A 17-year-old female presented with swelling of both lower limbs and was found to have renal impairment. She had fever, nausea, vomiting and progressive bilateral lower limb edema over the past week. One month prior she was treated for lower limb edema with prednisolone and was discovered to have renal impairment. On examination, she had pallor, neck vein congestion, lower limb edema, and mild pericardial effusion. Laboratory tests showed renal impairment with nephrotic range proteinuria. She was treated conservatively but did not improve and required hemodialysis. She underwent plasmapheresis and immunosuppression without recovery of renal function.

1. Case presentation
Presented By
Dr. Mohamed Yaseen
Nephrology Resident
New Mansoura General Hospital

2. A 17 years old female patient, from
Dakhalia,single, No Special habits of
medical importance .

3. Complaint
Swelling of both lower limb
Accidentally discovered renal
impairment one month ago.

4. Present History
 The condition started by fever, nausea and vomiting 1 week
ago of gradual onset and progressive course associated with
bilateral lower limb edema and persistent headache .
 One month prior to our admission, Patient discovered renal
impairment when seeked medical advice for lower limb
oedema and received prednisolone 60 mg daily as patient
treated as nephrotic syndrome.
 Two month prior to admission , patient has normal renal
function ( s.creatinine 0.6)

5. Past history
No past history of diabetes or
hypertension

6. Family history
Irrelevant

7. Examination on Admission
 Vital signs :
BL. Pressure : 140/90 mmHg R.R : 22 /min
Temperature: 38C Pulse: 100 /min.
 General : pallor , No jaundice , No cyanosis.
 Neck & head: Congested non pulsating neck veins .
 Abdomen : Lax with no organomegally
 Chest : decrease air entry on right side
 Cardiac : Tachycardia .
 Bilateral lower limb edema.
 Other: axillary L.N.

8. Investigations on Admission
4 mg/dlCreatnine
295 mg/dlUrea
8Wbcs
7 gmHB
65.000Plt
2.1 mg/dlAlbumin
resultUrine
analysis
8-10Pus cell
50-55RBCs
++Protein
granularcast
225S.Chols.
190TGS
1.2INR
o.5T.Bil
134Na
6.7mg/dlCa
10 mg/dlPo4
46CK
15 mg/dlUric acid
5.1 mg/dlk

9. Investigations on Admission
7.38PH
17HCO3
30PCO2
ve_HCV Ab
8.7(low)C3
1.3 (low)C4
_veANA
_veAds DNA

10. Urinary Albuminin/Creatinine ratio
5120 mg/g

11. Investigations on Admission
Blood Film : No Schistocytes Detected .
Abdominal U/S : normal
U/S on axillary region : few reactive L.N. with
preserved shape and hilum.
ECHO: Mild pericardial effusion, EF 63%

16. Management
Patient started the following regimen:
Fluid chart
Prednisolone 60 mg/day
Albumin /12 h
Furosomide 40 mg /12 h(just after albumin)
Acetylsalicylic acid 150 mg daily
Atorvast 20 mg once at night
Tienam 500 mg /12h
Paracetamol 1000 mg infusion(as needed)

17. FEW DAYS LATER
-The patient after few days on
previous treatment show no
improvement either clinically or
laboratory with rising s.creatinine.
-Patient still oliguric(400 ml/day)
-Patient still overloaded and
dyspneic
-Patient initiated haemodialysis
sessions.

18. Later on:
Patient received repeated plasmapharesis
sessions|(5 sessions)
Cellecept 500mcg 2×2
Patient remains oliguric with still high
s.creatinine