Nephrotic Syndrome (Nephrotic Syndromes)

Diabetic glomerulosclerosis (1) HE[1]

This is a nonspecific disease of the kidney characterized by proteinuria, edema and hypoalbuminemia. It results from increased permeability of the glomerulus leading to massive loss of protein in the urine.

Nephrotic Syndrome is related to the following process: auto-immune.

Presentation

The commonest presenting features are those due to fluid retention. Facial edema is usually the first sign of nephrotic syndrome in children. This is followed be generalized swelling of the whole body known as anasarca. There could be ascites, pleural effusion, and pitting pedal edema. The patient could also present with frothy urine. There could be dyspnea and cough. In cases of an underlying disease, patients will present with symptoms of that disease e.g. rash in patients with lupus.

On presentation, the cardiovascular and hepatic systems should be evaluated to rule out other causes of generalized edema [7].

Skin
  • more...
  • urogenital
    Oliguria
    • As mentioned previously, the nephritic syndrome ischaracterized by haematuria (which is absent in nephrotic syndrome) as well asuraemia, hypertension, proteinuria and oliguria.[newhealthadvisor.com]
    • The signs include cold hands and feet, delayed capillary filling, oliguria, and tachycardia.[emedicine.medscape.com]
    • Actual urinary complaints such as haematuria or oliguria are uncommon, though these are seen commonly in nephritic syndrome .[en.wikipedia.org]
  • more...
  • Eyes
  • more...
  • cardiovascular
    Hypertension
    • The hallmark features of nephritic syndrome are RBC casts and hypertension.[newhealthadvisor.com]
    • Treatment with Acthar was well tolerated; one patient had an early termination of treatment due to weight gain and hypertension.[prnewswire.com]
    • Hypercoagulability Hypertension in adults Renal sodium retention Bone disorder Corticosteroid use Chronic kidney disease Unknown Possibly hypovolemia, interstitial edema, and use of NSAIDs Proximal tubular dysfunction (acquired Fanconi syndrome), with[merckmanuals.com]
    • The substantial loss of protein in the urine results in complications such as HYPOPROTEINEMIA; generalized EDEMA; HYPERTENSION; and HYPERLIPIDEMIAS.[fpnotebook.com]
    • "The leading causes of kidney failure in children are hereditary often lacking obvious indicators such as hematuria (red blood cells in the urine), hypertension (high blood pressure) or edema (swelling)," said Dr Bharat Shah, director of renal science[dnaindia.com]
  • more...
  • gastrointestinal
    Abdominal Pain
    • The patient may note abdominal pain and difficulty breathing.[encyclopedia.com]
    • Call your child’s healthcare provider if your child has: Symptoms that don’t get better, or get worse New symptoms Nausea or vomiting, or abdominal pain Unexpected weight gain or swelling in the legs, ankles, or around the eyes Dark colored urine Less[urmc.rochester.edu]
    • Think of spontaneous bacterial peritonitis in patient with fever and abdominal pain.[pedemmorsels.com]
    • Anorexia, abdominal pain and diarrhea may be seen, possibly secondary to the formation of ascites.[hawaii.edu]
    Loss of Appetite
    • Other common signs include loss of appetite, diarrhea , less frequent urination, and urine that looks dark and foamy.[kidshealth.org]
    • However, as kidney function continues to worsen, symptoms of kidney failure can develop, including shortness of breath, weakness and easy fatigability (from anemia) and loss of appetite.[uptodate.com]
  • more...
  • respiratoric
    Pleural Effusion
    • Fluid retention may cause Dyspnea (pleural effusion or laryngeal edema) Arthralgia (hydrarthrosis) Abdominal pain (ascites or, in children, mesenteric edema) Corresponding signs may develop, including peripheral edema and ascites.[merckmanuals.com]
    • Fluid in the pleural cavity causing pleural effusion .[en.wikipedia.org]
    • Pleural effusions may cause chest pain and breathlessness.[patient.info]
    • As the edema accumulates, pleural effusions, ascites and decreased urine output may develop.[hawaii.edu]
    • Additional consequences include the following: Hypertension related to fluid retention and reduced kidney function may occur Edema of the gut may cause defective absorption, leading to malnutrition Ascites and pleural effusions may develop Infection Infection[emedicine.medscape.com]
  • more...
  • neurologic
    Headache
    • , including swelling in face, belly, or arms and legs, or skin sores You're being treated for nephrotic syndrome, but your symptoms don't improve New symptoms develop, including cough, decreased urine output, discomfort with urination, fever, severe headache[nlm.nih.gov]
    • […] burst blood vessels in the retina of the eye Cough containing mucus or pink, frothy material from fluid buildup in the lungs Shortness of breath, from fluid buildup in the lungs General ill feeling (malaise), drowsiness , confusion , aches and pains, headache[nlm.nih.gov]
    • The doctor just put me on cyclosporine and it makes my stomach hurt and I have headaches.[inspire.com]
    • […] don’t get better, or get worse New symptoms Nausea or vomiting, or abdominal pain Unexpected weight gain or swelling in the legs, ankles, or around the eyes Dark colored urine Less or no urine Call 911 if your child has: Severe weakness, dizziness, headache[urmc.rochester.edu]
  • more...
  • Face, Head & Neck
    Facial Swelling
    • Symptoms may include: Fatigue and malaise Decreased appetite Weight gain and facial swelling Abdominal swelling or pain Foamy urine Fluid accumulation in the body spaces (edema) Pale fingernail beds Dull hair Ears cartilage may feel less firm Food intolerances[childrensnational.org]
    • They can include: Extreme tiredness (fatigue) A general feeling of discomfort (malaise) Decreased appetite Weight gain and facial swelling Belly swelling or pain Foamy urine Fluid buildup in the body (edema) Fluid buildup in the belly area (ascites) Pale[urmc.rochester.edu]
  • more...
  • Entire body system
    Weight Gain
    • Prednisone can cause increased appetite mood changes; he may be moody or irritable while taking the medicine weight gain Weigh your child as directed and record his weight.[nationwidechildrens.org]
    • Weight gainWeight gain can occur in people who develop swelling.[uptodate.com]
    • A child with nephrotic syndrome may have: Very high levels of protein (albumin) in the urine Low levels of protein in the blood Tissue swelling all over the body (edema), especially in the belly (ascites) Weight gain from excess fluid High cholesterol[urmc.rochester.edu]
    • Weight gain (from fluid buildup).[webmd.com]
    • Symptoms may include: Fatigue and malaise Decreased appetite Weight gain and facial swelling Abdominal swelling or pain Foamy urine Fluid accumulation in the body spaces (edema) Pale fingernail beds Dull hair Ears cartilage may feel less firm Food intolerances[childrensnational.org]
    Fatigue
    • […] erythematosus Exposure to drugs or toxins Certain infections Symptoms Nephrotic syndrome may cause: Swelling around the following body parts: Feet Ankles Abdomen Hands Face Eyes Weight gain from excess fluids Shortness of breath Poor appetite Foamy urine Fatigue[lahey.org]
    • Dr Vishwanth urged parents to look out for early symptoms of kidney ailments in their children, such as sudden weight gain, unexplained anaemia and weakness, fatigue and recurring urinary infection.[thenewsminute.com]
    • Symptoms may include: Fatigue and malaise Decreased appetite Weight gain and facial swelling Abdominal swelling or pain Foamy urine Fluid accumulation in the body spaces (edema) Pale fingernail beds Dull hair Ears cartilage may feel less firm Food intolerances[childrensnational.org]
    Malaise
    • […] that may occur include: Blurred vision , usually from burst blood vessels in the retina of the eye Cough containing mucus or pink, frothy material from fluid buildup in the lungs Shortness of breath, from fluid buildup in the lungs General ill feeling (malaise[nlm.nih.gov]
    • Symptoms may include: Fatigue and malaise Decreased appetite Weight gain and facial swelling Abdominal swelling or pain Foamy urine Fluid accumulation in the body spaces (edema) Pale fingernail beds Dull hair Ears cartilage may feel less firm Food intolerances[childrensnational.org]
    • Symptoms of nephrotic syndrome The symptoms of nephrotic syndrome include: foamy and frothy urine unexplained weight loss general malaise (feeling unwell) oedema (fluid retention or swelling), particularly around the abdomen (belly area), legs and eyes[betterhealth.vic.gov.au]
    • They can include: Extreme tiredness (fatigue) A general feeling of discomfort (malaise) Decreased appetite Weight gain and facial swelling Belly swelling or pain Foamy urine Fluid buildup in the body (edema) Fluid buildup in the belly area (ascites) Pale[urmc.rochester.edu]
    Leg Swelling
    • Protein loss causes low protein count in the blood (hypoalbuminemia) and edemas (excess fluid in the interstitial cavity which is between the cells, causes leg swelling most often, and also in the adbomen and around the eyes).[medical-dictionary.thefreedictionary.com]
    Leg Edema
    • Edema — Swelling in the lower legs (edema) and collection of fluid in the abdomen (ascites) can occur in people with nephrotic syndrome.[uptodate.com]
  • more...
  • Workup

    • Laboratory investigations are the mainstay of diagnosis and they center on urine investigations. The first test should be urinalysis, 3 or 4 pluses of urine on the dipstick corresponds to at least 3g/L of protein and this is well within the nephrotic syndrome range. The presence of glucose should prompt further investigation of diabetes.
    • Urine sediment examination under a microscope with show waxy cast which indicates a proteinuric disease. It will also show red blood cells which indicates glomerular disease [8].
    • Measurement of 24-hour protein will reveal > 150mg of protein which is more than normal for a healthy kidney. Urine protein electrophoresis will show the exact protein and proteinuria without albumin may rule our nephrotic syndrome.
    • Serum electrolyte, urea and creatinine should also be checked to determine renal function.
    • A renal ultrasound can also be done and high echogenicity of the kidney is a pointer to chronic kidney disease. It will also show if a patient has one or two kidneys. One kidney is a contraindication for renal biopsy which may be done if the nephrotic syndrome is of unknown origin.

    Pathology

    Biopsy
  • more...
  • Laboratory

    Urine
  • more...
  • Serum
    Hypertriglyceridemia
    • Patients have increased LDL, increased lipoproteins, and hypertriglyceridemia .[pedemmorsels.com]
    • Clement LC, Macé C, Avila-Casado C, Joles JA, Kersten S, Chugh SS (2014) Circulating angiopoietin-like 4 links proteinuria with hypertriglyceridemia in nephrotic syndrome.[link.springer.com]
    • Elevation of plasma total cholesterol, or more specifically low-density lipoprotein cholesterol, is the major lipid abnormality in NS, although hypertriglyceridemia may develop as the disorder progresses.[link.springer.com]
    Hyponatremia
    Globulins Increased
    • Lab Increased alpha2-globulin, increased beta-globulin, decreased albumin, increased cholesterol, increased TGs, increased phospholipids; these increases are confined to lipoproteins containing apoB (chylomicrons and LDL-C), due to increased production[medical-dictionary.thefreedictionary.com]
    Beta Globulin Decreased
    • Lab Increased alpha2-globulin, increased beta-globulin, decreased albumin, increased cholesterol, increased TGs, increased phospholipids; these increases are confined to lipoproteins containing apoB (chylomicrons and LDL-C), due to increased production[medical-dictionary.thefreedictionary.com]
  • more...
  • Pleura
    Pleural Effusion
    • Fluid retention may cause Dyspnea (pleural effusion or laryngeal edema) Arthralgia (hydrarthrosis) Abdominal pain (ascites or, in children, mesenteric edema) Corresponding signs may develop, including peripheral edema and ascites.[merckmanuals.com]
    • Fluid in the pleural cavity causing pleural effusion .[en.wikipedia.org]
    • Pleural effusions may cause chest pain and breathlessness.[patient.info]
    • As the edema accumulates, pleural effusions, ascites and decreased urine output may develop.[hawaii.edu]
    • Additional consequences include the following: Hypertension related to fluid retention and reduced kidney function may occur Edema of the gut may cause defective absorption, leading to malnutrition Ascites and pleural effusions may develop Infection Infection[emedicine.medscape.com]
  • more...
  • Imaging

    X-ray
  • more...
  • Treatment

    • The treatment of nephrotic syndrome is directed at the specific cause of the disease.
    • In minimal change nephropathy, glucocorticoids are used. Children who do not respond to glucocorticoid treatment should be given rituximab. Rituximab also has application in the treatment of adult membranous nephropathy [9].
    • Anti-inflammatory treatment is used in amyloidosis and cyclophosphamide along with prednisone for lupus.
    • In patients with membranous nephropathy who have a low risk of progression, expectant management without immunosuppression can be employed.
    • Diuretics are used to control edema, antibiotics for infections, anticoagulation therapy to decrease risk of clots and the diet should be rich in protein and calories.

    Prognosis

    Treatment greatly reduces the morbidity and mortality associated with this condition. The prognosis is however dependent on the cause of the nephrotic syndrome. It is poor in infants with congenital nephrotic syndrome as they hardly survive beyond months. The best prognosis is in patients with minimal change nephropathy. Mesangiocapillary glomerulonephrits carries the worst prognosis and patients develop renal failure within 3 years. Without treatment, this condition carries a very bad prognosis especially in adults over 30 years [6].

    Complications

    Deep Vein Thrombosis
    Thromboembolism
    • Venous thromboembolism in pediatric nephrotic syndrome.[pedemmorsels.com]
    • Venous thromboembolism in patients hospitalized with nephrotic syndrome.[aafp.org]
    • A number of complications are noted more frequently in human patients with nephrotic syndrome as opposed to those with asymptomatic proteinuria, the most common of which is thromboembolism.[veterinarycalendar.dvm360.com]
    • While classically warfarin has been used as an anticoagulant in NS, newer oral anticoagulants, such as apixaban, are increasingly used to treat venous thromboembolism (VTE) in the general population.[clinicaltrials.gov]
    • Complications venous thromboembolism 1, 2 renal vein thrombosis 1,7 acute renal failure 1 superimposed bacterial infection 1 It may be classified as congenital or acquired 1 : congenital nephrotic syndrome of Finnish type focal and segmental hyalinosis[radiopaedia.org]
    Proteinuria
    • "La proteinuria en el mieloma múltiple" .[en.wikipedia.org]
    • Idiopathic glomerular diseases can cause proteinuria and nephrotic syndrome 1–4 Nephrotic syndrome is a constellation of 4 signs and symptoms 1,5,6 Urinary proteinuria of 3.5 g/d Hypoalbuminuria Hyperlipidemia Edema Acthar is used to induce a diuresis[actharnephrology.com]
    • Nephrotic syndrome is defined as the presence of proteinuria ( 3.5 g/24 hours), hypoalbuminaemia ( Patients presenting with isolated heavy proteinuria without the other components of nephrotic syndrome are described as having nephrotic-range proteinuria[bestpractice.bmj.com]
    • […] and hypoalbuminemia: Hypoalbuminemia in patients with nephrotic syndrome is a direct consequence of proteinuria.[veterinarycalendar.dvm360.com]
    • In nine of the 13 patients who completed at least six months of treatment with Acthar, 66.7 percent (6/9) showed proteinuria reduction of 37 percent or greater, with a range of proteinuria reduction from 37.3 percent to 99.4 percent.[prnewswire.com]
    Hypertension
    • The hallmark features of nephritic syndrome are RBC casts and hypertension.[newhealthadvisor.com]
    • Treatment with Acthar was well tolerated; one patient had an early termination of treatment due to weight gain and hypertension.[prnewswire.com]
    • Hypercoagulability Hypertension in adults Renal sodium retention Bone disorder Corticosteroid use Chronic kidney disease Unknown Possibly hypovolemia, interstitial edema, and use of NSAIDs Proximal tubular dysfunction (acquired Fanconi syndrome), with[merckmanuals.com]
    • The substantial loss of protein in the urine results in complications such as HYPOPROTEINEMIA; generalized EDEMA; HYPERTENSION; and HYPERLIPIDEMIAS.[fpnotebook.com]
    • "The leading causes of kidney failure in children are hereditary often lacking obvious indicators such as hematuria (red blood cells in the urine), hypertension (high blood pressure) or edema (swelling)," said Dr Bharat Shah, director of renal science[dnaindia.com]
    Hypokalemia
    • Acthar can cause elevation of blood pressure, salt and water retention, and hypokalemia.[prnewswire.com]
    • If hypokalemia develops, an oral potassium supplement or spironolactone may be added.[hawaii.edu]
    Hypertriglyceridemia
    • Patients have increased LDL, increased lipoproteins, and hypertriglyceridemia .[pedemmorsels.com]
    • Clement LC, Macé C, Avila-Casado C, Joles JA, Kersten S, Chugh SS (2014) Circulating angiopoietin-like 4 links proteinuria with hypertriglyceridemia in nephrotic syndrome.[link.springer.com]
    • Elevation of plasma total cholesterol, or more specifically low-density lipoprotein cholesterol, is the major lipid abnormality in NS, although hypertriglyceridemia may develop as the disorder progresses.[link.springer.com]
    Hypoalbuminemia
    • […] glomerular damage: Proteinuria and hypoalbuminemia: Hypoalbuminemia in patients with nephrotic syndrome is a direct consequence of proteinuria.[veterinarycalendar.dvm360.com]
    • Definition (CSP) diseases involving defective kidney glomeruli, characterized by massive proteinuria and lipiduria with varying degrees of edema, hypoalbuminemia, and hyperlipidemia.[fpnotebook.com]
    • ., New York, NY 10016. (800) 622-9010. . nephrotic syndrome [ nĕ-frot ik ] any of several conditions marked by massive edema, heavy proteinuria, hypoalbuminemia, and unusual susceptibility to intercurrent infections.[medical-dictionary.thefreedictionary.com]
    • Patients present with marked oedema, proteinuria, hypoalbuminemia, and often hyperlipidemia 1 .[radiopaedia.org]
    • Hypoalbuminemia : is treated using the medical nutrition therapy described as a treatment for edema.[en.wikipedia.org]
    Hyponatremia
    Ascites
    • Clinical presentation Patients diagnosed with nephrotic syndrome most commonly present for abdominal distention secondary to ascites.[veterinarycalendar.dvm360.com]
    • Fluid retention may cause Dyspnea (pleural effusion or laryngeal edema) Arthralgia (hydrarthrosis) Abdominal pain (ascites or, in children, mesenteric edema) Corresponding signs may develop, including peripheral edema and ascites.[merckmanuals.com]
    • A child with nephrotic syndrome may have: Very high levels of protein (albumin) in the urine Low levels of protein in the blood Tissue swelling all over the body (edema), especially in the belly (ascites) Weight gain from excess fluid High cholesterol[urmc.rochester.edu]
    • Paracentesis is performed if there is respiratory compromise secondary to severe ascites.[hawaii.edu]
    • In later stages, swelling may occur in the abdomen (ascites), hands, and around the eyes in the morning (called periorbital edema).[healthcommunities.com]
    Hypocalcemia
    • Hypocalcemia Hypocalcemia is common in the nephrotic syndrome, but rather than being a true hypocalcemia, it is usually caused by a low serum albumin level.[emedicine.medscape.com]
    • Because of the hypoalbuminemia, hypocalcemia is often seen, with calcium levels less than 9.0 mg/dL.[hawaii.edu]
    Membranoproliferative Glomerulonephritis
    • Diseases that may lead to nephrotic syndrome include: Glomerulonephritis —inflammation of the glomeruli from infection or other causes Diabetic nephropathy —kidney complications from diabetes Membranous nephropathy IgA nephropathy Membranoproliferative[lahey.org]
    • Nephrotic syndrome can also develop in patients with IgA nephropathy, membranoproliferative glomerulonephritis, and post-infectious glomerulonephritis.[bestpractice.bmj.com]
    • Membranoproliferative glomerulonephritis . . . . . c.[hawaii.edu]
    • Membranoproliferative Glomerulonephritis (MPGN): also known as mesangiocapillary glomerulonephritis, the main Hepatitis C associated nephropathy.[newhealthadvisor.com]
    • Glomerulonephritis ( 6%) others Losing protein and protein-bound molecules lead to several complications.[pedemmorsels.com]
    Rheumatoid Arthritis
    • Some disorders (for example, diabetes, rheumatoid arthritis, etc) that cause nephrotic syndrome can have various other symptoms and complications.[patient.info]
    Hyperlipidemia
    • The pathophysiology of nephrotic hyperlipidemia is complex.[link.springer.com]
    • The substantial loss of protein in the urine results in complications such as HYPOPROTEINEMIA; generalized EDEMA; HYPERTENSION; and HYPERLIPIDEMIAS.[fpnotebook.com]
    • A diet low in saturated fat and cholesterol may also be recommended to help control hyperlipidemia.[my.clevelandclinic.org]
    • Patients with hypoalbuminemia, proteinuria, and hyperlipidemia but no third-spacing of fluid are occasionally referred to as having 'incomplete' or 'incipient' nephrotic syndrome.[veterinarycalendar.dvm360.com]
    • Patients present with marked oedema, proteinuria, hypoalbuminemia, and often hyperlipidemia 1 .[radiopaedia.org]
    Malignant Hypertension
    • hypertension Preeclampsia *More commonly manifests as nephritic syndrome. † Infectious and postinfectious causes.[merckmanuals.com]
    Acute Glomerulonephritis
    • Glomerulonephritis - acute; Acute glomerulonephritis; Nephritis syndrome - acute Appel GB, Radhakrishnan.[nlm.nih.gov]
    Edema
    Anasarca
    Hypovolemia
    • Hypovolemia Hypovolemia occurs when hypoalbuminemia decreases the plasma oncotic pressure, resulting in a loss of plasma water into the interstitium and causing a decrease in circulating blood volume.[emedicine.medscape.com]
    • […] thromboembolism (especially renal vein thrombosis and pulmonary embolism, which occur in up to 5% of children and 40% of adults) Loss of antithrombin III Increased hepatic synthesis of clotting factors Platelet abnormalities Hyperviscosity caused by hypovolemia[merckmanuals.com]
    • This increased prevalence may be due to vascular stasis and/or reduced rate of blood flow due to hypovolemia, and reduced activity levels.[veterinarycalendar.dvm360.com]
    • Urinary losses of anticoagulants (antithrombin III, plasminogen, Protein S) Increased procoagulants (fibrinogen, Factor VIII, plasminogen activity factor-1) Procoagulant state can be further exacerbated by hypovolemia .[pedemmorsels.com]
    • Acute kidney failure due to hypovolemia : the loss of vascular fluid into the tissues (edema) produces a decreased blood supply to the kidneys that causes a loss of kidney function.[en.wikipedia.org]
    Serum Sickness
    • sickness Sjögren syndrome SLE* Idiopathic Castleman disease Sarcoidosis Neoplastic Carcinoma (eg, bronchus, breast, colon, stomach, kidney) Leukemia Lymphomas Melanoma Multiple myeloma Drug-related Gold Heroin Interferon alfa Lithium NSAIDs Mercury Pamidronate[merckmanuals.com]
    Glomerulonephritis
    • Rapidly Progressive Glomerulonephritis (RPGN): also known as crescentic glomerulonephritis, characterized by rapid loss of kidney function.[newhealthadvisor.com]
    • Glomerulonephritis - acute; Acute glomerulonephritis; Nephritis syndrome - acute Appel GB, Radhakrishnan.[nlm.nih.gov]
    • "Rapidly progressive glomerulonephritis" .[en.wikipedia.org]
    • Membranous glomerulonephritis is the most common cause in adults. [nlm.nih.gov]
    • The nephrotic syndrome may follow kidney damage from GLOMERULONEPHRITIS or DIABETES or it may be caused by severe high blood pressure ( HYPERTENSION ), poisoning or adverse reactions from drugs.[medical-dictionary.thefreedictionary.com]
    Lipoid Nephrosis
    • Causes of nephrotic syndrome Some of the causes of nephrotic syndrome include: changes to the immune system (minimal change or lipoid nephrosis) - this type is most common in children.[betterhealth.vic.gov.au]
    • Hopper J, Ryan P, Lee J, Rosenau W (1970) Lipoid nephrosis in 31 adult patients: renal biopsy study by light, electron and fluorescence microscopy with experience in treatment.[link.springer.com]
    Polyarteritis Nodosa
    • For example, nephrotic syndrome is a possible complication of diabetes , systemic lupus erythematosus (SLE) , rheumatoid arthritis , polyarteritis nodosa, Henoch-Schönlein purpura , various infections, some cancers and amyloidosis.[patient.info]
    Hypercholesterolemia
    • Brett AS (1989) Treating hypercholesterolemia.[link.springer.com]
    • Nephrotic Syndrome Signs and Symptoms In addition to proteinuria , there are three main symptoms of nephrotic syndrome associated with protein leaking into the urine: Hypoalbuminemia (low level of albumin in the blood) Edema (swelling) Hypercholesterolemia[healthcommunities.com]
    • […] sin'drōm ) Clinical state characterized by edema, albuminuria, decreased plasma albumin, doubly refractile bodies in the urine, and usually increased blood cholesterol. nephrotic syndrome a condition marked by edema, marked proteinuria, hypoalbuminemia and hypercholesterolemia[medical-dictionary.thefreedictionary.com]
    • That is in the range of serum cholesterol seen in familial hypercholesterolemia , a disease that predisposes individuals to myocardial infarction.[emedicine.medscape.com]
    • The diagnostic criteria are marked proteinuria, generalized edema, hypoalbuminemia, and hyperlipidemia (with hypercholesterolemia).[hawaii.edu]
    Preeclampsia
    • In adults, nephrotic syndrome is usually secondary, most often to diabetes or preeclampsia.[merckmanuals.com]
    • […] hypoalbuminemia, 30 g/L Etiology Diabetic nephropathy, 1º glomerular disease; membranous glomerulonephritis may by linked to neoplasia, myeloma, amyloidosis, DM, infection, SLE, toxins–eg, colloidal gold, 'street' heroin, penicillamine, rarely, HIV, preeclampsia[medical-dictionary.thefreedictionary.com]
    • […] hepatomegaly, peripheral neuropathy Multiple myeloma Abnormal urine protein electrophoresis, back pain, renal insufficiency HIV Pathologically similar to focal segmental glomerulosclerosis; risk factors for HIV transmission, possible reduced CD4 cell count Preeclampsia[aafp.org]
    Eclampsia
    • […] protein-repellant membrane) Postinfectious (occurs after an infection) IgA nephropathy (Berger's disease) (deposit of specific immunoglobulin A causing an inflammatory reaction and leading to glomerulonephritis) Minimal change disease (Nil's disease) Pre-eclampsia[healthcommunities.com]
    Lupus Nephritis
    • These can include: membranous nephropathy, focal segmental glomerulosclerosis, minimal change disease, membranoproliferative glomerulonephritis, lupus nephritis, and IgA nephropathy.[prnewswire.com]
    • ., IgA nephropathy), fibrillary glomerulopathies (the most common being amyloidosis), lupus nephritis, and multiple myeloma (e.g., light-chain deposition diseases). [14] Hull RP, Goldsmith DJ.[bestpractice.bmj.com]
    • The histopathologic findings in our patient are similar to those originally described in MPGN type III (but lacking proliferative changes) and also often seen in proliferative lupus nephritis, but they differ from the typical pattern of renal involvement[casesjournal.biomedcentral.com]
    • Urine protein-to-creatinine ratio in an untimed urine collection is a reliable measure of proteinuria in lupus nephritis.[aafp.org]
    • The disease can also cause lupus nephritis .[en.wikipedia.org]
    Hereditary Nephritis
    • nephritis* Sickle cell disease Physiologic Adaptation to reduced nephrons Morbid obesity Oligomeganephronia Miscellaneous Chronic allograft nephropathy Malignant hypertension Preeclampsia *More commonly manifests as nephritic syndrome. † Infectious and[merckmanuals.com]
    Membranous Glomerulonephritis
    • Membranous glomerulonephritis is the most common cause in adults. [nlm.nih.gov]
    • ., focal segmental glomerulosclerosis), IgA nephropathy, light-chain disease, mesangiocapillary, membranous glomerulonephritis (may by linked to neoplasia), myeloma, amyloidosis, diabetes, infection, SLE, toxins (e.g., colloidal gold, “street” heroin,[medical-dictionary.thefreedictionary.com]
    • ) Glomerulonephritis (GN) Diffuse mesangial proliferative GN (affecting the messangium) Membranous (damages the protein-repellant membrane) Postinfectious (occurs after an infection) IgA nephropathy (Berger's disease) (deposit of specific immunoglobulin[healthcommunities.com]
    • Membranous nephropathy This is sometimes called membranous nephritis or membranous glomerulonephritis.[patient.info]

    Etiology

    The causes of nephrotic syndrome are primary when it is due to a specific disease or secondary when it is an exhibition of a systemic illness.

    Primary causes of nephrotic syndrome include; Minimal change nephropathy, focal segmental glomerulosclerosis, rapidly progressing glomerulonephritis, membranous glomerulonephritis and mesangial proliferating glomerulonephritis.

    Secondary causes are; Diabetes mellitus causing diabetic nephropathy, systemic lupus erythematosus, sarcoidosis, preeclampsia, viral illnesses like hepatitis C, hepatitis B and HIV, amyloidosis, other infections like syphilis, multiple myeloma, vasculitis, genetic disorders and drugs [2].

    Causes

    Hypertension
    • The hallmark features of nephritic syndrome are RBC casts and hypertension.[newhealthadvisor.com]
    • Treatment with Acthar was well tolerated; one patient had an early termination of treatment due to weight gain and hypertension.[prnewswire.com]
    • Hypercoagulability Hypertension in adults Renal sodium retention Bone disorder Corticosteroid use Chronic kidney disease Unknown Possibly hypovolemia, interstitial edema, and use of NSAIDs Proximal tubular dysfunction (acquired Fanconi syndrome), with[merckmanuals.com]
    • The substantial loss of protein in the urine results in complications such as HYPOPROTEINEMIA; generalized EDEMA; HYPERTENSION; and HYPERLIPIDEMIAS.[fpnotebook.com]
    • "The leading causes of kidney failure in children are hereditary often lacking obvious indicators such as hematuria (red blood cells in the urine), hypertension (high blood pressure) or edema (swelling)," said Dr Bharat Shah, director of renal science[dnaindia.com]
    Hypokalemia
    • Acthar can cause elevation of blood pressure, salt and water retention, and hypokalemia.[prnewswire.com]
    • If hypokalemia develops, an oral potassium supplement or spironolactone may be added.[hawaii.edu]
    Rheumatoid Arthritis
    • Some disorders (for example, diabetes, rheumatoid arthritis, etc) that cause nephrotic syndrome can have various other symptoms and complications.[patient.info]
    Hypovolemia
    • Hypovolemia Hypovolemia occurs when hypoalbuminemia decreases the plasma oncotic pressure, resulting in a loss of plasma water into the interstitium and causing a decrease in circulating blood volume.[emedicine.medscape.com]
    • […] thromboembolism (especially renal vein thrombosis and pulmonary embolism, which occur in up to 5% of children and 40% of adults) Loss of antithrombin III Increased hepatic synthesis of clotting factors Platelet abnormalities Hyperviscosity caused by hypovolemia[merckmanuals.com]
    • This increased prevalence may be due to vascular stasis and/or reduced rate of blood flow due to hypovolemia, and reduced activity levels.[veterinarycalendar.dvm360.com]
    • Urinary losses of anticoagulants (antithrombin III, plasminogen, Protein S) Increased procoagulants (fibrinogen, Factor VIII, plasminogen activity factor-1) Procoagulant state can be further exacerbated by hypovolemia .[pedemmorsels.com]
    • Acute kidney failure due to hypovolemia : the loss of vascular fluid into the tissues (edema) produces a decreased blood supply to the kidneys that causes a loss of kidney function.[en.wikipedia.org]

    Epidemiology

    In adults, the main cause is diabetic nephropathy which presents mainly as mesangiocapillary glomerulonephritis. While in children, the most frequent glomerulopathy is minimal change disease. Overall, diabetic nephropathy is the most common cause of this disease with an estimated 50 cases per million population.African Americans, American Indians and Hispanics have a higher incidence which is attributable to the incidence of diabetes amongst these races. It generally affects more men than women although lupus nephritis is common in women. It affects more adult than children with an estimated adult:child ratio of 26:1. The peak period of incidence is between 40 – 50 years [3].

    Sex distribution
    Age distribution

    Pathophysiology

    The glomerulus is responsible for filtration in the kidney. In normal healthy individuals, the amount of protein filtered through the glomerulus is less than 0.1%. In nephrotic syndrome, there is destruction of the glomerular structure as it destructs the endothelial surface, glomerular basement membrane or the podocytes. This will lead to an increase in glomerular permeability that leads to loss of albumin in the urine. The loss of albumin, which is the major protein responsible for maintaining the plasma colloid osmotic pressure, will lead to a drop in the pressure. This drop in plasma oncotic pressure will lead to greater filtration of water at the capillaries throughout the body leading to edema. Eventually, as the damage worsens, bigger proteins like the immunoglobulins are also lost in urine [4].

    The metabolic effects of proteinuria are far reaching and include infections due to loss of immunoglobulins, hyperlipidemia secondary to the liver's attempt to compensate for protein loss by synthesizing lipoproteins. Other effects are hypocalcemia, hypercoagulability, and hypovolemia [5].

    Prevention

    In patients who are risk of developing this condition and have mild proteinuria, the use of Angiotensin converting enzyme inhibitors like elanapril has been shown to prevent worsening of proteinuria and kidney function. Also, treating infections that may cause it and preventing risk factors are known preventive measures [10].

    Summary

    Nephrotic syndrome is when there is proteinuria of over 3 grams daily or 2 grams of protein per gram of creatinine. It has a number of causes and water retention is a major component. Primary or secondary damage to the glomeruli alters their capacity to filter protein leading to the massive loss of protein [1].

    Patient Information

    Definition: Nephrotic syndrome is the presence of protein in the urine. It is characterized by an increase loss of protein due to damage to the filtering mechanisms in the kidney. In normal individuals, there is very little protein loss in urine

    Cause: It is caused by factors that either damage the filtration apparatus directly or as a result of another disease like diabetes causing the damage. It is also caused by infections and certain drug use.

    Symptoms: The early symptoms are facial puffiness which is usually worse in the morning. The may be leg and abdominal swelling and generalized swelling of the whole body. The urine could also be unusually foamy. Cough and difficulty in breathing as well as a general feeling of malaise.

    Diagnosis: This is usually done by urine investigations to check the amount and type of protein in urine. Blood tests could also be done to check for renal function. Ultrasound is also done to check the structure of the kidneys.

    Treatment: Treatment is directed at the cause of the disease. Drugs are also given to reduce the fluid level and to treat infections. Most children require steroid treatment.

    Other symptoms


    Self-assessment

    Ask Question


    5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.

    References

    1. Vaziri ND. Endocrinological consequences of the nephrotic syndrome. Am J Nephrol 1993; 13:360.
    2. MacDonald NE, Wolfish N, McLaine P, et al. Role of respiratory viruses in exacerbations of primary nephrotic syndrome. J Pediatr 1986; 108:378.
    3. Kerlin BA, Ayoob R, Smoyer WE. Epidemiology and pathophysiology of nephrotic syndrome-associated thromboembolic disease. Clin J Am Soc Nephrol. Mar 2012;7(3):513-20
    4. [Guideline] International Study of Kidney Disease in Children (ISKDC). Nephrotic syndrome in children: prediction of histopathology from clinical and laboratory characteristics at time of diagnosis. A report of the International Study of Kidney Disease in Children. Kidney Int. Feb 1978;13(2):159-65.
    5. Tryggvason K, Patrakka J, Wartiovaara J. Hereditary proteinuria syndromes and mechanisms of proteinuria.N Engl J Med. Mar 30 2006;354(13):1387-401.
    6. YAMAUCHI H, HOPPER J Jr. HYPOVOLEMIC SHOCK AND HYPOTENSION AS A COMPLICATION IN THE NEPHROTIC SYNDROME. REPORT OF TEN CASES. Ann Intern Med 1964; 60:242.
    7. White RH, Glasgow EF, Mills RJ. Clinicopathological study of nephrotic syndrome in childhood. Lancet 1970; 1:1353.
    8. Howard AD, Moore J Jr, Gouge SF, et al. Routine serologic tests in the differential diagnosis of the adult nephrotic syndrome. Am J Kidney Dis 1990; 15:24.
    9. Kamei K, Ito S, Nozu K, et al. Single dose of rituximab for refractory steroid-dependent nephrotic syndrome in children. Pediatr Nephrol. Jul 2009;24(7):1321-8.
    10. Bonilla-Felix M, Parra C, Dajani T, et al. Changing patterns in the histopathology of idiopathic nephrotic syndrome in children. Kidney Int 1999; 55:1885.

    • Acute renal failure in children with idiopathic nephrotic syndrome - N Agarwal, KD Phadke, I Garg, P Alexander - Pediatric Nephrology, 2003 - Springer
    • A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation - R Hull, G Raskob, G Pineo - England Journal of , 1993 - Mass Medical Soc
    • Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome - RH Kauffmann, JJ Veltkamp, NH Van Tilburg - The American journal of , 1978 - Elsevier
    • A relationship between proteinuria and acute tubulointerstitial disease in rats with experimental nephrotic syndrome. - AA Eddy, L McCulloch, E Liu - The American journal of , 1991 - ncbi.nlm.nih.gov
    • Acute interstitial nephritis with the nephrotic syndrome following recombinant leukocyte A interferon therapy for mycosis fungoides - SD Averbuch, HA Austin III, SA Sherwin - England Journal of , 1984 - Mass Medical Soc
    • A randomized trial of cyclosporine in steroid-resistant idiopathic nephrotic syndrome - C Ponticelli, G Rizzoni, A Edefonti, P Altieri - Kidney , 1993 - nature.com
    • Guidelines for thoracentesis and needle biopsy of the pleura - JW Sokolowski, LW Burgher, FL Jones - American Journal of , 1989 - Am Thoracic Soc
    • Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome - RH Kauffmann, JJ Veltkamp, NH Van Tilburg - The American journal of , 1978 - Elsevier
    • 1 1 Nephrotic Syndrome - A Bagga, RN Srivastava - Pediatric Nephrology, 2011 - books.google.com
    • Abnormalities of lipoprotein metabolism in patients with the nephrotic syndrome - J Joven, C Villabona, E Vilella, L Masana - England Journal of , 1990 - Mass Medical Soc
    • Amyloidosis (AL). Clinical and laboratory features in 229 cases. - RA Kyle, PR Greipp - Mayo Clinic proceedings. Mayo Clinic, 1983 - ukpmc.ac.uk
    • Abnormalities of lipoprotein metabolism in patients with the nephrotic syndrome - J Joven, C Villabona, E Vilella, L Masana - England Journal of , 1990 - Mass Medical Soc
    • 1 1 Nephrotic Syndrome - A Bagga, RN Srivastava - Pediatric Nephrology, 2011 - books.google.com
    • Preparations for topical administration comprising 2-amino-2-(2-(4-octylphenyl) ethyl) propane-1, 3-diol for the treatment of diseases induced from immune disorder - T IMAYOSHI - EP Patent 0,812,588, 2004 - freepatentsonline.com
    • Nephrotic syndrome induced by puromycin aminonucleoside in rats. I. The role of proteinuria, hypoproteinemia, and renin-angiotensin-aldosterone system on sodium - J Pedraza-Chaverri, C Cruz, ME Ibarra-Rubio - clinica; organo del , 1990 - ukpmc.ac.uk
    • Albuminuria and the nephrotic syndrome following exposure to mercury and its compounds - G Kazantzis, KFR Schiller, AW Asscher, RG Drew - QJM, 1962 - Oxford Univ Press
    • 1 1 Nephrotic Syndrome - A Bagga, RN Srivastava - Pediatric Nephrology, 2011 - books.google.com
    • Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome - RH Kauffmann, JJ Veltkamp, NH Van Tilburg - The American journal of , 1978 - Elsevier
    • Assessment of the antibody response to pneumococcal vaccine in high-risk populations - SH Landesman, G Schiffman - Review of Infectious Diseases, 1981 - cid.oxfordjournals.org
    • Atrial natriuretic factor in the acute nephritic and nephrotic syndromes. - B Rodríguez-Iturbe, D Colic, G Parra - Kidney , 1990 - ukpmc.ac.uk
    • 1 1 Nephrotic Syndrome - A Bagga, RN Srivastava - Pediatric Nephrology, 2011 - books.google.com
    • Abnormalities of lipoprotein metabolism in patients with the nephrotic syndrome - J Joven, C Villabona, E Vilella, L Masana - England Journal of , 1990 - Mass Medical Soc
    • Abnormalities of lipoprotein metabolism in patients with the nephrotic syndrome - J Joven, C Villabona, E Vilella, L Masana - England Journal of , 1990 - Mass Medical Soc
    • Abnormalities of lipoprotein metabolism in patients with the nephrotic syndrome - J Joven, C Villabona, E Vilella, L Masana - England Journal of , 1990 - Mass Medical Soc
    • Acquired hyperlipidemia (secondary dyslipoproteinemias). - A Chait, JD Brunzell - Endocrinology and metabolism clinics of North , 1990 - ukpmc.ac.uk
    • Of congestive heart failure: vasopressin, aldosterone, and angiotensin II: further evidence for renal-adrenal interaction from studies in hypertension and in cirrhosis - JH LARAGH - Circulation, 1962 - Am Heart Assoc
    • A relationship between proteinuria and acute tubulointerstitial disease in rats with experimental nephrotic syndrome. - AA Eddy, L McCulloch, E Liu - The American journal of , 1991 - ncbi.nlm.nih.gov
    • A study of the mechanisms of edema formation in patients with the nephrotic syndrome - HA Eder, HD Lauson, FP Chinard, RL Greif - Journal of Clinical , 1954 - ncbi.nlm.nih.gov
    • 1 1 Nephrotic Syndrome - A Bagga, RN Srivastava - Pediatric Nephrology, 2011 - books.google.com
    • Berger disease: Henoch-Schönlein syndrome without the rash - SR Meadow, DG Scott - The Journal of pediatrics, 1985 - Elsevier
    • Artificial intelligence in medicine - P Szolovits - 1982 - courses.csail.mit.edu
    • Disseminated autoimmune disease during levamisole treatment of nephrotic syndrome - G Barbano, F Ginevri, GM Ghiggeri, R Gusmano - Pediatric Nephrology, 1999 - Springer
    • Current medical diagnosis & treatment 2010 - SJ McPhee, MA Papadakis, MW Rabow - 2010 - media.matthewsbooks.com.s3.
    • Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome - RH Kauffmann, JJ Veltkamp, NH Van Tilburg - The American journal of , 1978 - Elsevier
    • Focal glomerular sclerosis - R Habib - Kidney int, 1973 - nature.com
    • Bilateral renal vein thrombosis and the nephrotic syndrome: Associated with lesions of polyarteritis nodosa - G Miller, JC Hoyt, BE Pollock - The American journal of medicine, 1954 - Elsevier
    • A pharmacoepidemiologic assessment of nonsteroidal anti-inflammatory drug exposure and the association withcolorectal cancer, gastrointestinal and renal adverse - TE Niecko - 2001 - athenaeum.libs.uga.edu
    • A case of “pure” preeclampsia with nephrotic syndrome before 15 weeks of gestation in a patient whose renal biopsy showed glomerular capillary endotheliosis - T Imasawa, T Nishiwaki, M Nishimura - American journal of , 2006 - Elsevier
    • Renal disease: alkylating and antimetabolic agents in the treatment of nephrotic syndrome, lupus nephritis, chronic glomerulonephritis, and purpura nephritis in - WE GRUPE, W HEYMANN - Archives of Pediatrics & Adolescent , 1966 - Am Med Assoc
    • Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome - RH Kauffmann, JJ Veltkamp, NH Van Tilburg - The American journal of , 1978 - Elsevier
    • Chylous ascites in an adult patient with nephrotic syndrome due to membranous nephropathy - A Kato, S Kohno, T Ohtake, T Takita, A Hirshida - Nephron, 2001 - content.karger.com
    • OF THE INFERIOR VENA CAVA AND THE RENAL AND PORTAL VEINSWITH THE CLINICAL PICTURE OF THE NEPHROTIC SYNDROME: REPORT OF A CASE, - HA DEROW, MJ SCHLESINGER - Archives of Internal , 1939 - archinte.jamanetwork.com
    • Study of anti‐tumour necrosis factor receptor superfamily 1A fusion protein, in tumour necrosis factor receptor associated periodic syndrome (TRAPS): clinical and - E Drewe, EM McDermott, PT Powell, JD Isaacs - , 2003 - Br Soc Rheumatology
    • Benign paroxysmal torticollis in infancy - T Deonna, D Martin - Archives of disease in childhood, 1981 - ncbi.nlm.nih.gov
    • Benign intracranial hypertension following corticosteroid withdrawal in childhood - BGR Neville, J Wilson - British medical journal, 1970 - ncbi.nlm.nih.gov
    • Acute lymphoblastic leukemia in a child with nephrotic syndrome - M Bhatia, K Kher, CP Minniti - Pediatric Nephrology, 2004 - Springer
    • And oxidase activity in sera of normal human subjects, pregnant women, and patients with infection, hepatolenticular degeneration and the nephrotic syndrome - H Markowitz, CJ Gubler, JP Mahoney - Journal of Clinical , 1955 - ncbi.nlm.nih.gov
    • Acute glomerulonephritis with the nephrotic syndrome - SGF Wilson, W Heymann - Pediatrics, 1959 - Am Acad Pediatrics
    • 1 1 Nephrotic Syndrome - A Bagga, RN Srivastava - Pediatric Nephrology, 2011 - books.google.com
    • Abnormalities of lipoprotein metabolism in patients with the nephrotic syndrome - J Joven, C Villabona, E Vilella, L Masana - England Journal of , 1990 - Mass Medical Soc
    • Acquired antithrombin III deficiency and thrombosis in the nephrotic syndrome - RH Kauffmann, JJ Veltkamp, NH Van Tilburg - The American journal of , 1978 - Elsevier
    • A case of fever and unexplained acute renal failure - V Sakhuja, R Agarwal, N Kalra - Indian journal of nephrology, 2008 - ncbi.nlm.nih.gov
    • 1 1 Nephrotic Syndrome - A Bagga, RN Srivastava - Pediatric Nephrology, 2011 - books.google.com
    • Copper deficiency in long-term parenteral nutrition - JT Karpel, VH Peden - The Journal of pediatrics, 1972 - Elsevier
    • Clinical and histologic spectrum of the nephrotic syndrome - LB Berman, GE Schreiner - The American Journal of Medicine, 1958 - Elsevier
    • Change nephrotic syndrome complicated with recurrence of malignant thymoma: an interesting case with remission due to steroid therapy of both nephrotic syndrome - A Fukuda, Y Sato, S Iwatsubo, H Komatsu - Jinzo Gakkai shi, 2009 - ncbi.nlm.nih.gov
    • Bilateral anterior tibial syndrome in association with the nephrotic syndrome: Report of a case - HE SWEENEY, GF O'BRIEN - Archives of internal medicine, 1965 - Am Med Assoc
    • A Case of Edematous Striae Distensae by Corticosteroid and Generalized Edema in Nephrotic Syndrome - SW Choe, YH Yoon, SJ Seo, CK Hong - Korean Journal of , 2004 - KoreaMed
    • CHRONIC ALLOGENEIC DISEASE I. DEVELOPMENT OF GLOMERULONEPHRITIS - RM Lewis, MYK Armstrong - The Journal of , 1968 - jem.rupress.org
    • Acute Syphilitic Nephrosis: Case Report - CJ McDONALD, AW BARILE - Archives of Internal Medicine, 1963 - Am Med Assoc
    • Bench-to-bedside review: Pulmonary–renal syndromes–an update for the intensivist - , GE Kapotsis, A Karakatsani, C Roussos - Crit Care, 2007 - biomedcentral.com
    • Congestive heart failure and outpatient risk of venous thromboembolism: a retrospective, case-control study - MD Howell, JM Geraci, AA Knowlton - Journal of clinical epidemiology, 2001 - Elsevier
    • Acute interstitial nephritis with the nephrotic syndrome following recombinant leukocyte A interferon therapy for mycosis fungoides - SD Averbuch, HA Austin III, SA Sherwin - England Journal of , 1984 - Mass Medical Soc
    • Abdominal Thrombotic and Ischemic Manifestations of the Antiphospholipid Antibody Syndrome: CT Findings in 42 Patients1 - S Kaushik, MP Federle, PH Schur, M Krishnan - , 2001 - radiology.rsna.org
    • ■ DERMATOLOGIC TOXICITY - SK AILOR, SC MILES - The Chemotherapy Source Book, 2007 - books.google.com
    • Clinical features of benign hypertensive nephrosclerosis at time of renal biopsy - A Innes, PA Johnston, AG Morgan, AM Davison - QJM, 1993 - Oxford Univ Press
    • Complications of chronic use of skin lightening cosmetics - YM Olumide, AO Akinkugbe, D Altraide - International journal , 2008 - Wiley Online Library
    • Current medical diagnosis & treatment 2010 - SJ McPhee, MA Papadakis, MW Rabow - 2010 - media.matthewsbooks.com.s3.
    • Aldosterone and the edema of congestive heart failure - LL SANDERS, JC MELBY - Archives of internal medicine, 1964 - Am Med Assoc
    • A relationship between proteinuria and acute tubulointerstitial disease in rats with experimental nephrotic syndrome. - AA Eddy, L McCulloch, E Liu - The American journal of , 1991 - ncbi.nlm.nih.gov
    • 30 Kidney Involvement in Systemic Lupus Erythematosus - GG Illei, JE Balow - Systemic lupus erythematosus: A companion , 2007 - books.google.com
    • Effect of plasmapheresis on familial type III hyperlipoproteinemia associated with glomerular lipidosis, nephrotic syndrome and diabetes mellitus - K Suzaki, S Kobori, S Ueno, M Uehara, T Kayashima - Atherosclerosis, 1990 - Elsevier

    Media References

    1. Diabetic glomerulosclerosis (1) HE, CC BY-SA 3.0

    Languages

    Self-assessment
    Symptoma
      • Hi, this is Symptoma.