Prof. a.elokely.complications of the nephrotic syndrome

COMPLICATIONS OF NEPHROTIC SYNDROME

AMIR EL OKELY

MRCP, MD

Questions

What is the definition of NS?

What are the complications of NS?

What are the indications of IV

albumin?

What is the effect of serum albumin

on warfarin dosing?

Nephrotic syndrome

Proteinuria

Hypoalbuminemia

Edema

Hyperlipidaemia

Lipiduria

.

Hypovolemia

Excessive diuresis.

Severe hypoalbuminemia cause fluid movement into the interstitum and hypovolemia.

When to give IV albumin?

Acute kidney injury

Excessive diuresis.

ATIN.

Superimposed crescentic GN.

Infection

Reduced serum concentration of IG.

Impaired ability to make specific AB.

Decreased level of the complement.

Immunosuppressive therapy.

A decrease in TBG can cause marked changes in

various thyroid function tests.

When renal failure complicates the nephrotic

syndrome, the thyroid function abnormalities

are often more severe.{TSH}

Steroids can cause small reduction in TSH

secretion inhibit peripheral conversion of T4 to

T3.{FT4}

Thyroid Dysfunction

Thrombo-embolic Complications

DVT is the most common.

PE has been described with or without evident DVT or RVT.

The prevalence of a symptomatic PE in patients with NS range from 12-30%.

The risk of PE increase in NS by 39 time compared to non NS patients.

Pathogenesis

Increase platelet aggregation.

Activation of the coagulation system.

Decrease endogenous anti-coagulant.

Clin J Am Soc Nephrol 7: 43–51, 2012.

Venous Thrombo-embolism and Membranous Nephropathy

RVT may be unilateral or bilateral

and may extend into the inferior

vena cava.

RVT most often has an insidious

onset and produces no symptoms

referable to the kidney.

Renal Vein Thrombosis

It typically presents with symptoms of

renal infarction, including flank pain,

microscopic or gross hematuria, a marked

elevation in serum LDH, and an increase

in renal size on radiographic study.

Bilateral RVT may present with acute

renal failure.

Renal Vein Thrombosis

Screening

Routine screening for RVT is not

recommended in patients with

nephrotic syndrome:

No proven benefit to diagnose occult

disease.

A patient with a negative study may

develop RVT at a later time.

It is also not useful to evaluate for RVT in a patient who experiences an overt embolic event such as PE.

It cannot be proven that the pulmonary embolus originated in the renal veins.

In situ pulmonary thrombosis may occur.

Patients will be treated with anticoagulants whether or not RVT is present.

Screening

Diagnosis of RVT

Selective renal venography is the standard diagnostic test for RVT

Specificity %Sensitivity %

10092.3CT angiography

5685Doppler US

8734IVU

Renal Biopsy

Treatment of RVT

There are no definitive studies that

have evaluated the role of

anticoagulation in patients with an

asymptomatic RVT, but case series

report treating such patients.

Patients with a symptomatic RVT or a

thromboembolic event in the absence of

RVT are treated with low molecular

weight heparin and then warfarin.

Some patients are partially resistant to

heparin therapy due to severe

antithrombin deficiency.

.

Treatment of RVT

Warfarin therapy is given for a minimum of 6 to

12 months and some people recommend

continuing treatment for as long as the patient

remains nephrotic.

Local thrombolytic therapy with or without

thrombectomy in patients who have signs of

acute RVT has been successfully performed in

small numbers of patients.

Treatment of RVT

J Am Soc Nephrol 22: 1856–1862, 2011.

Warfarin Induced Nephropathy

Nephrol Dial Transplant (2012) 27: 475–477

Warfarin Induced Nephropathy

Behavioural Abnormalities

Aspirin Resistance

Headache and Visual Disturbance

Questions

Thank You