Overview of Heavy Proteinuria and The: Nephrotic Syndrome

• Overview of heavy proteinuria and the
nephrotic syndrome
INTRODUCTION AND TERMINOLOGY
• — Diseases of the glomerulus can result in

three different urinary and clinical patterns:
1) focal nephritic (mild) ;
2) diffuse nephritic ( severe) ; and
3) nephrotic
Mild nephritic
• Disorders resulting in a mild nephritic
sediment are generally associated with
inflammatory lesions in less than one-half of
glomeruli on light microscopy (focal
glomerulonephritis).
The urinalysis reveals
1) red cells (which often have a dysmorphic
appearance),
2) red cell casts(occasionally) , and
3) mild proteinuria (usually less than 1.5 g/day).
Continue
• The findings of more advanced disease are
usually absent, such as
1) heavy proteinuria,
2) edema,
3) hypertension, and
4) renal insufficiency
Continue
• These patients often present with
asymptomatic hematuria and proteinuria
discovered on routine examination or ,
occasionally , with episodes of gross
hematuria.
Severe nephritic
• The urinalysis in diffuse glomerulonephritis is
similar to focal disease, but
1) heavy proteinuria (which may be in the
nephrotic range),
2) edema,
3) hypertension, and/or
4) renal insufficiency may be observed.
Continue
• Diffuse glomerulonephritis affects most or all
of the glomeruli
Nephrotic
• – The nephrotic sediment is associated with
1) heavy proteinuria and
2) lipiduria,
3) but few cells or casts.
It is specifically defined by the presence of
1) heavy proteinuria (protein excretion greater

than 3.5 g/24 hours),
2) hypoalbuminemia (less than 3 g/dL), and
3) peripheral edema.
-Hyperlipidemia and thrombotic disease are also
frequently observed.
Isolated heavy proteinuria
• Isolated heavy proteinuria without edema or
other features of the nephrotic syndrome is
suggestive of a glomerulopathy (with the
same etiologies as the nephrotic syndrome),
but is not necessarily associated with the
multiple clinical and management problems
characteristic of the nephrotic syndrome.
Continue
• This is an important clinical distinction
because heavy proteinuria in patients without
edema or hypoalbuminemia is more likely to
be due to secondary focal segmental
glomerulosclerosis (FSGS) (due, for example,
to diabetes)
ETIOLOGY
• — Heavy proteinuria with or without the
nephrotic syndrome may occur in association
with a wide variety of primary and systemic
diseases.
• Minimal change disease is the predominant
cause in children.
In adults
• approximately 30 percent have a systemic
disease such as
1) diabetes mellitus,
2) amyloidosis, or
3) systemic lupus erythematosus.
Continue
• The remaining cases are usually due to
primary renal disorders such as
1) minimal change disease,
2) focal segmental glomerulosclerosis (FSGS),
and
3) membranous nephropathy
Continue
• The nephrotic syndrome can also develop in
patients with
1) postinfectious glomerulonephritis,
2) membranoproliferative glomerulonephritis,
and
3) IgA nephropathy .
Continue
• However , these individuals typically have a
"nephritic" type of urinalysis with
1) hematuria and
2) cellular (including red cell) casts
as a prominent feature.
PATHOPHYSIOLOGY
Proteinuria
• There are three basic types of proteinuria;
1) Glomerular ;
2) Tubular ; and
3) overflow .
CONTINUE
• In the nephrotic syndrome, protein loss is due
to glomerular proteinuria, characterized by
increased filtration of macromolecules across
the glomerular capillary wall.
Conditions
• The podocyte appears to be the major target
of injury in diseases that cause idiopathic
nephrotic syndrome in adults and children
(membranous nephropathy , minimal change
disease, and focal segmental
glomerulosclerosis [FSGS]),
Continue
• In patients with nephrotic syndrome, albumin
is the principal urinary protein, but other
plasma proteins including clotting inhibitors,
transferrin, immunoglobulins, and hormone
carrying proteins such as vitamin D-binding
protein may be lost as well.
Hypoalbuminemia
• — The mechanism of hypoalbuminemia in
nephrotic patients is not completely
understood.
• Most of albumin loss is due to urinary
excretion.
Edema
• — Two mechanisms have been proposed to
explain the occurrence of edema in the
nephrotic syndrome.
Continue
• In some patients, marked hypoalbuminemia
leads to egress of fluid into the interstitial
space by producing a decrease in plasma
oncotic pressure.
Continue
• In most patients however , there is a parallel
fall in the interstitial protein concentration and
little change in the transcapillary oncotic
pressure gradient.
Continue
• In the latter patients,edema appears to be the
consequence of primary renal sodium
retention in the collecting tubules mediated
through the epithelial sodium channel and the
basolateral Na-KA TPase .
Continue
• The lack of major arterial underfilling has
important implications for diuretic therapy
since the excess fluid can usually be removed
without inducing volume depletion.
Hyperlipidemia and lipiduria
• — The two most common lipid abnormalities
in the nephrotic syndrome are
1) hypercholesterolemia and
2) hypertriglyceridemia.
Continue
• Decreased plasma oncotic pressure appears to
stimulate hepatic lipoprotein synthesis
resulting in hypercholesterolemia.
Continue
• Diminished clearance may also play a role in
the development of hypercholesterolemia.
• Impaired metabolism is primarily responsible
for nephrotic hypertriglyceridemia.
Inue con
• Lipiduria is usually present in the nephrotic
syndrome.
• Urinary lipid may be present in the sediment,
a) entrapped in casts (fatty casts),
b) enclosed by the plasma membrane of
degenerative epithelial cells (oval fat bodies),
or
c) free in the urine.

Overview of Heavy Proteinuria and The: Nephrotic Syndrome

Uploaded by

Copyright:

Available Formats

Overview of Heavy Proteinuria and The: Nephrotic Syndrome

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Overview of Heavy Proteinuria and The: Nephrotic Syndrome

Uploaded by

Copyright:

Available Formats

• Overview of heavy proteinuria and the

• — Diseases of the glomerulus can result in

1) heavy proteinuria (protein excretion greater

You might also like