Update February 17, 2020



    Nephrotic syndrome is usually caused by damage to glomeruli.

    The glomeruli filter your blood as it passes through your kidneys, separating things your body needs from those it doesn't. Healthy glomeruli keep blood protein (mainly albumin) — which is needed to maintain the right amount of fluid in your body — from seeping into your urine. When damaged, glomeruli allow too much blood protein to leave your body, leading to nephrotic syndrome.


    Four most common causes of nephrotic syndrome.

    (Minimal change disease,

    focal glomerular glomerulosclerosis,

    membranous nephropathy,

    membranoproliferative glomerulonephropathy.)

    • Corticosteroids and cytotoxic agents as indicated for primary renal lesion.
    • Loop and thiazide diuretics in combination and often in large doses.
    • ACE inhibitors and angiotensin receptor blockers (ARBs) (except in the setting of acute kidney injury)
      • Published studies have not found benefit from combined ARB and ACE inhibitor therapy.
    • Glucose and blood pressure control in diabetic nephropathy.
    • Antilipidemic agents.
    • Patients with frequent relapses may require cyclophosphamide or rituximab.
    • Warfarin for patients with thrombosis for at least 3 to 6 months.
    Therapeutic Procedures
    • In those with subnephrotic proteinuria or mild nephrotic syndrome, dietary protein restriction may be helpful in slowing progression of renal disease.
    • In those with very heavy proteinuria (>10 g/d), protein malnutrition may occur and daily protein intake should replace daily urinary protein losses.
    • Salt restriction helps edema.


    What common medication may precipitate nephrotic syndrome, mimic minimal change disease, and increase the chance of acute kidney injury? (Nonsteroidal anti-inflammatory drugs.)

    Patients with nephrotic syndrome have impaired immune defenses, and a significant fraction have a thrombotic event. Why? (Urinary loss of proteins [immunoglobulin G, antithrombin, plasminogen] likely plays a role.)

    Often associated with diabetes mellitus, amyloidosis, or systemic lupus erythematosus Four most common lesions Minimal change disease Focal glomerular glomerulosclerosis Membranous nephropathy Membranoproliferative glomerulonephropathy



Increased plasma volume; decreased plasma oncotic pressure from protein loss

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Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


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When neurofibromatosis causes large tumors or tumors that press on a nerve, surgery can help ease symptoms. Some people may benefit from other therapies, such as stereotactic radiosurgery or medications to control pain.

The definition of nephrotic syndrome requires all of the following EXCEPT: