Nephrotic Syndrome in Adults: Clinical Signs, Diagnostic Criteria, and Investigations

Nephrotic Syndrome in Adults: Clinical Signs, Diagnostic Criteria, and Investigations

Question. Describe the clinical and diagnostic features of nephrotic syndrome.
Answer.

Clinical Features Nephrotic Syndrome

• Age and sex: Nephrotic syndrome is two to three times more common in childhood with peak incidence at 2–3 years.
  In this age group, there is a male : female ratio of 2.5 : 1,in adults, sex incidence is equal.
• Edema: It is peripheral involving the limbs, particularly lower limbs.
  In children, edema may be more obvious in the face and abdomen.
  Usually, massive generalized anasarca, the patient almost weighing double his true weight.
  Intense edema of the scrotum or vulva may occur.
  There may be bilateral hydrothorax.
  Edema may persist for many weeks or months.
  Spontaneous subsidence with diuresis (nephrotic crisis) may occur, to be followed again by increase of edema.
• Gastrointestinal symptoms: Anorexia causes severe malnutrition, Diarrhea and vomiting due to edema of intestinal wall.
• General symptoms: Prolonged protein loss causes anorexia,lethargy, tiredness, frequent infections and muscle wasting.
  Dyspnea may occur, if there is flid in the pleural cavity.
• Blood pressure: There may be periods of hypertension;ultimately with development of chronic nephritis permanent hypertension may develop.

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Diagnostic Features Nephrotic Syndrome

Diagnosis is not diffilt when there is massive generalized edema with albuminuria, hypoproteinemia and hypercholesterolemia.
Diagnosis is based on clinical signs and investigations

Clinical Signs Nephrotic Syndrome

• Physical examination reveals generalized edematous person.
• Edema may persist for many weeks or months.
• Tachycardia is present while blood pressure is normal.
• Pittng edema is present over legs and feet, abdominal walls and lower eyelids.
• Eyelids become puff
• At places where edema is severe ascites and pleural effsion are seen.
• Kidneys are not palpable.

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Investigations Nephrotic Syndrome

1. Urine examiation:

• Oliguria while edema is forming, dieresis or normal amount of urine during period of subsidence of edema.
• Proteinuria: It is massive, usually more than 5 g/day though variable from time to time; urine becomes almost solid on boiling. Daily loss of protein may be 20–50 g.
• 24 hour urine shows excretion of albumin or protein more than 3.5 g/day.
• Red blood cells are absent or few are seen
• Casts: Fatt casts, tubular cells, oval fat bodies, doubly refractile bodies are seen

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2. Blood examination: Nephrotic Syndrome

• Anemia: It is slight normochromic.
• Hypoalbuminemia: Serum albumin usually less than 3 g/100 mL. Total serum globulin concentration frequently lowered with often elevation of α2 and β-globulins.
• Serum lipids show increase in LDL levels and cholesterol.
• ESR is raised due to hyperfirinogenemia.
• Serum complement level: Serum complement C3 and C4 levels get reduced.
• Other biochemical tests, i.e. blood urea, serum creatinine, creatinine clearance and electrolytes are normal.

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3. Ultrasound of abdomen: It can show normal small or large kidneys which depends on the underlying cause.
Amyloid and diabetic kidneys are large while kidney in glomerulonephritis is small.

4. Renal biopsy: It is normal on light microscopy but electron microscopy shows typical abnormalities (effcement of epithelial cell foot processes).