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Management of the Nephrotic Syndrome GAVIN C Arch Dis Child: first published as 10.1136/adc.43.228.257 on 1 April 1968. Downloaded from Personal Practice* Arch. Dis. Childh., 1968, 43, 257. Management of the Nephrotic Syndrome GAVIN C. ARNEIL From the Department of Child Health, University of Glasgow The nephrotic syndrome may be defined as gross (3) Idiopathic nephrosis. This may be re- proteinuria, predominantly albuminuria, with con- garded either as a primary disease, or as a secondary sequent selective hypoproteinaemia; usually accom- disorder, with the primary cause or causes still panied by oedema, ascites, and hyperlipaemia, and unknown. It is the common form of nephrosis in sometimes by systemic hypertension, azotaemia, or childhood, but the less common in adult patients. excessive erythrocyturia. Unless otherwise specified, the present discussion concerns idiopathic nephrosis. Grouping of Nephrotic Syndrome The syndrome falls into three groups. Assessment of the Case Full history and examination helps to exclude (1) Congenital nephrosis. A group of dis- many secondary forms of the disease. Blood orders present at and presenting soon after birth, pressure is recorded employing as broad a cuff as which are familial and may be acquired or inherited. practicable, and the width of the cuff used is Persistent oedema attracts attention in the first recorded as of importance in comparative estima- weeks of life. The disease may be rapidly lethal, tions. A careful search for concomitant infection but occasionally the patient will survive for a year is made, particularly to exclude pneumococcal copyright. or more without fatal infection or lethal azotaemia. peritonitis or low grade cellulitis. In a patient The disease pattern tends to run true within a previously treated elsewhere, evidence of steroid family. It does not respond to steroid treatment, therapy such as Cushingoid obesity, hirsutism, or and palliation alone is possible. Death from striae is sought, and osteoporosis is then assessed infection is usual before renal failure proves lethal. radiologically. Oliguria is the rule in the oedema- This group has been well described by Hallman, tous phase, with marked hyposaluria (sodium Hjelt, and Ahvenainen (1956) and Lange et al. excretion may be less than 1 mEq daily). Urine http://adc.bmj.com/ (1963), and will not be considered further. osmolality and specific gravity should be within normal limits. Haematuria, when present, con- (2) Secondary nephrosis. In this group of sists of intact erythrocytes rather than the smoky conditions a known primary disorder precedes or quality produced by lysis in the urine of acute coexists with the nephrotic syndrome. Causes haemorrhagic nephritis (Heymann et al., 1958). may be summarized as follows. The amount of protein in the urine fluctuates (a) Collagen disease: e.g. anaphylactoid purpura, widely from patient to patient and from day to day disseminated lupus erythematosus, polyarteritis in the same patient, and though arbitrary limits are on September 27, 2021 by guest. Protected nodosa. of little practical use, an attempt must be made to (b) Quartan malaria: as described from Nigeria define quantity per unit volume of urine, per unit (Gilles and Hendrickse, 1963). time, or even per unit surface area in relation to (c) Post-nephritic state: a rare form following unit time. Proteinuria usually exceeds 50 mg./hour acute haemorrhagic glomerulonephritis. and 1 g./litre at onset. The Esbach test is used for (d) Heavy metalpoisoning: due to lead or mercury. rough quantitation, but the turbidimetric salicylsul- (e) Renal vein thrombosis. phonic method is simple and useful for quantitation. (f) Diverse rare causes: amyloidosis, diabetic The precise but laborious biuret method is not here glomerulosclerosis, neoplastic infiltration, snake bite, employed for this measurement. and many others. Microscopy of the urine gives diverse results. Casts vary in frequency and cellularity. White * In the 'Personal Practice' series of articles an author is invited are save to set out his personal views on the handling of some current blood cells rarely present in excess, on the paediatric problem. not rare occasions when pyuria is superimposed on 257 Arch Dis Child: first published as 10.1136/adc.43.228.257 on 1 April 1968. Downloaded from 258 Gavin C. Arneil the nephrotic syndrome. Red blood cells are of individual diseased kidneys; this is a great present to gross excess in 10% of children and to advantage. The success rate of the procedure in microscopical excess in a further 15%. Techniques our unit is about 85%. of measuring haematuria vary, but our practice is Electron microscopy, though yielding fascinating to use quantitation per unit volume, employing a data on the pedicels of the epithelial cells, has so far simple method such as that of McGeachie and contributed little to the practical management of Kennedy (1963) or Stansfeld and Webb (1953). the disease. Simple light microscopy of serial The latter test is simpler and is recommended. sections, cut at 2-4 ,u, yields valuable data if a These simple quantitations may be complicated by range of stains (H. and E., P.A.S., silver, etc.) are expression in terms of unit time and/or surface area employed to reveal the underlying tissue changes. as desired. Initial haematuria carries a bad prog- Study of tubules, vessels, and interstitial tissue is of nosis, and in a recent series the mortality after 5-10 interest, but it is the glomeruli that yield the crucial years was 17% and continuing illness 29% when data. A simple classification is: there was initial haematuria, compared with 7% and (a) Light microscopy negative: no significant 18%, respectively, when there was not (Arneil and detectable lesion. Lam, 1966). (b) Light microscopy positive: (i) Membranous: showing significant thickening of basement mem- Renal function tests. These are of limited brane; (ii) Proliferative: proliferative changes with value and this particularly applies to urea-clearance or without membranous change. tests. The urea concentration and the endogenous (More detailed classifications demand an expert creatinine-clearance tests are usually normal. renal pathologist, and if unanimity of opinion is Selectivity of proteinuria, if the estimation is sought only one should be consulted!) available, is probably the most useful test of renal A further sophistication is the application of function applicable to this situation. immunofluorescent techniques. The presence or absence of 'bumps' of immunoglobulin is estab- Renal biopsy. Percutaneous renal biopsy of lished with specific antisera, whose delightful the child is easy to essay but difficult to apply wisely shimmer on microscopy beckons like will-o'-the- copyright. or with consistent success. Such acupuncture is wisp, and deludes the unwary employer of insuffi- carried out by a trained person where there is ciently specific agents just as successfully. The certainty that two kidneys exist, and where there is work of Drummond et al. (1966) in this respect is no gross hypertension, hydronephrosis, or bleeding worthy of study. diathesis. With local anaesthesia it is technically easier, and probably more often successful than Study of immune protein levels in serum. with general anaesthesia, which is nevertheless less Investigation of various fractions such as comple- http://adc.bmj.com/ traumatic physically and psychologically. Local ment and P3I c-globulin are now well established, anaesthesia for older children and general anaes- but confined to a few centres. P3Ic-globulin (a thesia for younger children is probably a reasonable component of complement) is low in level in the compromise. Of several simple marker techniques plasma when complement is being used, and indi- available, we prefer to take a straight postero- cates immunological activity (West, Northway, and anterior film of the prone patient with a marker Davis, 1964; Gotoffet al., 1965). These techniques are of little help in idiopathic nephrosis. The fixed on the skin at the proposed site of puncture; on September 27, 2021 by guest. Protected intravenous urography is then performed to check simple plate tests for IgG are a much more practical the correct placing of the marker, which is left in proposition, but not yet of proven use. situ until the actual operation. The necessarily limited amount of material Selectivity of proteinuria. Various tech- provided often reduces the value of needle biopsy, niques have been used to differentiate cases where so that there is something to be said for the view small protein molecules mainly constitute the that if biopsy is vital for the patient a small open proteinuria from those where larger molecules also biopsy is justified. A good surgical biopsy is leak through the glomerular membrane. Immuno- probably no more hazardous and is more informative logical techniques for quantitative assay of the than unskilled percutaneous needle biopsy. Although various components of protein in plasma and urine, some specimens are disappointing in glomerular and comparison of the relative proportions of each yield (i.e. less than 10 glomeruli), the practica- leaking out, have been developed by Blainey et al. bility of repeated percutaneous biopsies in the (1960), Soothill (1962), Cameron and White (1965), same patient has made possible the serial study and Cameron and Blandford (1966). Here, Arch Dis Child: first published as 10.1136/adc.43.228.257 on 1 April 1968. Downloaded from Management of the Nephrotic Syndrome 259 Cameron's method is used, the immunological tests some positive action such as renal transplant is being available as a 'prefabricated kit' readily used being considered in the future. in any laboratory. Cameron found that the patient with a highly selective small-molecular leak tended Antibiotic therapy. It is not our practice to to retain this pattern throughout the course of the give prophylactic antibiotic treatment when a illness, responded well to steroid, and had an patient is adequately supervised, though the use of excellent prognosis. Cases in which a greater cytostatic treatment may alter this practice in the proportion of larger protein molecules penetrated future.
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