COMPLICATIONS OF NEPHROTIC SYNDROME AMIR EL OKELY MRCP, MD
Jun 03, 2015
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