Case presentation of frequent relapsing nephrotic syndrome

1. CASE PRESENTATION ON
Frequent Relapsing Nephrotic
Syndrome
FLEMIN THOMAS, 11Q0407

2. Nephrotic syndrome
 Important chronic disease in children.
 Nephrotic syndrome is a kidney disorder that
causes body to excrete too much protein in
urine.
 The glomeruli are affected by an inflammation
or hyalinization that allows proteins such as
albumin, antithrombin or immunoglobulins to
pass through the cell membrane and appear in
urine
 “Minimal change disease” can usually be
treated with drug prednisone, but this type of

3.  It is a nonspecific kidney disorder
characterized by three signs of diseases:
 Large proteinuria: loss of protein through
the kidneys
 Hypoalbuminemia : low albumin levels in
the blood
 Edema : water to be drawn into soft
tissues

4. Causes
Nephrotic syndrome is caused by different disorders that
damage the kidneys. This damage leads to the release of too
much protein in the urine.
 The most common cause in children is minimal change
disease. Membranous glomerulonephritis is the most
common cause in adults.
This condition can also occur from:
 Cancer
 Diseases such as diabetes, systemic lupus erythematosus,
multiple myeloma, and amyloidosis
 Genetic disorders
 Immune disorders
 Infections (such as strep throat, hepatitis, or mononucleosis)

5.  Nephrotic syndrome can affect all age groups. In
children, it is most common between ages 2 and 6.
 This disorder occurs slightly more often in males than
females.

6. Symptoms
Swelling (oedema) is the most common symptom. It may
occur:
 In the face and around the eyes (facial swelling)
 In the arms and legs, especially in the feet and ankles
 In the belly area (swollen abdomen)
Other symptoms include:
 Foamy appearance of the urine
 Poor appetite
 Weight gain (unintentional) from fluid retention

7. PATIENT DETAILS
 PATIENT NAME:XYZ
 AGE: 5
 WEIGHT : 18.1Kgs
 IP.NO: 204
 DEPT: pediatrics (PICU)
 UNIT:C
 DOA: 02 - 01 – 2016
 DOD : 5-01-2016

8. REASON FOR ADMISSION:
c/o fever since 7 days , cough since 3 days ,
puffiness of face and leg swelling since 5 days

9. History of present illness
 Child was apparently alright one week back
,then he developed fever which was mild to
moderate grade not associated with chills
,intermittent type.
 c/o facial swelling and lower limb swelling
since 5 days it was insedious in oneset
,progressive.
Cough since 3days ,non productive type,
no h/o hurried breathing and no h/o loose stools

10. Past medical history
 k/c/o Nephrotic syndrome is diagnosed at the
age of 1 year old and is on medication during
the episodes.
 h/o frequent similar complaints every 6 months
in one year of span.

11. FAMILY HISTORY:
 No h/o similar complaints in the family
members
 No h/o TB, epilepsy in the family members.
 Immunization :
 BCG+
 DPT 1 2 3+ – booster dose not given
 Measles vaccination+

12. GPE/SE
 Pulse +++/++,
110bpm
 BP- 90/54mmhg
 RR- 30cpm
 Afebrile
 CVS – s1s2+ no
murmur
 RS- B/L AEE, B/L
crepts+
 CNS: intact
 P/A :soft, nontender
no organomegaly

13. 13
LABORATORY DATA
HEMATOLOGYInvestigation Normal range 30-12-15
Hb (13.5-17.5g/dl) 9.8 ↓
CBC:
•WBC
(4,500-10,500cells/uL) 11,600
DLC:
•Polymorphs (37-73%)
74
•Basophils (0-1%) 00
•Eosinophils (0-5%) 00
•Lymphocytes (20-40%) 26
•Monocytes (0-7%) 00
RBC (4.7-6.1million/uL) 5.01 ↓
Platelets (150,000-450,000cells/mm3) 351000 ↓

14. ELECTROLYTES
Investigation Normal range 31-12-15 1-1-16
Sodium (135-147mEq/L) 128 130
Potassium (3.5-5.2mEq/L) 2.7 3.4
Chlorides (95-107mEq/L) 93 99
ESR 75mm
PS study : microcytic hypochromic anemia with
relative neutrophilia

15.  Albumin (3.5 -5.2gm%) : 1.5 gm%
 Sr. urea : 73.0gm%
 Sr.creatinine : 0.4mg/dl
 Urine routine test – albumin present

16. TREATMENT CHART
BRAND NAME GENERIC NAME DOSE R FQ. 1 2 3 4 5
IVF DNS@56ml/hr
with 10 cc kcl
y 5c
c
kcl
Inj.Augmentin Amoxacillin+clavula
nic acid
550mg iv tid y y y y y
Neb. Asthalin salbutamol qid y y y y y
Syp. Pacimol DS paracetamol 5.5ml po tid y y y Y
Tab. Lasilactone Furosemide+spirino
lactone
20/50
mg
po ½-0-
½
y y y y
Tab.Amlong amlodipine 0.2mg po ½-½-
0
y y y
Inj. Levoflox Levofloxacin 36ml iv od y y y
Inj.vit k Vitamin k 1 amp 1mg OD po y y y

17. DAY 1:
 O/E:
pt is afebrile.
PR:110 bpm. BP:90/60 mmhg.
RS- B/L crepts+
P/A:soft, distented,no organomegaly.

18. DAY 2
 c/o cough, oedema +
 BP- 112/80mmhg
 Pulse-98bpm
 Rr-30cpm
 Urine albumin+
 P/A: soft ,nontender ,no organomegaly
 UO – 2.2ml/kg/hr

19. DAY 3:
Pulse: 98bpm. BP:
112/80 mmHg.
NFC
O/E
 CVS- S1S2 present.
 RS- B/L crepts+
 P/A- Soft, nontender,no organomegaly.
UO- 2.1ml/kg/hr

20. DAY 4
Pulse: 120bpm
BP:130/90mmhg
RS-B/L crepts+
UO- 3.7ml/kg/hr
P/A: soft, non tender,no organomegaly

21. Day 5
 Patient stabilized
 NFC
 BP-110/90mmhg
 Pulse- 100bpm
 Edema reduced, cough reduced
 All vitals stabilized
 Adv. For discharge

22. Discharge medications
Brand name Generic
name
dose Route frequency Nos.
Tab.amlong Amlodipine 0.2mg po ½-½-0 7
Syp.pacimol paracetamol sos
Advised salt
restricted
diet.
Review after 7 days in paediatric OPD.

23. PHARMACEUTICAL CARE
PLANS
 PUFFINESS OF
FACE AND LEG
SWELLING
 PITTING EDEMA
OVER THE LEGS.
 ABDOMINAL
DISTENTION
 k/c/o Nephrotic
syndrome
 Hb- 9.8g/dl
 ESR-75mm/hr
 WBC-11,600cells/uL
 Albumin -1.5gm%
 Sr.urea -73gm%
SUBJECTIVE EVIDENCES OBJECTIVE EVIDENCES

24. ASSESEMENT:
 By observing the subjective and objective
evidence it is diagnosed as frequent relapsing
nephrotic syndrome.

25. THERAPEUTIC GOALS:
 To reduce the signs and symptoms such as
pitting edema and facial puffiness.
 To reduce the cough.

26. MONITORING PARAMETERS:
 To monitor BP,PULSE RATE, urine output.
 To monitor the albumin level in blood and
infections .

27. Standard recommendation
Managing Children With Nephrotic
Syndrome.
 Diet: A balanced diet, adequate in protein (1.5-2
g/kg) and calories is recommended. Patients with
persistent proteinuria should receive 2-2.5 g/kg of
protein daily.
 Edema: Patients with persistent edema and weight
gain of 7-10% are treated with oral frusemide (1-3
mg/kg daily).
 Additional treatment with potassium sparing diuretics
is not required if frusemide is used at this dose for
less than one week. Patients requiring higher doses
and prolonged duration of treatment with frusemide

28.  Immunization: Parents should be advised
regarding the need for completing the primary
immunization.Administration of some
vaccines, e.g., hepatitis B,measles-mumps-
rubella or meningococcal vaccines may rarely
precipitate a relapse.

29. PATIENT COUNCELLING:
 ABOUT THE DISEASE:Parental motivation and
involvement is essential in the long-term
management of these children.
 Thrombosis: Children with nephrotic syndrome are
at risk for venous and, rarely, arterial thrombosis
 Children with nephrotic syndrome are susceptible to
severe infections, which need prompt treatment.
 ABOUT THE DRUGS:Parents should be advised
regarding the need for completing the primary
immunization.
 Drugs should be taken at the right time with right

30. ABOUT THE LIFE STYLE MODIFICATIONS:
 A low-salt diet may help with swelling in the hands and
legs. Water pills (diuretics) may also help with this
problem.
 Low-protein diets may be helpful. 1 gram of protein per
kilogram of body weight per day.
 You may need vitamin D supplements if nephrotic
syndrome is long-term and not responding to
treatment.

31. THANK YOU