Nephrotic Syndrome

Kidneys receive approximately 1 liter of blood every minute. Of this, about 100 ml gets filtered in the kidney. This contains, small molecules and few large molecules. This is due to the intricate cellular structure that prevents proteins from getting filtered into the urinary space. A derangement of this filter results in passage of heavy amounts of proteins in urine. This condition is called heavy proteinuria or Nephrotic syndrome or Nephrosis.

Definition:

In the urine, the protein excretion is > 3.5 gm/day or in children, it is >50mg/kg of body weight. In most cases, the serum albumin is <3gm/dl (normal>4), and passage of lipids in the urine. The lipids in the blood increase and swelling of face and feet also occur.

Causes of Nephrotic Syndrome:

In children, most cases are due to Minimal Change Disease, FSGS, MPGN etc. In adults, most cases are due to primary illness while upto 30% may be due to secondary illness.

Clinical Features:

Apart from edema, there is a tendency towards clotting of the blood in blood vessels. If this involves a critical area, like heart, brain or kidneys complications may occur. Infections also are common. In addition, kidney function may be reduced due to either the disease or its treatment. Sometime the blood pressure may be elevated.

In some cases, continuation of excess proteins in the urine may lead to glomerular damage and Chronic kidney disease leading to renal failure.

Diagnosis:

After confirmation of excess protein in the urine, a kidney biopsy is required in most cases. In children between 2 to 8 years, a biopsy may be deferred if there is a good response to steroids as Minimal Change disease is presumed.

Treatment:

The treatment consists of steroids in primary cases and in case of poor response other immunosuppressants and ACE-Inhibitors. Disease often has remissions and relapses which need to be monitored and treated appropriately.

Diabetes Care

For patients suffering from type II /adult onset diabetes :

In type II diabetes, diagnosis is often late (after the disease has already been present for some time). In early days T2DM (short for the adult type of diabetes) are often without symptoms. Hence the delay in diagnosis. This means complications will be seen early after diagnosis.

Foot Care :

Foot disease in diabetes may lead to difficulty in walking, pain and may lead to infections. If neglected amputation may be required.

Inspect feet with a mirror before going to sleep every night.

Use well fitting shoewear.

Do not walk bare feet even in the house.

Socks should be clean and correct size.

In case of deformities of feet, special shoes can be worn.

Eye Care :

It is nowadays the commonest cause of blindness throughout the world.

Check for refractory error at the time of diagnosis and once sugars are controlled.  In T2DM every year examination for changes in retina are required. If there are already changes, check up is required more often.

Retina is checked after dilating pupil with an ophthalmoscope.

Kidneys :

It is one of the common causes of kidney failure leading to requirement of dialysis and renal transplant. Early treatment may reverse diabetic kidney disease or slow its progression.

In early cases urine is checked for passage of extra amounts of albumin. This can be quantified to see response to therapy. This test is called urine for microalbuminuria, and urine albumin /creatinine ratio. If the disease is already present, USG, S Cr and testing for voiding function (Uroflowmetry) etc may be useful.

In those without evidence of kidney disease these tests are carried out every year. Frequency otherwise may depend on the stage of involvement. More severe involvement necessitates more frequent reviews.

Nerves :

Nerve involvement is checked by touch, pain, vibration sense.

During winters, hot water should be checked with either a thermometer or elbows. If fingers are used for checking temperature, very hot water may lead to burns.

Precautions should be taken to avoid falls.

Sugar Levels :

HbA1C level may be done every 3 months to monitor overall sugar control in blood. In most cases a level of < 7 is desirable.

If hypoglycaemia is frequent , a level of < 8 may be  all that can be achieved safely. In cases of some microvascular complications, a level < 6.5 may help but is difficult to achieve. Home sugar monitoring is done from capillary blood. The levels are different from venous blood levels tested in laboratories. Only sides of fingers should be used and not the areas used for holding functions of the hand. In T2DM once weekly sugars may be enough. In T1DM almost daily or before each meal sugars are required. Levels for control should not be done within 2 hours of meals. Check if there is uncertainty about diagnosis of hypoglycaemia. Do not wait for giving sugars, if testing takes time or symptoms are severe (loss of consciousness, confused talk, fits etc.) Treatment presumptively may prevent permanent damage to the brain. However sugar is not the treatment in diabetics for every small symptom. Record times of sugar checking and dates in a notebook for planning of drugs. Lipids and Statins : If there are more cardiovascular risk factors, age > 50 yrs in man, smoking, lower levels of LDL cholesterol are desirable. Daily 75 or 150 mg  of aspirin or statins may decrease risk of heart attacks. Bleeding complications however increase with aspirin.

Regular exercise, monitoring weight, smoking cessation all are essential parts of diabetic care.

Blood Pressure

How to measure BP: The correct way

BP measured at home and clinics of doctors vary with the time of day or night, physical activity and methods of measuring. To reach a diagnosis of hypertension, various precautions are required. The following should be kept in mind while measuring BP.

Methods used for measuring BP.

  1. Mercury sphygmomanometers: Traditional and accurate. Requires correct training. Now not used due to a ban on the use of mercury due to environmental pollution.
  2. Aneroid sphygmomanometers: The cuff may be inflated manually. With a stethoscope, sounds are heard over the brachial artery.
  3. Automated oscillometric BP measurement: The most popular method nowadays. It has a battery operated system for inflating the cuff. The cuff deflates on its own and BP is displayed digitally.
  4. Ambulatory BP monitoring(ABPM): Measures BP every 15 mins in the day and every 30 to 60 mins at night. The readings can be recorded and later displayed digitally via a computer.

ABPM is the best and close to the ideal way of measuring BP. Not used often as the instrument is not widely available, is costly and not many people including health personnel are aware of it. An average ABPM recording is usually lower than other methods of measurement and hypertension is diagnosed when average readings are > 135/85 mm Hg.

Cuff size: The length of bladder cuff should be 80% of arm circumference and its width 50%. Smaller size cuffs overestimate BP and bigger ones underestimate.

Cuff position: The centre of the cuff (may be marked with an arrow) should be over the middle of arm artery(brachial). It should be 2-3 cms above the elbow crease in auscultatory methods.

The position of the person whose BP is being measured:

It should in most cases be sitting without crossing the legs and back should be supported. The arm should be at the level of the heart, relaxed and supported on the table etc. It should not be hanging on the side of the chest or raised higher.

The timing of BP measurement: BP should be measured thrice over a week in clinics before a diagnosis of hypertension unless it is very high and targets organ damage or other evidence is clear. It should be measured at different times of the day, morning and evening etc.

It should not be measured within ½ hour of coffee, smoking, exercise or food intake.

Both the health personnel and the person whose BP is being measured should be sitting quietly without talking or moving.

BP is measured repeatedly with a gap of about 2 mins till the readings are almost similar or difference is < 5 mm. The lower readings are usually closer to truer BP as compared with ABPM.

White Coat Hypertension: About 20 to 25% of the population may have higher recordings of BP when measured by doctors. The repeated measurement may record lower BP readings. Nurses BP recording may be lower. With time in some cases, this effect disappears.

In follow up cases

In clinics, it should be measured at the same time of day during subsequent visits. It is best measured just before the BP medicines are due so that BP is recorded when the medicine concentration in the body is lowest.

Fats in the Diet

Each gram of fat provides 9 kcal of energy. Fats are essential for the human body as these make up the important part of all tissues and cells. The cell membrane is rich in lipids and brain is full of fat. In combination with proteins and phosphates, fats (lipids) for many important molecules. Linoleic and a-linolenic acids are essential fatty acids.

Trans fats are usually of animal origin or provided by hydrogenation of oils. These are harmful for the body. Poly-unsaturated fats and Mono-unsaturated fats are associated with less risk to heart and brain compared to saturated fats.

Fats of animal origin are more harmful compared to fats from vegetable sources.

In terms of health benefits, olive oil, soya oil, sunflower and safflower oils rank high.

In the body, lipids are measured in blood by the test of lipid profile (best done after 8-10 hrs of fasting). It measures S cholesterol (HDL or high density, LDL or low density and VLDL and IDL very low and intermediate respectively), Triglycerides and few other types of lipids.

HDL cholesterols are thought to be protective from cardiac and cerebrovascular attacks. LDL cholesterol, on the other hand, increases the risk of heart and cerebrovascular diseases.

Fats should usually make up about 30 % of the total caloric intake. About 1 gm/kg/day should be a rough estimate for those who are non-obese. Surprisingly, extra carbohydrates when taken in diet lead to more obesity.

The relation of fats in the diet and risk of cardiac and cerebrovascular disease is not very strong. Similarly, the risk of fats to cancer is also not well proven. However high lipids in blood are related to these disorders.

If Cholesterol, esp LDL cholesterols and triglycerides are elevated, these need to be reduced. Their value may be more in treating patients who are suffering from Ischemic heart or cerebrovascular disorders rather than preventing primary prevention.