Nephrotic Syndrome

Nephrotic Syndrome Causes

Nephrotic Syndrome is the outcome of number of diseases that damage the filtering units of the kidneys in a specific way that allows them to leak protein into the urine. Hence there is an array of diseases, which eventually end up in Nephrotic Syndrome. Some of the diseases that cause Nephrotic Syndrome, such as nephritis, affect only the kidney. Other diseases that cause Nephrotic Syndrome, such as diabetes and lupus erythematosus, affect other parts of the body as well. It should be also noted that in vast majority of cases exact cause cannot be pinpointed. The most common causes could be listed as under:

1. Local diseases (primarily affecting kidneys)
2. Systemic diseases (affecting various systems of body, one of them being kidney)
3. Allergy
4. Secondary to infections
5. Ill effects of drugs (e.g. antibiotics like penicillin or drugs given to control blood pressure)
6. Malignancy
7. Psychological factors
8. Idiopathic (Unknown causes)

Local Causes: This group categorizes all those conditions, which directly and primarily affect kidneys and damage glomeruli. Such conditions are largely termed as nephropathies or glomerulopathies. Some of them may be present since birth (e.g. congenital nephrosis) and others may be acquired during lifetime. Glomerulonephritis (GN) occupies peak position among glomerulopathies causing Nephrotic Syndrome. In GN, the kidneys’ filters become inflamed and scarred and slowly lose their ability to remove wastes and excess water from the blood to make urine.

The basis of various nephropathies causing Nephrotic Syndrome is related to problem in the body’s immune system. Under normal circumstances, immune system protects the body against invasion by foreign materials such as viruses and bacteria. However, if the immune system is not working properly, the kidneys may be harmed. The immune system may mistakenly attack the kidneys’ filters (glomeruli) and cause them to become inflamed. To know more about this click here.

There are many various variants of GN, basically depending upon how the kidneys look under microscope in particular condition. To know more about them click here.

General/ systemic diseases: This group categorizes all those diseases which affect wide spectrum of organs and systems in the body, one amongst them being kidney. When they affect kidney, they damage glomeruli and make them leak proteins. To enumerate some of them: Diabetes mellitus, systemic lupus erythematosus, Henoch-Schonlein purpura, multiple myeloma. To know more about them click here.

 Allergy: There is proven evidence that Nephrotic Syndrome is more common in individuals with family history or prior history of allergy. In fact, in number of cases Nephrotic Syndrome is precipitated by a hypersensitive event (e.g. insect sting, ant bites, poison ivy, and immunizations).

A few children have been reported with major food allergies along with Nephrotic Syndrome, and, in them, ultimate remission was associated with dietary elimination programs.

Infection: In some cases Nephrotic Syndrome is thought to be result of or after effect of infectious conditions like malaria, infective endocarditis, hepatitis B and C, syphilis, streptococcal throat infection, etc.

Drug toxicity: Certain modern medicines such as antibiotics (penicillin), antihypertensive medicines, gold preparations, etc are known to induce Nephrotic Syndrome in sensitive individuals.

Malignancy/ cancer: Cancers of kidneys or lymphatic system (Hodgkin’s lymphoma) have potential of inducing Nephrotic Syndrome.

Psychological factor: The mind plays a vital role in maintaining the health in general and in developing a wide range of disorders. There is proven evidence that emotional stress can produce alteration in our immune system. Some of the known causes of Nephrotic Syndrome like diabetes mellitus and SLE are offshoots of psychosocial stress.

Idiopathic: List is not complete without this entity, which means no cause can be identified. In vast majority cases of Nephrotic Syndrome exact cause cannot be pinpointed.

During homeopathic management of Nephrotic Syndrome, a lot of stress is given towards causative factors and there are various medicines to encompass these factors. It will not be an over-exaggeration to state that homoeopathy was first to identify role of genetically determined tendencies as root cause of chronic diseases, which has now been confirmed by so-called modern medicine. Homeopaths take special effort to eliminate these predisposed tendencies and this goes in a long way in treating these chronic conditions rather than just suppressing their expressions.

Nephrotic Syndrome Pathology

Nephrotic Syndrome starts when disease-fighting proteins called antibodies become deposited along the wall of the delicate blood vessels that comprise the glomeruli. Antibodies are made by the immune system to fight microorganisms such as bacteria and viruses or other agents that can cause disease. Collectively all these agents, which make body form antibodies against them, are called as antigen. The exquisite sensitivity of the immune system to these foreign molecules provides an effective defense against invasion of the body by foreign material.

In some cases, however, the immune system is activated inappropriately in response to antigens that may not have potential to cause disease. These immune hypersensitivities are called allergies. When antibodies encounter and bind to antigens in the circulation, they may form very large complexes that have difficulty staying dissolved in the blood.

These complexes may fall out of solution in the glomeruli and become lodged in the small pores where the blood is filtered. When antigen-antibody complexes are deposited in the glomeruli, the body responds by mounting an inflammatory response to try to remove them. Ultimately, the inflammation can cause even more damage and impair the function of the glomeruli, leading to Nephrotic Syndrome

Nephrotic Syndrome Diagnosis

To confirm the nature of the disease as well as to know to what extent it has damaged the kidneys, the physician will take following steps:

1. History: The doctor will take note of the chief complaints of the patient. Through the history, the doctor will gather more data about one’s symptoms, prior history or family history of allergy or related diseases and other related complaints. In most cases a detailed and precise history gives definite intimation to the diagnosis. Following this doctor will proceed with physical examination.
2. Physical Examination: The most common clinical finding in all patients with Nephrotic Syndrome is edema, which is present in more than 95% of individuals with the condition. When mild, edema is localized to those tissues, which are lax and can lead to fluid accumulation very easily (e.g., around the eyes, scrotum, labia).Generalized edema is dependent (increasing and decreasing with gravity) and pitting (impressionable to touch) in character. Ascites is common, and generalized swelling may be present. In children with marked ascites, mechanical restriction of breathing may be present, and the child may have compensatory tachypnea (fast, shallow breathing).Hypertension may be present in majority patients with any form of NS. Other positive findings, which may not be present in each and every case of Nephrotic Syndrome, are as follows:
   • Signs of a concurrent upper respiratory tract infection may be present and some children have overt evidence of an atopic state with varying degrees of eczema.
   • An occasional child demonstrates evidence of an insect sting and/or bite.
   • Abdominal tenderness will be evident in presence of peritoneal infection.
3. Investigations: In addition to a physical examination and the assessment of health history, the following three tests are instrumental for accurate diagnosis:
   1. Urinalysis
   2. Blood analysis
   3. Kidney biopsy>

   Urinalysis:- Urinalysis is done to demonstrate seepage of proteins in the urine. Evaluation of the urine by a simple urine dipstick test gives preliminary information on the amount of protein in the urine. For this your doctor will dip a strip of chemically treated paper into the urine sample. Too much protein in the urine will make the paper change color. This test can be done in the clinic itself. In order to determine the exact amount of proteins in the urine, a 24-hour quantitative test may be ordered. For this, the urine is collected over period of 24 hours and amount of protein in the urine is measured. The magnitude of proteinuria varies with the state of disease activity and variant of Nephrotic Syndrome. Some highlights of this test are: The amount of protein in a random urine sample of a patient with NS usually exceeds 100 mg/dL, and values as high as 1000 mg/L are common.

   The major protein excreted in any form of NS is albumin.

   Another positive finding in the urinalysis can be presence of blood in the urine and its frequency depends on the subtype of NS.

   Blood Analysis:- Blood analysis often shows high cholesterol levels and low albumin. Hypoalbuminemia is the second of the cardinal laboratory features of NS. The concentration of serum albumin in a patient of Nephrotic Syndrome is less than 2.5 g/dL.

   Hyperlipidemia is a common feature of NS and, in general, correlates inversely with the concentrations of serum albumin. The low-density lipoprotein and very-low-density lipoprotein cholesterol concentrations are elevated, whereas the high-density lipoprotein cholesterol level is decreased. The doctor may take a blood sample to see how well the kidneys are removing wastes. Healthy kidneys remove creatinine and urea nitrogen from the blood. If the blood contains high levels of these waste products, some kidney damage may have already occurred.

   Kidney Biopsy&gt:- Kidney biopsy: In some cases, the doctor may want to examine a small piece of the patient’s kidney under a microscope to determine the underlying cause and extent of disease. The procedure of collecting a small tissue sample from the kidney is called a biopsy, and it is usually performed with a long needle passed through the skin after the patient lies flat on his/her stomach. The doctor will use an ultrasound scan to find out exactly where the kidneys are and where to insert the needle. The procedure is more uncomfortable than painful and only a very small sample of one kidney is removed using a special needle. The sample is then examined under the microscope and it may take several days before the answer is available. The individual will be awake during the procedure and receive calming drugs and a local painkiller at the site of the needle entry. General anesthesia is used in the very rare cases where open surgery is required. The patient may be able to go home on the same day or may stay overnight in the hospital to rest and allow the health care team to ensure that no problems occur.

   Imaging Studies:-

   • No routine imaging studies are indicated in patients with NS.
   • On chest radiographs, pleural effusions (collection of fluid in the membranous covering of lungs) are not uncommon and their presence correlates directly with the degree of edema and indirectly with the serum albumin concentration. Ascites is common.
   • Renal sonography usually reveals normal to slightly enlarged kidneys. Patients with MPGN often demonstrate larger than normal renal shadows.

Complications Nephrotic Syndrome

Nephrotic Syndrome being a chronic disease affecting the vital organ such as kidney, it can have long term complications, which can briefly be described as under:

1. Less proteins in blood (hypoproteinemia): Constant and prolonged loss of proteins leads to low levels of proteins in the blood, which in turn lead to lowered resistance, making one prone to not only various infections but also many metabolic complications.
2. Infections: Recurrent infections occur in the case of Nephrotic syndrome due to protein and immunoglobulin loss. One becomes prone to various bacterial and viral infections, which include streptococcal, staphylococcal infections. Retention of fluid becomes a growth medium for various organisms. White blood cells have reduced capacity to fight against bacteria.
3. High blood pressure (hypertension): Due to loss low levels of proteins, there is a fluid retention in the body; which leads to high blood pressure. High blood pressure can hamper kidney functions.
4. Steroid (cortisone) dependency: Dependency on and resistance to cortisone, which occurs in many cases, should be considered a complication of the disease/treatment. Some complications arise due to the use of immunosuppressive medicines, which are:-
   • a. adverse effects of cortisone or cyclosporine
   • b. infections due to suppressed immunity
   • c. dependency on immunosuppressive medicines.
5. Hyperlipidemia: Low levels of proteins (hypoproteinemia) leads to low serum oncotic pressure, which in turn leads to increased lipids in blood, called as Hyperlipidemia, which is a part of Nephrotic Syndrome; sometimes appear as a complication. Increased levels of lipids (fats) get deposited on the blood vessels leading to the condition called atherosclerosis. Atherosclerosis, in turn, lead to high blood pressure.
6. Hypocalcemia: Low levels of calcium in blood called Hypocalcemia, occurs due to low proteins in blood. Low calcium, in turn, leads to weak bones and bony abnormalities. Use of cortisone (steroid) again adds to loss of calcium, and more hypocalcemia.
7. Hypercoagulability or hyper-clotting: Due to loss of anti-clotting factors such as antithrombin III and plasminogen, blood looses its capacity to remain fluid. This can lead to formation of abnormal clots in the blood and in different organs such as veins. Such clots may migrate to other parts such as lungs and may lead to what is called as pulmonary embolism, which is a serious condition.