Nephrotic Syndrome
Under Supervision
Dr/ Athar Ammar
2022 – 2023
Prepared By
.1محمد وهبة عبد المرضي محمد
.2محمد ياسر عبد العزيز نويشي
.3محمد ياسر عبد الونيس زهرة
.4محمد يسري عبد الجواد مرق
.5محمود أحمد عبد الدايم سالمان
.6محمود أحمد فهمي الجمال
.7محمود أشرف أحمد بدوي علي
.8محمود السيد محمود السيد عالم
.9محمود المصيلحي محمد المصيلحي التش
.10محمود بدر محمد محروس سالم عليوة
.11محمود رمضان محمود الجبالي
.12محمود سمير عبد العليم الجمل
Outlines
➢ Definition
➢ Incidence
➢ Signs and Symptoms
➢ Causes
➢ Risk Factors
➢ Pathophysiology
➢ Diagnosis
➢ Complications
➢ Medical Management
➢ Nursing Management
Definition
Nephrotic syndrome is a collection of symptoms that indicate that the
kidneys are not functioning as they should. Nephrotic syndrome can
result from diseases that affect just the kidneys or the entire body. It can
occur in both adults and children.
Incidence
Nephrotic syndrome is present in as many as 7 children per 100, 000
population younger than 9 years of age.
➢ The average age of onset is 2.5 years, with most cases occurring
between the ages of 2 and 6 years.
➢ In the United States, the reported annual incidence rate of
nephrotic syndrome is 2-7 cases per 100,000 children younger than
16 years.
➢ In children younger than 8 years at onset, the ratio of males to
females varies from 2:1 to 3:2 in various studies.
➢ In children, nephrotic syndrome may occur at a rate of 20 cases
per million children.
➢ Because diabetes is major cause of nephrotic syndrome, American
Indians, Hispanics, and African Americans have a higher incidence
of nephrotic syndrome than do white persons.
➢ There is a male predominance in the occurrence of nephrotic
syndrome, as for chronic kidney disease in general.
Signs and Symptoms
Signs
Nephrotic syndrome involves the following signs:
➢ Heavy Proteinuria: High levels of protein in the urine (3.5 g/day)
➢ Hypoalbuminemia: Low levels of albumin in the blood (Serum
Albumin < 2.5 g/dL)
➢ Hyperlipidemia: High levels of fat and cholesterol in the blood
(Serum Cholesterol < 350 mg/dL)
Symptoms
The symptoms of nephrotic syndrome include:
➢ Generalized Edema
➢ Foamy urine
➢ Weight gain due to fluid retention.
➢ Blood clots
➢ Fatigue
➢ Loss of appetite
➢ Bloating
Causes
Primary Causes
- Primary causes of nephrotic syndrome are conditions that only affect
the kidneys.
- Examples of primary causes include:
➢ Focal segmental glomerulosclerosis (FSGS): In FSGS, scarring
occurs in portions of the glomeruli. FSGS occurs more frequently
in males than females and has a higher prevalence among African
American people.
➢ Membranous nephropathy: Immune complexes build up in the
glomeruli, causing damage.
➢ Minimal change disease (MCD): The damage to the glomeruli is
only visible with a very powerful microscope. MCD is the most
common cause of nephrotic syndrome in children. In
adults, allergies, infections, or certain medications may cause
MCD.
➢ Membranoproliferative glomerulonephritis (MPGN): The
immune system attacks cells in the kidneys, damaging the
glomeruli. Sometimes, another disease, such as hepatitis
C, causes MPGN.
Secondary Causes
- Secondary causes are conditions that affect the entire body, resulting in
nephrotic syndrome.
- Some examples of secondary causes are:
➢ Diabetes
➢ Systemic lupus erythematosus
➢ Infections, such as hepatitis B, hepatitis C, or HIV
➢ Cancers, such as Hodgkin disease
Risk Factors
- Factors that can increase risk of nephrotic syndrome include:
➢ Medical conditions that can damage kidneys: Certain diseases
and conditions increase the risk of developing nephrotic syndrome,
such as diabetes, lupus, amyloidosis, reflux nephropathy and other
kidney diseases.
➢ Certain medications: Medications that might cause nephrotic
syndrome include nonsteroidal anti-inflammatory drugs and drugs
used to fight infections.
➢ Certain infections: Infections that increase the risk of nephrotic
syndrome include HIV, hepatitis B, hepatitis C and malaria.
Pathophysiology
Heavy Proteinuria
➢ Daily loss of 3.5g or more of protein/24hrs
➢ Normal a small amount of protein i.e., 20 to 150 mg/day passes
through the glomerular filtration barriers and is reabsorbed by the
tubules.
➢ If excess of protein is filtered exceeding the capacity of tubules for
reabsorption, these proteins appear in urine.
➢ Highly selective proteinuria consists of low molecular weight
proteins (albumin, 70KD, transferrin, 76KD molecular weight)
➢ Poorly selective proteinuria – high molecular weight globulins in
addition to albumin
➢ In nephrotic syndrome there is loss of albumin (molecular weight
66,000)
Hypoalbuminemia
- With plasma albumin levels less than 3g/dl
- These may be due to:
➢ Increased loss of albumin
➢ Increased renal catabolism.
➢ Inadequate hepatic synthesis of protein
Hyperlipidemia
➢ The exact mechanism is not known but may be due to stress on
liver for synthesis of proteins to compensate proteinuria.
➢ This causes increased synthesis of lipoproteins and there are
increased blood levels of total lipids, cholesterol, triglycerides,
VLDL and LDL but decrease in HDL.
➢ Increased lipoproteins may also be due to abnormal transport of
circulating lipid particles and increased lipid catabolism.
➢ Lipidemia is followed by lipiduria.
Generalized Edema
➢ Due to fall in colloid osmotic pressure consequent upon
hypoalbuminemia
➢ Na and H2O retention further contribute to Oedema.
➢ Na and water retention may be due to compensatory secretion
of aldosterone mediated by the hypovolemia enhanced renin
secretion, stimulation of sympathetic system and a reduction in the
secretion of natriuretic factors such as atrial peptides.
Diagnosis
➢ Urine Test: To check the abnormalities in the urine.
➢ Blood Test: To determine levels of protein albumin.
➢ Kidney Biopsy: A small sample of kidney tissue for testing.
Complications
- Without treatment, nephrotic syndrome can cause other problems,
including:
➢ Blood clots. These may form because of losing too much protein
from the blood, affecting the body’s ability to prevent clots.
➢ High cholesterol and triglycerides
➢ High blood pressure
➢ Kidney failure, because of damaged kidneys can no longer remove
waste products from bloodstream on their own.
➢ Infections such as pneumonia and meningitis because body loses
infection-fighting proteins called immunoglobulins
Medical Management
The management of nephrotic syndrome is a long process with
remissions and recurrence of symptoms common.
➢ Corticosteroid therapy. The general consensus now is daily
induction steroid treatment for 6 weeks, followed by alternate-day
maintenance therapy for another 6 weeks.
➢ Diuretic therapy. Diuretic therapy may be beneficial, particularly
in children with symptomatic edema; loop diuretics, such as
furosemide (starting at 1-2 mg/kg/d) may improve edema; their
administration, however, should be handled with care because
plasma volume contraction may already be present,
and hypovolemic shock has been observed with overly aggressive
therapy.
➢ Home monitoring. Home monitoring of urine protein and fluid
status is an important aspect of management; all patients and
parents should be trained to monitor first morning urine proteins at
home with urine dipstick; urine testing at home is also useful in
monitoring response (or non-response) to steroid treatment.
➢ Diet. A sodium-restricted diet should be maintained while a
patient is edematous and until proteinuria remits; during severe
edema, careful and modest fluid restriction may be appropriate, but
the patient must be monitored closely for excessive intravascular
volume depletion.
➢ Activity. A normal activity plan is recommended.
Pharmacologic Management
Prednisone is the first-line therapy for children with nephrotic syndrome.
Other immunosuppressive medications may be useful in those whose
symptoms fail to respond to standard corticosteroid therapy or in those
who have frequent relapses.
➢ Glucocorticoids. All glucocorticoids are effective; however,
prednisone or prednisolone is used most commonly; their specific
mode of action in nephrotic syndrome is unknown.
➢ Diuretics. Diuretics promote excretion of water
and electrolytes by the kidneys; these agents are used to treat heart
failure or hepatic, renal, or pulmonary disease when sodium and
water retention has resulted in edema or ascites.
➢ Plasma protein. This agent is used to supplement diuresis in
patients with edema; it increases oncotic pressure and thereby
promotes a fluid shift from interstitial tissues.
➢ Immunosuppressive agents. This agent is used to supplement
diuresis in patients with edema; it increases oncotic pressure and
thereby promotes a fluid shift from interstitial tissues.
Nursing Management
The nursing management of a child with nephrotic syndrome include the
following:
Nursing Assessment
Assess for the following:
➢ Edema. Observe for edema when performing physical
examination of the child with nephrotic syndrome.
➢ Weigh and measure. Weigh the child and record the abdominal
measurements to serve as a baseline.
➢ Vital signs. Obtain vital signs, including blood pressure.
➢ Pitting edema. Note any swelling about the eyes or the ankles and
other dependent parts.
➢ Skin. Inspect the skin for pallor, irritation, or breakdown; examine
the scrotal area of the male child for swelling, redness, and
irritation.
Nursing Diagnoses
Based on the assessment data, the major nursing diagnoses are:
➢ Excess fluid volume related to fluid accumulation in tissues and
third spaces.
➢ Risk for imbalanced nutrition: less than body
requirements related to anorexia.
➢ Risk for impaired skin integrity related to edema.
➢ Fatigue related to edema and disease process.
➢ Risk for infection related to immunosuppression.
➢ Deficient knowledge of the caregiver related to disease process,
treatment, and home care.
➢ Compromised family coping related to care of a child with
chronic illness.
Nursing Care Planning and Goals
The major nursing care planning goals for the child with nephrotic
syndrome are:
➢ Relieving edema.
➢ Improving nutritional status.
➢ Maintaining skin integrity.
➢ Conserving energy.
➢ Preventing infection.
Nursing Interventions
Nursing interventions for a child with nephrotic syndrome are:
➢ Monitoring fluid intake and output. Accurately monitor and
document intake and output; weigh the child at the same time
every day, on the same scale in the same clothing; measure the
child’s abdomen daily at the level of the umbilicus.
➢ Improving nutritional intake. Offer a visually appealing and
nutritious diet; consult the child and the family to learn which
foods are appealing to the child; serving six small meals may help
increase the child’s total intake better.
➢ Promoting skin integrity. Inspect all skin surfaces regularly for
breakdown; turn and position the child every 2 hours; protect skin
surfaces from pressure by means of pillows and padding; protect
overlapping skin surfaces from rubbing by careful placement of
cotton gauze; bathe the child regularly; a sheer dusting of
cornstarch may be soothing to the skin.
➢ Promoting energy conservation. Bed rest is common during the
edema stage of the condition; balance the activity with rest periods
and encourage the child to rest when fatigued; plan quiet, age-
appropriate activities that interest the child.
➢ Preventing infection. Protect the child from anyone with an
infection: staff, family, visitors, and other
children; handwashing and strict medical asepsis are essential; and
observe for any early signs of infection.
Evaluation
Goals are met as evidenced by:
➢ Relief from edema.
➢ Improvement of nutritional status.
➢ Maintenance of skin integrity.
➢ Conservation of energy.
➢ Prevention of infection.
