Nephrotic syndrome

Nephrotic syndrome is a collection of symptoms

due to kidney damage. This includes protein in the Nephrotic syndrome
urine, low blood albumin levels, high blood lipids,
and significant swelling. Other symptoms may
include weight gain, feeling tired, and foamy urine.
Complications may include blood clots, infections,
and high blood pressure.[1]

Causes include a number of kidney diseases such as

focal segmental glomerulosclerosis, membranous
nephropathy, and minimal change disease.[1][2] It
may also occur as a complication of diabetes, lupus, Microscopic image of diabetic
or amyloidosis. The underlying mechanism typically glomerulosclerosis, the main cause of
involves damage to the glomeruli of the kidney. nephrotic syndrome in adults.
Diagnosis is typically based on urine testing and
Specialty Nephrology
sometimes a kidney biopsy.[1] It differs from
Symptoms Swelling, weight gain, feeling
nephritic syndrome in that there are no red blood
tired, foamy urine[1]
cells in the urine.[2]
Complications Blood clots, infections, high
Treatment is directed at the underlying cause. Other blood pressure[1]
efforts include managing high blood pressure, high Causes Focal segmental
blood cholesterol, and infection risk. A low-salt diet glomerulosclerosis,
and limiting fluids are often recommended.[1] About membranous nephropathy,
5 per 100,000 people are affected per year.[3][4] The minimal change disease,
usual underlying cause varies between children and diabetes, lupus[1][2]
adults.[4] Diagnostic Urine testing, kidney biopsy[1]
method
Differential Nephritic syndrome, cirrhosis,
Signs and symptoms diagnosis severe malnutrition[2]

Nephrotic syndrome is characterized by large Treatment Directed at underlying

amounts of proteinuria (>3.5 g per 1.73 m body 2 cause[1]
surface area per day,[6] or > 40 mg per square meter Frequency 5 per 100,000 per year[3][4]
body surface area per hour in children),
hypoalbuminemia (< 3.5 g/dl), hyperlipidaemia, and edema that begins in the face. Lipiduria
(lipids in urine) can also occur, but is not essential for the diagnosis of nephrotic syndrome.

A few other characteristics seen in nephrotic syndrome are:

The most common sign is excess fluid in the body due to serum hypoalbuminemia. Lower
serum oncotic pressure causes fluid to accumulate in the interstitial tissues. Sodium and water
retention aggravates the edema. This may take several forms:
Puffiness around the eyes, characteristically in the morning.
Pitting edema over the legs.
 Fluid in the pleural cavity causing pleural effusion.
More commonly associated with excess fluid is
pulmonary edema.
Fluid in the peritoneal cavity causing ascites.
Generalized edema throughout the body known as
anasarca.
Most of the people with nephrotic syndrome are
normotensive but hypertension (rarely) may also occur.
Anaemia (iron resistant microcytic hypochromic type)
may be present due to transferrin loss.
Dyspnea may be present due to pleural effusion or due
to diaphragmatic compression with ascites.
Erythrocyte sedimentation rate is increased due to
increased fibrinogen & other plasma contents.
Some people may notice foamy or frothy urine, due to
a lowering of the surface tension by the severe
proteinuria. Actual urinary complaints such as Nephrotic syndrome is usually
haematuria or oliguria are uncommon, though these accompanied by retention of water and
are seen commonly in nephritic syndrome. sodium. The degree to which this occurs
May have features of the underlying cause, such as the can vary between slight edema in the
rash associated with systemic lupus erythematosus, or eyelids that decreases during the day, to
the neuropathy associated with diabetes. affecting the lower limbs, to generalized
Examination should also exclude other causes of gross swelling, to full blown anasarca.[5]
edema—especially the cardiovascular and liver
system.
Muehrcke's nails; white lines (leukonychia) that extend all the way across the nail and lie
parallel to the lunula[7]
The main signs of nephrotic syndrome are:[8]

Proteinuria of greater than 3.5 g /24 h /1.73 m2 (between 3 and 3.5 g/24 h /1.73 m2 is
considered to be proteinuria in the nephrotic range) or greater than 40 mg/h/m2 in
children.[9][10] The ratio between urinary concentrations of albumin and creatinine can be used
in the absence of a 24-hour urine test for total protein. This coefficient will be greater than 200–
400 mg/mmol in nephrotic syndrome. This pronounced loss of proteins is due to an increase in
glomerular permeability that allows proteins to pass into the urine instead of being retained in
the blood. Under normal conditions a 24-hour urine sample should not exceed 80 milligrams or
10 milligrams per decilitre.[11]
Hypoalbuminemia of less than 2.5 g/dL,[9] that exceeds the liver clearance level, that is, protein
synthesis in the liver is insufficient to increase the low blood protein levels.
Edema is thought to be caused by two mechanisms. The first being hypoalbuminemia which
lowers the oncotic pressure within vessels resulting in hypovolemia and subsequent activation
of the renin–angiotensin system and thus retention of sodium and water (underfill hypothesis).
Additionally, it is thought that urinary proteases (excreted as a result of significant proteinuria)
cause a direct effect by activating the epithelial sodium channel (ENaC) on the principal cell
that leads to the reabsorption of sodium and water (overfill hypothesis). Nephrotic syndrome
edema initially appears in parts of the lower body (such as the legs) and in the eyelids. In the
advanced stages it also extends to the pleural cavity and peritoneum (ascites) and can even
develop into a generalized anasarca.
Hyperlipidaemia in nephrotic syndrome is typically caused by two mechanisms.[12] First,
hypoproteinemia stimulates protein synthesis in the liver, resulting in the overproduction of low
and very-low-density lipoproteins. There is also an increase in the liver synthesis of cholesterol.
Second, lipid catabolism is decreased due to lower levels of lipoprotein lipase, the main
 enzyme involved in lipoprotein breakdown.[13] Cofactors, such as apolipoprotein C2, may also
be lost by increased filtration of proteins.
Thrombophilia, or hypercoagulability, is a greater predisposition for the formation of blood clots
that are caused by a decrease in the levels of antithrombin III in the blood due to its loss in
urine.
Lipiduria or loss of lipids in the urine is indicative of glomerular pathology due to an increase in
the filtration of lipoproteins.[14]

Complications
Nephrotic syndrome can be associated with a series of complications that can affect an individual's
health and quality of life:[15]

Thromboembolic disorders: particularly those caused by a decrease in blood antithrombin III

levels due to leakage. Antithrombin III counteracts the action of thrombin. Thrombosis usually
occurs in the kidney veins although it can also occur in arteries. Treatment is with oral
anticoagulants (not heparin as heparin acts via anti-thrombin 3 which is lost in the proteinuria
so it will be ineffective.) Hypercoagulopathy due to extravasation of fluid from the blood vessels
(edema) is also a risk for venous thrombosis.
Infections: The increased susceptibility of people with nephrotic syndrome to infections can be
a result of the leakage of immunoglobulins from the blood, the loss of proteins in general, and
the presence of oedematous fluid (which acts as a breeding ground for infections). The most
common infection is peritonitis, followed by lung, skin, and urinary infections,
meningoencephalitis and in the most serious cases septicaemia. The most notable of the
causative organisms are Streptococcus pneumoniae and Haemophilus influenzae.
Spontaneous bacterial peritonitis can develop where there is ascites present. This is a frequent
development in children but very rarely found in adults.[16]
Acute kidney failure due to hypovolemia: the loss of vascular fluid into the tissues (edema)
produces a decreased blood supply to the kidneys that cause a loss of kidney function. Thus it
is a tricky task to get rid of excess fluid in the body while maintaining circulatory euvolemia.
Pulmonary edema: the loss of proteins from blood plasma and the consequent fall in oncotic
pressure causes an abnormal accumulation of liquid in the lungs causing hypoxia and
dyspnoea.
Hypothyroidism: deficiency of the thyroglobulin transport protein thyroxin (a glycoprotein that is
rich in iodine and is found in the thyroid gland) due to decreased thyroid-binding globulin.
Vitamin D deficiency can occur. Vitamin D binding protein is lost.
Hypocalcaemia: lack of 25-hydroxycholecalciferol (the way that vitamin D is stored in the
body). As vitamin D regulates the amount of calcium present in the blood, a decrease in its
concentration will lead to a decrease in blood calcium levels. It may be significant enough to
cause tetany. Hypocalcaemia may be relative; calcium levels should be adjusted based on the
albumin level and ionized calcium levels should be checked.
Microcytic hypochromic anaemia: iron deficiency caused by the loss of ferritin (compound used
to store iron in the body). It is iron-therapy resistant.
Protein malnutrition: this occurs when the amount of protein that is lost in the urine is greater
than that ingested, this leads to a negative nitrogen balance.[17][18]
Growth retardation: This can occur in cases of relapse or resistance to therapy. Causes of
growth retardation are protein deficiency from the loss of protein in urine, anorexia (reduced
protein intake), and steroid therapy (catabolism).
Cushing's syndrome[19]
Causes
Nephrotic syndrome has many causes and may either be
the result of a glomerular disease that can be either limited
to the kidney, called primary nephrotic syndrome
(primary glomerulonephrosis), or a condition that affects
the kidney and other parts of the body, called secondary
nephrotic syndrome.[20]

Primary glomerulonephrosis
Primary causes of nephrotic syndrome are usually
Histological image of a normal kidney
described by their histology:[21]
glomerulus. It is possible to see a
glomerulus in the centre of the image
Minimal change disease (MCD): is the most common surrounded by kidney tubules.
cause of nephrotic syndrome in children. It owes its
name to the fact that the nephrons appear normal
when viewed with an optical microscope as the lesions
are only visible using an electron microscope. Another symptom is pronounced proteinuria.
Focal segmental glomerulosclerosis (FSGS): is the most common cause of nephrotic
syndrome in adults.[22] It is characterized by the appearance of tissue scarring in the glomeruli.
The term focal is used as some of the glomeruli have scars, while others appear intact; the
term segmental refers to the fact that only part of the glomerulus is damaged.
Membranous glomerulonephritis (MGN): The inflammation of the glomerular membrane causes
increased leaking in the kidney. It is not clear why this condition develops in most people,
although an auto-immune mechanism is suspected.[22]
Membranoproliferative glomerulonephritis (MPGN): is the inflammation of the glomeruli along
with the deposit of antibodies in their membranes, which makes filtration difficult.
Rapidly progressive glomerulonephritis (RPGN): (Usually presents as a nephrotic syndrome) A
person's glomeruli are present in a crescent moon shape. It is characterized clinically by a
rapid decrease in the glomerular filtration rate (GFR) by at least 50% over a short period,
usually from a few days to 3 months.[23]
They are considered to be "diagnoses of exclusion", i.e. they are diagnosed only after secondary
causes have been excluded.

Secondary glomerulonephrosis
Secondary causes of nephrotic syndrome have the same
histologic patterns as the primary causes, though they may
exhibit some differences suggesting a secondary cause, such
as inclusion bodies.[24] They are usually described by the
underlying cause, such as:

Diabetic nephropathy: is a complication that occurs in

some diabetics. Excess blood sugar accumulates in the
kidney causing them to become inflamed and unable to
carry out their normal function. This leads to the leakage
Diabetic glomerulonephritis in a person
of proteins into the urine.
with nephrotic syndrome.
Systemic lupus erythematosus: this autoimmune disease
can affect a number of organs, among them the kidney,
 due to the deposit of immunocomplexes that are typical to this disease. The disease can also
cause lupus nephritis.
Sarcoidosis: This disease does not usually affect the kidney but, on occasions, the
accumulation of inflammatory granulomas (collection of immune cells) in the glomeruli can lead
to nephrotic syndrome.
Syphilis: kidney damage can occur during the secondary stage of this disease (between 2 and
8 weeks from onset).
Hepatitis B: certain antigens present during hepatitis can accumulate in the kidneys and
damage them.
Sjögren's syndrome: this autoimmune disease causes the deposit of immunocomplexes in the
glomeruli, causing them to become inflamed, this is the same mechanism as occurs in
systemic lupus erythematosus.
HIV: the virus's antigens provoke an obstruction in the glomerular capillary's lumen that alters
normal kidney function.
Amyloidosis: the deposit of amyloid substances (proteins with anomalous structures) in the
glomeruli modifying their shape and function.
Multiple myeloma: kidney impairment is caused by the accumulation and precipitation of light
chains, which form casts in the distal tubules, resulting in kidney obstruction. In addition,
myeloma light chains are also directly toxic on proximal kidney tubules, further adding to kidney
dysfunction.
Vasculitis: inflammation of the blood vessels at a glomerular level impedes the normal blood
flow and damages the kidney.
Cancer: as happens in myeloma, the invasion of the glomeruli by cancerous cells disturbs their
normal functioning.
Genetic disorders: congenital nephrotic syndrome is a rare genetic disorder in which the
protein nephrin, a component of the glomerular filtration barrier, is altered.
Drugs ( e.g. gold salts, penicillin, captopril):[25] gold salts can cause a more or less important
loss of proteins in urine as a consequence of metal accumulation. Penicillin is nephrotoxic in
people with kidney failure and captopril can aggravate proteinuria.

By histologic pattern
Membranous nephropathy (MN)

Sjögren's syndrome
Systemic lupus erythematosus (SLE)
Diabetes mellitus
Sarcoidosis
Drugs (such as corticosteroids, gold, intravenous heroin)
Malignancy (cancer)
Bacterial infections, e.g. leprosy & syphilis
Protozoal infections, e.g. malaria
Focal segmental glomerulosclerosis (FSGS)[26]

Hypertensive nephrosclerosis
HIV[27]
Obesity[27]
Kidney loss
Minimal change disease (MCD)[26]

Drugs, especially NSAIDs in the elderly

 Malignancy, especially Hodgkin's lymphoma
Allergy
Bee sting
Membranoproliferative Glomerulonephritis

Hepatitis C

Genetics
Over 50 mutations are known to be associated with this condition.[28][29]

Non-Genetic

There is no known genetic cause for idiopathic nephrotic syndrome. This is thought to be caused by
a hitherto unknown circulating permeability factor that travels in the circulation to the podocyte
within the glomerulus of the kidney. This circulating factor damages the podocyte which changes
its structure. The podocytes are now less able to restrict urinary protein loss. Despite not knowing
the specific indentity of the circulating factor, scientists are learning more about it. It is thought to
be either T cell or B cell derived,[30][31] hence why staroid treatment can be effective for some
patients. There is also evidence that the circulating factor could be signalling via the PAR-1
receptro on the podocytes.[32]

Pathophysiology
The kidney glomerulus filters the blood that arrives at the kidney. It is
formed of capillaries with small pores that allow small molecules to pass
through that have a molecular weight of less than 40,000 daltons,[33] but
not larger macromolecules such as proteins.

In nephrotic syndrome, the glomeruli are affected by an inflammation or a

hyalinization (the formation of a homogenous crystalline material within
cells) that allows proteins such as albumin, antithrombin or the
immunoglobulins to pass through the cell membrane and appear in
urine.[15] Drawing of the
kidney glomerulus.
Albumin is the main protein in the blood that is able to maintain an oncotic
pressure, which prevents the leakage of fluid into the extracellular medium
and the subsequent formation of edemas.

As a response to hypoproteinemia the liver commences a compensatory mechanism involving the

synthesis of proteins, such as alpha-2 macroglobulin and lipoproteins.[15] An increase in the latter
can cause the hyperlipidemia associated with this syndrome.

Diagnosis
Along with obtaining a complete medical history, a series of biochemical tests are required in order
to arrive at an accurate diagnosis that verifies the presence of the illness. In addition, imaging of
the kidneys (for structure and presence of two kidneys) is sometimes carried out, and/or a biopsy
of the kidneys. The first test will be a urinalysis to test for high
levels of proteins,[35] as a healthy subject excretes an insignificant
amount of protein in their urine. The test will involve a 24-hour
bedside urinary total protein estimation. The urine sample is
tested for proteinuria (>3.5 g per 1.73 m2 per 24 hours). It is also
examined for urinary casts, which are more a feature of active
nephritis. Next a blood screen, comprehensive metabolic panel
(CMP) will look for hypoalbuminemia: albumin levels of ≤2.5
g/dL (normal=3.5-5 g/dL). Then a Creatinine Clearance CCr test
will evaluate kidney function particularly the glomerular filtration
capacity.[36] Creatinine formation is a result of the breakdown of
muscular tissue, it is transported in the blood and eliminated in
urine. Measuring the concentration of organic compounds in both Urinalysis will be able to detect
liquids evaluates the capacity of the glomeruli to filter blood. high levels of proteins and
Electrolytes and urea levels may also be analysed at the same time occasionally microscopic
as creatinine (EUC test) in order to evaluate kidney function. A haematuria.

lipid profile will also be carried out as high levels of cholesterol

(hypercholesterolemia), specifically elevated LDL, usually
with concomitantly elevated VLDL, is indicative of
nephrotic syndrome.

A kidney biopsy may also be used as a more specific and

invasive test method. A study of a sample's anatomical
pathology may then allow the identification of the type of
glomerulonephritis involved.[35] However, this procedure
is usually reserved for adults as the majority of children
experience minimal change disease that has a remission
rate of 95% with corticosteroids.[37] A biopsy is usually
Ultrasound of a kidney with nephrotic
only indicated for children that are corticosteroid resistant
syndrome. There is a hyperechoic kidney
as the majority have focal and segmental without demarcation of the cortex and
glomeruloesclerosis. [37]
medulla.[34]

Further investigations are indicated if the cause is not clear

including analysis of auto-immune markers (ANA, ASOT, C3, cryoglobulins, serum
electrophoresis), or ultrasound of the whole abdomen.

Classification
A broad classification of nephrotic syndrome based on underlying cause:

Nephrotic
syndrome

Primary Secondary

Nephrotic syndrome is often classified histologically:

Nephrotic
syndrome
 MCD FSGS MGN MPGN

Differential diagnosis
Some symptoms that are present in nephrotic syndrome, such as edema and proteinuria, also
appear in other illnesses. Therefore, other pathologies need to be excluded in order to arrive at a
definitive diagnosis.[38]

Edema: in addition to nephrotic syndrome there are two other disorders that often present with
edema; these are heart failure and liver failure.[39] Congestive heart failure can cause liquid
retention in tissues as a consequence of the decrease in the strength of ventricular
contractions. The liquid is initially concentrated in the ankles but it subsequently becomes
generalized and is called anasarca.[40] People with congestive heart failure also experience an
abnormal swelling of the heart cardiomegaly, which aids in making a correct diagnosis. Jugular
venous pressure can also be elevated and it might be possible to hear heart murmurs. An
echocardiogram is the preferred investigation method for these symptoms. Liver failure caused
by cirrhosis, hepatitis and other conditions such as alcoholism, IV drug use or some hereditary
diseases can lead to swelling in the lower extremities and the abdominal cavity. Other
accompanying symptoms include jaundice, dilated veins over umbilicus (caput medusae),
scratch marks (due to widespread itching, known as pruritus), enlarged spleen, spider
angiomata, encephalopathy, bruising, nodular liver and anomalies in the liver function tests.[41]
Less frequently symptoms associated with the administration of certain pharmaceutical drugs
have to be discounted. These drugs promote the retention of liquid in the extremities such as
occurs with NSAIDs, some antihypertensive drugs, the adrenal corticosteroids and sex
hormones.[41]
Acute fluid overload can cause edema in someone with kidney failure. These people are known to
have kidney failure, and have either drunk too much or missed their dialysis. In addition, when
Metastatic cancer spreads to the lungs or abdomen it causes effusions and fluid accumulation due
to obstruction of lymphatic vessels and veins, as well as serous exudation.

Proteinuria: the loss of proteins from the urine is caused by many pathological agents and
infection by these agents has to be ruled out before it can be certain that a person has
nephrotic syndrome. Multiple myeloma can cause a proteinuria that is not accompanied by
hypoalbuminemia, which is an important aid in making a differential diagnosis;[42] other
potential causes of proteinuria include asthenia, weight loss or bone pain. In diabetes mellitus
there is an association between increases in glycated hemoglobin levels and the appearance
of proteinuria.[43] Other causes are amyloidosis and certain other allergic and infectious
diseases.

Treatment
The treatment of nephrotic syndrome can be symptomatic or can directly address the injuries
caused to the kidney.

Symptomatic
The objective of this treatment is to treat the imbalances brought about by the illness:[44] edema,
hypoalbuminemia, hyperlipidaemia, hypercoagulability and infectious complications.
Edema: a return to an unswollen state is the prime objective of this treatment of nephrotic
syndrome. It is carried out through the combination of a number of recommendations:
Rest: depending on the seriousness of the edema and taking into account the risk of
thrombosis caused by prolonged bed rest.[45]
Medical nutrition therapy: based on a diet with the correct energy intake and balance of
proteins that will be used in synthesis processes and not as a source of calories. A total of
35 kcal/kg body weight/day is normally recommended.[46] This diet should also comply with
two more requirements: the first is to not consume more than 1 g of protein/kg body weight/
day,[46] as a greater amount could increase the degree of proteinuria and cause a negative
nitrogen balance.[18] People are usually recommended lean cuts of meat, fish, and poultry.
The second guideline requires that the amount of water ingested is not greater than the
level of diuresis. In order to facilitate this, the consumption of salt must also be controlled,
as this contributes to water retention. It is advisable to restrict the ingestion of sodium to 1
or 2 g/day, which means that salt cannot be used in cooking and salty foods should also be
avoided.[47] Foods high in sodium include seasoning blends (garlic salt, Adobo, season
salt, etc.) canned soups, canned vegetables containing salt, luncheon meats including
turkey, ham, bologna, and salami, prepared foods, fast foods, soy sauce, ketchup, and
salad dressings. On food labels, compare milligrams of sodium to calories per serving.
Sodium should be less than or equal to calories per serving.
Medication: The pharmacological treatment of edema is based on diuretic medications
(especially loop diuretics, such as furosemide). In severe cases of edema (or in cases with
physiological repercussions, such as scrotal, preputial or urethral edema) or in people with
one of a number of severe infections (such as sepsis or pleural effusion), the diuretics can
be administered intravenously. This occurs where the risk from plasmatic expansion[48] is
considered greater than the risk of severe hypovolemia, which can be caused by the strong
diuretic action of intravenous treatment. The procedure is the following:

1. Analyse haemoglobin and haematocrit levels.

2. A solution of 25% albumin is used that is administered for only 4 hours in order to avoid
pulmonary edema.
3. Haemoglobin and haematocrit levels are analysed again: if the haematocrit value is less
than the initial value (a sign of correct expansion) the diuretics are administered for at
least 30 minutes. If the haematocrit level is greater than the initial one this is a
contraindication for the use of diuretics as they would increase said value.
It may be necessary to give a person potassium or require a change in dietary habits if the
diuretic drug causes hypokalaemia as a side effect.

Hypoalbuminemia: is treated using the medical nutrition therapy described as a treatment for
edema. It includes a moderate intake of foods rich in animal proteins.[49]
Hyperlipidaemia: depending on the seriousness of the condition it can be treated with medical
nutrition therapy as the only treatment or combined with drug therapy. The ingestion of
cholesterol should be less than 300 mg/day,[46] which will require a switch to foods that are low
in saturated fats.[50] Avoid saturated fats such as butter, cheese, fried foods, fatty cuts of red
meat, egg yolks, and poultry skin. Increase unsaturated fat intake, including olive oil, canola oil,
peanut butter, avocadoes, fish and nuts. In cases of severe hyperlipidaemia that are
unresponsive to nutrition therapy the use of hypolipidaemic drugs may be necessary (these
include statins, fibrates and resinous sequesters of bile acids).[51]
Thrombophilia: low molecular weight heparin (LMWH) may be appropriate for use as a
prophylactic in some circumstances, such as in asymptomatic people that have no history of
having thromboembolism.[52][53] When the thrombophilia is such that it leads to the formation of
blood clots, heparin is given for at least 5 days along with oral anticoagulants (OAC). During
this time and if the prothrombin time is within its therapeutic range (between 2 and 3),[54] it may
be possible to suspend the LMWH while maintaining the OACs for at least 6 months.[55]
 Infectious complications: an appropriate course of antibacterial drugs can be taken
according to the infectious agent.
In addition to these key imbalances, vitamin D and calcium are also taken orally in case the
alteration of vitamin D causes severe hypocalcaemia, this treatment has the goal of restoring
physiological levels of calcium in the person.[56]

Achieving better blood glucose level control if the person is diabetic.

Blood pressure control. ACE inhibitors are the drug of choice. Independent of their blood
pressure-lowering effect, they have been shown to decrease protein loss.

Kidney damage
The treatment of kidney damage may reverse or delay the progression of the disease.[44] Kidney
damage is treated by prescribing drugs:

Corticosteroids: the result is a decrease in proteinuria and the risk of infection as well as a
resolution of the edema.[57] Prednisone is usually prescribed at a dose of 60 mg/m2 of body
surface area/day in a first treatment for 4–8 weeks. After this period the dose is reduced to
40 mg/m2 for a further 4 weeks. People experiencing a relapse or children are treated with
prednisolone 2 mg/kg/day until urine becomes negative for protein. Then, 1.5 mg/kg/day for 4
weeks. Frequent relapses treated by: cyclophosphamide or nitrogen mustard or cyclosporin or
levamisole. People can respond to prednisone in a number of different ways:
People with Corticosteroid sensitive or early steroid-responder: the subject responds to the
corticosteroids in the first 8 weeks of treatment. This is demonstrated by a strong diuresis
and the disappearance of edemas, and also by a negative test for proteinuria in three urine
samples taken during the night.
People with Corticosteroid resistance or late steroid-responder: the proteinuria persists
after the 8-week treatment. The lack of response is indicative of the seriousness of the
glomerular damage, which could develop into chronic kidney failure.
People with Corticosteroid intolerant: complications such as hypertension appear, and they
gain a lot of weight and can develop aseptic or avascular necrosis of the hip or knee,[58]
cataracts and thrombotic phenomena and/or embolisms.
People with Corticosteroid dependent: proteinuria appears when the dose of corticosteroid
is decreased or there is a relapse in the first two weeks after treatment is completed.
The susceptibility testing in vitro to glucocorticoids on the person's peripheral blood mononuclear
cells is associated with the number of new cases of not optimal clinical responses: the most
sensitive people in vitro have shown a higher number of cases of corticodependence, while the
most resistant people in vitro showed a higher number of cases of ineffective therapy.[59]

Immunosupressors (cyclophosphamide): only indicated in recurring nephrotic syndrome in

corticosteroid dependent or intolerant people. In the first two cases, the proteinuria has to be
negated before treatment with the immunosuppressor can begin, which involves a prolonged
treatment with prednisone. The negation of the proteinuria indicates the exact moment when
treatment with cyclophosphamide can begin. The treatment is continued for 8 weeks at a dose
of 3 mg/kg/day, the immunosuppression is halted after this period. In order to be able to start
this treatment the person should not have neutropenia nor anaemia, which would cause further
complications. A possible side effect of the cyclophosphamide is alopecia. Complete blood
count tests are carried out during the treatment in order to give advance warning of a possible
infection.
Prognosis
The prognosis for nephrotic syndrome under treatment is generally good although this depends on
the underlying cause, the age of the person and their response to treatment. It is usually good in
children, because minimal change disease responds very well to steroids and does not cause
chronic kidney failure. Any relapses that occur become less frequent over time;[60] the opposite
occurs with mesangiocapillary glomerulonephritis, in which the kidney fails within three years of
the disease developing, making dialysis necessary and subsequent kidney transplant.[60] In
addition children under the age of 5 generally have a poorer prognosis than prepubescents, as do
adults older than 30 years of age as they have a greater risk of kidney failure.[61]

Other causes such as focal segmental glomerulosclerosis frequently lead to end stage kidney
disease. Factors associated with a poorer prognosis in these cases include level of proteinuria,
blood pressure control and kidney function (GFR).

Without treatment nephrotic syndrome has a very bad prognosis especially rapidly progressing
glomerulonephritis, which leads to acute kidney failure after a few months.

Epidemiology
Nephrotic syndrome can affect any age, although it is mainly found in adults with a ratio of adults
to children of 26 to 1.[62]

The syndrome presents in different ways in the two groups: the most frequent glomerulopathy in
children is minimal change disease (66% of cases), followed by focal segmental glomerulosclerosis
(8%) and mesangiocapillary glomerulonephritis (6%).[24] In adults the most common disease is
mesangiocapillary glomerulonephritis (30-40%), followed by focal and segmental
glomeruloesclerosis (15-25%) and minimal change disease (20%). The latter usually presents as
secondary and not primary as occurs in children. Its main cause is diabetic nephropathy.[24] It
usually presents in a person from their 40s or 50s. Of the glomerulonephritis cases, approximately
60% to 80% are primary, while the remainder are secondary.[62]

There are also differences in epidemiology between the sexes, the disease is more common in men
than in women by a ratio of 2 to 1.[62]

The epidemiological data also reveals information regarding the most common way that symptoms
develop in people with nephrotic syndrome:[62] spontaneous remission occurs in up to 20% or
30% of cases during the first year of the illness. However, this improvement is not definitive as
some 50% to 60% of people with Nephrotic syndrome die and/or develop chronic kidney failure 6
to 14 years after this remission. On the other hand, between 10% and 20% of people have
continuous episodes of remissions and relapses without dying or jeopardizing their kidney. The
main causes of death are cardiovascular, as a result of the chronicity of the syndrome, and
thromboembolic accidents.

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External links
Childhood Nephrotic Syndrome (https://web.archive.org/web/20110608142448/http://kidney.nid
dk.nih.gov/kudiseases/pubs/childhoodnephrotic/) - National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK), NIH
Adult Nephrotic Syndrome (https://web.archive.org/web/20150331005429/http://kidney.niddk.ni
h.gov/kudiseases/pubs/nephrotic/) - National Institute of Diabetes and Digestive and Kidney
Diseases (NIDDK), NIH
Clardy, Chris (May 2000) "Nephrotic Syndrome in Children (https://web.archive.org/web/20160
109015832/http://pediatrics.uchicago.edu/chiefs/nephro/documents/Peds_Nephro_for_Residen
ts_Nov2005.pdf)" Pediatric Nephrology Handout
Retrieved from "https://en.wikipedia.org/w/index.php?title=Nephrotic_syndrome&oldid=1275811819"