Nephrotic syndrome

Let's learn the pharmacology related to nephrotic syndrome - features of nephrotic syndrome with underlying mechanisms, objectives of treatment, and management of the nephrotic syndrome.

1. NEPHROTIC SYNDROME

2. LEARNING OBJECTIVE To list the features of nephrotic syndrome with their underlying mechanisms. To define the objectives of treatment of nephrotic syndrome . To describe the management of nephrotic syndrome.

3. NEPHROTIC SYNDROME Feature Mechanism Consequence Proteinuria (> 3.5 g/day ) -Structural damage to glomerular basement membrane -Loss of size & charge barrier -Hypoalbuminemia Hypoalbuminemia (<3 g/dl) -Massive proteinuria -High catabolism of reabsorbed albumin (proximal tubule of kidney) -Reduced oncotic pressure -Edema Sodium retention - Secondary hyperaldosteronism -Edema Hypercholesterolemia -Increased hepatic lipoprotein synthesis in response to hypoalbuminemia -Atherosclerosis Hypercoagulability -Urinary loss of antithrombin III, protein C and S -Increased serum fibrinogen level -Venous thromboembolism Infection -Urinary loss of immunoglobulin -Pneumococcal infection

4. OBJECTIVES OF TREATMENT OF NEPHROTIC SYNDROME To identify the underlying cause and reverse it (if possible). To reduce proteinuria. To reduce edema formation. To reduce blood cholesterol level. To restrict dietary sodium.

5. OBJECTIVES OF TREATMENT OF NEPHROTIC SYNDROME To prevent complications like - hypercoagulability - infection - acute kidney disease To maintain electrolyte balance. To maintain quality of life.

6. MANAGEMENT OF NEPHROTIC SYNDROME Management of Edema Proteinuria H ypercholesterolemia Hypercoagulability Infection

7. Management of edema Dietary sodium restriction Thiazide diuretics ( Bendroflumethiazide ) Furosemide with amiloride - If unresponsive to thiazide Parenteral route if resistance to oral diuretic - Nephrotic patient may malabsorb diuretics owing to gut mucosal edema

8. Management of proteinuria Normal protein diet intake - High protein diet ( 80-90 g/day) increases proteinuria ACE inhibitors and/or angiotensin II antagonist - Reduces glomerular efferent arteriolar resistance - Reduces intraglomerular capillary pressure - Reduces protein filtration

9. Management of hypercholesterolemia Lipid lowering drugs - HMG CoA reductase inhibitors, fibrates Restrict saturated and trans-fatty acids in diet Management of hypercoagulability Prolonged bed rest avoided - T hromboembolism very common in nephrotic syndrome Long term prophylactic anticoagulant - In absence of any contraindications

10. Management of infection Early detection and aggressive treatment of infection Rather than long term antibiotic prophylaxis Pneumococcal vaccine given - Pneumococcal infections particularly common

11. REFERENCES Davidson’s Principles & Practice of Medicine; 21 st Edition ; page no. 481 KUMAR & CLARK CLINICAL MEDICINE; 6 th EDITION ; Page no.901-903 HARRISON’S Principles of INTERNAL MEDICINE; 17 th Edition ; Page no. 1210

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