Complications of Nephrotic Syndrome

Nephrotic syndrome may be caused by primary (idiopathic) renal disease or by a variety of secondary causes. Patients present with marked edema, proteinuria, hypoalbuminemia, and often hyperlipidemia. In adults, diabetes mellitus is the most common secondary cause, and focal segmental glomerulosclerosis and membranous nephropathy are the most common primary causes. Venous thromboembolism is a possible complication; acute renal failure and serious bacterial infection are also possible, but much less common. There are no established guidelines on the diagnostic workup or management of nephrotic syndrome. Imaging studies are generally not needed, and blood tests should be used selectively to diagnose specific disorders rather than for a broad or unguided workup. Renal biopsy may be useful in some cases to confirm an underlying disease or to identify idiopathic disease that is more likely to respond to corticosteroids. Treatment of most patients should include fluid and sodium restriction, oral or intravenous diuretics, and angiotensin-converting enzyme inhibitors. Some adults with nephrotic syndrome may benefit from corticosteroid treatment, although research data are limited. Intravenous albumin, prophylactic antibiotics, and prophylactic anticoagulation are not currently recommended.
In nephrotic syndrome, a variety of disorders cause proteinuria, often resulting in marked edema and hypoalbuminemia. Hyperlipidemia is a common associated finding. Family physicians may encounter persons with nephrotic syndrome from primary (idiopathic) renal disease or a number of secondary causes, and should initiate appropriate diagnostic workup and medical management pending specialist consultation.
Excessive fluid retention: 
Massive ascites or pleural effusions may lead to respiratory compromise. Scrotal edema can result in skin breakdown and infection. Management consists of intravenous infusion of albumin along with furosemide.
Peritonitis:
Children with nephrotic syndrome are at high risk for peritonitis during the period of heavy proteinuria. The most common causative organism is Streptococcus pneumoniae; less commonly, gram-negative organisms such as E. coli are involved. Untreated peritonitis can lead to septicemia, meningitis, and death. Peritonitis should be suspected in any child with nephrotic syndrome who has abdominal pain or tenderness. Emergency paracentesis should be performed to obtain a specimen for cell count, Gram stain, and culture and broad spectrum antibiotic therapy should be immediately initiated.

Thromboembolism: 
Nephrotic syndrome is a hypercoagulable state, presumably because of loss of antithrombin-3 in the urine. Arterial and venous thrombi can develop in the major vessels, and the thrombotic tendency is potentiated by overly aggressive diuretic therapy. Sudden death may occur from massive pulmonary embolism. The index of suspicion for thrombotic episodes should be high and anticoagulation initiated immediately if a thrombus is demonstrated.
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