Nephrotic Syndrome (Membranous)Urgent

45-year-old with 3 weeks of swelling from face to legs, frothy urine; albumin 1.8 g/dL, urine PCR 9 g/g, cholesterol 380 mg/dL; now painful swollen left leg

• Leg or flank pain, haematuria (renal vein thrombosis)
• Chest pain/breathlessness (PE)
• Rising creatinine
• Fever with abdominal pain (peritonitis)

• Diabetic nephropathy
• Amyloidosis/myeloma
• Lupus nephritis
• Heart failure or cirrhosis (other causes of oedema and low albumin)
• Pre-eclampsia

• Admit: Severe oedema/anasarca, AKI, thromboembolism, infection, for biopsy
• ICU: Massive PE, sepsis, refractory AKI

• Nephrotic = proteinuria + low albumin + oedema; nephritic = blood + RBC casts + hypertension + AKI.
• Commonest adult causes: membranous, FSGS, minimal change, diabetic, amyloid; in India also HBV, SLE and drug/herbal causes.
• Anti-PLA2R titres track response in membranous nephropathy.

• Give oral furosemide alone to a patient with gut oedema and expect a response
• Start ACE inhibitor during AKI or hypovolaemia
• Forget VTE risk in membranous nephropathy with low albumin
• Prescribe a high-protein diet

• Ignoring VTE risk
• Missing secondary causes
• Oral diuretics in gut oedema
• Overdiuresis into AKI

Ward for anasarca, AKI, thrombosis or biopsy; nephrology-led long-term care.