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NEPHROTIC SYNDROME
Nephrotic syndrome is a kidney disorder that causes a persons body to excrete too much protein in their urine. Nephrotic syndrome is usually caused by damage to the clusters of small blood vessels in the kidneys that filter waste and excess water from the blood. When healthy, these vessels keep blood protein from seeping into the urine and out of the body. When damaged, they don't perform this function effectively, and protein can leak out of the blood and lead to swelling all over the body (edema).

Incidence
A study from New Zealand found the incidence of nephrotic syndrome to be almost 20 cases per million children under age 15 years. In specific populations, such as those of Finnish or Mennonite origin, congenital nephrotic syndrome may occur in 1 in 10,000 or 1 in 500 births, respectively. According to the International Study of Kidney Diseases in Childhood (ISKDC), 84.5% of all children with primary nephrotic syndrome have minimal-change nephrotic syndrome (MCNS), 9.5% have focal segmental glomerulosclerosis (FSGS), 2.5% have mesangial proliferation, and 3.5% have membranous nephropathy or another cause of the disease. Increasing trends of FSGS incidence are being reported, but MCNS remains the most important cause of chronic renal disease in children.

Symptoms
Signs and symptoms of nephrotic syndrome include:

Swelling (edema), particularly around the eyes and in the ankles and feet Foam in the toilet water, which may be caused by excess protein in the urine Weight gain due to excess fluid retention The glomeruli filter blood as it passes through the kidneys, separating things that body needs from those it doesn't. Healthy glomeruli keep blood protein (mainly albumin) which is needed to maintain the right amount of fluid in the body from seeping into the urine. When damaged, glomeruli allow too much blood protein to leave the body, leading to nephrotic syndrome.

Causes
>Nephrotic syndrome is usually caused by damage to the clusters of tiny blood vessels (glomeruli) of the kidneys.

Many possible causes Many diseases and conditions can cause glomerular damage and lead to nephrotic syndrome, including:

Minimal change disease. The most common cause of nephrotic syndrome in children, this disorder results in abnormal kidney function, but when the kidney tissue is Intellectual property of BSN III-A, RLE Grp. Mariano Marcos State University College of Health Sciences

Urology P a g e | 2 examined under a microscope, it appears normal or nearly normal. The cause of the abnormal function typically can't be determined. Focal segmental glomerulosclerosis. Characterized by scattered scarring of some of the glomeruli, this condition may result from another disease or a genetic defect or occur for no known reason. Membranous nephropathy. This kidney disorder is the result of thickening membranes within the glomeruli. The exact cause of the thickening isn't known, but it's sometimes associated with other medical conditions, such as hepatitis B, malaria, lupus and cancer. Diabetic kidney disease. Diabetes can lead to kidney damage (diabetic nephropathy) that affects the glomeruli. Systemic lupus erythematosus. This chronic inflammatory disease can lead to serious kidney damage. Amyloidosis. This disorder occurs when substances called amyloid proteins accumulate in the organs. Amyloid buildup often affects the kidneys, damaging their filtering system. Blood clot in a kidney vein. Renal vein thrombosis, which occurs when a blood clot blocks a vein connected to the kidney, can cause nephrotic syndrome. Heart failure. Some forms of heart failure, such as constrictive pericarditis and severe right heart failure, can cause nephrotic syndrome.

Risk factors
Factors that can increase your risk of nephrotic syndrome include:

Medical conditions that can damage your kidneys. Certain diseases and conditions increase your risk of developing nephrotic syndrome, such as diabetes, lupus, amyloidosis, minimal change disease and other kidney diseases. Certain medications. Examples of medications that can cause nephrotic syndrome include nonsteroidal anti-inflammatory drugs and drugs used to fight infections. Certain infections. Examples of infections that increase the risk of nephrotic syndrome include HIV, hepatitis B, hepatitis C and malaria.

Complications
Possible complications of nephrotic syndrome include:

Blood clots. The inability of the glomeruli to filter blood properly can lead to loss of blood proteins that help prevent clotting. This increases your risk of developing a blood clot (thrombus) in the veins. High blood cholesterol and elevated blood triglycerides. When the level of the protein albumin in the blood falls, the liver makes more albumin. At the same time, the liver releases more cholesterol and triglycerides. Intellectual property of BSN III-A, RLE Grp. Mariano Marcos State University College of Health Sciences

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Poor nutrition. Loss of too much blood protein can result in malnutrition. This can lead to weight loss, but it may be masked by swelling. High blood pressure. Damage to the glomeruli and the resulting buildup of wastes in the bloodstream (uremia) can raise blood pressure. Acute kidney failure. If the kidneys lose their ability to filter blood due to damage to the glomeruli, waste products may build up quickly in the blood. If this happens, a person may need emergency dialysis an artificial means of removing extra fluids and waste from the blood typically with an artificial kidney machine (dialyzer). Chronic kidney failure. Nephrotic syndrome may cause the kidneys to gradually lose their function over time. If kidney function falls low enough, a person affected may require dialysis or a kidney transplant. Infections. People with nephrotic syndrome have an increased risk of infections.

Tests and diagnosis

Tests and procedures used to diagnose nephrotic syndrome include:

Urine tests. A urinalysis can reveal abnormalities in the urine, such as large amounts of protein, if someone have nephrotic syndrome. The person may be asked to collect urine samples over 24 hours for an accurate measure of the protein in the urine. Blood tests. If a person have nephrotic syndrome, a blood test may show low levels of the protein albumin (hypoalbuminemia) specifically and decreased levels of blood protein overall. Loss of blood protein may cause an increase in blood cholesterol and blood triglycerides. Serum creatinine and blood urea also may be measured to assess the overall kidney function. Removing a sample of kidney tissue for testing. the doctor may recommend a procedure called a kidney biopsy to remove a small sample of kidney tissue for testing. During a kidney biopsy, a special needle is inserted through the skin and into your kidney. Kidney tissue is collected and sent to a laboratory for testing.

Treatments and drugs

Treatment for nephrotic syndrome involves treating the underlying medical condition that's causing the nephrotic syndrome. The doctor may also recommend medications that may help control the signs and symptoms or treat complications of nephrotic syndrome. Medications may include:

Blood pressure medications. Drugs called angiotensin-converting enzyme inhibitors reduce blood pressure and also reduce the amount of protein released in urine. Medications in this category include benazepril (Lotensin), captopril (Capoten) and enalapril (Vasotec). Another group of drugs that works in a similar way is called angiotensin II receptor blockers and includes losartan (Cozaar) and valsartan (Diovan). Intellectual property of BSN III-A, RLE Grp. Mariano Marcos State University College of Health Sciences

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Water pills. Water pills (diuretics) help control swelling by increasing your kidneys' fluid output. Diuretic medications include chlorothiazide, hydrochlorothiazide, furosemide (Lasix) or spironolactone (Aldactone). Cholesterol-reducing medications. Medications called statins can help lower cholesterol levels. Statins include atorvastatin (Lipitor), fluvastatin (Lescol), lovastatin (Altoprev, Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor) and simvastatin (Zocor). Blood thinners. Medications called anticoagulants help decrease the blood's ability to clot and reduce the risk of developing blood clots. Anticoagulants include heparin or warfarin (Coumadin). Immune-system-suppressing medications. Medications to control the immune system, such as corticosteroids, may decrease the inflammation that accompanies kidney disorders, such as membranous nephropathy. Antibiotics. Antibiotics can help control infections caused by bacteria.

-THERE IS NO SPECIFIC TREATMENT FOR NEPHROTIC SYNDROME

Diet Management
Dietary CHON of 1 g/kg/day depending on the GFR Adults require 35-45 kcal/kg/day Na restricted to 0.3-1 g/day to control edema Patients receiving diuretics should have adequate K intake Limiting dietary fat is a little help to reduce triglyceride level Low salt diet and fluid limited to 1L

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URINARY CALCULI/KIDNEY STONES/ NEPHROLITIASIS/RENAL CALCULI

Kidney stones (renal lithiasis) are small, hard deposits that form inside the kidneys. Kidney stones are made of mineral and acid salts. Kidney stones have many causes. In one common scenario, kidney stones form when the urine becomes concentrated, allowing minerals to crystallize and stick together. Passing kidney stones can be painful. A renal calculus is one which forms in the pelvis or calyces of the kidney. A vesical calculus is one which forms in the bladder. A urinary calculus or stone consists of a nucleus of organic material around which urinary salts are deposited in concentric layers. These layers are bound together by a matrix of organic matter.

Symptoms
A kidney stone may or may not cause signs and symptoms until it has moved into the ureter the tube connecting the kidney and bladder. At that point, these signs and symptoms may occur:

Severe pain in the side and back, below the ribs Pain that spreads to the lower abdomen and groin Pain on urination Pink, red or brown urine Intellectual property of BSN III-A, RLE Grp. Mariano Marcos State University College of Health Sciences

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Nausea and vomiting Persistent urge to urinate Fever and chills if an infection is present

Causes
Kidney stones often have no definite, single cause. A number of factors, often in combination, create the conditions in which susceptible people develop kidney stones. Kidney stones form when the components of urine fluid and various minerals and acids are out of balance. When this happens, the urine contains more crystal-forming substances, such as calcium, oxalate and uric acid, than the available fluid can dilute. At the same time, the urine may be short of substances that keep crystals from sticking together and becoming stones. This creates an environment in which kidney stones are more likely to form.

Types of kidney stones

Most kidney stones contain crystals of more than one type. Types of kidney stones include: Calcium stones. Most kidney stones are calcium stones, usually in the form of calcium oxalate. High oxalate levels can be found in some fruits and vegetables, as well as in nuts and chocolate. The liver also produces oxalate. Dietary factors, high doses of vitamin D, intestinal bypass surgery

Oxalate calculus consists of calcium oxalate and is popularly known as the mulberry stone, being covered with sharp projections. These projections cause the kidney to bleed and altered blood is precipitated on the stone. Such stones are usually single and are extremely hard. Phosphatic calculus consists of calcium phosphate but this may be combined with ammonium magnesium phosphate and, rarely, composed of the latter only. In an alkaline urine, it grows rapidly and may fill the renal calyces, taking on their shape and then being known as Staghorn calculus. These stones are smooth, soft and crumble easily. Uric acid and urate calculus is hard, smooth and, because it is uncommonly found singly, is typically faceted. Cystine calculus only occurs in the urinary tract of those with Cystinuria, a genetic disorder affecting renal and intestinal handling of lysine, arginine, ornithine and cystine. Such stones are usually soft, multiple, may assume a cast of the renal pelvis and calyces and only appear in acid urine.

and several different metabolic disorders can increase the concentration of calcium or oxalate in urine. Calcium stones may also occur in the form of calcium phosphate. Struvite stones. Struvite stones form in response to an infection, such as a urinary tract infection. Struvite stones can grow quickly and become quite large.

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Urology P a g e | 7 Uric acid stones. Uric acid stones can form in people who are dehydrated, those who eat a high-protein diet and those with gout. Certain genetic factors and disorders of the blood-producing tissues also may predispose to uric acid stones. Cystine stones. These stones represent only a small percentage of kidney stones. They form in people with a hereditary disorder that causes the kidneys to excrete excessive amounts of certain amino acids (cystinuria). Other stones. Other, rarer types of kidney stones can occur. Knowing the type of kidney stone helps to understand what might have caused the stone to form and may give clues as to what a person can do to reduce their risk of getting additional kidney stones.

Risk factors
Factors that increase a persons risk of developing kidney stones include: Family or personal history of kidney stones. If someone in the family has kidney stones, the person is more likely to develop stones, too. And if he/she already had one or more kidney stones, they are at increased risk of developing another. Being an adult. Kidney stones are most common in adults age 40 and older, though kidney stones may occur at any age. Being a man. Men are more likely to develop kidney stones. Dehydration. Not drinking enough water each day can increase the risk of kidney stones. People who live in warm climates and those who sweat a lot may need to drink more water than others. Certain diets. Eating a diet that's high-protein, high-sodium and high-sugar may increase the risk of some types of kidney stones. Being obese. High body mass index (BMI), increased waist size and weight gain have been linked to an increased risk of kidney stones.

Digestive diseases and surgery. Gastric bypass surgery, inflammatory bowel disease or chronic diarrhea can cause changes in the digestive process that affect the absorption of calcium and increase the levels of stone-forming substances in teh urine. Other medical conditions. Diseases and conditions that may increase the risk of kidney stones include renal tubular acidosis, cystinuria, hyperparathyroidism and certain urinary tract infections. Intellectual property of BSN III-A, RLE Grp. Mariano Marcos State University College of Health Sciences

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Tests and diagnosis

If the doctor suspects that a person have a kidney stone, he/she may undergo tests and procedures to diagnose the condition, such as: Blood tests. Blood tests may reveal excess calcium or uric acid in the blood. Blood tests allow the doctor to check for other medical conditions and to monitor the health of the kidneys. Urine tests. Tests of urine, such as the 24-hour urine collection, may show that a person is excreting too many stone-forming minerals or too few stone-inhibiting substances. Imaging tests. Imaging tests may show kidney stones in the urinary tract. Imaging tests may include computerized tomography (CT) or, less commonly, X-ray. Analysis of passed stones. Person may be asked to urinate through a strainer designed to catch any stones that may pass. That way, any stones can be collected for laboratory testing. A laboratory analysis will reveal the makeup of kidney stones. The doctor uses this information to determine what's causing kidney stones and to formulate a plan to prevent future kidney stones.

Treatments and drugs

Treatment for kidney stones varies, depending on the type of stone and the cause.

Treatment for small stones with minimal symptoms

Most kidney stones won't require invasive treatment. You may be able to pass a small stone by: Drinking water. Drinking as much as 2 to 3 quarts (1.9 to 2.8 liters) a day may help flush out the urinary system. Pain relievers. Passing a small stone can cause some discomfort. To relieve mild pain, the doctor may recommend pain relievers such as ibuprofen (Advil, Motrin, others), acetaminophen (Tylenol, others) or naproxen sodium (Aleve). Treatment for larger stones and those that cause symptoms Kidney stones that can't be treated with conservative measures either because they're too large to pass on their own or because they cause bleeding, kidney damage or ongoing urinary tract infections may require more invasive treatment. Procedures include:

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Urology P a g e | 9 Using sound waves to break up stones. A procedure called extracorporeal shock wave lithotripsy uses sound waves to create strong vibrations called shock waves that break the stones into tiny pieces that are then passed in the urine. The procedure creates a loud noise and can cause moderate pain, so the person may be under sedation or light anesthesia to make him/her comfortable. The specifics of the procedure may vary depending on the type of equipment the doctor uses. Extracorporeal shock wave lithotripsy can cause blood in the urine, bruising on the back or abdomen, bleeding around the kidney and other adjacent organs, and discomfort as the stone fragments pass through the urinary tract. Surgery to remove very large stones in the kidney. A procedure called percutaneous nephrolithotomy involves surgically removing a kidney stone through a small incision in the back. This surgery may be recommended if extracorporeal shock wave lithotripsy has been unsuccessful or if the stone is very large. Using a scope to remove stones. To remove a stone in thr ureter or kidney, the doctor may pass a thin lighted tube (ureteroscope) equipped with a camera through the urethra and bladder to the ureter. The doctor maneuvers the ureteroscope to the stone. Once the stone is located, special tools can snare the stone or break it into pieces that will pass in the urine. Parathyroid gland surgery. Some calcium stones are caused by overactive parathyroid glands, which are located on the four corners of the thyroid gland, just below the Adam's apple. When these glands produce too much parathyroid hormone, the body's level of calcium can become too high, resulting in excessive excretion of calcium in the urine. This is sometimes caused by a small benign tumor in one of the four parathyroid glands. A surgeon can remove the tumor or the parathyroid glands.

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