What is nephrotic syndrome?

It is a commonly occurring disease of the renal glands characterised by excessive edema, proteinuria, and hypoalbuminemia. It affects children and adults too. It can be a primary disease or a secondary issue to some other underlying disease. It is caused due to injury to podocytes and glomeruli which are the major filtration unit of the kidneys.

This condition can be treated when detected early with glucocorticoid. There is a good rate of this disease getting cured. If it is left untreated it leads to worsening of the condition by accelerated abnormal lipids and lipoprotein production. 

The causes of nephrotic syndrome are idiopathic infections, systemic lupus erythematosus, Hodgkin’s lymphoma, toxins like gold, captopril, penicillamine, diabetes mellitus, and amyloidosis.

Children are affected more that 80 percent of the time. Adults are less affected which contributes to about 20 percent of the time. It is a rare illness but cases show to increase due to co-morbid conditions which tend to deteriorate the health status.

What is dyslipidemia in nephrotic syndrome?

• The oncotic pressure falls due to excessive protein excretion in the urine. 
• This further leads to lipogenesis in the liver to accelerate and produce lipids more than what is normal.
• In nephrotic syndrome, lipid levels in the body are elevated.
• Low density lipoprotein or LDL, very low density lipoprotein or VLDL are high in concentration in the blood.
• The carriers or vehicles which transport the lipid molecules called lipoproteins are produced abnormally.
• Cholesterol levels in the blood are very much altered and are abnormal. 
• High density lipoprotein or HDL and its relationship with nephrotic syndrome are yet to be proved.
• High levels of lipoprotein and lipids in the body are harmful. It causes various complications which can further be life-threatening.

Clinical features of dyslipidemia in nephrotic syndrome.

• Puffy eyes and face. This is due to oedematous changes.
• Fluid retention causes an increase in body weight.
• Urine becomes foamy due to the presence of amino acids which together form protein.
• Malaise, weakness, and fatigue.
• High blood pressure.
• Exertional dyspnea and inability to walk long distances due to tiredness or chest discomfort which can be because of high lipid accumulated concentration in the coronary arteries.
• The abdominal area may swell along with scrotal or labial areas.
• Nausea, vomiting.
• There can sometimes be infections.
• The patient can become irritated and may not obey some commands.
• Headache, and body ache are general and non-specific clinical features.

Diagnostic tests for diagnosis of nephrotic syndrome.

• Blood test to check lipid levels, low level of protein in it.
• Urine test to check the presence of protein in it which is the main diagnostic feature.
• A kidney biopsy may be required in some undiagnosed cases.

Secondary complications of dyslipidemia in nephrotic syndrome.

• Due to the high level of lipids in the blood, it gets accumulated in the periphery along the blood vessel wall inside. This causes a reduction in the lumen of the vessel. The cholesterol deposits keep increasing and the lumen becomes narrower. This condition is called atherosclerosis. Plaque formation occurs further which may lead to heart attack and infarction.
• Thrombus can form in the blood vessels. A thrombus is a blood clot that is adherent to the inner wall of the vessel. This again reduces the lumen further causing the reduced blood supply to the organs and increased pressure on the heart.
• Thrombo-embolism is when the thrombus detaches from the vessel and travels in the bloodstream. This is a dangerous complication as emboli can get stuck in any of the major vessels of the heart or brain leading to heart attack or stroke respectively.
• Hypertension can occur due to excessive pressure of the blood column on the vessel wall.
• Edema of the feet, face, eyes, and ankle can occur.

How to treat dyslipidemia and nephrotic syndrome?

• Statins like simvastatin, lovastatin, and atorvastatin are the group of medications that help in lowering the levels of lipids and cholesterol.
• Bile acid binding compounds which help in lowering the cholesterol levels are given to the patient which are cholestyramine type drugs.
• Fibrates group of drugs are given for the same purpose.
• Lifestyle modifications and dietary modifications are the keys to keeping the lipid levels under control and to maintain a healthy lipid profile.
• Corticosteroids like prednisolone are given to children as the initial line of medication and treatment.
• Antihypertensive drugs are prescribed to avoid cardiovascular complications which are very likely to occur in such patients.
• Reducing obesity is a great way to deal with this issue.
• Weight reduction, physical activity, and avoiding alcohol and other abusive drugs can bring the patient’s condition under control.
• If relapse occurs and there are complications with corticosteroids, then the patient is put on cyclosporine and tacrolimus, and rituximab.
• Anticoagulant therapy may be essential in some cases.

How do you avoid or treat the complications of nephrotic syndrome associated with dyslipidemia?

• Edema reduction should be done. It can be done by reducing water retention and better lymphatic drainage. This is achieved by reducing electrolyte intake and salt intake. The edematous limb is kept in elevation with support with or without compression bandage as per requirement.
• Protein in the diet should be below 1 gram per kilogram of body weight. More protein causes excessive pressure on the kidneys and therefore can worsen the condition. Severe loss of protein causes nephrotic syndrome so, protein should be consumed with proper consultation with a doctor and dietitian.
• Continuous monitoring of urine and frequent renal function tests are essential.
• Body mass index should be between 18 to 24. This can be achieved by proper diet and fitness training.
• Control the hypertension and diabetes mellitus.  
• Reduce potassium in the diet. Eat a fresh and kidney friendly diet with low protein and fat. This can be achieved by reducing oil, meat, sweets, and dairy products along with foods with preservatives.
• Daily activity which keeps weight under control should be done.
• Medications should be taken from time to time and the health should be kept good and avoid further deterioration which as mentioned earlier can lead to cardiovascular risk and complications.