A case presentation on Nephrotic Syndrome

1. ORATOR: RAYAZ AHMAD BHAT
STUDENT NIPER, GUWAHATI, ASSAM
MODERATOR: DR. (Mrs.) MANGALA LAHKAR
CAC, NIPER, GUWAHATI, ASSAM
MENTOR HOSPITAL: GUWAHATI MEDICAL COLLEGE AND HOSPITAL

2. CASE: NEPHROTIC SYNDROME
Deptt. Of Nephrology
Guwahati Medical College And Hospital
Assam

3. PATIENT DETAILS
NAME: XYZ
SEX: MALE
AGE: 82yrs
DOA: 10/09/2016
Deptt. Regd. No: 4654/16
BED NO. 04
MRD NO. 59868

4. CHIEF COMPLAINTS
Swelling of both legs from last 2 months
Lower urinary tract symptoms from last 15 days
Respiratory difficulty with on/off cough from last
15 days

5. PATIENT HISTORY
SOCIAL HISTORY
SMOKER: NO
ALCOHOLIC: NO
MEDICAL HISTORY
No history of T2DM or Hypertension
H/o of pain killer for knee joint pain (B/L) 1 month prior
to swelling
No H/o intake of herbal medication
No H/o Haematemesis or Melena
No H/o renal calculi, burning micturation or fever.

6. ON PHYSICAL EXAMINATIOM
PULSE RATE: 86/MIN
CVS : S1 S2 -Normal
PALLOR: +
OEDEMA: +
CHEST: VESICULAR BREATH SOUNDS were audible
Bp: 110/80

7. LAB INVESTIGATIONS
INVESTIGATION
NORMAL
VALUE/RANGE
10/09/16
D1
12/09/1
6
D3
15/09/16
D6
20/09/1
6
D11
Sodium 137-145 mmol/l 127 128 124
Potassium 3.5-5.1 mmol/l 3.7 2.4 3.2
Calcium(total) 8.4-10.2 mg/dl 6.9 6.6
AST 17-59 u/l 61
ALT 21-72 u/l 40
WBC 4000-11000 7900 8500
Hemoglobin 13-17 g/dl 10.1 9.0
Neutrophills 37-72 % 46 87.3
Lymphocytes 20 -40 % 35 10

8. INVESTIGATION NORMAL VALUE/RANGE D1 D3 D6 D11
Monocytes 2 – 10 % 7 2.1
Eosinophills 1 – 6 % 12 6
Prothrombin
time/INR
12-16 sec/.8-1.5 18.7/1.7
TSH 0.465-4.68mIU/L 300
Cholesterol <200mg/dl 369
Triglycerides 50-150mg/dl 401
Albumin 3.5-5mg/dl 1.8 1.5
Total Protein 6-8g/dl 4.84
Urea 10-45mg/dl 48.3 1O2.
9
Creatinine 0.80-1.50 mg/dl 2.06 2.83
Iron 65-180ug/dl 55
TIBC 240-450 mcg/dl 183

9. INVESTIGATION NORMAL
VALUE/RANGE
D1 D3 D6
Random
Glucose
79-140mg/dl 124.4
Fasting
Glucose
70-110mg/dl 95
Hb1Ac 0-6% 5.50
tPSA 0-4ng/dl 0.365
Urine
Protein
(24hr)
24-
141mg/24hrs
336
CPK 55-170u/l 439

10. USG REPORT
12/09/16
RESULT
Bilateral renal parenchymal changes and
Right kidney cyst
Liver
Gall bladder
COMMON BILE DUCT
PORTAL VEIN
SPLEEN
NORMAL

11. SERUM PROTEIN ELECTROPHORESIS
SHOWED
HYPERGAMAGLOBULINEMIA (POLYCLONAL)

12. Other Tests
HIV-I and II-------Non-reactive
Hep-B and C------Non-reactive

13. RENAL BIOPSY (NEEDLE) REPORT
25/09/16
RESULT
RENAL AMYLOIDOSIS WITH GLOMERULAR AND
VASCULAR DEPOSITION OF AMYLOID

14. DIAGNOSIS
NEPHROTIC SYNDROME

15. EPIDEMIOLOGY
Nephrotic syndrome is relatively rare but important
manifestation of kidney disease with a incidence of 3
new cases per 100,000 each year in adults and has
serious complications , caused by a number of
primary and secondary glomerular diseases
Reference : PatientPLUS , Document ID-2505(v24)

16. MEDICATIONS CHART
DRUG ROA DOSE RREQ DAYS 10/09/16 0nwards
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
TORASEMIDE
(DYTOR)
ORAL 10mg BD  
PANTOPRAZOLE
SODIUM
(PANTACID)
ORAL 40mg ODAC                
ATORVASTATIN
AND
FENOFIBRATE
(ATORLIP-F)
ORAL 10/160
mg
OD HS             
FUROSEMIDE
(LASIX)
I.V 60mg BD               
PIPERACILLIN
AND
TAZOBACTAM
(PIPZO)
I.V 4/0.5g OD               

17. DRUG ROA DOSE RREQ DAYS 10/09/16 0NWARDS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
TRYPSIN,
BROMELAIN
AND RUTOSIDE
(ENZOMAC)
ORAL 40mg,
90mg,
100mg
TD               
TRAMADOL
I.M 50mg S0S 
LEVOTHYROXINE
(THYRONORM)
ORAL 50mg OD AC               
TRANEXIMIC
ACID
(TRANOSTAT)
I.V 1 AMP STATIM 

18. DRUG ROA DOSE RREQ DAYS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PREDNISOLONE
(OMNACORTIL)
ORAL 10mg BD        
CALCIUM
CARBONATE
AND VITAMIN D
(SHELCAL)
ORAL 500mg OD       
ATORVASTATIN
(ATORLIP)
ORAL 10mg OD
HS
  

19. Patient was discharged on
request on 26/09/16

20. DISCHARGE MEDICATIONS
 TABLET OMNACORTIL (PREDNISOLONE) 20mg 2 tab for
one week
• Followed by 20mg 1 and half tab for 0ne week
• Followed by20 mg 1 tab for 1 week
• Followed by 10mg 1 tab for 10 days
 TABLET THYRONORM 75mg OD
 TABLET PANTACID 40mg OD BBF
 TABLET ATORLIP 20mg OD
 TABLET LASIX 60mg BD till swelling subsides
FOLLOW UP
HEMATOLOGY AND NEPHROLOGY OPD EVERY 2 WEEKS

21. PHARMACEUTICAL ISSUES AND SUGGESSIONS
 Concurrent use of statins and fibrates increase the risk of
Rhabdomyolysis and Myopathy and the risk is more in eldery
and renal disease patients
SUGGESTION
CREATINE KINASE levels should be monitored regularly
 As a general rule any patient given a statin and fibrate should
be told to report any signs of myopathy and possible
RHABDOMYOLYSIS( unexplained muscle pain, tenderness,
weakness or dark urine)
 If Myopathy does occur the statin should be stopped
immediately or dose adjusted and monitored closely.
 Generally a lower dose of statin with fibrate is recommended

22. •CYP3A4 inhibitors like macrolide antibiotics ,
azole antifungals if required should be prescribed
very cautiously for a patient on statins –High risk
of rhabdomyolysis
 Monitoring of liver function is recommended
for all statins to rule out any toxicity to liver

23.  High dose of any corticosteriod can produce
hypokalemia via mineralocorticoid action which is
further increased by concurrent administration of
Ferusemide and may produce symptoms of
muscle pain/cramps, confusion , dizziness etc
SUGGESTION
• Increase dietary intake of potassium
• Supplements of Potassium chloride
• Concurrent use of Potassium sparing diuretic
• Dose adjustment

24. PREDNISOLONE may elevate serum TG and LDL levels if used
for prolonged period
SUGGESTION
Close monitoring of lipid levels and dose titration
 PREDNISOLONE may also increases blood
coagulability
SUGGESTION
Since the patient is already at risk of
thromboembolism due to loss of anthithrombin-III
close monitoring of PT is necessary to prevent any
complication

25. Response to Prednisolone should be closely
monitored because there are variations in
response to Corticosteroids which include:
Corticosteroid sensitive patients
Corticosteroid resistant patients or Late steroid
responders
Corticosteroid intolerant patients
Corticosteroid dependent patients

26. One of the complication of disease is immune
deficiency due to leakage of immunoglobulin's
and loss of proteins in general making the patient
prone to infections ,so, the patient should be
prescribed appropriate antibiotics and should not
stop taking antibiotic unless told because the
patient is taking PREDNISOLONE which has
IMMUNOSUPRESSANT action further increasing
risk of infections.

27. Concurrent administration of Levothyroxine
with calcium containing products (SHELCAL)
reduces its oral bioavailability by nonspecific
adsorption of levothyroxine to calcium carbonate
at acidic pH
SUGGESTION
Patient should be advised to take Levothyroxine with
a gap of at least 4 hours after or before any calcium
and iron containing products, sucralfate,PPIs

28. Patient was given Tranostat I.V after renal
biopsy to watch for haematuria
SUGGESTION
TRANSTAT being antifibrinolytic and given I.V may
increases the risk of thrombus formation since the
patient is already at risk of thromboembolism
therefore it should be given cautiously and the
patient should be monitored closely for any
thromboembolic complication.

29. Other Suggestions
Chances of embolism increases at rest so, Doctor should
consider this
Patient could be recommended DOPPLER ULTRASOUND to check
any thromboembolic complication
Growth retardation occurs due to loss of proteins and steroid
therapy so the patient should be prescribed suitable
supplements

30. LIFE STYLE MODIFICATIONS
 Low fat , low cholesterol diet
 limitation of saturated and trans fats
 salt restriction
 Lean sources of protein
 Exercise to prevent thromboembolic complications
 Patient should be advised not to take any other medication
without doctors or pharmacists consultation since there are various
complications of the SYNDROME which restricts the use or require
close monitoring of various drugs