Nephrotic Syndrome

Kidneys receive approximately 1 liter of blood every minute. Of this, about 100 ml gets filtered in the kidney. This contains, small molecules and few large molecules. This is due to the intricate cellular structure that prevents proteins from getting filtered into the urinary space. A derangement of this filter results in passage of heavy amounts of proteins in urine. This condition is called heavy proteinuria or Nephrotic syndrome or Nephrosis.


In the urine, the protein excretion is > 3.5 gm/day or in children, it is >50mg/kg of body weight. In most cases, the serum albumin is <3gm/dl (normal>4), and passage of lipids in the urine. The lipids in the blood increase and swelling of face and feet also occur.

Causes of Nephrotic Syndrome:

In children, most cases are due to Minimal Change Disease, FSGS, MPGN etc. In adults, most cases are due to primary illness while upto 30% may be due to secondary illness.

Clinical Features:

Apart from edema, there is a tendency towards clotting of the blood in blood vessels. If this involves a critical area, like heart, brain or kidneys complications may occur. Infections also are common. In addition, kidney function may be reduced due to either the disease or its treatment. Sometime the blood pressure may be elevated.

In some cases, continuation of excess proteins in the urine may lead to glomerular damage and Chronic kidney disease leading to renal failure.


After confirmation of excess protein in the urine, a kidney biopsy is required in most cases. In children between 2 to 8 years, a biopsy may be deferred if there is a good response to steroids as Minimal Change disease is presumed.


The treatment consists of steroids in primary cases and in case of poor response other immunosuppressants and ACE-Inhibitors. Disease often has remissions and relapses which need to be monitored and treated appropriately.

Metabolic Syndrome

(Syndrome X, MetS, Insulin Resistance Syndrome)

It is being increasingly identified in the urban population. The importance lies in its association with risk of developing diabetes mellitus and cardiovascular disease. The incidence in South Asian Population during middle age groups is estimated at 30 to 40%.

The criteria for diagnosis (ATPIII) are

  1. Waist circumference >40 inches in man and > 35 inches in woman
  2. Fasting blood glucose >100 mg/dl or treatment for high sugars
  3. BP of >130/85 mm Hg or drug treatment for hypertension
  4. S Triglycerides >150 mg/dl or drug treatment for elevated triglycerides
  5. HDL cholesterol <40 mg/dl in man or <50 mg/dl in woman

Any 3 of these 5 criteria qualify for a diagnosis of metabolic syndrome. In some modifications, waist circumference has been made an essential criterion while in some waist circumference has been modified for different ethnic groups. In South Asians now the waist circumference has been reduced to 90 and 80 cms respectively for man and woman.

The factors associated with high risk for metabolic syndrome are

age, race, weight, postmenopausal status, smoking, lack of physical activity, alcohol intake, household income etc.

The syndrome gains importance as it has been found to

  • Increase risk of diabetes mellitus by 5 to 5 times
  • Risk of Cardiovascular ailments by 5 to 2 times.

It is also associated with increased risk for

  • Chronic kidney disease
  • Fatty liver,(steatosis), fibrosis and cirrhosis of liver
  • Cholangiocarcinoma and hepatocellular carcinoma
  • Obstructive sleep apnea
  • Polycystic ovary syndrome
  • Hyperuricemia and Gout.

Treatment requires multimodality approach with modifications of diet, physical activity, cessation of smoking, and drugs as needed. Aggressive treatment reduces the risk of diseases associated with syndrome X and is thus rewarding.

CKD (Chronic Kidney Disease)

CKD ( Chronic kidney disease)


The  common causes of CKD are

  • Long standing Diabetes mellitus

  • Hypertension

  • Chronic glomerular diseases ( usually underlying cause is obscure)

  • Chronic interstitial diseases.

  • Stone disease or other obstructive diseases like enlarged prostate, narrowing of urethra, cancer of cervix in woman or prostate in man,

  • Genetic diseases Polycystic kidneys, vesicoureteric reflux

  • Acute kidney injury that does not recover, Analgesic abuse,

  • HIV related kidney disease etc.

Chronic Kidney Disease

Chronic Kidney Disease


Disease of the kidney of long standing, ie > 3 months are called chronic disease. These can be diagnosed.

If the kidney function is lower, this is measured indirectly by Serum Creatinine. If the measured GFR is > 90 ml / min, it is normal. CKD is diagnosed if GFR is < 60 ml/min persistently for > 3 months. If the urine albumin is > 30 mg/day, red or white blood cells are present in urine.

If on ultrasound, X Rays or kidney biopsy, the kidneys are found to have abnormalities.

CKD in early cases is without symptoms. Symptoms gradually increase as the kidney function decreases over time.

Nearly all kidney diseases are progressive in nature and keep worsening with time. These will result in End-Stage renal disease in most cases. End-Stage is diagnosed when the kidney function is so low that life without external support is difficult and RRT or Renal Replacement Therapy in the form of Dialysis (either Hemo or Peritoneal dialysis) or Renal transplant is required.

In some case, the function deteriorates suddenly and rapidly. This then is called Acute superimposed on CKD (Ac on CKD). This sometimes is reversible and the patient may require dialysis till this improvement is achieved.

The aim of the treatment is to alter the course of the disease (slow its progression or halt the progression).

In some cases the progression is very rapid (over months) while in others it may take decades.