10.01 Nephrotic Syndrome

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Facial Edema in Nephrotic Syndrome (Image)
Anatomy of the Nephron (Image)
Nephrotic Syndrome Pathochart (Cheat Sheet)
Symptoms of Nephrotic Syndrome (Mnemonic)
Nephrotic Syndrome (Picmonic)

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Hey guys, in this lesson we are going to talk about Nephrotic Syndrome.

Alright, let’s dive into this topic because it’s super interesting! When a patient is diagnosed with nephrotic syndrome, the primary problem is that the glomeruli in the kidney are damaged. We don’t fully understood why this is happening. And when there is no obvious cause it is called Minimal Change Nephrotic Syndrome. There are a lot of different types, but we are going to focus on this one because it is the most common.

So like I said, the glomeruli are damaged, well what does that mean? Well, these glomeruli are located in the nephron in the kidney’s and they are a these little capillaries that are responsible for filtering the blood. Well in this diagnosis, they are damaged, so they have become more permeable to proteins which means that an excessive amount of protein is leaving the blood and moving into the urine.

This causes excessive proteinuria and a lack of protein in the body. This presents as hypoalbuminemia in our patients. Albumin makes up a huge part of the plasma (Remember plasma is the liquid part of the blood that carries blood cells throughout the body) and plays a really important role in helping fluids stay inside the plasma. The way albumin does this is by maintaining what’s called colloidal osmotic pressure in the capillaries. The pressure that is created by albumin exerts a pulling force that keeps fluids inside the capillaries. Without albumin, the fluid shifts out of the plasma into interstitial spaces, which is edema.

So, a patient without enough protein will have fluids in all the wrong places. Interstitial spaces are full of fluid while the vascular system has very little, which we call hypovolemia.

It’s not fully understood why but the bodies production of lipids increases in this clinical pictures so another important finding is hyperlipidemia.

Diagnostic testing reflects the pathology we just discussed. So we need urine tests to look for excessive proteinuria. One urine dipstick, this is higher than 2+. We need a blood test looking at albumin levels and another one to assess lipid levels. In some cases a kidney biopsy will also be required.

The first and most classic symptom with nephrotic syndrome is periorbital edema. Parents will bring their child in to be seen for puffy eyes in the morning that lessens throughout the day. Initially, this is often attributed to allergies then as the edema worsens, nephrotic syndrome is considered as a cause.

Due to the edema patients will often experience weight gain and hypertension can occur as well.

There will also be a decrease in urine output and the extra protein in the urine will cause it to be frothy.

One important thing to note about Nephrotic syndrome is that these patients are at increased risk for serious infections. It isn’t fully understood why this is the case, but most deaths from nephrotic syndrome are caused by sepsis. So, it’s important to be on the lookout for signs of sepsis. So, fever, lethargy, tachycardia and increased cap refill time. The most common infectious problems are peritonitis, so pay close attention to any abdominal pain, and respiratory infections.

The first-line of therapy for nephrotic syndrome are corticosteroids. The sooner these are given the better the outcome. Patients will be on steroids for weeks and most will recover. Relapses can occur though and further, long-term courses of steroids may be needed.

To help manage symptoms: diuretics may be given to help manage edema, antihypertensives are given to treat hypertension and lipid lowering drugs are given to treat hyperlipidemia.

For nursing care a major focus is keeping an eye on the excess fluid. Is it accumulating in the lungs and affecting breathing? Are there signs of peritonitis that may have developed from the ascites or fluid on the abdomen?

We need to weigh these patients daily to keep a close eye on these fluid build up and we have to ensure strict
I&O’s are in place. We will also be performing frequent urine dipsticks to check for protein levels. Make sure to involve the parents in all of this care because they will need to know how to do them so they can monitor for relapse when they go home. Parents also need to know that their kid will be very susceptible to infection so they will need to be kept away from other sick people.

Complications are a huge problem for these patients. I mentioned they are at increased risk for infection, but they are also at risk for thrombosis, and pulmonary edema. So always be vigilant about looking for symptoms of these.

Your priority nursing concepts for a pediatric patient with nephrotic syndrome are elimination, nutrition, and infection control

Let’s recap your key points for Nephrotic Syndrome. So the patho basics are that the glomeruli are damaged and allow excessive amounts of protein to be excreted in the urine. There is then a lack of albumin in the plasma which allows fluids to shift into interstitial spaces causing edema.

The classic presentation is edema around the eyes, but it will become more systemic with labial and scrotal swelling, peripheral edema and ascites on the abdomen.

Other symptoms to add to the clinical picture are hypertension, frothy urine and weight gain

The first step to treatment is the administration of corticosteroids. The earlier the better.

The biggest concern for these patients are the complications that can occur- because all of them are life threatening- Infection, thrombosis and pulmonary edema.

That's it for our lesson on Nephrotic Syndrome. Make sure you check out all the resources attached to this lesson. We have a case study, a care plan, patho chart, all those good things that will help you really commit this all to memory! Now, go out and be your best self today. Happy Nursing!
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