Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 28-1978

Prolonged reversible renal failure with nephrotic syndrome

Steroid nonresponsive nephrotic syndrome in a 15-year-old girl with reversible renal failure required dialysis and aggressive nutritional therapy for 1 year. Severe interstitial edema and foot process fusion were the only processes identified to explain the renal failure. Diabetes-like alterations of the glomerular capillary wall basement membrane may have been an outcome of the intense alimentation.

Reversibility of acute renal failure in elderly patients with the nephrotic syndrome

Acute renal failure may occur in the nephrotic syndrome due to minor glomerular changes, especially in the elderly. We describe five cases and review the literature. Previous renal damage due to ischaemia and drugs may be important in pathogenesis. We stress the importance of active management of these cases, as the renal lesions are reversible and recovery can be expected.

Urospasm

This article theorizes that acute reversible narrowing can occur in the calyx/infundibular regions of the kidney. This narrowing could result from a spasm of the urinary tract smooth muscle analogous to spasms of other tubular structures containing smooth muscle (bronchi, esophagus, peripheral arteries, and coronary arteries). The spasm in the calyx/infundibular region could help explain the phenomenon of the acute renal failure that can occur with minimal change disease.

Renal dysfunction. 2. Proteinuria

Proteinuria greater than 150 mg/24 hr without antecedent strenuous exercise demands an explanation. As an aid in the search for that explanation, this article provides a simple, logical classification of the various causes of proteinuria. Part 1 of this two-part article, published last month (page 93), discussed urea and creatinine.

Renal failure in minimal change nephrotic syndrome

Renal insufficiency, with serum creatinines ranging from 2.3 to 13.4 mg/dl, was observed in 15 patients with the minimal change nephrotic syndrome. Recovery of renal function occurred in association with diuretic therapy in 13, eight of whom subsequently underwent steroid-induced remission of the nephrotic syndrome. Two patients failed to undergo diuresis or to have a remission of the nephrotic syndrome and died with persistent renal failure. Glomerular filtration rate (Cinulin) was reduced out of proportion to renal plasma flow (CPAH) as evidenced by remarkably low filtration fractions ranging from 0.03 to 0.095. The invariable association between diuresis and recovery of renal function, the recurrence of renal failure when fluid reaccumulated and the finding of markedly depressed filtration fractions lead us to postulate that renal failure in minimal change nephrotic syndrome may be due to a reversible alteration in glomerular hemodynamics which is related to fluid retention and associated intrarenal edema.