Rosen & Barkin's 5-Minute Emergency Medicine Consult (483 page)

Renal US:

• Used in suspected secondary causes of nephrotic syndrome
  

• Renal biopsy:
  
  • Definitive test for patients who do not respond to a short course of corticosteroids
    
  • Helps discern primary vs. secondary pathology
    
• Renal angiography, CT scan, or MRI for suspected renal vein thrombosis
  

Proteinuria resulting from other causes:

• Renal parenchymal disease:
  
  • Chronic renal disease
    
  • Mechanical nephropathy (outlet obstruction/reflux)
    
  • Acute pyelonephritis
    
  • Sickle cell disease
    
• Other causes:
  
  • CHF
    
  • Essential hypertension
    
  • Acute febrile illness
    
  • Pregnancy (pre-eclampsia)
    
  • Severe obesity
    

TREATMENT

Support ABCs

ABCs:

• Supplemental oxygen if respiratory distress
  
• IV fluids:
  
  • For decreased BP or orthostatic hypotension due to decreased intravascular volume
    
  • Active rehydration in the presence of severe hypotension, shock
    

• Control edema:
  
  • Restrict sodium intake: 2 g NaCl/d
    
  • Loop diuretic (furosemide): Titrate dose until response seen
    
  • Thiazides and potassium-sparing diuretics
    
  • Goal:
    Slow
    diuresis:
    
    • Aggressive diuresis can precipitate acute renal failure due to hypovolemia and increase the risk of thromboembolic complications.
      
• Thromboembolic prevention/treatment:
  
  • Heparin: 80 IU/kg bolus followed by 18 IU/kg drip IV for thromboembolic event
    
  • Prophylactic anticoagulation now considered acceptable when level of hypoalbuminemia is extremely low (<2.5 g/dL): Goal INR 1.8–2
    
  • Consider low-dose aspirin 81 mg
    
  • Support stockings
    
• Plasmapheresis, for severe cases
  
• Glucocorticosteroid: Mainstay of treatment for primary nephrotic syndrome
  
• ACEIs/ARBs: Decreases proteinuria, prevents worsening of renal function:
  
  • Adverse effects of ACEI include renal failure and hyperkalemia.
    
• Cholesterol-lowering agents/dietary manipulation (e.g., bile acid resin, statins)
  
• Other agents to be considered, under supervision of a specialist:
  
  • Cytotoxic agents/cyclosporine
    
  • Recombinant erythropoietin for anemia
    

• Enoxaparin (Lovenox): 30–40 mg (peds: 0.5–0.75 mg/kg) SC q12h
  
• Furosemide: 20–80 mg (peds: 1–6 mg/kg) PO daily/BID
  
• Heparin: 80 IU/kg bolus followed by 18 IU/kg/h drip IV
  
• Lisinopril (ACEI): 10–40 mg (peds: >6 yr: 0.07 mg/kg) PO daily
  
• Losartan (ARB): 25–100 mg (peds: >6 yr: 0.7 mg/kg) PO daily
  
• Metolazone: 5–20 mg (peds: 0.2–0.4 mg/kg) PO daily
  
• Prednisone: 5–60 mg (peds: 0.5–2 mg/kg) PO daily
  

FOLLOW-UP

• Moderate to severe heart failure, ascites, respiratory compromise
  
• Signs of comorbid illness, such as undiagnosed malignancy, poorly controlled diabetes, immunocompromised patients
  
• Acute renal failure
  
• Evidence of thromboembolic event
  

• Patients with no comorbid disease, normal vital signs, and normal blood work
  
• Close follow-up with a nephrologist for further evaluation and treatment is mandatory.
  

Nephrology:

• Routine follow-up for BP and disease management
  
• Renal biopsy for appropriate patients
  

• In addition to nephrology, patients should follow up with rheumatology, infectious disease, hematology/oncology, or endocrine specialist (dependent on underlying disorder contributing to nephritic syndrome).
  
• Strict BP control and attention to low-cholesterol diet allow for best prognosis in long-term disease management.
  

• Characterized by proteinuria, hypoalbuminemia, and peripheral edema
  
• Most common causes are minimal change disease in pediatric patients and diabetic nephropathy in adults.
  
• May present along spectrum from hypertensive to severe hypotension and shock; maintain high index of suspicion in the appropriate setting.
  
• Consider associated risks of thromboembolic disease.
  

• Crew RJ, Radhakrishnan J, Appel G. Complications of the nephrotic syndrome and their treatment.
  Clin Nephrol
  . 2004;62(4):245–259.
  
• Glassock RJ. Prophylactic anticoagulation in nephrotic syndrome: A clinical conundrum.
  J Am Soc Nephrol
  . 2007;18(8):2221–2225.
  
• Huerta C, Castellsague J, Varas-Lorenzo C, et al. Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population.
  Am J Kidney Dis
  . 2005;45(3):531–539.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Acute Renal Failure
  
• Glomerulonephritis
  
• Nephritic Syndrome
  

The author gratefully acknowledges the contribution of Anwer Hussain.

CODES

• 581.1 Nephrotic syndrome with lesion of membranous glomerulonephritis
  
• 581.3 Nephrotic syndrome with lesion of minimal change glomerulonephritis
  
• 581.9 Nephrotic syndrome with unspecified pathological lesion in kidney
  

BASICS

• Life-threatening neurologic disorder most often caused by an adverse reaction to a neuroleptic or antipsychotic medication.
  
• Mortality can be as high as 20%
  
• May develop any time during therapy with neuroleptics—from a few days to many years:
  
  • Most often occurs in the 1st mo of therapy
    
• Muscular rigidity and tremor resulting from dopamine blockade in the nigrostriatal pathway
  
• Hyperthermia due to central dopamine receptor blockage in the hypothalamus.
  
• More likely in the setting of benzodiazepine withdrawal
  
• May be indistinguishable from other causes of drug-induced hyperthermia (malignant hyperthermia, serotonin syndrome, anticholinergic toxins, or sympathomimetic poisoning)
  
• Most episodes resolve within 2 wk after cessation of offending agent.
  
• Diagnostic criteria:
  
  • Development of elevated temperature and severe muscle rigidity in association with use of antipsychotic/neuroleptic medication
    
  • 2 or more of the following:
    
    • Diaphoresis
      
    • Dysphagia
      
    • Tremor
      
    • Incontinence
      
    • Altered mental status (range from confusion to coma)
      
    • Mutism
      
    • Tachycardia
      
    • Elevated labile BP
      
    • Leukocytosis
      
    • Lab evidence of muscle injury
      
  • Symptoms are not caused by another disease process
    

• Rare complication of treatment with neuroleptics:
  
  • Phenothiazines
    
    • Chlorpromazine (Thorazine)
      
    • Fluphenazine (Modecate)
      
    • Prochlorperazine (Compazine)
      
    • Promethazine (Phenergan)
      
    • Metoclopramide (Reglan)
      
  • Butyrophenones
    
    • Haloperidol
      
    • Droperidol
      
  • Atypical antipsychotics
    
    • Risperidone (Risperdal)
      
    • Olanzapine (Zyprexa)
      
    • Quetiapine (Seroquel)
      
    • Clozapine (Clozaril)
      
    • Aripiprazole (Abilify)
      
• Occurs in ∼1% of patients treated with neuroleptics (especially haloperidol)
  
• Has also been associated with abrupt withdrawal from dopamine agonists in Parkinson disease
  
• SSRIs or lithium along with neuroleptic medication may be associated with an increased risk
  
• Risk factors:
  
  • Rapid drug loading
    
  • High-dose antipsychotics
    
  • High-potency antipsychotics
    
  • IV administration of drug
    
  • Dehydration
    
  • Prior neuroleptic malignant syndrome (NMS)
    
  • Preceding extreme psychomotor agitation or catatonia
    
  • Infection or surgery