ACD 9/18/14
Andy Johnsrud
A ~60 yr old woman presents to the ED with chest pain and confusion
Minimally able to answer questions, you hear from EMS that chest pain has been present about 10-12 hours, confusion was more acute so someone called 911.
PE: BP 60/~, HR 55, is awake and confused/disoriented, lungs clear, s1s2 no murmurs, 2+ bilat LE edema, hepatomegaly present.What now? What
might the diagnosis be?
You give 2LNS, place pads, have a nurse draw up atropine and 1mg of epinephrine (just in case), and get an ECG
{
Rate? Rhythm? Axis? Q wave infarcts? Intervals? Hypertrophy? ST segment anomalies? Want any other type of ECG?
You diagnose sinus bradycardia with grade I AV block, voltage criteria for inferolateral MI. You ask for a right sided ECG and activate the cath lab (or order thrombolytics or call for a helicopter to a cath lab, as appropriate).
BP remains low but improves w low dose norepinephrine drip
RCA thrombus found and removed, stent placed. Pt recovers slowly over the next 72 hours.
Hospital day 3 pt is recovering slowly but edema remains quite prominent, it is also noticed that routine blood tests on admission revealed significant hypalbuminemia. No known liver, kidney, gastrointestinal, or nutritional cause for this is present.
UA and UPC reveals nephrotic range proteinuria >8gm/day, repeat albumin <2.0
Cath Lab and beyond
Could the nephrotic syndrome have caused the myocardial infarction?
In a word… yes
Nephrotic Syndrome
Some famous people with nephrotic syndrome
Linus Pauling
Alonzo Mourning
Sean Elliott
Essentials of Diagnosis
PROTEINURIA > 3.5 g/ 24 hrs (40-50 mg/kg/day)
HYPOALBUMINEMIA
EDEMA
HYPERLIPIDEMIA
LIPIDURIA
Primary renal disease -membranous nephropathy -focal segmental glomerular sclerosis (FSGS) -minimal change disease -membranoproliferative glomerulonephritis (MPGN)
In association with systemic conditions -diabetes mellitus -SLE -amyloidosis -HIV -viral hepatitis -malignancy
General Considerations
Pathogenesis
Non-inflammatory damage to the glomerular capillary wall, resulting in proteinuria due to
altered charge or size selectivity.
Complications
HYPERLIPIDEMIA – increased synthesis and decreased catabolism of individual lipid fractions
INFECTION – urinary losses of immunoglobulins, complement defects
MALNUTRITION – negative nitrogen balance 2/2 massive proteinuria , with loss of lean body mass
ANEMIA – urinary losses of EPO
THROMBOSIS – multifactorial…
Can Nephrotic Thrombophila cause an MI?
Urinary losses of antithrombin III, proteins C and S
Increase in plasma fibrinogen levels and decreased tissue plasminogen activator levels
Increase in platelet aggregability
Increase in von Willebrand factor levels
THESE ABERRATIONS LEAD TO AN INCREASED
INCIDENCE OF VENOUS AND ARTERIAL
THROMBOEMBOLISM
Management of Nephrotic SyndromeHYPERLIPIDEMIA: lipid lowering therapy
EDEMA: Loop diuretics, salt restriction
THROMBOEMBOLISM: If thrombosis occurs, it is typically treated with OAC for as long as the patient remains nephrotic. Prophylactic anticoagulation is controversial with no formal recommendations. The ATRIA tool is available for patients with membranous nephropathy.
PROTEINURIA: ACE inhibitors lower intraglomerular capillary hydrostatic pressure- NSAID’s? – possibly decreases basement
membrane permeability- low protein diet? 0.7 g protein/kg/day
decreases urinary protein excretion and improves lipid profile
Prophylactic anticoagulation in nephrotic syndrome: a clinical conundrum. AU, Glassock RJ, SO J Am Soc Nephrol. 2007;18(8):2221.
Personalized prophylactic anticoagulation decision analysis in patients with membranous nephropathy. AU Lee T, Biddle AK, Lionaki S, Derebail VK, Barbour SJ, Tannous S, Hladunewich MA, Hu Y, Poulton CJ, Mahoney SL, Charles Jennette J, Hogan SL, Falk RJ, Cattran DC, Reich HN, Nachman PH SO Kidney Int. 2014;85(6):1412.
Thrombosis in Nephrotic Syndrome. Barbano Biagio, Gigante Antonietta, Amoroso Antonio, Cianci Rosario. Seminars in Thrombosis and Hemostasis. 2013; (39).
Mahmoodi, B.K., Kate, M.K. et al. High absolute risks and predictors of venous and arterial thromboembolic events in patients with nephrotic syndrome: Results from a large retrospective cohort study. Circulation. 2008; 117: 224-30.