1. COMPLICATIONS OF
NEPHROTIC SYNDROME
AMIR EL OKELY
MRCP, MD

2. Questions
 What is the definition of NS?
 What are the complications of NS?
 What are the indications of IV
albumin?
 What is the effect of serum albumin
on warfarin dosing?

3. Nephrotic syndrome
 Proteinuria
 Hypoalbuminemia
 Edema
 Hyperlipidaemia
 Lipiduria

4. .

6. Hypovolemia
 Excessive diuresis.
 Severe hypoalbuminemia cause fluid
movement into the interstitum and
hypovolemia.
 When to give IV albumin?

7. Acute kidney injury
 Excessive diuresis.
 ATIN.
 Superimposed crescentic GN.

8. Infection
 Reduced serum concentration of IG.
 Impaired ability to make specific AB.
 Decreased level of the complement.
 Immunosuppressive therapy.

9. Thyroid Dysfunction
 A decrease in TBG can cause marked changes in
various thyroid function tests.
 When renal failure complicates the nephrotic
syndrome, the thyroid function abnormalities
are often more severe.{TSH}
 Steroids can cause small reduction in TSH
secretion inhibit peripheral conversion of T4 to
T3.{FT4}

10. Thrombo-embolic
Complications
 DVT is the most common.
 PE has been described with or
without evident DVT or RVT.
 The prevalence of a symptomatic
PE in patients with NS range from
12-30%.
 The risk of PE increase in NS by 39
time compared to non NS patients.

11. Pathogenesis
 Increase platelet aggregation.
 Activation of the coagulation
system.
 Decrease endogenous anti-
coagulant.

12. Venous Thrombo-embolism and
Membranous Nephropathy
Clin J Am Soc Nephrol 7: 43–51, 2012.

13. Renal Vein Thrombosis
 RVT may be unilateral or bilateral
and may extend into the inferior
vena cava.
 RVT most often has an insidious
onset and produces no symptoms
referable to the kidney.

14. Renal Vein Thrombosis
 It typically presents with symptoms of
renal infarction, including flank pain,
microscopic or gross hematuria, a marked
elevation in serum LDH, and an increase
in renal size on radiographic study.
 Bilateral RVT may present with acute
renal failure.

15. Screening
Routine screening for RVT is not
recommended in patients with
nephrotic syndrome:
No proven benefit to diagnose occult
disease.
A patient with a negative study may
develop RVT at a later time.

16. Screening
It is also not useful to evaluate for RVT in a
patient who experiences an overt embolic
event such as PE.
It cannot be proven that the pulmonary
embolus originated in the renal veins.
In situ pulmonary thrombosis may occur.
Patients will be treated with anticoagulants
whether or not RVT is present.

17. Diagnosis of RVT
Sensitivity % Specificity %
CT angiography 92.3 100
Doppler US 85 56
IVU 34 87
 Selective renal venography is the standard
diagnostic test for RVT

18. Renal Biopsy

19. Treatment of RVT
 There are no definitive studies that
have evaluated the role of
anticoagulation in patients with an
asymptomatic RVT, but case series
report treating such patients.

20. Treatment of RVT
 Patients with a symptomatic RVT or a
thromboembolic event in the absence of
RVT are treated with low molecular
weight heparin and then warfarin.
 Some patients are partially resistant to
heparin therapy due to severe
antithrombin deficiency.
.

21. Treatment of RVT
 Warfarin therapy is given for a minimum of 6 to
12 months and some people recommend
continuing treatment for as long as the patient
remains nephrotic.
 Local thrombolytic therapy with or without
thrombectomy in patients who have signs of
acute RVT has been successfully performed in
small numbers of patients.

22. Warfarin Induced
Nephropathy
J Am Soc Nephrol 22: 1856–1862, 2011.

23. Warfarin Induced
Nephropathy
Nephrol Dial Transplant (2012) 27: 475–477

24. Behavioural Abnormalities

25. Aspirin Resistance

26. Headache and Visual
Disturbance

27. Questions

28. Thank You