Nephrotic syn with thromboembolism

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Nephrotic syn with thromboembolism

  1. 1. DEPARTMENT OF PEDIATRIC NEPHROLOGY DEPARTMENT OF PEDIATRIC NEUROLOGY MEHTA’S CHILDREN HOSPITAL
  2. 2. <ul><li>Complications of NS are </li></ul><ul><li>Infection </li></ul><ul><li>Acute renal failure </li></ul><ul><li>Dyselectrolytemia </li></ul><ul><li>Fluid overload disorders </li></ul><ul><li>Bone mineral loss </li></ul><ul><li>Stunted growth </li></ul><ul><li>Hypertension </li></ul><ul><li>Thromboembolism </li></ul>
  3. 3. <ul><li>3⅟₂ years old, Male </li></ul><ul><li>Diagnosed as NS in April 2008 </li></ul><ul><li>Remission after 12 weeks of oral prednisolone therapy </li></ul><ul><li>1 st relapse in March 2009 responded to daily prednisolone therapy </li></ul>
  4. 4. <ul><li>Two weeks later when in remission on alternate day prednisolone therapy came with </li></ul><ul><li>Headache </li></ul><ul><li>Poor oral intake </li></ul><ul><li>Progressively increasing lethargy </li></ul>
  5. 5. <ul><li>Mild dehydration </li></ul><ul><li>HR: 98/min, volume good </li></ul><ul><li>BP: 100/70 </li></ul><ul><li>Fundus normal </li></ul><ul><li>Systemic examination: essentially normal </li></ul>
  6. 6. <ul><li>Urine albumin: Neg </li></ul><ul><li>Serum albumin: 3.7g/dl </li></ul><ul><li>Creatinine: 0.5mg/dl </li></ul><ul><li>Sodium: 137meq/l </li></ul><ul><li>Calcium: 9.4mg/dl </li></ul><ul><li>WBC count: 11,500 cmm </li></ul><ul><li>Polymorphs 60%, Lymphocytes 37% </li></ul><ul><li>Hb 14, PCV 40% </li></ul><ul><li>Platelet count: 5.04lacs/cmm </li></ul>
  7. 8. <ul><li>In absence of </li></ul><ul><li>Dyselectrolytemia </li></ul><ul><li>Hypertension </li></ul><ul><li>Hypovolemia </li></ul><ul><li>CT Brain was done </li></ul>
  8. 9. <ul><li>Thrombosis of superior sagital sinus with possible extension to Right transverse sinus </li></ul>
  9. 11. <ul><li>Protein C: 204 (67-195%) </li></ul><ul><li>Protein S: 101 (77-143%) </li></ul><ul><li>Anti Thrombin III: 158 (70-122%) </li></ul>
  10. 12. <ul><li>Low molecular weight Heparin </li></ul><ul><li>IV Diuretics for raised ICP </li></ul><ul><li>Oral anticonvulsants </li></ul>
  11. 13. <ul><li>After 1 week of treatment he did not improve symptomatically </li></ul><ul><li>MRI Brain with MR Venogram was done </li></ul>
  12. 14. <ul><li>Thrombosis of superior sagital sinus, torcula, Right transverse sinus and Right sigmoid sinus </li></ul>
  13. 15. <ul><li>Oral anticoagulants with dose adjustment was done to maintain INR between 2-3 and was discharged </li></ul>
  14. 16. <ul><li>COMPLETE RECOVERY OF RIGHT LATERAL RECTUS PALSY </li></ul>
  15. 17. <ul><li>Incidence of Thromboembolism in children with NS is 1.8-5% </li></ul><ul><li>Bryce A, et al. Epidemiology and risk factors for thromboembolic complications of childhood nephrotic syndrome: A midwest pediatric nephrology consortium study. J Pediatr 2009;155:105-10 </li></ul><ul><li>Mahmoodi BK, ten Kate MK, Waanders F, Veeger NJ, Brouwer JL, Vogt L. High absolute risks and predictors of venous and arterial thromboembolic events in patients with nephrotic syndrome: results from a large retrospective cohort study.  Circulation . Jan 15 2008;117(2):224-30.  </li></ul>
  16. 18. <ul><li>Platelet hyper-aggregability </li></ul><ul><li>Hypercoagulation </li></ul><ul><li>Decreased endogenous anti-coagulants </li></ul><ul><li>Decreased activity of fibrinolytic system </li></ul><ul><li>Endothelial cell injury </li></ul>
  17. 19. <ul><li>Hyperviscosity </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>RBC hyperaggregation </li></ul>
  18. 20. <ul><li>Renal vein thrombosis (30-40%) </li></ul><ul><li>Deep vein thrombosis (15-20%) </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Mesenteric vein thrombosis </li></ul><ul><li>Cerebral venous thrombosis (1-2%) </li></ul><ul><li>Arterial thrombosis </li></ul>
  19. 21. <ul><li>Children >12 years of age </li></ul><ul><li>Congenital NS </li></ul><ul><li>Severe proteinuria </li></ul><ul><li>Previous episodes of thrombosis/DVT </li></ul><ul><li>Central line access </li></ul><ul><li>SLE </li></ul>
  20. 22. <ul><li>Hypertension </li></ul><ul><li>Hypovolemia </li></ul><ul><li>Dyselectrolytemia </li></ul><ul><li>Acute renal failure </li></ul><ul><li>CNS infection </li></ul><ul><li>Thromboembolism </li></ul>

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