A 44-year-old presents with two weeks of progressive peripheral oedema, urine protein:creatinine ratio 780 mg/mmol and albumin 18 g/L. How would you proceed?

Question

A 44-year-old man has periorbital and lower limb oedema, blood pressure 158/94, creatinine 102, cholesterol 9.2, urine dip protein ++++ with no blood.

Accepted Answer

This is nephrotic syndrome — heavy proteinuria with a protein:creatinine ratio of 780, hypoalbuminaemia at 18, oedema and hyperlipidaemia — and in an adult it requires a histological diagnosis, so my endpoint is a renal biopsy and a same-week nephrology referral. First I would screen for secondary causes, because that changes management: HbA1c and a fundoscopic assessment for diabetes, hepatitis B and C and HIV serology, ANA, ANCA, complement, anti-PLA2R which is often positive in membranous nephropathy, serum free light chains and immunoglobulins with urine electrophoresis for myeloma and amyloid, and a careful drug history including NSAIDs. I would also consider an underlying malignancy in a patient of this age with membranous disease. Second, I would anticipate the complications, and the one I would raise first is venous thromboembolism: nephrotic patients lose antithrombin III and other regulatory proteins in the urine and are markedly prothrombotic, so I would give prophylactic anticoagulation and discuss therapeutic prophylaxis with nephrology given an albumin of 18, particularly if the biopsy shows membranous nephropathy. Infection is the second, especially with encapsulated organisms because of urinary immunoglobulin loss, so I would ensure pneumococcal vaccination and have a low threshold for treating. Supportive management would be salt and fluid restriction, a loop diuretic titrated against daily weights aiming for a controlled loss of around half to one kilogram a day, because over-diuresis in an intravascularly depleted patient precipitates AKI, an ACE inhibitor or ARB for proteinuria and blood pressure, and a statin. I would monitor renal function and potassium closely after starting RAAS blockade. I would refer to nephrology this week for biopsy, and the histology will then determine whether he needs immunosuppression and of what kind.

Nephrotic Syndrome in an Adult

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