Abstract              Background: Nephrotic syndrome is a disorder characterized by proteinuria >3.5g/24hr, hypoalbuminemia <3g/dL and peripheral edema. The underlying etiology of the condition is influenced in large part by the age of the patient. In adults aged 15–65 the cause of nephrotic syndrome varies from primary kidney pathologies such as focal segmental glomerulosclerosis, membranous nephropathy, or less commonly minimal change disease. Aims and objectives: To study the clinical profile of patients with nephrotic syndrome ijnn adult at department of medicine of a tertiary health care centre. Materials and method: In the present was retrospective record based descriptive study all the patients of adult nephritic syndrome admitted during January 2015 to December 2016 were enrolled. The detailed history of all the selected patients was recorded on a prestructured proforma including demographic. Clinical examination and biochemical investigations findings wewre also recorded. Renal biopsy findings to know the lesion responsible for the proteinuria were also recorded. Results: Majority of the patients in the present study were young male with age less than 30 years (50%). Followed by 31-40 years of age (21.05%). The proportion of male patients (68.42%) suffering from nephritic syndrome was more as compared to female patients (31.58%). Edema was the most common presenting symptom (81.58%) followed by hematuria (31.58%) and hypertension (28.95%). Anemia was observed in 60.53% patients. Hypoalbuminemia was seen in 86.84% patients. Hypercholesterolemia (>200mg/Dl) was seen in 55.26%. Increased Levels of Creatinine and RBSc in urine were observed in 34.21% and 36.84% patients. The most common lesion responsible for the nephrotic syndrome in adults was Focal Segmental Glomerulosclerosis (44.74%) followed by Membranous Glomerulonephritis (15.79%) and Membranoproliferative glomerulonephritis (13.16%) were observed. Conclusion: Thus we conclude that the most common lesion responsible for the nephrotic syndrome in adults was Focal Segmental Glomerulosclerosis (FSGS) 2^nd common lesion was Membranous Glomerulonephritis (MGN) and 3^rd common lesion was Membranoproliferative glomerulonephritis. Adult nephrotic syndrome was seen commonly in young male. Commonest mode of presentation was edema followed by hematuria and hypertension. Hypoalbuminemia and anaemia were common laboratory findings.

Key Words: Adult Nephrotic Syndrome, edema, Focal Segmental Glomerulosclerosis.

 

INTRODUCTION

Nephrotic syndrome is a disorder characterized by proteinuria >3.5g/24hr, hypoalbuminemia <3g/dL, and peripheral edema¹. The underlying etiology of the condition is influenced in large part by the age of the patient. In children under the age of 16, a large majority of cases (76.6%) are due to minimal change disease (MCD)². However, in adults aged 15–65 the cause of nephrotic syndrome becomes more varied to include primary kidney pathologies such as focal segmental glomerulosclerosis, membranous nephropathy, or less commonly minimal change disease.³ Progressive lower extremity edema, weight gain, and fatigue are typical presenting symptoms of nephrotic syndrome. In advanced disease, patients may develop periorbital or genital edema, ascites, or pleural or pericardial effusion. Persons who present with new edema or ascites, without typical dyspnea of congestive heart failure or stigmata of cirrhosis, should be assessed for nephrotic syndrome.⁴ The mechanism of edema formation in Nephrotic syndrome is unclear. The primary defect seems to be increased glomerular permeability to albumin and other plasma proteins. Pri­mary renal sodium retention and decreased oncotic pressure from hypoalbuminemia lead to increased extravasation of fluid from the intravascular space into the interstitial space, resulting in edema⁵. Nephrotic syndrome constitutes the most recurrent revelation of about 50% of chronic kidney diseases observed as well in the United States, in Europe or in Africa⁶. Renal biopsy is mandatory in the identification and the characterization of lesions⁷.

 

MATERIALS AND METHOD

The present was retrospective record based descriptive study was conducted in the department of Medicine of Dr. Ulhas Patil Medical College and Hospital. Following inclusion and exclusion criteria was used to select the study subjects.

Inclusion Criteria

• Adults with nephrotic syndrome age > 18yrs.
• Urinary protein excretion more than 3.5g/24hrs. Or Urinary protein to creatinine ratio more than 3.5 on spot sample of urine. Or Heavy proteinuria on a spot sample of urine with a serum albumin of less than 2.5g/dl.

Exclusion Criteria

• Evidence of diabetic nephropathy as suggested by other target organ such as diabetic retinopathy.
• H/o episodes of nephrotic syndrome in childhood.

With reference to above inclusion and exclusion criteria all the patients of adult nephritic syndrome admitted during January 2015 to December 2016 (2 years) were enrolled in the present study. The detailed history of all the selected patients was recorded on a prestructured proforma including demographic. Clinical examination and biochemical investigations findings wewre also recorded. Renal biopsy findings to know the lesion responsible for the proteinuria were also recorded. According to WHO Anemia was defined as haemoglobin level <13gm% in males and <12gm% in females⁸. Hypertension was defined as a blood pressure either systolic BP> 140mmHg and/or diastolic BP> 90mmHg⁹. Nephrotic range proteinuria was defined >3gm/24hrs^10,11; hypoalbuminemia <3.5gm/dL¹². Hematuria as >5RBCs/hpf¹³. Renal failure has been defined as GFR (MDRD) <60 mL/min¹⁴. Normal levels of serum urea was defined as 15 – 45 mg/dl¹² and serum creatinine was considered to be in the abnormal range when >1.4mg/dl¹⁵ and serum cholesterol was defined (NCEP-ATP III Classification) as being in the higher range when >200mg/dl¹².

                                       

RESULTS

Table 1: Distribution of according to age and sex

Total 38 cases of nephritic syndrome were enrolled in the present study. It was observed that majority of the patients in the present study were young male with age less than 30 years (50%). Followed by 31-40 years of age (21.05%). The proportion of male patients (68.42%) suffering from nephritic syndrome was more as compared to female patients (31.58%).

 

Table 2: Distribution of according clinical profile

Edema was the most common presenting symptom (81.58%) followed by hematuria (31.58%) and hypertension (28.95%). Anemia was observed in 60.53% patients. Hypoalbuminemia was seen in 86.84% patients. Hypercholesterolemia (>200mg/Dl) was seen in 55.26%. Increased Levels of Creatinine and RBSc in urine were observed in 34.21% and 36.84% patients.

 

Table 3: Distribution according to Etiology of adult nephrotic syndrome

 

The most common lesion responsible for the nephrotic syndrome in adults was Focal Segmental Glomerulosclerosis (44.74%) followed by Membranous Glomerulonephritis (15.79%) and Membranoproliferative glomerulonephritis (13.16%) were observed. Renal Amyloidosis was seen in 10.53% patients.

DISCUSSION

The present study was conducted among the patients of nephritic syndrome admitted in the Department of Medicine and who were of >18years of age. The Demographic profile of the adult patients who presented with nephritic range proteinuria was studied which revealed that, majority of the patients were young with age less than 30 years (50%). Followed by 31-40 years of age (21.05%). Naini EA et al¹⁵, Sanjay Dhawale¹⁶ and Rajeev Malipatil¹⁹ also observed similar findings in their study. The proportion of male patients (68.42%) suffering from nephritic syndrome was more as compared to female patients (31.58%). Sanjay Dhawale¹⁶ in their study revealed that, 64.8% of the patients were males and the mean age at presentation was 31.7±8.5 years. Haraldsson et al¹⁷ and Javed Iqbal Kazi et al¹⁸ also showed that there was male predominance in the occurrence of nephrotic syndrome in adults. Edema was the most common presenting symptom (81.58%) followed by hematuria (31.58%) and hypertension (28.95%). According to Sanjay Dhawale¹⁶ edema was the most common complaint at the time of presentation and was seen in 96.3 % cases while 33. 3% had hypertension and 37% had microscopic hematuria. Anaemia was observed in 60.53% patients. Hypoalbuminemia was seen in 86.84% patients. Hypercholesterolemia (>200mg/Dl) was seen in 55.26%. Increased Levels Of Creatinine and RBSc in urine was observed in 34.21% and 36.84% patients. Rajeev Malipatil¹⁹ in their study observed that Hypoalbuminemia was present in 92.5% of patients with an average of 1.97g/dl. Hypercholesterolemia was present in 80% of patients with an average value of 325.9mg/dl. Serum creatinine was elevated in 19 patients (47.5%). Similar findings were also observed by Sanjay Dhawale¹⁶. The most common lesion responsible for the nephrotic syndrome in adults was Focal Segmental Glomerulosclerosis (44.74%) followed by Membranous Glomerulonephritis (15.79%) and Membranoproliferative glomerulonephritis (13.16%) were observed. Renal Amyloidosis was seen in 10.53% patients. Sanjay Dhawale¹⁶ in their study observed that the most common lesion responsible for the nephrotic syndrome in adults was Focal Segmental Glomerulosclerosis (FSGS). FSGS was the lesion responsible in 37% of the cases. The next common lesion was Membranous Glomerulonephritis (MGN) which contributed to around 18.5% of the cases. The third most common lesion in our study was Renal Amyloidosis which constituted 14.8% of the total. Membranoproliferative Glomerulonephritis (MPGN) was found in 13% of the cases. Lupus Nephritis (LN) was identified as the cause of adult nephrotic syndrome in 9.3 % cases. Minimal Change Disease (MCD) was responsible for adult nephrotic syndrome in 5.5% of the cases with adult nephritic syndrome. Only one among the 54 cases studied came out to be IgA Nephropathy (IgAN) which contributed to 1.8%. Thus the findings of the present study were comparable with Sanjay Dhawale¹⁶ study. Similar findings were also observed by M. Faye et al²⁰.

 

CONCLUSION

Thus we conclude that the most common lesion responsible for the nephrotic syndrome in adults was Focal Segmental Glomerulosclerosis (FSGS) 2^nd common lesion was Membranous Glomerulonephritis (MGN) and 3^rd common lesion was Membranoproliferative glomerulonephritis. Adult nephrotic syndrome was seen commonly in young male. Commonest mode of presentation was edema followed by hematuria and hypertension. Hypoalbuminemia and anemia were common laboratory findings.

 

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