frequent relapse nephrotic syndrome

1. Presenter : Dr Rupak Das
First year PGT
Department of Pediatrics
IGM Hospital

2. Introduction
 As per pattern of response to corticosteroid therapy
Nephrotic syndrome is classified as
TYPES CRITERIA
Remission Protein free urine for 3 consecutive days
Relapse Proteinuria for 3 consecutive days
Infrequent relapses Responder with 1 relapse in 6 months
Frequent relapses Responder with ≥ 2 relapse in 6 months or ≥ 4 in 1 yr
Steroid dependent Occurrence of 2 relapses during alt day steroid therapy or within
2 wks of discontinuation
Initial resistance Absence of remission despite steroid treatment for 2 wks
Late responder Patient with initial resistance who responded later on
Late resistance Initial responder who subsequently developed resistance

3. Basic details
 Name : Utkarsh Banik
 Fathers name : Late Uttam Banik
 Mothers name : Gouri Pal Banik (informant)
 Age : 4yrs 7 months
 Sex : Male
 Address : Jogendranagar
 Date of admission : 13/02/2019
 Date of discharge : 07/03/2019
 Period of hospital stay : 22 days

4. Present and past history of illness
 Chief complaints : swelling of whole body x 7days
pain abdomen x 1 night
 History of present illness :
Swelling of both limbs started about 10 days back →
then face → abdomen → finally whole body
Decrease in urine output for last 4 days; Urine was
normal in colour which turned mild yellowish after
steroid therapy
From night before admission he started having pain
abdomen along with mild temperature

5. Contd.
 History of past illness :
Patient is a known case of nephrotic syndrome
with history of relapse 5 times in last 1 year. Even after
giving oral steroids there was relapse within 10 days of
completion of treatment. No history of pain abdomen
earlier.
 Family history and other histories are insignificant

6. • BP- 90/60 mm of Hg
•Pulse rate- 96/min
•Respiratory rate-28/min
•Temperature- 99˚F
•Weight – 20kg
•Height – 101cm
•Respiratory system-
Chest clear B/L with occasional
wheeze
•Cardio-vascular system-
NAD
•Central nervous system-NAD
•Abdomen -
distended, fluid thrill +,
shifting dullness +, no
organomegaly, everted
umbilicus, tenderness present
all over abdomen with mild
guarding

7. Investigations
Date 13/2/19
Day 1
20/2/19
Day7
27/2/19
Day 14
2/3/19
Day17
Serum urea 22 41 32
Serum
creatinine
0.5 0.6 0.6
Serum total
Protein
4.1 3.27
Serum
Albumin
1.5 1.39
C3 level 163.3
Random
plasma
Glucose
99

8. Contd.
 Serum electrolytes :
 Urine examination
Date 14/02/19
Serum sodium 134.4
Serum potassium 4.4
Serum chloride 99.2
13/02/19 21/02/19 26/02/19 5/3/19
Protein
+++
Protein
+++
Protein
+++
Protein
Absent

9. Other lab investigations
 Serum bilirubin : 0.2
 SGOT : 21
 SGPT : 8
 Serum cholesterol : 300mg/dl (13/02/19)
 Chest X ray findings : suggestive of pneumonitis in
right upper and middle lobe
 Report of blood examination : (13/02/19)
Hb- 11.1 %; TLC- 7300; DLC- N-54,L-46; plt count- 1.82
lakh
 Stool routine examination: within normal limits

10. VBG results
Parameter
(Normal
Range)
Day 12 Day 16 Day 17
Sodium
(135-145)
128 126 132
Pottasium
(3.5-5.1)
2.9 5.2 2.2
Calcium
(1.12-1.32)
0.76 0.81 0.56
pO2
(30-40)
23 36 30
pCO2
(41-51)
34 43 47
Hb%
(12-17) gm%
14.1 12.7 10.9
pH
(7.20-7.60)
7.47 7.34 7.38

11. Diagnosis
 Provisional Diagnosis :
Frequent relapse nephrotic syndrome with anasarca
with peritonitis (clinical)
 Other Causes of pain abdomen in nephrotic
syndrome :
a) acute gastroenteritis
b) UTI
c) umbilical or inguinal hernias
d) referred pain from pneumonia
e) acute appendicitis
f) intussusception

12. Management
 Patient was started with :-
 IV antibiotic Inj ceftriaxone with tazobacum
 IV diuretics (frusemide)
 IV stress dose of steroid (Inj Hydocortisone)
 Nil orally as peritonitis
 IV maintenance fluid
 Salbutamol nebulisation

13. Contd.
 Patient was improving with this regime
 Oral diet was gradually started
 On Day 7 the patient developed loose motion and
increased cough
 Inj metrogyl was added along with IV replacement fluid
 As there was no improvement of loose motion and cough
antibiotic was changed to Inj levofloxacin and Inj
netilmicin after omitting Inj ceftriaxone and tazobactum
 All antibiotics were given in corrected dose according to
GFR
 Budesonide nebulisation was added

14.  On Day 12 patient developed hyponatremia with
hypoklemia with hypocalcemia though his initial
electrolytes were normal
 Considering hyponatremia to be dilutional
hyponatremia, fluid restriction was done and dose of
diuretic was enhanced. Aldactone was added. Orally
potassium and calcium was supplemented
 By Day 14 loose motion was controlled but his
anasarca increased
 So we started albumin infusion as his repeated
albumin was low
Contd.

15.  On Day 16 patient developed convulsion (status)
 Causes of convulsion could be:
1) Hyponatremia
2) Cerebral venous sinus thrombosis
3) Galloway Mowatt Syndrome
 NCCT brain was need of the hour but failed to do as GC
was poor and facility was not available in hospital
 VBG was done.
 Hyponatremia was recorded along with hypocalcemia
 Initially we gave per rectal Inj diazepam 2 doses
 As convulsion was not controlled loaded with Inj eptoin
Contd.

16.  But still convulsion was not controlled
 Then we started Inj 3% NaCl and Inj calcium
gluconate
 Subsequently convulsion was controlled
 Oral eptoin continued and patient was started with
treatment for relapse with corticosteroid
Contd.

17.  Patient started to respond positively to the treatment
 Proteinuria subsided
 Eptoin withdrawn
 Patient was successfully discharged on Day 22 with the
advice to continue steroid therapy as that of relapse
 And to do NCCT brain and an EEG
Contd.

18. Follow up
 After completion of
steroid therapy for relapse
now the patient is on
routine follow up
 Treatment he is receiving
currently:
 Prednisolone 0.5mg/kg
every alternate day
 Levamisole 2mg/kg every
alternate day

19. Significance
 Clinical evaluation of a patient is of utmost
importance as facilities for investigation like CT scan
and renal biopsy is not available with us
 This case highlighted the importance of management
of electrolyte imbalance mainly hyponatremia
 Recent advances in management of hyponatremia are
given in a table in the next slide

20. United States Guidelines European Union Guidelines
Acute or
symptomatic
hyponatremia
Continuous infusion 3% NaCl
(0.5-2ml /kg/hr)
Bolous 3% NaCl (150 ml 0ver 20
minutes once)
Chronic
hyponatremia
1) SIADH
2) Hypovolemic
hyponatremia
3) Hypervolemic
hyponatremia
Fluid restriction (first line)
Demelocycline, urea or vaptan
(second line)
Isotonic saline
Fluid restriction
Fluid restriction (first line)
Urea or loop diuretics + oral NaCl
(second line)
Isotonic saline or balanced
crystalloid solution
Fluid restriction
Hoorn EJ, Zietse R. Diagnosis and treatment of
hyponatremia: Compilation of the guidelines. J Am Soc
Nephrol. 2017;28:1340–9

21. Take home message
 While managing a case of nephrotic syndrome a
periodical analysis of serum electrolyte should be done
to avoid severe complications due to electrolyte
imbalance.

22. Thank
you