CHARLES KODNER, MD, University of Louisville School of Medicine, Louisville, Kentucky
Am Fam Physician. 2009 Nov 15;80(10):1129-1134.
http://www.aafp.org/afp/2009/1115/p1129.pdf
The common causes of nephrotic syndrome are focal segmental, membranous, minimal change, IgA, and membranoproliferative. Secondary causes include diabetes, SLE, hepatitis B/C, NSAIDs, amyloidosis, and HIV. The pathology is unknown, but the proteinuria may be the cause of the edema and tubulointerstitial inflammation. Clinical features include edema (lower extremity, periorbital and genital), weight gain, ascites, effusion (heart and lung) and fatigue. Lab values include proteinuria (3-3.5g/day or 3+ on a dipstick), spot protein/creatinine ratio above 3, hypoalbuminemia (<2.5 g/dL), and possibly an elevated total cholesterol. Complications of nephrotic syndrome include DVT, PE, infection, and acute renal failure.
Evaluation of these patients involves looking for an underlying cause of the nephrotic syndrome. In addition to the above mentioned lab tests, tests screening for HIV, Hep B or C, amyloidosis, multiple myeloma, syphilis, and SLE should be considered if the history warrants. Biopsy may be necessary to confirm the diagnosis, ut specific recommendations for biopsy are not available.
Management is dependent on clinician experience as solid recommendations have yet to surface. Sodium and fluid restriction is often done to reduce edema. Diuretics are often used as well. Whether to use loops or thiazides depends on the rise in creatinine, where loops would be preferred. ACEIs have helped to lower proteinuria. Albumin can help with diuresis, but it has a short half life and high cost. Corticosteroids are a mainstay. They are especially helpful in minimal change disease compared to other diseases. The use of cyclophosphamide should trigger a referral to a nephrologist.
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