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.

Urinary Tract Infection: Men

UTI in Men

Compared to women, Urinary tract infections in men are uncommon. This is due to the longer length of urethra and dryness of the urethral opening (called meatus). Prostatic secretions have antibacterial properties and hence these may prevent urinary tract infections. Non-circumcision is also a risk factor for UTI. The commonest organism is E coli.

UTI is common if there is an anatomic abnormality, obstruction, instrumentation of the urinary tract or prior surgery. In men after 50 years of age, prostatic enlargement can make a person prone to UTI.

As in the case of women, the infections of the urinary tract may involve urethra, bladder or kidney or a combination of all of them. In addition, the prostate gland can also be infected.

Symptoms :

Symptoms are similar to those in women. However, infections of the prostate can give rise to fever and pain in the perineum (the area between anus and scrotum).

Diagnosis of UTI is by its symptoms, physical examination and laboratory tests. The prostate is tender on digital examination of the rectum.

Urine shows increased pus cells, nitrate test is positive and midstream urine culture shows >105 bacteria /ml of urine. In case of recurrence, if no cause is apparent, tests are done to ascertain anatomical details of the urinary tract.

Treatment is started empirically. In case of no or poor response in 2-3 days, the drugs are modified based on culture results.

Urinary Tract Infections : Women

UTI in short, is a common illness in woman, especially during the reproductive period. The incidence in western countries is .5/woman /year.

It is commoner in women compared to men due to their shorter urethra (Tube from the lower end of the bladder to opening for urine). Bacteria from large intestines contaminate the skin around the anus, migrate to the vaginal opening and may ascend through the urethra to the bladder and sometimes via ureter to the kidneys.

Infections of the bladder are called cystitis, infections of urethra  urethritis and that of kidneys pyelonephritis.

Symptoms of UTI

In cases of urethritis, pain while passing urine (dysuria), more frequency, pus discharge from urine opening may occur.

In cases of cystitis, dysuria, frequency, urgency (inability to hold urine), lower abdominal pain or discomfort and sometimes blood in urine may occur.

In pyelonephritis the symptoms usually are : fever (temp above 38° C ), flank pain or discomfort, tenderness on touching at the angle of lower ribs with muscles( costovertebral angle) in addition to dysuria frequency etc. Nauusea and vomitings are also common. This can be a serious illness with fall of BP, shock and malfunction of other organs in the body.

Risk Factors In Women

Risk factors for UTI in a woman are previous UTI’s, abnormal anatomy, stones or other obstructions, sexual intercourse and use of spermicidal jellies. Women in some countries may not complain due to social taboos.

Diagnosis is based on history and finding of pus cells and bacteria in midstream urine. It can be confirmed by urine culture. Collection of proper midstream sample after proper cleaning and drying of genital areas is important to avoid false results.

Treament consists of short course of antibiotics in uncomplicated cases. Complicated cases may require hospitalisation and injectable antibiotics. Antibiotic selection depends on the usual causative agents in the area. Treatment of repeated UTI is different. In urethritis the organisms are often different and require other chemotherapeutic agents.