Patient information: The nephrotic syndrome

NEPHROTIC SYNDROME OVERVIEW

The term nephrotic syndrome refers to a group of symptoms that occur in people with kidney (renal) disease.

• High levels of protein (albumin) in the urine
• Low levels of the protein (albumin) in the blood
• Swelling (also called edema) of the face, legs, or ankles due to the abnormal collection of fluids in the tissues

This article will review the causes, evaluation, and treatment of nephrotic syndrome. More detailed information is available by subscription. (See "Overview of heavy proteinuria and the nephrotic syndrome".)

HOW DOES NEPHROTIC SYNDROME DEVELOP?

Nephrotic syndrome develops when there is damage to the glomeruli, the structures in the kidneys that work to filter the blood (figure 1). This damage allows proteins in the blood (such as albumin) to leak into the urine, causing proteinuria. (See "Patient information: Protein in the urine (proteinuria)".) Eventually, blood levels of albumin become reduced. Reduced kidney function leads to accumulation of fluid in the tissues (edema).

How are glomeruli damaged? — Many disorders can cause damage to the glomeruli, resulting in nephrotic syndrome. In some cases, damage is confined to the kidneys alone. In other cases, organs other than the kidney are also affected (such as in diabetes mellitus or systemic lupus erythematosus).

• In children, the most common cause of glomerular damage is a condition known as minimal change disease.
• In adults, approximately 30 percent of people with nephrotic syndrome have an underlying medical problem, such as diabetes or lupus; the remaining cases are due to kidney disorders such as minimal change disease, focal glomerulosclerosis, or membranous nephropathy.

Minimal change disease — Minimal change disease is a kidney disease that can occur in adults and children. People with minimal change disease have normal or very mild abnormalities of the glomeruli. (See "Diagnosis and causes of minimal change disease in adults".)

Focal glomerulosclerosis — Focal glomerulosclerosis (FSGS) is the most common cause of nephrotic syndrome in adults. FSGS causes collapse and scarring of some glomeruli. The cause of primary FSGS is unknown, although some cases (usually in children or young adults) are the result of a genetic defect.

Membranous nephropathy — Membranous nephropathy is a condition in which the walls of the glomerular blood vessels become thickened from the accumulation of protein deposits, causing increased "leakiness". It is not clear why membranous nephropathy develops in most people. (See "Causes and diagnosis of membranous nephropathy".)

Diabetes mellitus — Kidney disease is common in people with diabetes who have chronically elevated blood glucose levels and/or high blood pressure. (See "Patient information: Diabetes mellitus type 1: Overview" and "Patient information: Diabetes mellitus type 2: Overview".)

Lupus — Lupus is a disease that can affect multiple organs of the body, including the kidney. Nephrotic syndrome is common in people with severe lupus. (See "Patient information: Systemic lupus erythematosus (SLE)".)

NEPHROTIC SYNDROME SYMPTOMS

The most common symptoms of nephrotic syndrome are swelling, weight gain, fatigue, blood clots, and infections. Kidney failure may develop in some people. Increased excretion of protein may lead to "frothy" appearing urine in the toilet bowel.

Swelling (edema) — Swelling that occurs in people with nephrotic syndrome commonly affects the lining of the eye socket, which often causes swelling around the eyes upon waking in the morning. Swelling (edema) can also occur in the feet or ankles after sitting or standing for any period of time. (See "Patient information: Edema (swelling)".)

Weight gain — Weight gain can occur in people who develop swelling. Weight gain can occur rapidly.

Uncommonly, weight loss can occur in people who are losing large quantities of protein in the urine. This may be due to malnutrition or an underlying conditions, such as poorly controlled diabetes mellitus.

Kidney failure — Some people with nephrotic syndrome have a gradual decline in kidney function, which causes no symptoms in the early stages. However, as kidney function continues to worsen, symptoms of kidney failure can develop, including shortness of breath, elevated blood potassium levels, high blood pressure, anemia (low red blood cell count), and bone disease.

Blood clots — People with nephrotic syndrome are at an increased risk of blood clots in the veins or arteries. Clots in the veins can travel to the lungs. This can be dangerous, or even fatal. (See "Renal vein thrombosis and hypercoagulable state in nephrotic syndrome".)

Infection — People with nephrotic syndrome are at risk for infections, although the reasons for this are not well understood.

NEPHROTIC SYNDROME DIAGNOSIS

Nephrotic syndrome is diagnosed based upon a number of laboratory tests, including urine and blood tests, and often a renal (kidney) biopsy. (See "Patient information: Renal (kidney) biopsy".)

Urine tests — Urine tests are often done to determine the amount of protein in the urine.

Blood tests — A number of blood tests may be recommended to help determine the underlying cause of nephrotic syndrome. (See "Serologic tests in the evaluation of nephrotic syndrome".)

Renal biopsy — Renal (kidney) biopsy is the standard procedure for determining the underlying cause of nephrotic syndrome. (See "Patient information: Renal (kidney) biopsy".)

NEPHROTIC SYNDROME TREATMENT

Treat the underlying disease — The first line of treatment in nephrotic syndrome is to treat the underlying cause, if the cause is found. In addition, almost all patients are given an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), which lower blood pressure, prevent worsening of kidney disease, and reduce the amount of protein excreted in the urine.

Diabetes mellitus — The optimal treatment for diabetic kidney disease is not well understood, although the best approach likely includes intensive management of blood sugar levels, cholesterol, and blood pressure.

Lupus — People with lupus who have nephrotic syndrome or evidence of worsening kidney function can be treated with steroids and other medications that suppress the immune system. Most people respond well to such a regimen.

Minimal change disease — People with minimal change disease almost always respond initially to treatment with glucocorticoids (steroids). However, relapses are common, and additional treatments are often required. (See "Treatment of minimal change disease in adults".)

Focal glomerulosclerosis — Prolonged treatment with glucocorticoids (steroids) is often recommended for people with primary focal glomeruloscerlosis (FSGS). Secondary FSGS is treated only with ACE inhibitors or ARBs (see 'Treat the underlying disease' above.

Membranous nephropathy — The best treatment for membranous nephropathy is a source of debate. In many people, a period of "watch and wait" is recommended initially to determine if the condition is worsening or causing complications. During this time, an ACE inhibitor or ARB are recommended and it is important to keep blood pressure and cholesterol levels controlled. Additional treatment, including medications that suppress the immune system, may be needed if membranous nephropathy progresses.

Without immunosuppressive treatment, approximately 10 to 30 percent of people with membranous nephropathy have a complete resolution of symptoms over several years; a further 10 to 30 percent of people have a partial remission; approximately 40 percent of people slowly lose renal function. As a result, most people with mild symptoms are advised to delay immunosuppressive treatment until/unless symptoms worsen. (See "Treatment of idiopathic membranous nephropathy".)

Treating the symptoms of nephrotic syndrome — In addition to treating the underlying cause of nephrotic syndrome, the signs and symptoms of nephrotic syndrome can sometimes be treated.

Proteinuria — An ACE inhibitor or angiotensin receptor blocker (ARB) is often recommended to reduce the loss of protein in the urine (proteinuria). (See "Overview of heavy proteinuria and the nephrotic syndrome".)

Edema — Swelling in the lower legs (edema) and collection of fluid in the abdomen (ascites) can occur in people with nephrotic syndrome. Edema and ascites often improve in people who follow a low sodium diet and take a "water pill" (diuretic). (See "Patient information: Low sodium diet" and "Mechanism and treatment of edema in nephrotic syndrome".)

High cholesterol — High cholesterol levels are often seen in people with nephrotic syndrome. If nephrotic syndrome persists, treatment is needed to lower blood cholesterol. Most people are initially treated with a cholesterol-lowering medication called a statin. (See "Patient information: High cholesterol and lipids (hyperlipidemia)".)

Blood clots — If a blood clot forms in a blood vessel, treatment may include a blood thinner, such as warfarin (Coumadin), for as long as the nephrotic syndrome persists. (See "Patient information: Warfarin (Coumadin®)" and "Renal vein thrombosis and hypercoagulable state in nephrotic syndrome".)

WHERE TO GET MORE INFORMATION

Your healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Protein in the urine (proteinuria)
Patient information: Diabetes mellitus type 1: Overview
Patient information: Diabetes mellitus type 2: Overview
Patient information: Systemic lupus erythematosus (SLE)
Patient information: Edema (swelling)
Patient information: Renal (kidney) biopsy
Patient information: Low sodium diet
Patient information: High cholesterol and lipids (hyperlipidemia)
Patient information: Warfarin (Coumadin®)

Professional Level Information:
Acute kidney injury (acute renal failure) in minimal change disease and other forms of nephrotic syndrome
Causes and diagnosis of membranous nephropathy
Diagnostic approach to the patient with acute or chronic kidney disease
Differential diagnosis of glomerular disease
Evaluation of isolated proteinuria in adults
Hyperlipidemia in nephrotic syndrome
Mechanism and treatment of edema in nephrotic syndrome
Overview of heavy proteinuria and the nephrotic syndrome
Renal vein thrombosis and hypercoagulable state in nephrotic syndrome
Serologic tests in the evaluation of nephrotic syndrome
Urinalysis in the diagnosis of renal disease
Diagnosis and causes of minimal change disease in adults
Treatment of minimal change disease in adults
Treatment of idiopathic membranous nephropathy

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Institute of Diabetes and Digestive and Kidney Diseases

      (www.niddk.nih.gov)

• National Kidney Foundation

      (www.kidney.org)

• American Kidney Fund

      (www.akfinc.org)

• American Association of Kidney Patients

      (www.aakp.org)

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