CHP. 22. Nephrotic Syndrome 163.
Symptoms of nephrotic syndrome
- Nephrotic syndrome can occur at any age but is most common
between the ages of 2 to 8 years. It affects boys more often than girls.
164. Save Your Kidneys
- The first sign of nephrotic syndrome in children is usually puffiness
or swelling around the eyes and swelling of the face. Because of
puffiness around the eyes, the patient is likely to consult an
ophthalmologist (eye doctor) first.
- In nephrotic syndrome swelling of the eyes and the face is most
noticeable in the morning and is less marked in the evening.
- With time, the swelling develops in the feet, hands, abdomen and all
over the body and is associated with increase in weight.
- Swelling may occur after a respiratory tract infection and fever in
many patients.
- Excluding swelling, the patient is usually well, active and does not
seem sick.
- A decreased urine output compared to normal is common.
- Frothy urine and white stain on tiles due to albumin in urine may be
a revealing feature.
- Red urine, breathlessness and high blood pressure are less common
in nephrotic syndrome.
What are the complications of nephrotic syndrome?
Possible complications of nephrotic syndrome include an increased risk
of developing infections, blood clots in the veins (deep vein thrombosis),
malnutrition, anemia, heart disease due to high cholesterol and
triglycerides, kidney failure and different treatment-related complications.
Diagnosis:
A. Basic laboratory tests
In patients with swelling the first step is to establish a diagnosis of nephrotic syndrome. Laboratory tests should confirm (1) heavy loss of
protein in the urine, (2) low blood protein levels, and (3) high cholesterol
levels.
The first sign of nephrotic syndrome in children is
swelling around the eyes and swelling of the face.
CHP. 22. Nephrotic Syndrome 165.
1. Urine tests
- Urine examination is the first test used in the diagnosis of nephrotic
syndrome. Normally, routine examination of urine will show negative
or trace protein (albumin). The presence of 3+ or 4+ protein in a
random urine sample is suggestive of nephrotic syndrome. Remember
though that the presence of albumin in urine is not a specific diagnostic
confirmation of nephrotic syndrome. It only suggests urinary loss of
protein. Further investigations are necessary to determine the exact
cause of urine protein loss.
- After starting treatment, urine is tested regularly to assess its response
to treatment. The absence of protein in urine tests suggests a positive
response to treatment. For self monitoring, protein in urine can be
estimated by using a urine dipstick at home.
- In microscopic examination of urine, red blood cells and white blood
cells are usually absent.
- In nephrotic syndrome, the loss of protein in urine is more than 3.5
grams in a day. The amount of protein lost in 24 hours can be
estimated by a 24-hour urine collection or more conveniently by a
spot urine protein/creatinine ratio. These tests provide precise
measurements of the amount of protein lost and identify whether
protein loss is mild, moderate or heavy. In addition to its diagnostic
value, estimation of urine protein loss in 24 hours is useful for
monitoring response to treatment.
Urine test is very important for diagnosis as well as
monitoring of treatment of nephrotic syndrome.
166. Save Your Kidneys
2. Blood tests
- The characteristic findings of nephrotic syndrome that accompany
the high urine protein levels are low blood albumin level (less than 3
g/dL) and elevated cholesterol (hypercholesterolemia) in blood tests.
- The value of serum creatinine is normal in nephrotic syndrome due
to minimal change disease, but may be increased in patients with
more severe kidney damage from other forms of nephrotic syndrome
like focal segmental glomerulosclerosis. Serum creatinine is measured
to assess overall kidney function.
- Complete blood count is a routine blood test performed in most of
the patients.
B. Additional tests
Once the diagnosis of nephrotic syndrome has been established,
additional tests are performed selectively. These tests determine whether
the nephrotic syndrome is primary (idiopathic) or secondary to a systemic
disorder; and to detect the presence of associated problems or
complications.
1. Blood tests
- Blood sugar, serum electrolytes, calcium and phosphorus.
- Testing for HIV, hepatitis B and C and VDRL test.
- Complement studies (C3, C4) and ASO titer.
- Antinuclear antibody (ANA), anti–double-stranded DNA antibody,
rheumatoid factor and cryoglobulins.
2. Radiological tests
- An ultrasound of the abdomen is performed to determine the size and shape of the kidney, and to detect mass, kidney stone, cyst or
other obstruction or abnormality.
- X-ray of the chest is done to rule out infections.
3. Kidney biopsy
The kidney biopsy is the most important test used to determine the
exact underlying type or cause of nephrotic syndrome. In a kidney biopsy,
a small sample of kidney tissue is taken and examined in a laboratory.
(for further information read Chapter 4).
Important diagnostic clues are loss of protein in urine and low
protein, high cholesterol and normal creatinine in blood tests.