Nephrotic syndrome - NYSORA

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Nephrotic syndrome

Learning objectives

  • Definition of nephrotic syndrome
  • Management of nephrotic syndrome

Definition and mechanisms

  • Nephrotic syndrome is a collection of symptoms due to kidney damage including protein in the urine, low blood albumin levels, high blood lipids, and edema
  • Characterized by glomerular injury
  • Can be primary, being a disease specific to the kidneys, or secondary to a systemic condition
  • Primary causes:
    • Minimal-change disease (nephropathy)
    • Focal segmental glomerulosclerosis
    • Membranous glomerulonephritis
    • Membranoproliferative glomerulonephritis 
    • Hereditary nephropathies
  • Secondary causes:
  • A defect in the glomerular barrier leads to an increased glomerular permeability resulting in proteinuria/albuminuria
  • Leading to a decrease in plasma oncotic pressure, retention of sodium and water, peripheral edema, ascites, pleural effusions, and hypovolemia
  • Most cases spontaneously remit without treatment, hypertension occurs commonly, and renal failure is rare
  • Patients may develop renal failure as well as secondary complications including arterial and venous thromboembolism and infection

Signs and symptoms

  • Proteinuria (>3 g/24 h) and foamy urine
  • Hypoalbuminemia (< 3.5 g/dl)
  • Hypercholesterolemia and hyperlipidemia 
  • Thromboembolic episodes
  • Puffy eyelids and swelling in the legs, ankles, feet, or lower abdomen
  • Weight gain
  • Fatigue
  • Loss of appetite

Risk factors



  • Urine dipstick test to check for albuminuria
  • 24-hour urine collection
  • Urine albumin-to-creatinine ratio
  • Blood tests: serum albumin level, creatinine concentrations
  • Kidney ultrasound
  • Kidney biopsy


  • Diuretics
  • ACE inhibitors and angiotensin-receptor blockers are used alone or in combination
  • Prednisolone
  • Cyclophosphamide
  • Mycophenolate
  • Cyclosporin
  • Low salt diet and limited fluid intake
  • Specific treatment depending on etiology:
    • Statins to lower cholesterol
    • Glucocorticosteroids for minimal-change nephropathy
    • Prednisone and cyclophosphamide are useful in some forms of lupus nephritis
    • Secondary amyloidosis with nephrotic syndrome may respond to anti-inflammatory treatment of the primary disease


Nephrotic syndrome, edema, central venous pressure, potassium supplementation, thipental, benzodiazepines, atracurium, cisatracurium, thromboembolic prophylaxis, NSAIDs, MAP, albumin, hematocrit

Suggested reading

  • Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.
  • Vishnu D, Tempe D, Arora K, Virmani S, Chander J, Agarwal S.(2012). Anesthetic management of a child with nephrotic syndrome undergoing open heart surgery: Report of a rare case. Annals of cardiac anaesthesia. 15. 305-8.

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