**3. Secondary causes of nephrotic syndrome requiring surgery**

Increasing evidences are available regarding an emerging causal relationship between renal artery stenosis (RAS)/ischemia and the development of nephrotic syndrome. It is well established now that patients with accelerated hypertension used to have proteinuria of nephrotic range. However, it is rarely seen in patients with essential hypertension. Varying degrees of proteinuria are in unilateral RAS patients but normally in around 0.5 g/day. Reduction in this proteinuria is possible with surgical correction of this hemodynamic problem. Various kinds of surgical corrections are reported like nephrectomy, arterial stenosis correction, percutaneous transluminal angioplasty, and stenting. The use of angiotensin-converting enzyme inhibitors (ACE-I) also has shown benefit in minimizing the proteinuria and degrees of hypertension [18].

### **3.1 Immunoglobulin light chain amyloidosis (AL)**

Up to half of all patients presents with renal involvement at the time of diagnosis. About 40% of patients will land up into end-stage renal disease and ultimately will require renal replacement therapy. Management of nephrotic syndrome is difficult and challenging for patients not yet on dialysis. Ablation of natural filtration through medical and/or surgical means has been used to achieve remission from massive proteinuria associated with the nephrotic syndrome. Conservative treatments consist of mercury salt (sodium mercaptomerin), angiotensin II and cyclosporine, and inhibitors of prostaglandin synthesis. Bilateral renal infarction has been used as a substitute to nephrectomy in patients with chronic kidney disease and massive proteinuria. This is carried out by percutaneous route and renal artery embolized using ethanol and irritant coils. Removal of the kidney surgically offers complete relief from proteinuria but carries the risks of complications of an open surgery in severely debilitated patients. Nephrectomy through minimally invasive techniques is a less invasive procedure, even though this procedure also has been

**9**

**Author details**

**4. Conclusion**

Intezar Ahmed\* and Enono Yhoshu

provided the original work is properly cited.

done is essential and much needed.

All India Institute of Medical Sciences, Rishikesh, India

\*Address all correspondence to: ahmed\_intezar@rediffmail.com

*Role of Surgery in Nephrotic Syndrome DOI: http://dx.doi.org/10.5772/intechopen.86732*

used frequently due to the hazards of complications of hypoalbuminemia, hypotension, deranged coagulation profile, and impaired renal function. A novel approach to renal ablation is laparoscopic ligation of both ureters which has been considered by some surgeons for these patients with proteinuria as a disabling refractory complication [19]. The patient will need a long-term hemodialysis after this.

About 30 years ago, the initial descriptions of nephropathy associated with obesity

were published, which were followed by lots of reports of kidney disease in obese subjects without diabetes. Obesity-associated nephrotic syndrome has been described as a glomerulopathy that presents with a variable kind of proteinuria. The mechanisms of renal injury are attributed to the body adapting adversely to the rise in the excretory load, salt retention, and the direct or indirect effects of hyperinsulinemia/insulin resistance and renal lipotoxicity. The most commonly used treatment for nephropathy associated with obesity stresses on the use of antiproteinuric agents, with ACE inhibitors and angiotensin II receptor blockers, which in turn improve sensitivity to insulin and protect the kidneys and cardiovascular system. Bariatric surgery has been accepted as one of the

essential procedures for achieving these goals but involves a reasonable risk [20].

Ramirez et al. in their report of two cases of nondiabetic obese patients with FSGS stated that there was an effective reduction of body weight by bariatric surgery and this was successfully accompanied by sustained remission of proteinuria allowing significant reduction or total removal of blockers of the renin-angiotensin system. Huan et al. also reported a case of obesity-related nephropathy and FSGS on renal biopsy. The patient underwent bariatric surgery and attained successful weight reduction with significant decrease in proteinuria and stabilization of renal function [21].

The literature on the role of surgery in nephrotic syndrome is scanty, though the association of nephrologists with surgeons has been ongoing. We have tried to enumerate some of the role of surgeons in nephrotic syndrome patients, with some review of the available literature. In order to bring out more specific outcomes of complications of nephrotic syndrome patients being managed surgically, more randomized controlled studies with better documentation of interventions being

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

**3.2 Bariatric surgery in nephrotic syndrome due to obesity**

#### *Role of Surgery in Nephrotic Syndrome DOI: http://dx.doi.org/10.5772/intechopen.86732*

*Renal Diseases*

term complications of ESRD and dialysis.

recur and frequently followed by graft loss [16].

Preemptive transplantation (PET), which signifies transplantation prior to the initiation of dialysis, has recently been introduced in the pediatric population, as it is observed that children undergoing renal transplantation before the features of severe uremia sets in are helped by the avoidance of many of the associated long-

One of the common causes of ESRD is focal segmental glomerulosclerosis (FSGS). In idiopathic nephrotic syndrome, FSGS is a common pathologic diagnosis, especially in steroid-resistant cases. After kidney transplantation FSGS is known to

**3. Secondary causes of nephrotic syndrome requiring surgery**

**3.1 Immunoglobulin light chain amyloidosis (AL)**

Increasing evidences are available regarding an emerging causal relationship between renal artery stenosis (RAS)/ischemia and the development of nephrotic syndrome. It is well established now that patients with accelerated hypertension used to have proteinuria of nephrotic range. However, it is rarely seen in patients with essential hypertension. Varying degrees of proteinuria are in unilateral RAS patients but normally in around 0.5 g/day. Reduction in this proteinuria is possible with surgical correction of this hemodynamic problem. Various kinds of surgical corrections are reported like nephrectomy, arterial stenosis correction, percutaneous transluminal angioplasty, and stenting. The use of angiotensin-converting enzyme inhibitors (ACE-I) also has shown benefit in minimizing the proteinuria and degrees of hypertension [18].

Up to half of all patients presents with renal involvement at the time of diagnosis. About 40% of patients will land up into end-stage renal disease and ultimately will require renal replacement therapy. Management of nephrotic syndrome is difficult and challenging for patients not yet on dialysis. Ablation of natural filtration through medical and/or surgical means has been used to achieve remission from massive proteinuria associated with the nephrotic syndrome. Conservative treatments consist of mercury salt (sodium mercaptomerin), angiotensin II and cyclosporine, and inhibitors of prostaglandin synthesis. Bilateral renal infarction has been used as a substitute to nephrectomy in patients with chronic kidney disease and massive proteinuria. This is carried out by percutaneous route and renal artery embolized using ethanol and irritant coils. Removal of the kidney surgically offers complete relief from proteinuria but carries the risks of complications of an open surgery in severely debilitated patients. Nephrectomy through minimally invasive techniques is a less invasive procedure, even though this procedure also has been

In renal transplantation, patient size and age matching are generally not essential. In fact, it was seen that there is very high rate of graft loss if one matches very young donors to very young recipients, as a consequence of thrombosis. Hence, now pediatric programs are considering the transplant of adult kidneys into small children, once the recipient attains a sufficient size, typically 6.5–10.0 kg of body weight. It has been seen that the peritoneal cavity of an infant has enough space to accommodate an adult kidney without fear of the compression of graft. It has been observed that if body weight of a child is more than 30 kg, the surgical procedure for a kidney transplantation will be similar to that in an adult. However, if the body weight is less than 10 kg, a midline longitudinal abdominal incision is required, and blood vessels from the donor are connected to the recipient's aorta and inferior vena cava. But a tailored approach is needed in children with a body weight of 10–30 kg, in terms of incision site/size, anastomoses of vessels, and allograft sites on the basis of the child's anatomy [17].

**8**

used frequently due to the hazards of complications of hypoalbuminemia, hypotension, deranged coagulation profile, and impaired renal function. A novel approach to renal ablation is laparoscopic ligation of both ureters which has been considered by some surgeons for these patients with proteinuria as a disabling refractory complication [19]. The patient will need a long-term hemodialysis after this.
