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The Natural History of Nephrosis

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The Natural History of Nephrosis Arch Dis Child: first published as 10.1136/adc.32.162.99 on 1 April 1957. Downloaded from THE NATURAL HISTORY OF NEPHROSIS BY R. McLAREN TODD From the Department of Child Health, University of Liverpool (RECEIVED FOR PUBLICATION SEPTEMBER 7, 1956) The suffix 'osis' signifies 'a diseased condition' by Kramer, Goldman and Cason (1952) in the and hence nephrosis means a diseased condition of following terms: the kidney (Webster'sNew International Dictionary). 'Nephrosis occupies a position shared by few The term nephrosis was used by Muller (1905) to diseases in medicine; its aetiology is unknown, its differentiate what he considered degenerative renal course unpredictable, its prognosis uncertain and its treatment unsatisfactory. Nevertheless, its cardinal disease from other renal conditions to which the manifestations-oedema, hypoproteinaemia, albu- term nephritis was applied. He pointed out that minuria, hypercholesterolaemia-are so striking, hitherto the word nephrosis had been used to and the remissions and exacerbations at times so describe disorders of the renal pelvis (hydro- dramatic as to challenge the attention of both the nephrosis, pyonephrosis), but considered that it clinician and the scientist.' would be more appropriate to use it for certain Ellis (1942) attempted to correlate the clinical diseases of the kidney itself. Volhard and Fahr features and the histological changes encountered in (1914) classified renal diseases into three groups: Bright's disease. His researches, carried out over (1) Nephroses, in which degenerative lesions were a 20-year period at the London Hospital and based copyright. present, with or without amyloidosis; (2) nephritides upon 370 patients, resulted in the concept of two or inflammatory lesions; and (3) scleroses or arterio- types of nephritis with dissimilar clinical and histo- sclerotic diseases. Munk (1925) considered that logical features. In type 1 Ellis nephritis the illness the term nephrosis should be used for all degenera- is of sudden onset, is often preceded by an acute tive renal lesions whether of albuminous, fatty, streptococcal throat infection, has haematuria as the lipoid, necrotic, hyaline, amyloid or glycogen types. most prominent feature and is followed by complete Evans (1932) restricted the term nephrosis to those recovery after about six weeks in over 80% of the http://adc.bmj.com/ types of Bright's disease which were associated with patients. Type 2 Ellis nephritis is of insidious onset, syphilis or amyloidosis. Allen (1952) used the is without preceding throat infection, has oedema term nephrosis for either chronic glomerular diseases as the most marked feature and carries a poor of the kidney with oedema (lipoid nephrosis) or prognosis. Confirmation of the views expressed by tubular diseases involving the proximal, distal or Ellis has come from many workers including both parts of the renal tubules. Fishberg's (1954) Davson and Platt (1949) who also stated that 'the conception of nephrosis is of a non-inflammatory concept so common in textbooks of oedematous on September 29, 2021 by guest. Protected disease of the nephron including necrotizing nephritis as a usual intermediate stage between nephrosis, chronic lipoid nephrosis, diabetic acute and chronic phases is at variance with clinical glomerulosclerosis (the Kimmelstiel-Wilson syn- experience'. drome), amyloidosis and toxaemia of pregnancy. It could be argued that the use of the term By virtue of long usage the term 'pure' nephrosis has nephrosis has confused rather than clarified our been applied to degenerative conditions of the renal knowledge of Bright's disease and to some extent tubules caused either by poisons, for example, this is true. I would suggest that nephrosis be no mercury, lead, arsenic, or by general diseases, for longer used when the cause of the renal disturbance example, syphilis and amyloidosis. is known, as, for example, in amyloid disease, These concepts of nephrosis are based largely syphilis, mercury poisoning, but that the more upon histological evidence of damage to different appropriate terms such as 'renal amyloidosis' or parts of the nephron, but to many other writers 'renal syphilitic disease' or 'mercurial tubular nephrosis is a clinical rather than a histological degeneration' should be employed. It would seem entity, a view which has been well summarized reasonable to retain the term nephrosis, which is a 99 Arch Dis Child: first published as 10.1136/adc.32.162.99 on 1 April 1957. Downloaded from 100 ARCHIVES OF DISEASE IN CHILDHOOD conveniently short word without aetiological con- that 11 (34%) of the patients were under 3 years of notation, to describe the condition of those patients age, 14 (44%) between 4 and 7 years, and 7 (22%) who have no evidence of amyloidosis, syphilis, over 7 years of age when first seen. A survey of the diabetic nephrosclerosis, renal vein thrombosis, but literature shows that during this eight-year period who present many of the following features: An six large series of patients with nephrosis were illness of insidious onset with the main clinical reported, and of a total of 349 patients, 228 (65%) findings of generalized oedema and pallor; no were under 3 years of age, 71 (20%) between 4 and 7 history of recent throat infection; marked albumin- years and 50 (15%) over 7 years of age. uria, with little or no haematuria; normal blood pressure; lowered plasma protein levels, raised blood Mode of Onset cholesterol and normal blood urea concentrations; a prolonged course lasting many months or years. The mode of onset was insidious in all patients The use of the word nephritis with division into and there was a period of general ill health varying types 1 and 2 implies that these two conditions are from a few weeks to several months before the onset intimately related, whereas the symptoms and signs, of oedema. In a few patients increasing abdominal the biochemical abnormalities in the blood, treat- girth had been noticed. The onset was closely ment, prognosis and histological appearance of the related to the first immunizing injection against kidneys are so obviously dissimilar. diphtheria in one infant aged 7 months, and in In medical paediatric practice three main clinical another child it was related to the 'booster' diph- types of renal disease are commonly met: (a) a con- theria injection when he was 5j years old. I do not dition of sudden onset, with haematuria as the most know the significance of these observations but it is obvious feature, sometimes called type 1 Ellis possible that the onset of the disease in close asso- nephritis but for which I would prefer the descriptive ciation with diphtheria immunization was entirely term 'acute (haemorrhagic) nephritis'; (b) an illness fortuitous. There was no family history of allergic having the six main features described above, some- disorders or nephritis in any of the patients. Clinically the degree of oedema was variable but times called type 2 Ellis nephritis but which I would copyright. call 'nephrosis'; and (c) a form of renal disease many patients showed gross generalized oedema with increasing evidence of renal insufficiency when first admitted to hospital. The urine in all resulting either from acute nephritis or from patients was loaded with albumin; in a few patients nephrosis or following recurrent attacks of pyelo- red blood cells were found on microscopical nephritis or occurring in association with a con- examination, and macroscopic blood was present in genital renal lesion, which I would call 'chronic two patients for a short period. nephritis'. The patients reported in this paper were http://adc.bmj.com/ suffering from nephrosis as I have defined it above, Biochemical Investigations and were admitted to Alder Hey Children's Hospital, Biochemical investigations showed that the level Liverpool, during the eight-year period 1948 to 1955 of blood urea was below 40 mg. % in 28 of the 32 inclusive. They were all seen personally during patients and in the remaining four it showed a some stage of the illness and have been followed up temporary elevation. The serum cholesterol values either in the Out-patient Department or when were raised to an average of 470 mg. %. The readmitted to the wards. serum protein levels on admission averaged 4*2 g. % Thirty-two patients have been observed, 21 being and the albumin fraction was especially reduced; on September 29, 2021 by guest. Protected males and 11 females. The age of onset of the this led to an alteration of the albumin/globulin illness is shown in Fig. 1, from which it is apparent ratio from the average normal of 1I25 to 1 to a figure as low as 0 05 to 1, at which point albumin AGE OF ONSET 32 PATIENTS WITH 'NEPHROSIS' comprises as little as 5% of the total protein. The I 05 - electrophoretic pattern of the globulin fraction was studied in six of the patients, and at the time of their 4 - Lu admission to hospital the most striking features - 4.Z0 3 were a diminution of the y globulin and an increase |.l 2 in X2 globulin. When the electrophoretic pattern is studied in relation to the clinical response of the Is;I patient it is apparent that disappearance of oedema zO 1 2 3 4 5 6 7 8 9 10 11 12 13 and gross albuminuria may precede by many weeks AGE IN YEARS a return to biochemical normality. For example, Mo. 1. in one patient the total protein level rose from Arch Dis Child: first published as 10.1136/adc.32.162.99 on 1 April 1957. Downloaded from THE NATURAL HISTORY OF NEPHROSIS 101 4 g. 00 to 6-1 g. % over a period of one month, but sions in 25%~of cases, exacerbations in 49% and no at this stage the albumin/globulin ratio was still change in 26%. abnormal.
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