The document provides information on proteinuria in children. It discusses the basics of proteinuria including normal protein excretion and causes of increased protein excretion. It describes evaluating proteinuria using urine dipsticks, 24-hour urine protein tests, and urine protein-to-creatinine ratios. It distinguishes between transient, orthostatic, and fixed proteinuria. The document outlines evaluating and managing nephrotic syndrome in children including pathogenesis, clinical consequences, idiopathic nephrotic syndrome types, treatment including steroids and relapse therapy, and immunizations.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
introduction for renal system
nephron
protein & urine
definition of microalbuminuria
causes
atherosclerosis role
DM role (micro¯ovascular changes due to atherosclerosis )
Hypertension role
possible sign and symptoms associated with microalbuminuria
enjoooooooooy ....... :)
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Liver Function Tests - An Approach for Primary CareJarrod Lee
This presentation is aimed at primary care physicians. It covers the fundamentals of liver function tests, including the basic principles of interpretation, and the key patterns of abnormalities. The focus is on how to approach liver function tests in a primary care setting.
Hematuria is the presence of blood in a person’s urine. The two types of hematuria are
gross hematuria—when a person can see the blood in his or her urine
microscopic hematuria—when a person cannot see the blood in his or her urine, yet it is seen under a microscope
introduction for renal system
nephron
protein & urine
definition of microalbuminuria
causes
atherosclerosis role
DM role (micro¯ovascular changes due to atherosclerosis )
Hypertension role
possible sign and symptoms associated with microalbuminuria
enjoooooooooy ....... :)
This was a review of different guidelines on lupus nephritis from ACR, EULAR, and KDIGO. Goal is appreciate similarities and differences between the different guidelines.
Liver Function Tests - An Approach for Primary CareJarrod Lee
This presentation is aimed at primary care physicians. It covers the fundamentals of liver function tests, including the basic principles of interpretation, and the key patterns of abnormalities. The focus is on how to approach liver function tests in a primary care setting.
Hematuria is the presence of blood in a person’s urine. The two types of hematuria are
gross hematuria—when a person can see the blood in his or her urine
microscopic hematuria—when a person cannot see the blood in his or her urine, yet it is seen under a microscope
LAB INVESTIGATIONS IN ORAL AND MAXILLOFACIAL SURGERYPunam Nagargoje
• INTRODUCTION
• Diagnosis & identification - disease by careful investigation of patients signs, symptoms and history
• Times when more information is required through the use of diagnostic tests.
• Clinical and/or lab data must be used to distinguish between different diagnoses.
• laboratory tests - important in assisting & management of the patient during treatment of disease besides diagnosis.
1. screen - disease in asymptomatic individual
2. to establish or exclude presence of diseases in symptomatic patients
3. assist the practitioner in the management of the patient.
• CBC
• Hemoglobin & Hematocrit
• Hemoglobin :
M: 13.8 to 17.2 gm/dL
F: 12.1 to 15.1 gm/dL
Hematocrit : (packed cell volume)
• It is ratio of the volume of red cell to the volume of whole blood.
M: 40.7 to 50.3 %
F: 36.1 to 44.3 %
• ERYTHROCYTE SEDIMENTATION RATE [ESR]
• Normal range-
male = 0 to 20mm/hr
female = 0 to 10mm/hr
• Non specific test
• Eleveted in infections ,infarctions, trauma , or tumours.
• The Reticulocyte Count
• This important value is needed in the evaluation of any anemia.
• Normal range 1-2%
• Retic count goes up with
– Hemolytic anemia
– Retic goes down with
– Nutritional deficiencies
• _ Diseases of the bone marrow itself
• Clinical importance
• Hematocrit is valuable in evaluating polycythemia, anemia and blood loss.
• RBC count provides a gross estimate of the bodys oxygen carrying capacity and used in red blood cell indices.
• NEUTROPHIL
• polymorphneuclear leukocytes (PMN,s)
• Nucleus 3-5 lobes.
• Diameter 10-14 µm
• 50-70% WBC
• Function: Phagocytosis of bacteria and cell debris
• Numbers rise with all manner of stress, especially bacterial infections
• Neutrophil disorders
– Neutrophilia – an increase in neutrophils
– Conditions associated with neutrophilia are:
1-Bacterial infections (most common cause)
2-Tissue destruction
e.g. tissue infarctions, burns.
3- leukemoid reaction
4-Leukemia
• NEUTROPENIA
• Decrease in neutrophill count
• Conditions associated ;
1. Certain infections- typhoid, malaria
2. Drugs , chemical and physical agent
3. Certain hematological diseases; aplastic anemia.
• EOSINOPHIL
• Bilobed nucleus
• 1-5% of WBC
• Diameter about 10-14 µm
• Function: Involved in allergy, parasitic infections
• Contains: Eosinophilic granules
– Eosinophilia may be found in
• Parasitic infections
• Allergic conditions and hypersensitivity reaction
• LYMPHOCYTES
• No specific granules
• 20-40% of WBC
• Diameter 8-10 µm
• T cells: cellular
• (for viral infections)
• B cells: humoral (antibody)
• Natural Killer Cells
• Lymphocytosis – may indicate
_ Viral infection
e.g. Infectious mononucleosis, CMV or pertussis.
_ Bacterial infection
e.g. TB
• Lymphopenia – caused by
• _Stress.
• _Steroid therapy
• _ Irradiation
• Abnormal result of WBC
• (Leukocytosis) may indicate:
• _ Infectious diseases
• _Inflammatory disease (such
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
ICH Guidelines for Pharmacovigilance.pdfNEHA GUPTA
The "ICH Guidelines for Pharmacovigilance" PDF provides a comprehensive overview of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines related to pharmacovigilance. These guidelines aim to ensure that drugs are safe and effective for patients by monitoring and assessing adverse effects, ensuring proper reporting systems, and improving risk management practices. The document is essential for professionals in the pharmaceutical industry, regulatory authorities, and healthcare providers, offering detailed procedures and standards for pharmacovigilance activities to enhance drug safety and protect public health.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
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Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
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2. BASICS
• Significant amounts of albumin, globulin etc are reabsorbed in PCT
• ‘Normal’ protein excreted in urine is Tamm-Horsefall *
• PROTENIURIA
• Glomerular
• Tubular
• ↑ production of plasma proteins
3.
4. BASICS……….CONTD.
• Dipsticks primarily detect albumin(1+ to 4+)
• False +ve ur. pH>7, concentrated urine, blood, pyuria
• False –Ve ur. pH<4.5, dilute urine, non-albumin
proteinuria(BJ, γ-glob)
• Protein excretion
• Normal <4mg/m2
• Abnormal-4-40 (Tubular)
• Nephrotic range >40
5.
6. URINE PROTEIN : CREATININE RATIO (UPC RATIO)
• Has largely replaced 24 hours Urinary Protein estimation
• Ur. Protein Conc. (mg/dL)/Ur. Creatinine Conc.(mg/dL)
• Done on 1st morning sample*
• Normal values: <0.5 in 0-2 yrs, <0.2 in >2 yrs
• UPC >2 Nephrotic range
• Microalbuminuria#- to detect diabetic nephropathy/obesity
7. TRANSIENT V/S ORTHOSTATIC PROTEINURIA
Transient Protenuria(TP)
Fever
Exercise
Cold Exposure
Seizures
Dehydration
CHF
Stress
Orthostatic Proteinuria(OP)
Most common in school going kids
Can go up to 1000 mg/24 hrs
No hematuria/HTN/edema/oliguria/
hypoalbuminemia
Correct collection of 1st sample is critical
Absence of Pr’uria & UPC<0.2 in 1st
morning sample on 3 consecutive days OP
8. FIXED PROTEINURIA (FP)
Glomerular plus
PIGN-HCV HBV IE HIV
HSP
SLE
Alport
Serum Sickness
Tubular
Cystinosis
Fanconi
Wilson
Lowe’s
Galactosemia
ATN
Renal Dysplasis
PKD
Drugs(AG)
Glomerular Isolated
Idiopathic NS
FSG
MPGN
MN
Diab NP
Sec causes
FP Urine with Sp.Gr.>1.015 having Pr>1+ on dipstick OR UPC > 0.2
9. EVALUATION OF A CHILD WITH PROTEINURIA
Persistent Asymptomatic Proteinuria
mostly glomerular in origin
Such pts should be evaluated every
4-6 mo for
B.P/Creatinine/UPC/Hematuria
Tubular Proteinuria
Low grade-UPC 0.2-1.0
Initial Evaluation
UPC
S. Creatinine
Electrolytes
S. Albumin
C3/C4
ANA
Indications for Renal Biopsy
UPC>1.0 – Increasing
trend
Hematuria
HTN
↓ Renal Function
11. PATHOGENESIS• Basic path↑permeability of glomerular
capillary wall
• Crucial role of PODOCYTE-highly specialized
cell-it’s a visceral epith cell lining the GBM
• 2 Podocytes are connected by – Slit
Diaphragm
• Slit Diaphragm- regulates protein filtration-
not just a passive filter-contains Signaling
proteins
12.
13. PATHOGENETIC MECHANISMS
• Signaling proteins (Podocyte Proteins)-
• Nephrin
• Podocin
• CD2AP
• ∝-Actinin4
• Immune/Non Immune insults to Podocytes cause
• Foot process effacement
• ↓ no of functional podocyte
• Altered slit diaphragm permeability
Podocyte injury or
genetic mutations of
genes producing
signaling proteins cause
nephrotic proteinuria
15. CLINICAL CONSEQUENCES OF NS-I
• Edema- most common symptom
• Cause – not clear-
• Underfill Hypothesis
• Overfill Hypothesis
• AIM is to gradually ↓ edema by careful use of diuretics, sos IV
Albumin
• Hypocalcemia
• Not a true hypocalcemia-due to ↓Se Albumin
• Due to urinary loss of Vit D binding protein
16. CLINICAL CONSEQUENCES OF NS-II
• Infections- ↑ed susceptibility
• Due to urinary Loss of IgG, C3, C5, alt pathway Factors B & D,
impaired opsonization capacity-due to loss of Properdin factor B
• ↑ risk of infection with encap. Bact esp PC, and Gr-ve bactSBP
• So child with NS c/o pain abdomen + fever- be alert to possibility of
SBP besides Mesenteric ischemia sec. to hypovolemia
17. CLINICAL CONSEQUENCES OF NS-III
• Hypercoagulability
• Due to vascular stasis/hemoconcn/ ↑plt ct/ ↑coag. F
levels
• ↑ed platelet counts with ↑ed aggregation
• ↑production of Fibrinogen & Ur loss of Antithrombotic f’s
(antithrombin III & protein ‘S’ & ‘C’)
• DVT Cerebral vein thrombosis, Renal V thrombosis pulm
v thrombosis
• Altered endothelial function
18. CLINICAL CONSEQUENCES OF NS-IV
• Hyperlipidemia-
• ↑Cholesterol, TGs,
• ↑ in LDL & VLDLsevere disease
• HDL normal
• Low Oncotic pressure triggers hepatic lipoprotein synthesis
• ↑es risk of MI & risk of progression to ESRD
21. IDIOPATHIC NS-1
• 90% kids with NS are Idiopathic- MCD
• Rest are-
• Focal & Segmental Glomerulosclerosis
• Membranous Nephropathy
• Membranoproliferative GN
• Mesangial Proliferation
• In MCD/MP- ↑ed no of mesangial cells & effacement of foot processes- 50% respond to
steroids
• In FSG-scarring of Glomerular tuft with ↓glom cap lumen- 20% respond to steroids
22. IDIOPATHIC NS-2
• M>F, 2:1, 2-6 years median age, can be seen as early as 6 months
• If an adolescent presents with NSFSG
• ATYPICAL FEATURES
• Ass. Hematuria
• HTN (Nephritic pic)
• Age<1
• +ve family h/o NS
• Presents with ARF
• DD in a child with Edema++++ PLE, CHF, Hepatic Failure, PEM, AGN
Against
diagnosis of
MCD
23. • C3
• ANA
• dS DNA
• HBsAg
• HCV
• HIV
• Renal Biopsy
DIAGNOSIS OF IDIOPATHIC NEPHROTIC SYNDROME
UPC
BUN/Creatinine
S.Albumin
Lipid profile
Electrolytes
IN
ALL
KIDS
IN KIDS >10 YRS
TO R/O SEC. FORMS
24. TREATMENT OF MCD-NS
• Short Admission is necessary
• TB must be r/o with MT & IGT
• Indications for RENAL BIOPSY
• HTN
• Hematuria(gross)
• <1 yr or >12 yrs
• ↓C3
• ARF
STEROID THERAPY
Prednisolone@60mg/m2 OR 2mg/kg single
dose(AM) or 4-6 weeks
Followed by
40 mg/m2 or 1.5 mg/kg qod for 8-20 weeks
Fb tapering over 2-5 months
FOLLOW UP
Adv. UPC every 2-3 weeks to see control of
proteinuria
Anthropometry & BP check
Periodic S. Albumin & Cholesterol levels
25.
26. • RESPONSE-
• Remission within 1st
4 wks
RELAPSE-UPC>2.0 or DS>2+
for 3 consec days
REMISSION-
UPC<0.2/DS <1+
for 3 consec. days
FREQUENT RELAPSING
2 or > in 1st 6 mo OR
Or >4 in 12 mo
STEROID DEPENDENT
Relapse during steroid tapering or
within 1st 2 wks of stopping Rx
STEROID RESISTANCE
No remission in 4 wks of
steroid Rx
27. RX OF SEQUELAE
EDEMA
Na restriction(1.5 g/day)
Fluid restriction
Frusemide-very cautiously
25% Albumin fb Lasix
DYSLIPIDEMIA
Low Fat Diet(<30% of
Cal.Req.)
HMG-CoA-??
INFECTIONS
Teach Parents to recognize
signs of infection
Life threatening SBP
Rx with Antibioticss which can
cover both PC & Gr-ve bacteria
THROMBO-
EMBOLISM
Cautious Hydration
Use of LMWH/Warfarin
OBESITY
Dietary counselling
Use of Steroid sparing Rx
28.
29. RELAPSE & RESISTANCE
• RELAPSE
• UPC>2.0 or DS>3+ on 3 consecutive days
• Triggered by URTI/AGE
• Rx in same way as initial Rx except duration is short
• Frequent Relapsers (>2 in 6 mo or >4 in 12 mo)-rest are infrequent relapsers
• RESISTANCE
• Caused by FGS/MCNS/MPGN
• Candidates for Renal Bx
• 50% risk of ESRD within 5 yrs
31. IMMUNIZATION IN NS
• Full PCV (13 valent & 23 valent) to
prevent against life threatening
pneumococcal SBP
• Influenza Vaccination annually
• Hold Live vaccines (MMR, Varicella) till
steroids are tapered to <1 mg/kg/day(or2
mg/kg/day-alt. days)
LIVE VACCINES ARE
CONTRAINDICATED IN
KIDS RECEIVING
STEROID SPARING
AGENTS