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DDx

Diagnostic Considerations

Heart failure may cause a presentation similar to that of nephrotic syndrome. In typical cases of heart failure, however, the patient will have a history of heart disease and/or features of poor heart function on exam, such as a third heart sound and even low blood pressure. In heart failure without kidney disease, the patient will have little or no proteinuria.

Nephrotic syndrome with renal impairment, such as may occur in IgA nephropathy, may cause secondary reduction in heart function, with cardiomegaly on exam. Such patients would typically be hypertensive and have substantial proteinuria on urinalysis.

Patients with cirrhosis may have substantial fluid retention, both as ascites and as peripheral edema. However, patients with cirrhosis will have little or no proteinuria unless they have associated kidney disease.

Differential Diagnoses

Workup

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Media Gallery

Schematic drawing of the glomerular barrier. Podo = podocytes; GBM = glomerular basement membrane; Endo = fenestrated endothelial cells; ESL = endothelial cell surface layer (often referred to as the glycocalyx). Primary urine is formed through the filtration of plasma fluid across the glomerular barrier (arrows); in humans, the glomerular filtration rate (GFR) is 125 mL/min. The plasma flow rate (Qp) is close to 700 mL/min, with the filtration fraction being 20%. The concentration of albumin in serum is 40 g/L, while the estimated concentration of albumin in primary urine is 4 mg/L, or 0.1% of its concentration in plasma. Courtesy of the American Physiological Society (www.the-aps.org) and reproduced from Haraldsson B, Nystrom J, Deen WM. Properties of the glomerular barrier and mechanisms of proteinuria. Physiol Rev. 2008 Apr;88(2):451-87.
Incidence of important causes of nephrotic syndrome, in number per million population. The left panel shows systemic causes, and the right panel lists primary renal diseases that can cause nephrotic syndrome. fgs = focal glomerulosclerosis, MN = membranous nephropathy, min change = minimal-change nephropathy. Data are in part from Swaminathan et al and Bergesio et al.
A schema of the average patient age at presentation in various common forms of nephrotic syndrome. (Timeline not to scale.)
Forces determining capillary filtration

of 4

Author

Ramapriya Sinnakirouchenan, MD, MBBS Assistant Professor, Department of Medicine, Division of Nephrology, Medical College of Wisconsin; Medical Director of Dialysis Unit, Fresenius Kidney Care

Ramapriya Sinnakirouchenan, MD, MBBS is a member of the following medical societies: American Society of Nephrology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Society of Nephrology<br/>Received income in an amount equal to or greater than $250 from: Healthcare Quality Strategies, Inc<br/>Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Chief Editor

Vecihi Batuman, MD, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Interim Chair, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Eric P Cohen, MD Professor, Department of Medicine, Division of Nephrology, University of Maryland School of Medicine; Nephrology Section Chief, Baltimore Veterans Affairs Hospital

Eric P Cohen, MD is a member of the following medical societies: American Society of Nephrology, International Society of Nephrology, Radiation Research Society, Société Francophone de Dialyse

Disclosure: Nothing to disclose.

Laura Lyngby Mulloy, DO, FACP Professor of Medicine, Chief, Section of Nephrology, Hypertension, and Transplantation Medicine, Glover/Mealing Eminent Scholar Chair in Immunology, Medical College of Georgia, Georgia Regents University

Disclosure: Nothing to disclose.

Cassiopia Lippold, MD Resident Physician, Department of Internal Medicine, Pinnacle Health Hospitals

Cassiopia Lippold, MD is a member of the following medical societies: American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

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