This is a nonspecific disease of the kidney characterized by proteinuria, edema and hypoalbuminemia. It results from increased permeability of the glomerulus leading to massive loss of protein in the urine.
Presentation
The commonest presenting features are those due to fluid retention. Facial edema is usually the first sign of nephrotic syndrome in children. This is followed be generalized swelling of the whole body known as anasarca. There could be ascites, pleural effusion, and pitting pedal edema. The patient could also present with frothy urine. There could be dyspnea and cough. In cases of an underlying disease, patients will present with symptoms of that disease e.g. rash in patients with lupus.
On presentation, the cardiovascular and hepatic systems should be evaluated to rule out other causes of generalized edema [7].
Entire Body System
- Amyloidosis
Abstract In secondary amyloid A amyloidosis resulting from rheumatologic diseases, tumor necrosis factor α blockers have been reported to be effective in the treatment of both arthritis and amyloidosis. [ncbi.nlm.nih.gov]
- Weight Gain
Case presentation: A 4-year-old boy and a 2-year-old boy presented with bilateral periorbital oedema and weight gain. [ncbi.nlm.nih.gov]
Symptoms may include: Fatigue and malaise Decreased appetite Weight gain and facial swelling Abdominal swelling or pain Foamy urine Fluid accumulation in the body spaces (edema) The symptoms of nephrotic syndrome may resemble other conditions and medical [chop.edu]
Swelling and weight gain tend to be the most common signs. Swelling happens because too many fluids and salt build up in the body. Extra fluids can cause weight gain. Parents might notice their child quickly outgrows clothes and shoes. [kidshealth.org]
Prednisone can cause Increased appetite Mood changes; he may be moody or irritable while taking the medicine Weight gain Weigh your child as directed and record his weight. Check the urine protein once weekly or as directed. [nationwidechildrens.org]
- Ascites
Fluid retention may cause Dyspnea (pleural effusion or laryngeal edema) Arthralgia (hydrarthrosis) Abdominal pain (ascites or, in children, mesenteric edema) Corresponding signs may develop, including peripheral edema and ascites. [merckmanuals.com]
Examination revealed bilateral pedal edema and mild ascites. Laboratory investigations showed low hemoglobin 79 g/L, low mean corpuscular volume 53 fL, thrombocytosis 973 × 109/L, and marked hypochromia and microcytosis, with low iron and ferritin. [ncbi.nlm.nih.gov]
Breathlessness: pleural effusion (occasionally, severely hypoalbuminaemic cases may have pleural effusions or ascites), fluid overload (high jugular venous pressure), acute kidney injury. [patient.info]
Organ edema (ascites, pulmonary effusion, facial swelling and lower extremities) and anasarca Loss of albumin through the glomeruli leads to a significant drop in oncotic pressure at the venular end of the vascular beds, causing fluid accumulation in [pathophys.org]
- Fatigue
The PROMIS domains of Mobility, Fatigue, Pain Interference, Depressive Symptoms, and Anxiety each showed a significant overall improvement over time (p CONCLUSION: This study demonstrates that the PROMIS Mobility, Fatigue, Pain Interference, and Anxiety [ncbi.nlm.nih.gov]
[…] alternates between strong craving for food and aversion to food; characterized by excessive eating followed by periods of fasting or self-induced vomiting Lambert-Eaton syndrome a disease seen in patients with lung cancer and characterized by weakness and fatigue [vocabulary.com]
Signs and symptoms Common signs and symptoms of nephrotic syndrome include: swelling, especially around the eyes and in the ankles and feet; foamy urine due to excess protein in the urine; weight gain from excess fluid retention; fatigue; and loss of [healio.com]
Fatigue, weakness (anemia) Loss of transferrin through the nephrons. [pathophys.org]
- Weakness
Fc gamma receptors might modulate response to rituximab; since 60 of the enrolled patients were treated with rituximab, we also tested the association between the studied SNPs and rituximab efficacy in this patient subgroup, but found only a weak association [ncbi.nlm.nih.gov]
[…] person alternates between strong craving for food and aversion to food; characterized by excessive eating followed by periods of fasting or self-induced vomiting Lambert-Eaton syndrome a disease seen in patients with lung cancer and characterized by weakness [vocabulary.com]
The patient feels increasingly weak and fatigued. Appetite is greatly decreased. Over time, the loss of protein causes the muscles to become weak and small (called muscle wasting). The patient may note abdominal pain and difficulty breathing. [encyclopedia.com]
Respiratoric
- Pleural Effusion
Chest radiography and computed tomography scans revealed right pleural effusion and a mass in the right middle lung field, which were confirmed by a percutaneous lung biopsy as metastatic invasive thymoma. [ncbi.nlm.nih.gov]
Breathlessness: pleural effusion (occasionally, severely hypoalbuminaemic cases may have pleural effusions or ascites), fluid overload (high jugular venous pressure), acute kidney injury. [patient.info]
Fluid retention may cause Dyspnea (pleural effusion or laryngeal edema) Arthralgia (hydrarthrosis) Abdominal pain (ascites or, in children, mesenteric edema) Corresponding signs may develop, including peripheral edema and ascites. [merckmanuals.com]
effusion Ascites Infection (increased risk in nephrotic state) Cellulitis Spontaneous bacterial peritonitis – abdominal pain, fever, nausea/vomiting, rebound tenderness Thrombosis (increased risk in nephrotic state) Features suggesting diagnosis other [rch.org.au]
Gastrointestinal
- Abdominal Pain
Think of spontaneous bacterial peritonitis in patient with fever and abdominal pain. Thromboembolic Events 2-9% of children with nephrotic syndrome will develop clots. Imbalance between anticoagulants and procoagulants. [pedemmorsels.com]
Increased work of breathing from pleural effusion Ascites Infection (increased risk in nephrotic state) Cellulitis Spontaneous bacterial peritonitis – abdominal pain, fever, nausea/vomiting, rebound tenderness Thrombosis (increased risk in nephrotic [rch.org.au]
Anorexia, abdominal pain and diarrhea may be seen, possibly secondary to the formation of ascites. Blood pressure and renal function are usually normal. [hawaii.edu]
Fluid retention may cause Dyspnea (pleural effusion or laryngeal edema) Arthralgia (hydrarthrosis) Abdominal pain (ascites or, in children, mesenteric edema) Corresponding signs may develop, including peripheral edema and ascites. [merckmanuals.com]
The patient may note abdominal pain and difficulty breathing. Because the kidneys are involved in blood pressure regulation, abnormally low or abnormally high blood pressure may develop. [encyclopedia.com]
- Loss of Appetite
[…] of appetite When to see a doctor Make an appointment with your doctor if you have any signs or symptoms that worry you. [mayoclinic.com]
Symptoms Signs and symptoms of nephrotic syndrome include: Severe swelling (edema), particularly around your eyes and in your ankles and feet Foamy urine, a result of excess protein in your urine Weight gain due to fluid retention Fatigue Loss of appetite [mayoclinic.org]
Swelling most often happens in the: face, especially around the eyes (this is most noticeable in the morning) ankles and feet, especially after sitting or standing a long time belly Other common signs include loss of appetite, peeing less often, and pee [kidshealth.org]
- Abdominal Distension
Eight years after LGD was detected, he complained of abdominal distension and pain. Stenosis of the upper rectum by an advanced rectal carcinoma was detected. Abdominal computed tomography showed a rectal tumor with multiple lymph node metastases. [ncbi.nlm.nih.gov]
In addition, a careful history should exclude possible complications and identify children with atypical presentations that might reflect other serious systemic illnesses. 39 It should include an evaluation of any abdominal distension, which is usually [slideplayer.com]
Cardiovascular
- Hypertension
He had no remarkable family history, but had a medical history of hypertension and hyperlipidemia. [ncbi.nlm.nih.gov]
[…] patients with severe renal impairment (serum creatinine # mol/l or # mg/dl in women and # mol/l or # mg/dl in men and/or estimated glomerular filtration rate (GFR) < # ml/min), history of dialysis, nephrotic syndrome or renovascular hypertension en [et.glosbe.com]
(can have mild hypertension first 1-2 days) Features of Nephritic Syndrome (macroscopic haematuria, hypertension and renal impairment) Management Investigations The diagnosis of nephrotic syndrome includes: Heavy proteinuria (dipstick 3-4+ or urine protein [rch.org.au]
The substantial loss of protein in the urine results in complications such as hypoproteinemia; generalized edema; hypertension; and hyperlipidemias. Diseases associated with nephrotic syndrome generally cause chronic kidney dysfunction. [icd9data.com]
- Orthostatic Hypotension
Other symptoms include stomach pain, muscle wasting, orthostatic hypotension, and a general feeling of being unwell. Who to See & Types of Treatment Available Patients who display the above symptoms, should consult their family doctor. [docdoc.com.sg]
hypotension). loss of appetite fatigue Causes of nephrotic syndrome Some of the causes of nephrotic syndrome include: changes to the immune system (minimal change disease or lipoid nephrosis) – nephrotic syndrome due to changes to the immune system is [betterhealth.vic.gov.au]
Skin
- Yellow Discoloration of the Skin
This may be visible as an increase in abdominal girth.[13] Fetor hepaticus is a musty breath odor resulting from increased dimethyl sulfide.[14] Jaundice, or icterus is yellow discoloration of the skin and mucous membranes, (with the white of the eye [en.wikipedia.org]
Face, Head & Neck
- Facial Swelling
Organ edema (ascites, pulmonary effusion, facial swelling and lower extremities) and anasarca Loss of albumin through the glomeruli leads to a significant drop in oncotic pressure at the venular end of the vascular beds, causing fluid accumulation in [pathophys.org]
Symptoms may include: Fatigue and malaise Decreased appetite Weight gain and facial swelling Abdominal swelling or pain Foamy urine Fluid accumulation in the body spaces (edema) The symptoms of nephrotic syndrome may resemble other conditions and medical [chop.edu]
It may occur: In the face and around the eyes (facial swelling) In the arms and legs, especially in the feet and ankles In the belly area (swollen abdomen) Other symptoms include: Skin rash or sores Foamy appearance of the urine Poor appetite Weight gain [ufhealth.org]
Symptoms may include: Fatigue and malaise Decreased appetite Weight gain and facial swelling Abdominal swelling or pain Foamy urine Fluid accumulation in the body spaces (edema) Pale fingernail beds Dull hair Ears cartilage may feel less firm Food intolerances [stanfordchildrens.org]
- Facial Edema
Signs and symptoms of glomerulonephritis include hematuria (tea-colored urine), hypertension, decreased GFR (glomerular filtration rate), low urinary output, facial edema, mild proteinuria etc. [youtube.com]
Facial edema is usually the first sign of nephrotic syndrome in children. This is followed be generalized swelling of the whole body known as anasarca. There could be ascites, pleural effusion, and pitting pedal edema. [symptoma.com]
Treatment[edit] Vein obstruction causes facial edema while lying down to sleep. After being upright all day, the swelling disappears. When possible, treatment involves resolving the underlying cause. [en.wikipedia.org]
Urogenital
- Renal Insufficiency
We herein describe a case of nephrotic syndrome with thrombocytopenia, lymphadenopathy, systemic inflammation, splenomegaly, kidney enlargement, and progressive renal insufficiency. [ncbi.nlm.nih.gov]
Diet doesn’t cause nephrotic syndrome, but what you eat could worsen symptoms and cause other complications, such as high blood pressure, renal insufficiency, and increased fat in the bloodstream. [healthline.com]
These drugs may cause or exacerbate hyperkalemia in patients with moderate to severe renal insufficiency. Protein restriction is not recommended because of lack of demonstrated effect on progression. [merckmanuals.com]
- Oliguria
She fell into oliguria and required dialysis. A kidney biopsy revealed focal and segmental glomerulosclerosis. [ncbi.nlm.nih.gov]
As mentioned previously, the nephritic syndrome ischaracterized by haematuria (which is absent in nephrotic syndrome) as well asuraemia, hypertension, proteinuria and oliguria. [newhealthadvisor.com]
[…] proteinuria (>3g/day), edema, hypoalbuminemia, hyperlipidemia, and lipiduria (can be localized kidney process or as part of a systemic disease) vs. nephritic syndrome: hematuria, oliguria, hypertension, and renal insufficiency (almost always immune mediated [errolozdalga.com]
Nephritic syndrome Other names Acute nephritic syndrome[1] Hematuria (one of the symptoms of Nephritic syndrome) Specialty Nephrology Symptoms Oliguria[2] Causes Infectious, autoimmune, or thrombotic[3] Diagnostic method Urinalysis, kidney biopsy[4] Treatment [en.wikipedia.org]
The signs include cold hands and feet, delayed capillary filling, oliguria, and tachycardia. Hypotension is a late feature. [emedicine.medscape.com]
- Frothy Urine
Other common effects include anemia, foamy urine, frothy urine, and shortness of breath. Nephrotic syndrome is diagnosed with a 24 hour urine specimen which measures the proteins in the urine. [disability-benefits-help.org]
The patient could also present with frothy urine. There could be dyspnea and cough. In cases of an underlying disease, patients will present with symptoms of that disease e.g. rash in patients with lupus. [symptoma.com]
urine (caused by high concentrations of protein). [merckmanuals.com]
Diagnosis of nephrotic syndrome Diagnosing nephrotic syndrome involves a number of tests, including: urine tests – excessive protein makes the urine appear frothy and foamy. [betterhealth.vic.gov.au]
[…] comparison of nephrotic and nephritic syndrome see nephrotic vs. nephritic syndrome References:[1] Diagnostics Urinalysis Dipstick (commonly used for screening); : usually shows ≥ 3+ protein 24-hour urine collection or spot urine (confirmatory tests): [amboss.com]
Neurologic
- Headache
In our center, a 5-yearold boy with steroid-dependent nephrotic syndrome (SDNS) presented with headache and blurring of vision during relapse after a long course of immunosuppressive therapy. [ncbi.nlm.nih.gov]
including swelling in face, belly, or arms and legs, or skin sores You're being treated for nephrotic syndrome, but your symptoms don't improve New symptoms develop, including cough, decreased urine output, discomfort with urination, fever, severe headache [nlm.nih.gov]
On day six of his hospitalization and while on prednisone 60 mg/m²/day, he developed severe headache with sudden onset of convergent strabismus of his left eye without deterioration of his sensorium. [hindawi.com]
Workup
- Laboratory investigations are the mainstay of diagnosis and they center on urine investigations. The first test should be urinalysis, 3 or 4 pluses of urine on the dipstick corresponds to at least 3g/L of protein and this is well within the nephrotic syndrome range. The presence of glucose should prompt further investigation of diabetes.
- Urine sediment examination under a microscope with show waxy cast which indicates a proteinuric disease. It will also show red blood cells which indicates glomerular disease [8].
- Measurement of 24-hour protein will reveal > 150mg of protein which is more than normal for a healthy kidney. Urine protein electrophoresis will show the exact protein and proteinuria without albumin may rule our nephrotic syndrome.
- Serum electrolyte, urea and creatinine should also be checked to determine renal function.
- A renal ultrasound can also be done and high echogenicity of the kidney is a pointer to chronic kidney disease. It will also show if a patient has one or two kidneys. One kidney is a contraindication for renal biopsy which may be done if the nephrotic syndrome is of unknown origin.
Urine
- Albuminuria
Underfill hypothesis An increase in glomerular permeability leads to albuminuria and eventually to hypoalbuminemia. [emedicine.medscape.com]
The authors also found that the relationship between BP and albuminuria was bidirectional; genetically elevated albuminuria led to higher BP and higher systolic BP predicted an increase in albuminuria. [frontiersin.org]
Serum
- Hypoalbuminemia
Patients present with marked edema, proteinuria, hypoalbuminemia, and often hyperlipidemia 1. [radiopaedia.org]
May be associated with hypoalbuminemia and hypercholesterolemia. [icd9data.com]
However, neither trial was focused on treating hypoalbuminemia, but rather resuscitation from circulatory shock. [emedicine.medscape.com]
Definition (CSP) diseases involving defective kidney glomeruli, characterized by massive proteinuria and lipiduria with varying degrees of edema, hypoalbuminemia, and hyperlipidemia. [fpnotebook.com]
- Hypercholesterolemia
May be associated with hypoalbuminemia and hypercholesterolemia. [icd9data.com]
Severe hypoalbuminemia, heavy proteinuria, hyponatremia, and hypercholesterolemia were features of the nephrotic syndrome. A kidney needle biopsy suggested focal segmental glomerulosclerosis. [ncbi.nlm.nih.gov]
The nephrotic syndrome is a distinct abnormal clinical and biochemical entity characterized by edema, massive proteinuria, hypoalbuminemia and hypoproteinemia, and hyperlipemia and hypercholesterolemia. [jamanetwork.com]
Introduction Nephrotic syndrome (NS) is a renal disorder characterized by heavy proteinuria, hypoalbuminemia, edema, and hypercholesterolemia. [hindawi.com]
- Hyponatremia
Severe hypoalbuminemia, heavy proteinuria, hyponatremia, and hypercholesterolemia were features of the nephrotic syndrome. A kidney needle biopsy suggested focal segmental glomerulosclerosis. [ncbi.nlm.nih.gov]
MedCram: Medical topics explained clearly including: Asthma, COPD, Acute Renal Failure, Mechanical Ventilation, Oxygen Hemoglobin Dissociation Curve, Hypertension, Shock, Diabetic Ketoacidosis (DKA), Medical Acid Base, VQ Mismatch, Hyponatremia, Glomerulonephritis [youtube.com]
Identify the cause of hyponatremia in nephrotic syndrome. Recognize complications associated with nephrotic syndrome, including those resulting from diuretic therapy. Understand the various factors that affect the prognosis of nephrotic syndrome. [pedsinreview.aappublications.org]
- Hypertriglyceridemia
Patients have increased LDL, increased lipoproteins, and hypertriglyceridemia. Anemia Transferrin and Erythropoietin are lost. Both can lead to microcytic anemia. Low 25-hydroxy-Vitamin D levels Loss of Vitamin D binding protein. [pedemmorsels.com]
Clement LC, Macé C, Avila-Casado C, Joles JA, Kersten S, Chugh SS (2014) Circulating angiopoietin-like 4 links proteinuria with hypertriglyceridemia in nephrotic syndrome. Nat Med 20(1):37–46 PubMedCentral CrossRef PubMed Google Scholar 17. [link.springer.com]
- Beta Globulin Decreased
Lab Increased alpha2-globulin, increased beta-globulin, decreased albumin, increased cholesterol, increased TGs, increased phospholipids; these increases are confined to lipoproteins containing apoB (chylomicrons and LDL-C), due to increased production [medical-dictionary.thefreedictionary.com]
Pleura
- Pleural Effusion
Chest radiography and computed tomography scans revealed right pleural effusion and a mass in the right middle lung field, which were confirmed by a percutaneous lung biopsy as metastatic invasive thymoma. [ncbi.nlm.nih.gov]
Breathlessness: pleural effusion (occasionally, severely hypoalbuminaemic cases may have pleural effusions or ascites), fluid overload (high jugular venous pressure), acute kidney injury. [patient.info]
Fluid retention may cause Dyspnea (pleural effusion or laryngeal edema) Arthralgia (hydrarthrosis) Abdominal pain (ascites or, in children, mesenteric edema) Corresponding signs may develop, including peripheral edema and ascites. [merckmanuals.com]
effusion Ascites Infection (increased risk in nephrotic state) Cellulitis Spontaneous bacterial peritonitis – abdominal pain, fever, nausea/vomiting, rebound tenderness Thrombosis (increased risk in nephrotic state) Features suggesting diagnosis other [rch.org.au]
Treatment
- The treatment of nephrotic syndrome is directed at the specific cause of the disease.
- In minimal change nephropathy, glucocorticoids are used. Children who do not respond to glucocorticoid treatment should be given rituximab. Rituximab also has application in the treatment of adult membranous nephropathy [9].
- Anti-inflammatory treatment is used in amyloidosis and cyclophosphamide along with prednisone for lupus.
- In patients with membranous nephropathy who have a low risk of progression, expectant management without immunosuppression can be employed.
- Diuretics are used to control edema, antibiotics for infections, anticoagulation therapy to decrease risk of clots and the diet should be rich in protein and calories.
Prognosis
Treatment greatly reduces the morbidity and mortality associated with this condition. The prognosis is however dependent on the cause of the nephrotic syndrome. It is poor in infants with congenital nephrotic syndrome as they hardly survive beyond months. The best prognosis is in patients with minimal change nephropathy. Mesangiocapillary glomerulonephrits carries the worst prognosis and patients develop renal failure within 3 years. Without treatment, this condition carries a very bad prognosis especially in adults over 30 years [6].
Etiology
The causes of nephrotic syndrome are primary when it is due to a specific disease or secondary when it is an exhibition of a systemic illness.
Primary causes of nephrotic syndrome include; Minimal change nephropathy, focal segmental glomerulosclerosis, rapidly progressing glomerulonephritis, membranous glomerulonephritis and mesangial proliferating glomerulonephritis.
Secondary causes are; Diabetes mellitus causing diabetic nephropathy, systemic lupus erythematosus, sarcoidosis, preeclampsia, viral illnesses like hepatitis C, hepatitis B and HIV, amyloidosis, other infections like syphilis, multiple myeloma, vasculitis, genetic disorders and drugs [2].
Epidemiology
In adults, the main cause is diabetic nephropathy which presents mainly as mesangiocapillary glomerulonephritis. While in children, the most frequent glomerulopathy is minimal change disease. Overall, diabetic nephropathy is the most common cause of this disease with an estimated 50 cases per million population.African Americans, American Indians and Hispanics have a higher incidence which is attributable to the incidence of diabetes amongst these races. It generally affects more men than women although lupus nephritis is common in women. It affects more adult than children with an estimated adult:child ratio of 26:1. The peak period of incidence is between 40 – 50 years [3].
Pathophysiology
The glomerulus is responsible for filtration in the kidney. In normal healthy individuals, the amount of protein filtered through the glomerulus is less than 0.1%. In nephrotic syndrome, there is destruction of the glomerular structure as it destructs the endothelial surface, glomerular basement membrane or the podocytes. This will lead to an increase in glomerular permeability that leads to loss of albumin in the urine. The loss of albumin, which is the major protein responsible for maintaining the plasma colloid osmotic pressure, will lead to a drop in the pressure. This drop in plasma oncotic pressure will lead to greater filtration of water at the capillaries throughout the body leading to edema. Eventually, as the damage worsens, bigger proteins like the immunoglobulins are also lost in urine [4].
The metabolic effects of proteinuria are far reaching and include infections due to loss of immunoglobulins, hyperlipidemia secondary to the liver's attempt to compensate for protein loss by synthesizing lipoproteins. Other effects are hypocalcemia, hypercoagulability, and hypovolemia [5].
Prevention
In patients who are risk of developing this condition and have mild proteinuria, the use of Angiotensin converting enzyme inhibitors like elanapril has been shown to prevent worsening of proteinuria and kidney function. Also, treating infections that may cause it and preventing risk factors are known preventive measures [10].
Summary
Nephrotic syndrome is when there is proteinuria of over 3 grams daily or 2 grams of protein per gram of creatinine. It has a number of causes and water retention is a major component. Primary or secondary damage to the glomeruli alters their capacity to filter protein leading to the massive loss of protein [1].
Patient Information
Definition: Nephrotic syndrome is the presence of protein in the urine. It is characterized by an increase loss of protein due to damage to the filtering mechanisms in the kidney. In normal individuals, there is very little protein loss in urine
Cause: It is caused by factors that either damage the filtration apparatus directly or as a result of another disease like diabetes causing the damage. It is also caused by infections and certain drug use.
Symptoms: The early symptoms are facial puffiness which is usually worse in the morning. The may be leg and abdominal swelling and generalized swelling of the whole body. The urine could also be unusually foamy. Cough and difficulty in breathing as well as a general feeling of malaise.
Diagnosis: This is usually done by urine investigations to check the amount and type of protein in urine. Blood tests could also be done to check for renal function. Ultrasound is also done to check the structure of the kidneys.
Treatment: Treatment is directed at the cause of the disease. Drugs are also given to reduce the fluid level and to treat infections. Most children require steroid treatment.
References
- Vaziri ND. Endocrinological consequences of the nephrotic syndrome. Am J Nephrol 1993; 13:360.
- MacDonald NE, Wolfish N, McLaine P, et al. Role of respiratory viruses in exacerbations of primary nephrotic syndrome. J Pediatr 1986; 108:378.
- Kerlin BA, Ayoob R, Smoyer WE. Epidemiology and pathophysiology of nephrotic syndrome-associated thromboembolic disease. Clin J Am Soc Nephrol. Mar 2012;7(3):513-20
- [Guideline] International Study of Kidney Disease in Children (ISKDC). Nephrotic syndrome in children: prediction of histopathology from clinical and laboratory characteristics at time of diagnosis. A report of the International Study of Kidney Disease in Children. Kidney Int. Feb 1978;13(2):159-65.
- Tryggvason K, Patrakka J, Wartiovaara J. Hereditary proteinuria syndromes and mechanisms of proteinuria.N Engl J Med. Mar 30 2006;354(13):1387-401.
- YAMAUCHI H, HOPPER J Jr. HYPOVOLEMIC SHOCK AND HYPOTENSION AS A COMPLICATION IN THE NEPHROTIC SYNDROME. REPORT OF TEN CASES. Ann Intern Med 1964; 60:242.
- White RH, Glasgow EF, Mills RJ. Clinicopathological study of nephrotic syndrome in childhood. Lancet 1970; 1:1353.
- Howard AD, Moore J Jr, Gouge SF, et al. Routine serologic tests in the differential diagnosis of the adult nephrotic syndrome. Am J Kidney Dis 1990; 15:24.
- Kamei K, Ito S, Nozu K, et al. Single dose of rituximab for refractory steroid-dependent nephrotic syndrome in children. Pediatr Nephrol. Jul 2009;24(7):1321-8.
- Bonilla-Felix M, Parra C, Dajani T, et al. Changing patterns in the histopathology of idiopathic nephrotic syndrome in children. Kidney Int 1999; 55:1885.