Pathophysiology & Risk Factors

Both syndromes injure the glomerulus, but differently. Nephrotic is a permeability problem: the membrane becomes too porous, leaking massive protein, so low albumin drops oncotic pressure and fluid floods the tissues. Nephritic is an inflammatory problem: immune-mediated injury (classically post-streptococcal, 1-3 weeks after strep throat or skin infection) causes the glomerulus to bleed and to retain salt and water.

Nephrotic vs Nephritic - the native discriminator

NephroticNephritic

Core problemPermeability (protein leaks)Inflammation (glomerulus bleeds)

ProteinuriaMassive >3.5 g/dayMild-to-moderate <3 g/day

Hallmark findingsGeneralized edema/anasarca, hypoalbuminemia, hyperlipidemiaHematuria with RBC casts, hypertension, azotemia, mild edema

Urine appearanceFrothy/foamyTea- or cola-colored

Urine castsFatty casts, oval fat bodiesRBC casts

Blood pressureOften normalHypertension prominent

Nursing focusAlbumin and edemaBlood pressure and urine output

Nephrotic

Core problem: Permeability (protein leaks)
Proteinuria: Massive >3.5 g/day
Hallmark findings: Generalized edema/anasarca, hypoalbuminemia, hyperlipidemia
Urine appearance: Frothy/foamy
Urine casts: Fatty casts, oval fat bodies
Blood pressure: Often normal
Nursing focus: Albumin and edema

Nephritic

Core problem: Inflammation (glomerulus bleeds)
Proteinuria: Mild-to-moderate <3 g/day
Hallmark findings: Hematuria with RBC casts, hypertension, azotemia, mild edema
Urine appearance: Tea- or cola-colored
Urine casts: RBC casts
Blood pressure: Hypertension prominent
Nursing focus: Blood pressure and urine output

Signs & Symptoms

EarlyProgresses →

Periorbital edema on awakening

earliest sign, esp. in children

Frothy/foamy urine

nephrotic - protein

Tea- or cola-colored urine

nephritic - gross hematuria

Late / Severe

Generalized edema

nephrotic - ascites, anasarca

Other findings

Hypertension

prominent in nephritic

Decreased urine output

oliguria common in nephritic

Diagnostics & Labs

Diagnostic

24-hour urine protein Hallmark

nephrotic >=3.5 g/day; nephritic mild

Serum lipid panel

hyperlipidemia in nephrotic

Urinalysis for RBC casts Hallmark

hallmark of nephritic

ASO titer

elevated if post-streptococcal nephritic

Serum complement C3

low in post-strep nephritic

Monitor

Serum albumin

low in nephrotic (hypoalbuminemia)

BUN and creatinine

elevated/azotemia in nephritic

Interventions & Priorities

Monitor blood pressure

priority in nephritic

Measure urine output

detect oliguria

Daily weights

track fluid shifts

Sodium and fluid restriction

nephritic edema/HTN management

Replace albumin before diuresing

nephrotic is intravascularly depleted

Treatments & Medications

Corticosteroids

reduce glomerular protein leak in nephrotic

Diuretics

after albumin in nephrotic; cautious in nephritic

Antihypertensives

control nephritic hypertension

IV albumin

restores oncotic pressure to mobilize edema

Patient Teaching

Do not stop corticosteroids abruptly

taper required; abrupt stop risks adrenal crisis and relapse

Report decreasing urine output

Report cola-colored urine

Limit dietary sodium

Watch for signs of infection

urinary immunoglobulin loss raises infection risk

Complications

Venous thromboembolism

nephrotic antithrombin III loss = hypercoagulable

Infection

urinary immunoglobulin loss

Acute kidney injury

from impaired GFR / aggressive diuresis

Report Nowescalate immediately

Unilateral calf pain and swelling

probable DVT - notify provider, anticipate anticoagulation; do NOT apply SCDs

Sudden severe dyspnea or chest pain

possible pulmonary embolism

Worsening severe edema with falling urine output

AKI/fluid crisis

Fever or signs of sepsis

infection from immunoglobulin loss

Clinical Pearl

ProTEIN leaks in nephroTIC; fighTIng (inflammation) happens in nephriTIC. Foamy urine = protein = nephrotic; cola urine = blood = nephritic.

Nephrotic vs Nephritic Syndrome