Nephrotic and Nephritic Syndromes

Nephrotic and Nephritic
Syndromes
13/7/14
What are they, and why do we care?

The nephrotic and nephritic syndromes are distinct
clusters of symptoms caused by various glomerular
diseases.
For each syndrome, there is a set of possible underlying
causes.
So while the syndromes are not diagnoses, identifying
whether your patient is nephrotic or nephritic can narrow
down the DDx.
The syndromes may overlap, and some diseases can
cause either.
glomerular
disease:
Silly picture
A
presentation:
DDx:
nephritic
nephrotic
ABCD
CDEF
Nephritic syndrome
-itic like -itis means inflammation, so think of a
glomerulus damaged by inflammation.
Such a glomerulus will be leaking
inappropriately, i.e.:
1. Leaking things it shouldnt be (blood)
2. Not leaking things it should be (GFR).
GFR leads to too much fluid on one side

(hypertension) and less than normal on the
other side (oliguria).
Pathogenesis of nephritic syndrome

underlying cause
glomerular damage with

inflammation
(GFR but glomerulus
becomes very leaky to
other things)

underlying cause

inflammation
(GFR but glomerulus
other things)
?minor proteinuria
hematuria with RBC casts
GFR

underlying cause

inflammation
(GFR but glomerulus
other things)
?minor proteinuria
GFR
plasma creatinine
and urea
(uremia)
oliguria

underlying cause

inflammation
(GFR but glomerulus
other things)
?minor proteinuria
GFR
plasma creatinine
and urea
(uremia)
severe GFR activates

RAAS system, as it should
oliguria
Na+ retention

underlying cause

inflammation
(GFR but glomerulus
other things)
?minor proteinuria
GFR
plasma creatinine
and urea
(uremia)

oliguria
Na+ retention occurs even if GFR is not

significantly reduced. Appears to be due
to upregulation of basolateral Na+/K+
ATPase in late DT, but the mechanism
by which glomerular damage causes this
is unknown.
Na+ retention

underlying cause

inflammation
(GFR but glomerulus
other things)
?minor proteinuria
GFR


is unknown.
Na+ retention
water retention
plasma creatinine
and urea
(uremia)
plasma volume
oliguria

underlying cause

inflammation
(GFR but glomerulus
other things)
?minor proteinuria
GFR


is unknown.
Na+ retention
water retention
plasma creatinine
and urea
(uremia)
plasma volume
oliguria
?edema
hypertension
JVP, cardiomegaly

underlying cause

inflammation
(GFR but glomerulus
other things)
?minor proteinuria
GFR


is unknown.
Na+ retention
water retention
plasma creatinine
and urea
(uremia)
plasma volume
oliguria
?edema
hypertension
JVP, cardiomegaly
Nephritic syndrome summary

Defining symptoms:
Hematuria
Hypertension
Oliguria.
A quick way to remember:

H2O.
Nephrotic syndrome
The glomerulus is damaged but not inflamed,
so it leaks things it shouldnt, but otherwise filters
normally.
The damage is more subtle than nephritic, so
proteins can leak, but not usually blood.
Symptoms are all consequences of this protein
loss.
Pathogenesis of nephrotic syndrome

underlying cause
protein filtration
glomerular damage
without inflammation
(preserves GFR but makes
glomerulus leaky to protein)

underlying cause
protein filtration
glomerular damage
hypoalbuminemia
?anemia
(loss of transferrin)
proteinuria

underlying cause
protein filtration
glomerular damage
Filtered proteases
cleave inactive
ENaC in late DT
hypoalbuminemia
?anemia
proteinuria
Na+ retention

underlying cause
protein filtration
glomerular damage
Filtered proteases
cleave inactive
ENaC in late DT
hypoalbuminemia
?anemia
proteinuria
Glomerular damage may cause

Na+ retention by additional
mechanisms, but this is poorly
understood.
Na+ retention

underlying cause
protein filtration
glomerular damage
Filtered proteases
cleave inactive
ENaC in late DT
hypoalbuminemia
?anemia
proteinuria

understood.
Na+ retention
water retention
plasma volume

underlying cause
protein filtration
glomerular damage
Filtered proteases
cleave inactive
ENaC in late DT
hypoalbuminemia
?anemia
proteinuria

understood.
Na+ retention
water retention
plasma volume
plasma oncotic
pressure
edema

underlying cause
protein filtration
glomerular damage
Filtered proteases
cleave inactive
ENaC in late DT
hypoalbuminemia
?anemia
proteinuria

understood.
Na+ retention
water retention
plasma volume
plasma oncotic
pressure
edema
In the setting of plasma

oncotic pressure, extra fluid
moves straight into
interstitium, so BP is rarely/
barely raised.

underlying cause
protein filtration
glomerular damage
Filtered proteases
cleave inactive
ENaC in late DT
hypoalbuminemia
?anemia
Liver makes more

proteins (not just
albumin)
plasma LDL
(hyperlipidemia)
proteinuria

understood.
Na+ retention
water retention
plasma volume
plasma oncotic
pressure
edema

moves straight into
barely raised.

underlying cause
protein filtration
glomerular damage
Filtered proteases
cleave inactive
ENaC in late DT
hypoalbuminemia
?anemia
Liver makes more

proteins (not just
albumin)
plasma LDL
(hyperlipidemia)
proteinuria

understood.
Na+ retention
water retention
plasma volume
plasma oncotic
pressure
edema

moves straight into
barely raised.
Summary of nephrotic syndrome

Defining symptoms:
Hypoalbuminemia
Edema
Lipids
Proteinuria 3.5g/day (equivalently, protein/
creatinine ratio 350mg/mmol)
A quick way to remember:

HELP
Summary and comparison

Nephritic
Inflammatory causes
Nephrotic
Non-inflammatory causes
Hematuria
Hypertension
Oliguria
+Maybe edema and mild
proteinuria
Hypoalbuminemia
Edema
Lipids
Proteinuria
Potential confusing things

Nephritic
Nephrotic
In nephritic, Na+ and water

retention lead to hypertension.
But in nephrotic, which also
involves these processes, the
BP is usually normal. (This is
because the low plasma
oncotic pressure allows the
extra fluid to go straight into
the interstitium, so it doesnt
hang around long enough to
raise BP).
Glomerulus is damaged enough to

let big RBCs through, so youd
think proteins would easily pass
through. However proteinuria is
not usually seen, and if it is
present, its mild.
In the next episode

Explore some of the different types of
glomerulonephritis (GN).
For each type of GN, learn whether it
typically presents as nephrotic or nephritic
syndrome, and why.

Nephrotic and Nephritic Syndromes

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What are the main differences between nephritic and nephrotic syndromes?

What are the main differences between nephritic and nephrotic syndromes?

What are some of the key symptoms of nephritic syndrome?

What are some of the key symptoms of nephritic syndrome?

Nephrotic and Nephritic

What are they, and why do we care?

GFR leads to too much fluid on one side

Pathogenesis of nephritic syndrome

glomerular damage with

Pathogenesis of nephritic syndrome

glomerular damage with

Pathogenesis of nephritic syndrome

glomerular damage with

Pathogenesis of nephritic syndrome

glomerular damage with

severe GFR activates

Pathogenesis of nephritic syndrome

glomerular damage with

severe GFR activates

Na+ retention occurs even if GFR is not

Pathogenesis of nephritic syndrome

glomerular damage with

severe GFR activates

Na+ retention occurs even if GFR is not

Pathogenesis of nephritic syndrome

glomerular damage with

severe GFR activates

Na+ retention occurs even if GFR is not

Pathogenesis of nephritic syndrome

glomerular damage with

severe GFR activates

Na+ retention occurs even if GFR is not

Nephritic syndrome summary

A quick way to remember:

Pathogenesis of nephrotic syndrome

Pathogenesis of nephrotic syndrome

Pathogenesis of nephrotic syndrome

Pathogenesis of nephrotic syndrome

Glomerular damage may cause

Pathogenesis of nephrotic syndrome

Glomerular damage may cause

Pathogenesis of nephrotic syndrome

Glomerular damage may cause

Pathogenesis of nephrotic syndrome

Glomerular damage may cause

In the setting of plasma

Pathogenesis of nephrotic syndrome

Liver makes more

Glomerular damage may cause

In the setting of plasma

Pathogenesis of nephrotic syndrome

Liver makes more

Glomerular damage may cause

In the setting of plasma

Summary of nephrotic syndrome

A quick way to remember:

Summary and comparison

Potential confusing things

In nephritic, Na+ and water