prepared by:dr.boshra hasanzamani conditions associated with membranous glomerulopathy idiopathic...
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Prepared by:Dr.Boshra Hasanzamani
www.mums.ac.ir/rsc-ktc
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Definition of NS
Etiology of NS
Pathology of NS
Pathophysiology of NS
Clinical Manifestation of NS
Complication NS
Laboratory Data
Diagnosis
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Nephrotic syndrome (NS) results from increased permeability of Glomeulrar basement membrane (GBM) to plasma protein.
It is clinical and laboratory syndrome characterized by massive proteinuria, which lead to hypoproteinemia ( hypo-albuminemia), hyperlipidemia and pitting edema.
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Proteinuria > 3.5 g per 1.73 m2
Hypoalbuminemia
Edema
Hyperlipidemia
Lipiduria
hypercoagulability
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Increase glomerular permeability for proteins due to loss of negative charged glycoprotein
-Type of proteinuria:-
A-Selective proteinuria: where proteins of low molecular weight .such as albumin, are excreted more readily than protein of HMW
B-Non selective :
LMW+HMW are lost in urine
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*Response to Hypoalbuminemia → reflex to liver --→ synthesis of generalize protein ( including lipoprotein ) and lipid in the liver ,the lipoprotein high molecular weight no loss in urine → hyperlipidemia
*Diminished catabolism of lipoprotein
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Hyperlipidemia Increased hepatic lipoprotein synthesis
Increased urinary loss of proteins that regulate lipid homeostasis
Increase LDL and cholesterol: in the majority of patients
Increased VLDL and TG : severe disease
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*Reduction plasma colloid osmotic pressure↓ secondary to hypoalbuminemia Edema and hypovolemia
*Intravascular volume↓ antidiuretic hormone (ADH ) and aldosterone(ALD) water and sodium retention Edema
*Intravascular volume↓ glomerular filtration rate
(GFR)↓ water and sodium retention Edema
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Hypercoagulability Increased urinary loss of antithrombin III
Altered levels and or activity of proteins C and S
Hyperfibrinogenemia
Impaired fibrinolysis
Increased platelet aggregability
Spontaneous peripheral arterial or venous thrombosis – renal vein thrombosis – pulmonary embolisms
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Acute RVT : Sudden onset of flank or abdominal pain
Gross hematuria
Left-sided varicocele
Increased proteinuria
Acute decline in GFR
Chronic RVT: asymptomatic
RVT :common(40%) MGN
MPGN
Amyloidosis
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Other complications: Protein malnutrition
Iron-resistant microcytic hypochromic anemia (transferrin loss )
Hypocalcemia & secondary hyperparathyroidism
Depressed thyroxine levels
Increased susceptibility to infection Low levels of IgG
Changes in the pharmacokinetics of drug
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A-Primary Idiopathic NS (INS): majority
The cause is still unclear up to now. Recent 10 years ,increasing evidence has suggested that INS may result from a primary disorder of T– cell function.
B-Secondary NS:
NS resulted from systemic diseases, such as anaphylactoid purpura , systemic lupus erythematosus, HBV infection.
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Drug,Toxic,Allegy: mercury, snake venom, vaccine, pellicillamine, Heroin, gold, NSAID, captopril, probenecid, volatile hydrocarbons
Infection: APSGN, HBV, HIV, shunt nephropathy, reflux nephropathy, leprosy, syphilis, Schistosomiasis, hydatid disease
Autoimmune or collagen-vascular diseases: SLE, Hashimoto’s thyroiditis,, HSP, Vasculitis
Metabolic disease: Diabetes mellitus
Neoplasma: Hodgkin’s disease, carcinoma ( renal cell, lung, neuroblastoma, breast, and etc)
Genetic Disease: Alport syn, Sickle cell disease, Amyloidosis, Congenital nephropathy
Others: Chronic transplant rejection, congenital nephrosclerosis
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Primary glomerulonephritis
Minimal change disease
Focal segmental glomerulosclerosis (most common cause in adults)
Membranous glomerulonephritis
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sometimes known as nil lesion
causes 70–90% of nephrotic syndrome in childhood but only 10–15% of nephrotic syndrome in adults
usually presents as a primary renal disease
can be associated with several other conditions, including :
- Hodgkin's disease
- allergies
- use of nonsteroidal anti-inflammatory agents;
(significant interstitial nephritis often accompanies
cases associated with nonsteroidal use )
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on renal biopsy shows :
L.M :
- no obvious glomerular lesion
I.F :
- negative for deposits
- or occasionally shows small amounts of IgM in the
mesangium
E.M :
- effacement of the foot process supporting the epithelial
podocytes with weakening of slit-pore membranes
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Table 274-1. Major Causes of Minimal Change Disease (Nil Disease, Lipoid Nephrosis)
Idiopathic (majority)
In association with systemic diseases or drugs
Drug-induced interstitial nephritis induced by NSAIDs, rifampin, interferon a
Hodgkin's disease and other lymphoproliferative malignancy
HIV infection
NOTE: NSAIDs, nonsteroidal anti-inflammatory drugs.
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IN MCDS , The male preponderance of 2:1
: 1.Main manifestations:
Edema (varying degrees) is the common symptom Local edema: edema in face , around eyes( Periorbital swelling) ,
in lower extremities. Generalized edema (anasarca), edema in penis and scrotum.
2-Non-specific symptoms:
Fatigue and lethargy loss of appetite, nausea and vomiting ,abdominal pain , diarrhea body weight increase, urine output decrease pleural effusion (respiratory distress)
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acellular urinary sediment
Average urine protein excretion reported in 24 hours is 10 grams with severe hypoalbuminemia
Less common clinical features include :
- hypertension (30% in children, 50% in adults)
- microscopic hematuria (20% in children, 33% in
adults)
-atopy or allergic symptoms (40% in children, 30% in
adults)
-decreased renal function (<5% in children, 30% in adults)
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Idiopathic (majority)
In association with systemic diseases or drugs
HIV infection
Diabetes mellitus
Fabry's disease
Sialidosis
Charcot-Marie-Tooth disease
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As consequence of sustained glomerular capillary
hypertension
Congenital oligonephropathies
Unilateral renal agenesis
Oligomeganephronia
Acquired nephron loss
Surgical resection
Reflux nephropathy
Glomerulonephritis or tubulointerstitial nephritis
Other adaptive responses
Sickle cell nephropathy
Obesity with sleep apnea syndrome
Familial dysautonomia
Miscellaneou
Heroin use
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LM: Sclerosis with hyalinosis – intrapment of amorphouse hyaline material
EM:damage of visceral epithelial cell
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30-40%nephrotic syn. In adults
Rare cause in children
Peak incidence:30 – 50 years
Male – female ratio: 2:1
LM:diffuse thickening of GBM
IF:granular deposition of IgG – C3 – CH50 along the glomerular capillary wall
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>80% nephrotic syn.
Microscopic hematuria:50%
HTN:10-30%
ANA-ANCA-anti-GBM-cryoglobulin-comlement: Negative
One-third occurs in association with systemic dis.
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Conditions Associated with Membranous
Glomerulopathy
Idiopathic (majority)
In association with systemic diseases or drugs
Infection
Hepatitis B and C, secondary and congenital syphilis,
malaria, schistosomiasis, leprosy, hydatid disease,
filariasis, enterococcal endocarditis
Systemic autoimmune diseases
SLE, rheumatoid disease, Sjogren's syndrome,
Hashimoto's disease, Graves' disease, mixed connective
tissue disease, primary biliary cirrhosis, ankylosing
spondylitis, dermatitis herpetiformis, bullous pemphigoid,
myasthenia gravis
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Neoplasia
Carcinoma of the breast, lung, colon, stomach, and
esophagus; melanoma; renal cell carcinoma;
neuroblastoma; carotid body tumor
Drugs
Gold, penicillamine, captopril, NSAIDs, probenecid,
trimethadione, chlormethiazole, mercury
Miscellaneous
Sarcoidosis, diabetes mellitus, sickle cell disease,
Crohn's disease, Guillain-Barre syndrome, Weber-
Christian disease, Fanconi's syndrome, a1
antitrypsin deficiency, angiofollicular lymph node
hyperplasia
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Spontaneous remission :40%
Relapses and remission:30-40%
Slow progressive decline in GFR:10-20%
Poor prognosis: HTN
Severe proteinuria and hyperlipidemia
Impaired renal function
Older age
Male gender
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MESANGIOCAPILLARY GN
LM: thickening of the GBM and proliferative changes
Two major types Both:diffuse increase in mesangial cellularity and matrix
Thickening and reduplication of the GBM
DDX- EM: TYPE I :subendothelial and mesangial deposits contain IgG or
IgM and C3
Type II (dense deposit disease):
Electron –dense deposits within the GBM
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Type I :immunecomplex GN Heavy protenuria and nephrotic syn.
Active urinary sediment
Normal or mildly impaired GFR
C3 depressed
C4 and C1q :borderline or low
ESRD:50% by 10 years
No proven therapy
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Type II : autoimmune disease
Nephrotic syn.
RPGN
Recurrent macroscopic hematuria
Have an IgG autoantibody(C3 nephritic factor)
No effective therapy
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Causes of Membranoproliferative
(Mesangiocapillary) Glomerulonephritis
(MPGN)
Idiopathic
Type I
With subendothelial and mesangial immune deposits
Type II
With intramembranous dense deposits containing sparse
or no Ig; associated with C3 nephritic factor
Type III
Features of type I MPGN and membranous
nephropathy
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Systemic immune-complex disease SLE, mixed cryoglobulinemia, Sjogren's syndrome
Chronic infections Hepatitis B and C, HIV, bacterial endocarditis,
ventriculoatrial shunts, visceral abscess
Malignancy Leukemias, lymphomas
Liver disease Chronic active hepatitis and cirrhosis (usually associated
with hepatitis B or C)
Miscellaneous Partial lipodystrophy, heroin use, sarcoidosis, inherited C2
deficiency, thrombotic microangiopathies
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Edema
Hyperlipidemia
Hypercoagulability
Anemia
Hyperfibrinogenemia
transferrin loss
Oncotic pressure
lipoprotein synthesis
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