteins ) • Indications for mutational analysis : – Congenital Nephrotic Syndrome – Family History of SRNS – Sporadic resistance to steroids – Girls with steroid resistant FSGS Ghai Essential Paediatrics,8th edition, page 481
  • 36. Management of SRNS • Steroids + calcineurin inhibitors + ACE inhibitors / ARBs’ + HMG coenzyme-A + Diuretics Ghai Essential Paediatrics,8th edition, page 481, 482
  • 37. Prognosis • Steroid Responsive NS : Good prognosis ( MCNS ) • Steroid Resistant NS : Poor prognosis ( FSGS ) - Nelson Textbook of Paediatrics, Vol 2, 19th Edition, page 1806
  • 38. Congenital Nephrotic Syndrome • Presents in first 3 months of life • Anasarca, hypoalbuminaemia, oliguria ‘Finnish’ Type Nephrotic Syndrome • Antenatally detectable : – Raised AFP in maternal serum and amniotic fluid • Complications – Failure o thrive – Infections – Hypothyroidism – Renal Failure ( 2 – 3 yrs ) Ghai Essential Paediatrics,8th edition, page 4
  • 45. Dietary management of ns A balanced diet, adequate in protein (1.5-2 g/kg) and calories is recommended Patients with persistent proteinuria should receive 2-2.5 g/kg of protein daily < 30% calories should be derived from fat and saturated fats avoided
  • 46. • A ‘no added salt’ diet is advisable in view of the salt and water overload • There is no evidence for use of a high protein diet • Children should be encouraged to have a normal healthy diet
  • 47. • Weight control –In between meal snacks such as biscuits, crisps, and fizzy (high sugar) drinks should be avoided with low energy alternatives promoted –Healthy eating advice should again be reinforced
  • 48. • Steroid resistant nephrotic syndrome –Vitamin supplementation and iron treatment may also be indicated –Such children are often hospitalised for long periods and the clinical course may be complicated by diarrhoea and other nosocomial infections from the ward
  • 51. Due to loss of proteins in the urine Due to ↓ oncotic pressure •Immunoglobulin ↑susceptibility to infection •antithrombin III and proteins C and S Thromboembolism •vit D–binding protein  vit D deficiency •Transferrin Iron deficiency anemia •Hyperlipidaemia •Hypovolemia Acute renal failure •Anasarca risk of cellulitis, bacterial peritonitis with ascites ,large pleural effusions or pulmonary edema