Nephrotic Syndrome: How to Recognise and Manage It in General Practice

Nephrotic syndrome is a critical clinical pattern that GPs and registrars must be able to identify. Though often managed by nephrologists, early recognition in general practice is essential to prevent complications like infection, thromboembolism, and progressive kidney disease.

At PassGP, we regularly test nephrotic syndrome in KFP and CCE scenarios, because it represents a classic "hidden red flag" - subtle but significant. According to A/Prof George Eskander, PassGP’s Chief Examiner:

“Nephrotic syndrome teaches clinical humility. You must listen for vague cues like fatigue and ankle swelling - and match them with urinalysis and a working knowledge of renal medicine.”

 What Is Nephrotic Syndrome?

Nephrotic syndrome is a triad:

• Heavy proteinuria (>3.5g/day)
• Hypoalbuminaemia
• Oedema

It may also include:

• Hyperlipidaemia
• Thromboembolic risk
• Increased infection susceptibility

 Classic Clinical Features

Always ask:

“Have you noticed your socks leaving deep marks or your rings feeling tighter?”

Red Flags for Urgent Referral

GPs should refer urgently if:

• Rapid weight gain or fluid overload
• Serum albumin <25 g/L
• Creatinine rising
• Suspected thrombotic event (e.g. PE or DVT)
• Unexplained proteinuria + haematuria → suspect glomerulonephritis

 Causes of Nephrotic Syndrome

 In adults, secondary causes are more common.
 Investigate underlying conditions like diabetes, autoimmune diseases, or infections.

GP Workup in Primary Care

Initial Investigations:

• Urine dipstick: Protein +++
• Urine ACR or PCR: Quantify proteinuria
• U&Es, eGFR
• Serum albumin, cholesterol
• FBC, CRP
• Blood pressure monitoring

Further Workup (guided by nephrology):

• ANA, dsDNA (autoimmune)
• Hepatitis serology
• HIV
• Renal ultrasound
• Biopsy (by specialist)

 Initial GP Management

While awaiting nephrology input:

• Start salt restriction
• Manage hypertension (ACEi/ARB if renal function allows)
• Monitor fluid balance and daily weights
• Consider statin for hyperlipidaemia (controversial – specialist advice needed)
• Educate about DVT/PE risk and signs to watch for

 Early nephrology referral is critical - avoid delaying biopsy and immunosuppression where needed.

 Why It’s Tested in RACGP and ACRRM Exams

Nephrotic syndrome is common in exams because:

• It's often missed or under-investigated
• Requires good differential diagnosis
• Emphasises the GP’s role in referral and surveillance

In KFP and CCE, candidates are expected to:

• Recognise the pattern from history and urinalysis
• Avoid anchoring on “just fluid overload”
• Initiate investigations and referral
• Counsel on the risk of complications

Learn These Patterns with PassGP

At PassGP, we teach you how to connect vague symptoms to critical diagnoses. Our nephrology content includes:

• High-level KFP cases
• CCE station scripts for renal presentations
• Drug options with doses and referral strategies

Start your free trial at PassGP.au today to access exam-level nephrology questions written by experts, including A/Prof George Eskander.