ANEXURE –I

1. Name of the candidate                    DR. ADITYA LAJAMI
   and address                              PLOT NO 53. SECTOR 32,
                                            BAGALKOT -587102
2. Name of the institution                  J.J.M. MEDICAL COLLEGE
                                            DAVANGERE -577004
3. Course of the study and subject          POSTGRADUATE DEGREE
                                            M.D GENERAL MEDICINE
4. Date of Admission to course              16th APRIL, 2009

5. Title of the Topic                          “CLINICAL AND
                                             HISTOPATHOLOGICAL STUDY
                                             OF ADULT NEPHROTIC


   6.1 Need for the Study:

         The nephrotic syndrome is a clinical complex characterized by a number of
   renal and extra renal features, the most prominent of which are proteinuria of >3.5
   grams per 1.73m2 per 24h (in practice >3.0 to 3.5 grams per 24h),
   Hypoalbuminemia, Edema, Hyperlipidemia, Lipiduria and Hypercoagulability.
       Primary nephrotic syndrome has been one of the important renal diseases in
   adults carrying significant morbidity and mortality.
      The multiplicity of etiologic factors, associated conditions, underlying
   pathology and pathogenesis makes it difficult to review nephrotic syndrome
   without encompassing all of the diseases that constitute the general group of
glomerular diseases.
Occurrence of morbidity and mortality depends on the underlying etiology.
Biopsy and immunoflorosence          studies are indispensable to elucidate the
    Nephrotic syndrome happens to be the most common indication for renal
    Newer studies (after 1995) have revealed a difference in the prevalence of
underlying etiology as compared to older studies2.
    Late in the disease when renal replacement therapy is required, a definitive
diagnosis is seldom possible , and the need for the early detection is evident.1
   The need for the study is to look into the increasing trend of FSGS as it is a
clinicopathological syndrome with substantial risk of progression to ESRD.

6.2 Review of Literature :
    In the data compiled during the 1970’s and early 80’s indicated the relative
frequency of membranous Nephropathy – 36%, minimal change nephropathy –
23% and focal segmental glomerulosclerosis 15% as the causes of Nephrotic
syndrome10. However analysis of data after 1995 revealed FSGS in more than
50% of cases of Nephrotic syndrome, and it has been well documented. .Similar
study in Indian adults showed Nephrotic syndrome as 15% of all admissions, with
FSGS showing relatively raising trend 2.
     A detail search of treasure of literature showed that, FSGS is increasing now
a days. Stephen.M.Kobert et all in his study: The racial prevalence of Glomerular
Lesions in Nephrotic Adults-has shown that the primary glomerular lesions in
adults who had a renal biopsy for nephrotic proteinuria, was FSGS.23%
(P<0.0001) in a logistic regression analysis. Race remained the significant
predictor of FSGS, with black patients showing four times increase in FSGS as
white patients, and over 20 years the incidence of FSGS increased from 39% to
           Braden et all have shown that the evidence of FSGS in nephrotic
syndrome patients has risen significantly by two to three folds over the last 20
         Kitiyakara.C.Eggors et all9 examined the incidence of FSGS- ESRD during
21 years of period, and reported that the annual incidence of FSGS-ESRD has
increased considerably from 0.2% to 2.3% and is multifactorial in origin with
contribution from changes in renal increase in the incidence of FSGS disease.
    Gregery.L.Braden8,5,3 performed at large metropolitan medical centers have
reported an increasing incidence of idiopathic FSGS in adults. The relative
frequency of FSGS has increased from 13.7% to 25% and no changes in MCN,
MPGN and IgA nephropathy also with a racial increase of FSGS in Blacks &
Diocef. B.Kaef, et all7 conducted a similar study in Necker Hospital in Paris-
Dakar (Senegal) and reviewed retrospectively all the patients who underwent
renal biopsy, of which 67% represented nephrotic syndrome and out of which
47% were FSGS, where as MCN was 6%.
    Few INDIAN STUDIES were all simultaneously conducted in few reputed
hospitals like AIIMS, PGI & CMC, and concluded that out of 2947 pt of
Nephrotic Syndrome, 69% cases were primary GMN, and also made it clear that
Minimal change disease is the commonest primary glomerulonephritis in India is
about 37% and FSGS is 20%.

    However retrospective analysis of renal biopsy performed in CMC
HOSPITAL-VELLORE showed that males out numbered females in all disease
categories expect SLE. In Nephrotic Syndrome, FSGS was the commonest
histological diagnosis- 16.8% in all age groups, and thus showed the raising trend
of FSGS than MCN, and constituted 14% of primary GN, when compared to 9.6%
primary GN in the 1991 report. Increasing incidence of IgA world wide is well
  6.3 Objectives of the Study :
     1. To study the clinical profile of nephritic syndrome in adults.

    2. To study the different etiologies of nephrotic syndrome and to determine any
  significant changes in the spectra of glomerular disease causing nephrotic
  syndrome in adults.


  7.1 Source of Data :
      Fifty adult patients of nephrotic syndrome will be selected for study. Patients
  will be selected from Chigateri General Hospital and Bapuji Hospital attach to
  JJM Medical college, Davangere.

  7.2 Method of collection of Data (including sampling procedure if any
  patients (cases) :
      All patients (minimum) of 50 of nephrotic syndrome admitted in medical
  wards of Chigateri & Bapuji Hospital attached to JJM Medical college, Davangere
  will be included in study subject to fulfilling inclusion and exclusion criteria.
   Patients presenting with complaints of facial puffiness, pedal edema and urinary
  disturbance will be enrolled, clinically examined and relevant investigations like
  urine routine, complete Haemogram, 24 hour urine protein ultrasound abdomen,
  HIV, HBsAg, antiHCV, renal biopsy, electrolytes and renal function test will be
  done. Renal biopsy will be performed in appropriate patient and the specimen will
  be sent for histopathological examination and expert opinion will be taken.
Inclusion Criteria :
  1.    All patient with proteinuria of >3.5gms /24 hours
  2. Diabetic patient with nephrotic range protienuria where non diabetic cause
       is likely (Not accompanied by retinopathy, short duration of diabetes) that is
       diabetes is a coincidental finding.
Exclusion criteria :
   1. Age less than 14 years
  2. Secondary causes like amyloidosis, DM with retinopahty .

7.3 Does the study require any investigation or interventions to be
      Conducted on patients or other human or animals? If so please
      describe briefly.

       Haematology       :       Hb%, CBC, ESR, RBS, Blood urea, Serum
                                  creatinine, serum sodium, serum potassium,
                                  Lipid profile, Serum albumin.
   Serology              :       HIV, HBsAg
   Ultra sound           :
   Urine                 :       24 hour urine protien
   Renal biopsy              :

7.4 Has ethical clearance been obtained from your institution in case of

  1. van Rensburg BW, van Staden AM, Rossouw GJ, Joubert G. “the profile of
     adult nephrology patient admitted to renal unit of university tertiary hospital in
     Bloemfontein, south Africa 1997- 2006” ; Nephrol Dial Transplant. 2009 Oct
  2. Balakrishnan N, GT John GT, Korula*A, Visalakshi J**, Talaulikar
     GS, Thomas PP, et al; “ Spectrum of biopsy proven renal disease and
     changing trends at a tropical tertiary care centre 1990 – 2001,” Indian J
     Nephrol 2003;13:29-35
  3. Noor Khan L, Farzana K, Haroon K, Ghias B., “Morphology of nephrotic
     syndrome in adults, an experience at PIMS, Islamabad”       Jn Rawal Med Coll
     Dec 2001;5(2):84-8.
  4. Braden GL, Mulhern JG, O'Shea MH, Nash SV, Ucci AA, Germain MJ.
     “Changing incidence of glomerular in adults”; Am J kidney ds;2000 vol 35,
     No 5 878-83.
  5. Agrwal SK, Dash SC: “Spectrum of Renal diseases in Indian adults”, JAPI,
     2000 Vol46, No 6.
  6. Harris RC, Nuhad I ; “External complications of the nephrotic syndrome”
     American journal of kidney disease, April 1994 vol 123 No.4 p477-497.
  7. Diouf B, Ka EF, Niang A, Mbengue M, Diouf ML, Pouye A, Moreira-Diop T.
     et al : “Analysis of 115 kindey Biopsies, performed in Dakar” ; Dakar Med
     2001; 4(1):51-3.
  8. Khawar A, Muhammad M, Javed IK, Rana M. “ Pattern of morphology in
     renal biopsies of nephrotic syndrome patients. co relation with
     immunoglobulin and compliment deposition”; J Pak Med Assoc. 2001 August
  9. Kitiyakara. C. Eggers: “Twenty one year trend in ESRD due to FSGS in the
     uk”: AMJRDS 2004 Nov; 44(5):815-25.
9.   Signature of Candidate

10. Remarks of the Guide       Primary nephrotic syndrome as been one of
                               the important renal diseases in adults carrying
                               significant    morbidity     and     mortality.
                               Occurrence of morbidity and mortality
                               depends on the underlying etiology. This
                               study will be interesting, clinically useful and

11. Name and Designation of
     (in block letters)
     11.1 Guide                DR. RAJEEV AGARWAL MD.DNB(Nephro)
                               DEPT OF GENERAL MEDICINE,
                               J.J.M. MEDICAL COLLEGE,
                               DAVANGERE – 577 004.

     11.2 Signature

     11.3 Co-Guide (if any)

     11.4 Signature

     11.5 Head of Department   Dr. G. RAJASHEKARAPPA M.D
                               PROFESSOR AND HEAD,
                               DEPT OF GENERAL MEDICINE,
                               J.J.M. MEDICAL COLLEGE,
                               DAVANGERE – 577 004.

     11.6 Signature
12. 12.1 Remarks of the
        Chairman and Principal

    12.2 Signature

To top