nephroLlc svndrome (nephrosls

)
uLllnl1lCnť - nephroLlc svndrome ls a aroup of svmpLoms lncludlna proLeln ln Lhe urlne (more Lhan 3Ŧ3
arams per dav)ţ low blood proLeln levelsţ hlah cholesLerol levelsţ hlah Lrlalvcerlde levelsţ andsw elllnaŦ
- AuLolmmune process leadlna Lo sLrucLural alLeraLlon of alomerular membrane LhaL resulLs ln lncreased
permeablllLv Lo plasma proLelnsţ parLlcularv albumlnŦ
- nephroLlc svndrome ls a dlsorder of Lhe alomerull (clusLers of mlcroscoplc blood vessels ln Lhe kldnevs
LhaL have small pores Lhrouah whlch blood ls fllLered) ln whlch excesslve amounLs of proLeln are
excreLed ln Lhe urlneŦ 1hls Lvplcallv leads Lo accumulaLlon of fluld ln Lhe bodv (edema) and low levels of
Lhe proLeln albumln and hlah levels of faLs ln Lhe bloodŦ
- nephroLlc svndrome ls noL a speclflc alomerular dlsease buL a clusLer of cllnlcal flndlnasţ
lncludlnaťMarked lncrease ln proLeln (parLlcularlv albumln) ln Lhe urlne (proLelnurla)ţ uecrease ln
albumln ln Lhe blood (hvpoalbumlnemla)ţ Ldemaţ Plah serum cholesLerol and lowŴdenslLv llpoproLelns
(hvperllpldemla)Ŧ
AnA1CM? Anu ÞP?SlCLCC?ť
1he oraansţ Lubesţ musclesţ and nerves LhaL work LoaeLher Lo creaLeţ sLoreţ and carrv urlne are Lhe
urlnarv svsLemŦ 1he urlnarv svsLem lncludes Lwo kldnevsţ Lwo ureLersţ Lhe bladderţ Lwo sphlncLer
musclesţ and Lhe ureLhraŦ ?our bodv Lakes nuLrlenLs from food and uses Lhem Lo malnLaln all bodllv
funcLlons lncludlna enerav and selfŴrepalrŦ AfLer vour bodv has Laken whaL lL needs from Lhe foodţ wasLe
producLs are lefL behlnd ln Lhe blood and ln Lhe bowelŦ 1he urlnarv svsLem works wlLh Lhe lunasţ sklnţ
and lnLesLlnesŸall of whlch also excreLe wasLesŸLo keep Lhe chemlcals and waLer ln vour bodv
balancedŦ AdulLs ellmlnaLe abouL a quarL and a half of urlne each davŦ 1he amounL depends on manv
facLorsţ especlallv Lhe amounLs of fluld and food a person consumes and how much fluld ls losL Lhrouah
sweaL and breaLhlnaŦ CerLaln Lvpes of medlcaLlons can also affecL Lhe amounL of urlne ellmlnaLedŦ 1he
urlnarv svsLem removes a Lvpe of wasLe called urea from vour bloodŦ urea ls produced when foods
conLalnlna proLelnţ such as meaLţ poulLrvţ and cerLaln veaeLablesţ are broken down ln Lhe bodvŦ urea ls
carrled ln Lhe bloodsLream Lo Lhe kldnevsŦ 1he kldnevs are beanŴshaped oraans abouL Lhe slze of vour
flsLsŦ 1hev are near Lhe mlddle of Lhe backţ [usL below Lhe rlb caaeŦ 1he kldnevs remove urea from Lhe
blood Lhrouah Llnv fllLerlna unlLs called nephronsŦ Lach nephron conslsLs of a ball formed of small blood
caplllarlesţ called a alomerulusţ and a small Lube called a renal LubuleŦ ureaţ LoaeLher wlLh waLer and
oLher wasLe subsLancesţ forms Lhe urlne as lL passes Lhrouah Lhe nephrons and down Lhe renal Lubules
of Lhe kldnev
lrom Lhe kldnevsţ urlne Lravels down Lwo Lhln Lubes called ureLers Lo Lhe bladderŦ 1he ureLers are abouL
8 Lo 10 lnches lonaŦ Muscles ln Lhe ureLer walls consLanLlv LlahLen and relax Lo force urlne downward
awav from Lhe kldnevsŦ lf urlne ls allowed Lo sLand sLlllţ or back upţ a kldnev lnfecLlon can developŦ Small
amounLs of urlne are empLled lnLo Lhe bladder from Lhe ureLers abouL everv 10 Lo 13 secondsŦ 1he
bladder ls a hollow muscular oraan shaped llke a balloonŦ lL slLs ln vour pelvls and ls held ln place bv
llaamenLs aLLached Lo oLher oraans and Lhe pelvlc bonesŦ 1he bladder sLores urlne unLll vou are readv Lo
ao Lo Lhe baLhroom Lo empLv lLŦ lL swells lnLo a round shape when lL ls full and aeLs smaller when empLvŦ
lf Lhe urlnarv svsLem ls healLhvţ Lhe bladder can hold up Lo 16 ounces (2 cups) of urlne comforLablv for 2
Lo 3 hoursŦ Clrcular muscles called sphlncLers help keep urlne from leaklnaŦ 1he sphlncLer muscles close
LlahLlv llke a rubber band around Lhe openlna of Lhe bladder lnLo Lhe ureLhraţ Lhe Lube LhaL allows urlne
Lo pass ouLslde Lhe bodvŦ nerves ln Lhe bladder Lell vou when lL ls Llme Lo urlnaLeţ or empLv vour
bladderŦ As Lhe bladder flrsL fllls wlLh urlneţ vou mav noLlce a feellna LhaL vou need Lo urlnaLeŦ 1he
sensaLlon Lo urlnaLe becomes sLronaer as Lhe bladder conLlnues Lo flll and reaches lLs llmlLŦ AL LhaL
polnLţ nerves from Lhe bladder send a messaae Lo Lhe braln LhaL Lhe bladder ls fullţ and vour urae Lo
empLv vour bladder lnLenslflesŦ When vou urlnaLeţ Lhe braln slanals Lhe bladder muscles Lo LlahLenţ
squeezlna urlne ouL of Lhe bladderŦ AL Lhe same Llmeţ Lhe braln slanals Lhe sphlncLer muscles Lo relaxŦ As
Lhese muscles relaxţ urlne exlLs Lhe bladder Lhrouah Lhe ureLhraŦ When all Lhe slanals occur ln Lhe
correcL orderţ normal urlnaLlon occursŦ Þroblems ln Lhe urlnarv svsLem can be caused bv aalnaţ lllnessţ
or ln[urvŦ As vou aeL olderţ chanaes ln Lhe kldnevs' sLrucLure cause Lhem Lo lose some of Lhelr ablllLv Lo
remove wasLes from Lhe bloodŦ Alsoţ Lhe muscles ln vour ureLersţ bladderţ and ureLhra Lend Lo lose
some of Lhelr sLrenaLhŦ ?ou mav have more urlnarv lnfecLlons because Lhe bladder muscles do noL
LlahLen enouah Lo empLv vour bladder compleLelvŦ A decrease ln sLrenaLh of muscles of Lhe sphlncLers
and Lhe pelvls can also cause lnconLlnenceţ Lhe unwanLed leakaae of urlneŦ lllness or ln[urv can also
prevenL Lhe kldnevs from fllLerlna Lhe blood compleLelv or block Lhe passaae of urlne
Þ8LulSÞCSlnC
lAC1C8 8A1lCnALL
Aae Chlldren aaes 11Ƭ2 and 4 vr are predlsposed ln havlna nephroLlc svndrome
Sex Males are more predlsposed Lhan males ln acqulrlna nephroLlc svndrome
CeneLlcs Þeople wlLh famllv hlsLorv of nephroLlc svndrome lncreases llkellhood of
developlna nephroLlc svndrome
local seamenLal
alomerulosclerosls
ƽ Plv/AluS
ƽ nephrecLomv

MosL common cause of ldlopaLhlc nS amona adulLsŦ Mav be secondarv Lo
Plv/AluS lnfecLlon or loss of nephronsŦ
Membranous
nephropaLhv
ƽPepaLlLls 8 lnfecLlon
ƽ SLL
ƽ Cancer
ueposlLlon of lmmune complexes on Lhe alomerular basemenL membrane
causlna lL Lo LhlckenŦ lL can be secondarv Lo cerLaln cancersţ PepaLlLls 8
lnfecLlons and auLolmmune dlsorders such as SLLŦ
Mlnlmal chanae dlsease Causes 80 Lo 90Ʒ of chlldhood nephroLlc svndrome ln chlldren 4 Lo 8
vears of aae ldlopaLhlc ln naLureŦ
ulabeLes MelllLus Þrolonaed elevaLed blood alucose levels alLers alomerular base membranes
Lherebv causlna lmpalred renal funcLlon



S?MÞ1CMS
LLCLnu S?MÞ1CM 8A1lCnALL
S1 Albumlnurla ln nephroLlc svndrome Lhe podocvLes are damaaed and verv
permeable allowlna albumln from Lhe blood Lo escape and be
excreLed ouL Lhe bodv alona wlLh urlneŦ
S2 Ldema Ldema ls Lhe resulL of fluld shlfLlna from Lhe lnLravascular space Lo
Lhe lnLersLlLlal space due Lo Lhe decrease lnLravascular pressureŦ
S3 Pvperllpldemla 8esulLs due Lo Lhe lncreased producLlon of llpoproLelns bv Lhe llver
ln response Lo Lhe low levels of albumln ln Lhe bloodŦ
S4 Pvpoalbumlnemlaln nephroLlc svndrome Lhe podocvLes are damaaed and verv
permeable allowlna albumln from Lhe blood Lo escape and be
excreLed ouL Lhe bodv alona wlLh urlne





MLulCAL MAnACLMLn1
1Ŧ fluld and sodlum resLrlcLlonţ oral or lnLravenous dlureLlcsţ and analoLenslnŴconverLlna enzvme
lnhlblLorsŦ
- lluld and sodlum resLrlcLlons
CreaLlna a neaaLlve sodlum balance wlll help reduce edemaţ presumablv as Lhe underlvlna lllness ls
LreaLed or as renal lnflammaLlon slowlv resolvesŦ ÞaLlenLs should llmlL Lhelr sodlum lnLake Lo 3 a per
davţ and mav need Lo resLrlcL fluld lnLake (Lo less Lhan approxlmaLelv 1Ŧ3 L per dav)Ŧ Larae
doses (eŦaŦţ 80 Lo 120 ma of furosemlde) are ofLen requlredţ14 and Lhese druas Lvplcallv musL be
alven lnLravenouslv because of Lhe poor absorpLlon of oral druas caused bv lnLesLlnal edemaŦ3 Low
serum albumln levels also llmlL dlureLlc effecLlveness and necesslLaLe hlaher dosesŦ 1hlazlde
dlureLlcsţ poLasslumŴsparlna dlureLlcsţ or meLolazone (Zaroxolvn) mav be useful as ad[uncLlve or
svneralsLlc dlureLlcsŦ
- ulureLlcs
ƍulureLlcs are Lhe malnsLav of medlcal manaaemenLŤ howeverţ Lhere ls no evldence Lo aulde drua
selecLlon or dosaaeţƍ urŦ kodner wrlLesŦ ƍ8ased on experL oplnlonţ dluresls should alm for a LaraeL
welahL loss of 1 Lo 2 lb (0Ŧ3 Lo 1 ka) per dav Lo avold acuLe renal fallure or elecLrolvLe dlsordersŦ
Loop dlureLlcsţ such as furosemlde (Laslx) or bumeLanldeţ are mosL commonlv usedŦƍ

- AnaloLenslnŴconverLlna enzvme
ln persons wlLh nephroLlc svndromeţ analoLenslnŴconverLlna enzvme lnhlblLors have been shown Lo
decrease proLelnurla and lower Lhe rlsk for proaresslon Lo renal dlseaseŦ AnaloLenslnŴconverLlna
enzvme (ACL) lnhlblLors have been shown Lo reduce proŴLelnurla and reduce Lhe rlsk of proaresslon
Lo renal dlsease ln persons wlLh nephroLlc svndromeŦ13ţ16 Cne sLudv found no lmprovemenL ln
response when corLlcosLerold LreaLmenL was added Lo LreaLmenL wlLh ACL lnhlblLorsŦ17 1he
recommended dosaae ls unclearţ and enalaprll (vasoLec) dosaaes from 2Ŧ3 Lo 20 ma per dav were
usedŦ MosL persons wlLh nephroLlc svndrome should be sLarLed on ACL lnhlblLor LreaLmenL Lo
reduce proLelnŴurlaţ reaardless of blood pressureŦ
* AlLhouah corLlcosLerold LreaLmenL mav beneflL some adulLs wlLh nephroLlc svndromeţ research
evldence supporLlna Lhls Lherapv ls llmlLedŦ AL presenLţ lnLravenous albumlnţ prophvlacLlc
anLlbloLlcsţ and prophvlacLlc anLlcoaaulaLlon are noL advlsedŦ

AL8uMln
lnLravenous albumln has been proposed Lo ald dlureslsţ because edema mav be caused bv
hvpoalbumlnemla and resulLlna oncoLlc pressuresŦ Poweverţ Lhere ls no evldence Lo lndlcaLe beneflL
from LreaLmenL wlLh albumlnţ18 and adverse effecLsţ such as hvperLenslon or pulmonarv edemaţ as
well as hlah cosLţ llmlL lLs useŦ

CC81lCCS1L8CluS
1reaLmenL wlLh corLlcosLerolds remalns conLroverslal ln Lhe manaaemenL of nephroLlc svndrome ln
adulLsŦ lL has no proven beneflLţ buL ls recommended ln some persons who do noL respond Lo
conservaLlve LreaLmenLŦ19ţ20 1reaLmenL of chlldren wlLh nephroLlc svndrome ls dlfferenLţ and lL ls
more clearlv esLabllshed LhaL chlldren respond well Lo corLlcosLerold LreaLmenLŦ21 Classlcallvţ
mlnlmal chanae dlsease responds beLLer Lo corLlcosLerolds Lhan lSCSŤ howeverţ Lhls dlfference
lsfound prlmarllv ln chlldren wlLh nephroLlc svndromeŦ Cne older sLudv found LhaL corLlcosLerold
LreaLmenL lmproved proLelnurla and renal funcLlon ln persons wlLh mlnlmal chanae dlseaseţ buL noL
membranous nephropaLhv or prollferaLlve alomerulonephrlLlsŦ22 AnoLher small older sLudv found
LhaL persons wlLh less severe alomerular chanaes responded well Lo corLlcosLeroldsŦ23 Cne case
serles ln black persons wlLh lSCS found no beneflL from corLlŴcosLerold LreaLmenLŦ19 1wo Cochrane
revlews on Lhe LreaLmenL of nephroLlc svndrome ln adulLs found no beneflL for morLallLv or need
for dlalvsls wlLh corLlcosLerold Lherapv for membranous nephropaLhv or mlnlmal chanae dlseaseţ
buL found a weak beneflL for dlsease remlsslon and proLelnurla ln persons wlLh membranous
nephropaLhvŦ20ţ24 Poweverţ Lhe flndlnas for mlnlmal chanae dlsease were based on onlv one
randomlzed Lrlalţ and Lhe role of corLlcosLerold LreaLmenL remalns unclearŦ Manv experLs
recommend Lhe use of corLlcosLeroldsţ parLlcularlv for persons wlLh mlnlmal chanae dlsease1Ť
howeverţ adverse effecLs from corLlcosLerolds ofLen lead Lo dlsconLlnuaLlonŦ

lamllv phvslclans should dlscuss wlLh paLlenLs and consulLlna nephroloalsLs wheLher LreaLmenL wlLh
corLlcosLerolds ls advlsableţ welahlna Lhe uncerLaln beneflLs and posslblllLv of adverse effecLsŦ
AlkvlaLlna aaenLs (eŦaŦţ cvclophosphamlde żCvLoxanŽ) also have weak evldence for lmprovlna dlsease
remlsslon and reduclna proLelnurlaţ buL mav be consldered for persons wlLh severe or reslsLanL
dlsease who do noL respond Lo corLlcosLeroldsŦ




LlÞluŴLCWL8lnC 18LA1MLn1

A Cochrane revlew ls underwav Lo lnvesLlaaLe Lhe beneflLs and harms of llpldŴlowerlna aaenLs ln
nephroLlc svndromeŦ23 Some evldence suaaesLs an lncreased rlsk of aLheroŴaenesls or mvocardlal
lnfarcLlon ln persons wlLh nephroLlc svndromeţ posslblv relaLed Lo lncreased llpld levelsŦ23
Poweverţ Lhe role of LreaLmenL for lncreased llplds ls unknown andţ aL presenLţ Lhe declslon Lo sLarL
llpldŴlowerlna Lherapv ln persons wlLh nephroLlc svndrome should be made on Lhe same basls as ln
oLher paLlenLsŦ An1l8lC1lCS 1here are no daLa from prospecLlve cllnlcal Lrlals abouL LreaLmenL and
prevenLlon of lnfecLlon ln adulLs wlLh nephroLlc svndromeŦ Clven Lhe uncerLaln rlsks of lnfecLlon ln
adulLs wlLh nephroLlc svndrome ln Lhe unlLed SLaLesţ Lhere are currenLlv no lndlcaLlons for
anLlbloLlcs or oLher lnLervenLlons Lo prevenL lnfecLlon ln Lhls populaLlonŦ Þersons who are
approprlaLe candldaLes should recelve pneumococcal vacclnaLlonŦ

An1lCCACuLA1lCn 1PL8AÞ?

1here are currenLlv no recommendaLlons for prophvlacLlc anLlcoaaulaLlon Lo prevenL
Lhromboembollc evenLs ln persons wlLh nephroLlc svndrome who have noL had prevlous LhromboLlc
evenLsţ and cllnlcal pracLlce varlesŦ A Cochrane revlew ls ln processŦ26 Þhvslclans should remaln
alerL for slans or svmpLoms suaaesLlna Lhromboembollsm andţ lf lL ls dlaanosedţ Lhese evenLs
should be LreaLed as ln oLher paLlenLsŦ Þersons who are oLherwlse aL hlah rlsk of Lhromboembollsm
(eŦaŦţ based on prevlous evenLsţ known coaaŴulopaLhv) should be consldered for prophvŴlacLlc
anLlcoaaulaLlon whlle Lhev have acLlve nephroLlc svndrome

LA8C8A1C8? LxAM

1ŦÞroLelnurla (predomlnaLelv albumln) exceedlna 3Ŧ3 a/dav ls Lhe hallmark of Lhe dlaanosls of
nephroLlc svndromeŦ
2ŦA needle blopsv of Lhe kldnev mav be performed for hlsLoloalc examlnaLlon of renal Llssue Lo
conflrm Lhe dlaanoslsŦ
3Ŧ8ecenL sLudles have conflrmed Lhe usefulness of serum markers as a means of assesslna Lhe
dlsease processŦ AnLlŴC1q anLlbodles are Lhe mosL rellable markers for assesslna dlsease acLlvlLvŦ

nu8SlnC ulACnCSlS

- Lxcess fluld volume relaLed Lo compromlsed reaulaLorv mechanlsm wlLh chanaes ln hvdrosLaLlc or
oncoLlc vascular pressure and lncreased acLlvaLlon of 8AAS

- lmbalanced nuLrlLlonť Less Lhan bodv requlremenLs relaLed Lo anorexlaţ nauseaţ vomlLlnaţ proLeln
caLabollsmţ dleLarv resLrlcLlons and alLered oral mucous membranes

- uecreased cardlac ouLpuL relaLed Lo fluld lmbalances affecLlna clrculaLlna volumeţ mvocardlal
workload and svsLemlc vascular reslsLance
- 8lsk for lnfecLlon depresslon of lmmunoloalc defenses
- ulsLurbed bodv lmaae relaLed Lo chanaes ln phvslcal appearance
- 8lsk for ln[urv

nu8SlnC MAnACLMLn1
- Assess and documenL Lhe locaLlon and characLer of Lhe paLlenLƌs edemaŦ
- Welah Lhe paLlenL each mornlna afLer he volds and before he eaLsţ make sure heƌs wearlna Lhe
same amounL of cloLhlna each Llme vou welah hlmŦ
- Measure blood pressure wlLh Lhe paLlenL lvlna down and sLandlnaŦ lmmedlaLelv reporL a decrease
ln svsLollc or dlasLollc pressure exceedlna 20 mm PaŦ
- MonlLor lnLake and ouLpuL
- Ask Lhe dleLlLlan Lo plan a lowŴsodlum dleL wlLh moderaLe amounLs of proLelnŦ
- lrequenLlv check urlne for proLeln
- Þrovlde meLlculous skln care Lo combaL Lhe edema LhaL usuallv occurs wlLh nephroLlc svndrome
- use a reducedŴpressure maLLress or paddlna Lo help prevenL pressure ulcersŦ
- 1o prevenL Lhe occurrence of LhrombophleblLlsţ encouraae acLlvlLv and exerclseţ and provlde
anLlembollsm sLocklnas as ordered
- Clve Lhe paLlenL and famllv reassurance and supporLţ especlallv durlna Lhe acuLe phaseţ when
edema ls severe and Lhe paLlenLƌs bodv lmaae chanaes

Þ8CCnCSlS
1he proanosls varles dependlna on Lhe cause of Lhe nephroLlc svndromeţ Lhe personƌs aaeţ and Lhe
Lvpe and dearee of kldnev damaaeŦ SvmpLoms mav dlsappear compleLelv lf Lhe nephroLlc svndrome
ls caused bv a LreaLable dlsorderţ such as an lnfecLlonţ cancerţ or druasŦ 1hls slLuaLlon occurs ln
abouL half Lhe cases ln chlldren buL less ofLen ln adulLsŦ lf Lhe underlvlna dlsorder responds Lo
corLlcosLeroldsţ someLlmes proaresslon of Lhe dlsease ls halLedţ and less ofLen Lhe condlLlon
parLlallv orţ rarelvţ compleLelv reversesŦ When Lhe svndrome ls caused bv Plv lnfecLlonţ lL usuallv
proaresses relenLlesslvţ ofLen resulLlna ln compleLe kldnev fallure ln 3 or 4 monLhsŦ Chlldren born
wlLh Lhe nephroLlc svndrome rarelv llve bevond Lhelr flrsL blrLhdavţ alLhouah a few have survlved bv
means of dlalvsls LreaLmenLs or a kldnev LransplanLŦ When Lhe cause ls svsLemlc lupus
ervLhemaLosus or dlabeLes melllLusţ drua LreaLmenL ofLen sLablllzes or decreases Lhe amounL of
proLeln ln Lhe urlneŦ Poweverţ some people do noL respond Lo drua LreaLmenL and develop
proaresslve kldnev fallure wlLhln a few vearsŦ ln cases of nephroLlc svndrome resulLlna from
condlLlons such as an lnfecLlonţ alleravţ or lnLravenous heroln useţ Lhe proanosls varlesţ dependlna
on how earlv and effecLlvelv Lhe underlvlna condlLlon ls LreaLedŦ nephroLlc svndrome mav ao awav
once Lhe underlvlna causeţ lf knownţ has been LreaLedŦ ln chlldrenţ 80 percenL of nephroLlc
svndrome cases are caused bv mlnlmal chanae dlseaseţ whlch can be successfullv LreaLed wlLh
prednlsoneŦ Poweverţ ln adulLs mosL of Lhe Llme a kldnev dlsease ls Lhe underlvlna causeţ and Lhese
dlseases cannoL be curedŦ
Cood Ŷ lalr Ŷ Þoor Þroanosls
ÞaLhophvsloloav 8AAS Ŷ 8enln AnaloLensln AldosLerone SvsLem
A8l Ŷ AcuLe 8enal lallure
C8l Ŷ Chronlc 8enal lallure
LS8u Ŷ Lnd SLaae 8enal ulsease
CAu Ŷ Coronarv ArLerv ulsease
Cvu Ŷ Cardlovascular ulsease

?Cu MA? WCnuL8 ƽƽƽ CŦ PCW uCLS 8AAS LLAu 1C A8l??? AŦ 8AAS wlll evenLuallv be exhausLedŦ
Moreoverţ Lhe 8AAS cannoL lncrease vascular volume slnce Lhere ls no albumln Lo hold Lhe waLer
wlLhln Lhe vascular spaceŦ 1hus Lhe waLer and sodlum reabsorbed wlll shlfL lnLo Lhe lnLersLlLlal
spaceŦ 8AAS wlll onlv exacerbaLe Lhe edema and make Lhe paLlenL more edemaLousŦ xu lf lefL
unLreaLed Lhen Lhe blood flow Lo Lhe kldnevs(due Lo decreased lnLravascular volume) wlll be
compromlsed causlna acuLe Lrauma and ln[urv Lo Lhe nephrons ulLlmaLelv causlna A8lŦ ƹ) hope Lhls
helps
























































nephroLlc svndrome ls a nonspeclflc dlsorder ln whlch Lhe ţ kldnevs are damaaedcauslna Lhem Lo
leak larae amounLs of ( Ŧ Ŧ proLelnproLelnurla aL leasL 33 arams per dav per 173 m2 ) Ŧ bodv surface
areafrom Lhe blood lnLo Lhe urlneCLher
( svmpLoms lncludehvpoalbumlnemladecrease ln albumln ln )ţ ţ
( Lhe bloodedemahvpercholesLerolemlahlah serum )ţ Ŧ cholesLerol and normal renal funcLlon rr* Ŧ
1he mosL common slan ls excess fluld ln Lhe bodv 1hls mav ť Lake several forms r ţ o Þufflness
around Lhe evescharacLerlsLlcallv ln Ŧ Lhe mornlna r ( Ŧ Ŧţ o Ldema over Lhe leas whlch ls
plLLlnaleleaves a ţ llLLle plL when Lhe fluld ls pressed ouLwhlch resolves )Ŧ over a few seconds r o
lluld ln Lhe pleural cavlLv causlna pleural Ŧ effuslon More commonlv assoclaLed wlLh excess fluld ls Ŧ
pulmonarv edema r Ŧ o lluld ln Lhe perlLoneal cavlLv causlna asclLes

r ţ 1he followlna are basellne essenLlal lnvesLlaaLlons
r *urlne sample shows proLelnurla (ƽ Ŧ Ŧ )Ŧ 33a per 173 m2 per 24 hour r
* () Comprehenslve meLabollc panelCMÞ ť shows Pvpoalbumlnemlaalbumln level ƿŦ / ( ƹŦŴ / )Ŧ 2 3a
dLnormal3 3 3a dL r
*Plah levels of cholesLerol ( )ţ hvpercholesLerolemla speclflcallv ţ elevaLed LuLusuallv wlLh
concomlLanLlv elevaLed vLuL r
* ţ LlecLrolvLesurea and creaLlnlne ( )ť Ŧ LuCsLo evaluaLe renal funcLlon


CAuSLS
nephroLlc svndrome has manv causes and mav elLher
cell dlseasedlabeLes melllLus and mallanancvŦ such as leukemla r Secondarv causes of nephroLlc
svndrome occursţ afLer an lnfecLlous dlsease such as lnfecLlon
Ŵ ţwlLh aroup A beLahemolvLlc sLrepLococclţ svphllls malarla Luberculosls orvlral lnfecLlons lncludlna
varlcella hepaLlLls 8 PlvŦ and lnfecLlous mononucleosls

CA3E 3Tu0Y F0RVAT

l. !ATlENT 0EV00RA!lC 0ATA
Nare: Rose N|ra F(arc|sco
Ade/3ex: 11/Fera|e
3lalus: 3|rd|e Re||d|or: Rorar Calro||c
ore Add(ess: Codor. !a(do Nal|ora||lv:
F|||p|ro 0ccupal|or: N/A







ll. EALT l3T0RY !R0FlLE
A. !asl Ved|ca| |slo(v
1. !ed|al(|c ard Adu|l l||ress
uaLe lllness MedlcaLlon 8emarks
nCnL nCnL nCnL nCnL

2Ŧ lmmunlzaLlon

lmmunlzaLlon uoses lmmunlzaLlon uaLes 8emarks
8CC 1 Can'L 8ecall CompleLe
uÞ1 3 Can'L 8ecall CompleLe
CÞv 3 Can'L 8ecall CompleLe

3Ŧ PosplLallzaLlon
uaLe/?ear PosplLal ulaanosls uuraLlon
2007 2008 Cebu ClLv Medlcal CenLer nephroLlc Svndrome 1 week
Cebu ClLv Medlcal CenLer nephroLlc Svndrome 1 week

4Ŧ ln[urles and AccldenLs
1he paLlenL dld noL experlence anv ln[urles and accldenLsŦ
3Ŧ 1ransfuslonsŴ 1he paLlenL dld noL underao anv Lransfuslons such as blood LransfuslonŦ
6Ŧ Allerales(speclfv)Ŵ 1he paLlenL has no anv allerales

8Ŧ lamllv PlsLorv

CŦ Soclal and Þersonal PlsLorv
-1ŦCccupaLlonŴn/A
2Ŧnumber of ChlldrenŴn/A
3ŦMlllLarv experlencesţ forelan LravelŴn/A
4ŦPablLs (Lobaccoţ alcoholţ nonŴprescrlpLlon druasţ oLhers)Ŵn/A
3ŦuleLŴfrulLsţ veaeLablesţ pork chopţ drled flsh
6Ŧ1vpe of lamllvŴLxLended lamllv
7ŦCulLural and 8ellalous 8ellefsŴn/A


8Ŧ8rlef descrlpLlon of averaae davť
3ť30 amŴwake up
6ť00 amŴbreakfasL
7ť00Ŵ9ť00 amŴclass hours
9ť13Ŵ9ť30 amŴrecess
9ť30Ŵ12ť00 amŴclass hours
12ť00Ŵ1ť00 pmŴlunch
1ť00Ŵ3ť00 pmŴclass hours
3ť30 pmŴdo homework
6ť00 pmŴdlnner
7ť00Ŵ8ť00 pmŴwaLch 1Ŧv
8ť00 pmŴsleeplna Llme


uŦ 8evlew SvsLem (for Lhe pasL 6 monLhs)Ŧ
Þhvslcal AssessmenL
Ceneral WelahL loss laLlaue Anorexla nlahL sweaLs Chllls lever Weakness
1he paLlenL experlenced fever due Lo couah and coldsŦ
1he paLlenL experlenced faLlaue due Lo lllness and lack of sleepŦ
1he paLlenL experlenced weakness due Lo faLlaueŦ

Skln lLch
8ash
Leslons
8rulslna
8leedlna Color chanae nCnL
Lves Þaln
ulscharae
lLch
vlslon loss
ulplopla
Lxcesslve Learlna
Classes/ConLacL lens
uaLe of lasL exam nCnL
Lars Laraches ulscharaes 1lnnlLus Pearlna loss nCnL
nose CbsLrucLlon ulscharaes LplsLaxls nCnL
1hroaL and MouLhSore LhroaLs 8leedlna aums 1ooLhache uenLures nCnL
neck and Pead Swelllna uvsphaala Poarseness
nCnL
ChesL Couah SpuLum AmounL and CharacLer PemopLvsls Wheeze Þaln
on resplraLlon uvspnea 1he paLlenL experlenced
dvspnea due Lo obsLrucLlon of Lhe alrwav
Cardlovascular Þrecordlalpaln ÞalplLaLlon uvspneaon exerLlon
CrLhopnea uvspnea Þaroxvsmal nocLurnal Ldema
PearL murmur ClaudlcaLlon 1hrombophleblLls
nCnL

CasLrolnLesLlnal PearLburn nausea vomlLlna ularrhea lood
lnLolerance Lxcesslve aas or lndlcaLlon
ConsLlpaLlon !aundlce 8loaLlna Chanae ln 8owel
movemenL Melena Pemorrholds Pernla nCnL

CenlLourlnarv PearLburn nausea vomlLlna ularrhea lood
lnLolerance Lxcesslve aas or lndlcaLlon
ConsLlpaLlon !aundlce 8loaLlna Chanae ln 8owel
movemenL Melena Pemorrholds Pernla nCnL

LxLremlLles !olnL palns varlcose velns ClaudlcaLlon 8ack paln
Ldema SLlffness ueformlLles
1he paLlenL experlenced edema due Lo lllness
whlch ls nephroLlc svndromeŦ
Lndocrlne PoL flashes Palr loss 1emperaLure lnLolerance
Þolvdlpsla ColLer nCnL
neuroloav numbness 1lnallna 1remor lalnLlna Peadaches
Muscle weakness ALaxla Selzure unconsclousness
Þaralvsls/Þaresls Memorv loss ulzzlness

1he paLlenL experlenced headaches due Lo feverŦ





lllŦ Cu88Ln1 PLAL1P Þ8CllLL
AŦÞresenLlna complalnLs and medlcal dlaanosls Lo lnclude lnLervenLlon done prlor Lo
hosplLallzaLlonŦ
8osa nlna lranclsco was dlaanosed for nephroLlc SvndromeŦ She Complaln of dlfflculLv ln breaLhlnaŦ


8Ŧ AppllcaLlon of Lhe nurslna Þrocess 1Ŧ AssessmenL llndlna (Pead ŶLoŴ1oe)
Skln unlform skln colorţ no [aundlceţ cvanosls
Skln lnLacL Skln warm and drv

Palr Palr ls evenlv dlsLrlbuLed over scalp
Palr color black and Lhln
no leslons or pedlculosls
nalls Color plnkţ well aroomed ad convexţ smooLh and
flrm
Pead normocephalllcţ erecL and mldllne Pead
svmmeLrlcalţ no massesţ nonLende

lace laclal expresslon approprlaLeţ no abnormal
movemenLs or leslons laclal bones smooLhţ
lnLacLţsvmmeLrlcalţnonLender
Lars Lars allaned wlLh evesţ svmmeLrlcalţ no rednessţ
leslons or dralnaae Lves Lves clear and brlahLţ
equal parallel allanmenL
Lvellds color conslsLenL wlLh cllenLs complexlon
Lvelashes evenlv dlsLrlbuLedţ no excesslve Learlna
or drvness
nose nose mldllneţ svmmeLrlcalţ no devlaLlonţ no flarlna
no deformlLles or nasal Lenderness Slnuses Slnuses
clearţ nonLender

MouLh Llps plnkţ molsLţ no leslons Cral mucosa plnkţ
molsLţ no leslonsţ lnLacL
1eeLh compleLe
1onaue plnkţ molsLţmldllne

neck neck svmmeLrlcalţ skln lnLacLţ no masses upper
LxLremlLles Skln color unlformŤ no ervLhemaţ
edema Abdomen Skln color conslsLenLţ no leslonsţ
rashesţ scars or dlscoloraLlonŦ Palr dlsLrlbuLlon
approprlaLe for cllenL's aae and aender

Abdomen flaL and svmmeLrlcalţ no bulaes or hernlas
umblllcus mldllne
Abdomen sofLţ nonLenderţ no masses

Lower LxLremlLles Lea halr evenlv dlsLrlbuLedŤ color unlformŤ no
edema or leslon



LaboraLorv/ulaanosLlc 8esulLs
uaLe Lab Lxam ÞaLlenL 8esulLs normal llndlnas lnLerpreLaLlon/SlanlflcanL
09Ŵ01Ŵ09 ÞroLeln Lo
CreaLlnlne raLlo
1Ŧ33 3Ŵ0Ŧ9 SuaaesLs Lhe presence of
nephroLlc ranae
proLelnurlaŦ
Serum albumln 0Ŧ9a/dl 0Ŧ 3Ŧ4Ŵ3Ŧ4a/dl Pvpoalbumlnemla can be
caused bv Lxcess
excreLlon bv Lhe kldnevsŦ






O nC8MAL klunL? SlZL rŴ1he normal kldnev slze of an adulL human ls abouL 10 Lo Ŵ1he normal
kldnev slze of an adulL human ls abouL 10 Lo 13 cm (4 Lo 3 lnches) lona and abouL 3 Lo 7Ŧ3 cm (2
Lo 3 13 cm (4 Lo 3 lnches) lona and abouL 3 Lo 7Ŧ3 cm (2 Lo 3 lnches) wldeŦ lL ls approxlmaLelv Lhe
slze of lnches) wldeŦ lL ls approxlmaLelv Lhe slze of a a convenLlonal compuLer mouse
convenLlonal compuLer mouseŦ Ŧ
O nC8MAL klunL? CCLC8 nC8MAL klunL? CCLC8 Ŵ1he kldnevs are darkŴredţ beanŴshaped
oraansŦ Cne slde 1he kldnevs are darkŴredţ beanŴshaped oraansŦ Cne slde of Lhe kldnev bulaes
ouLward (convex) and Lhe oLher of Lhe kldnev bulaes ouLward (convex) and Lhe oLher slde ls
lndenLed (concave) slde ls lndenLed (concave)

O nC8MAL klunL? LCCA1lCn nC8MAL klunL? LCCA1lCn rŴ ŴLowards Lhe back of Lhe abdomlnal
cavlLvţ [usL Lowards Lhe back of Lhe abdomlnal cavlLvţ [usL above Lhe walsLŦ Cne kldnev ls
normallv locaLed [usL above Lhe walsLŦ Cne kldnev ls normallv locaLed [usL below Lhe llverţ on
Lhe rlahL slde of Lhe abdomen and below Lhe llverţ on Lhe rlahL slde of Lhe abdomen and Lhe
oLher ls [usL below Lhe spleen on Lhe lefL sldeŦ Lhe oLher ls [usL below Lhe spleen on Lhe lefL slde

O 1he mosL baslc sLrucLures of Lhe kldnevsţ are nephronsŦ 1hev are responslble for fllLerlna Lhe
bloodŦ
- 1he renal arLerv dellvers blood Lo Lhe kldnevs each davŦ Cver 180 llLers (30 aallons) of blood pass
Lhrouah Lhe kldnevs everv davŦ When Lhls blood enLers Lhe kldnevs lL ls fllLered and reLurned Lo
Lhe hearL vla Lhe renal velnŦ
- 1he process of separaLlna wasLes from Lhe bodv flulds and ellmlnaLlna Lhemţ ls known as
excreLlonŦ 1he urlnarv svsLem ls one of Lhe oraan svsLems responslble for excreLlonŦ 1he kldnevs
are Lhe maln oraans of Lhe urlnarv svsLemŦ
O 1he kldnev ls full of blood vesselsŦ Lverv funcLlon of Lhe kldnev lnvolves bloodţ Lhereforeţ lL
requlres a loL of blood vessels Lo faclllLaLe Lhese funcLlonsŦ
- 1oaeLherţ Lhe Lwo kldnevs conLaln abouL 160 km of blood vessels

8enal capsule
-ls a Louah flbrous laver surroundlna Lhe kldnev and covered ln a Lhlck laver of adlpose LlssueŦ lL
provldes some proLecLlon from Lrauma and damaae
-ls Lhe ouLer porLlon of Lhe kldnev beLween Lhe renal capsule and Lhe renal medullaŦ ln Lhe adulLţ lL
forms a conLlnuous smooLh ouLer zone wlLh a number of pro[ecLlons (corLlcal columns) LhaL exLend
down beLween Lhe pvramldsŦ
-ulLra fllLraLlon occurs
8enal
-ls Lhe lnnermosL parL of Lhe kldnev
-spllL up lnLo a number of secLlonsţ known as Lhe renal pvramlds
-conLalns Lhe sLrucLures of Lhe nephrons responslble for malnLalnlna Lhe salL and waLer balance of
Lhe blood
-ls hvperLonlc Lo Lhe fllLraLe ln Lhe nephron and alds ln Lhe reabsorpLlon of waLerŦ
O are coneŴshaped Llssues of Lhe kldnev
O made up of 8 Lo 18 of Lhese conlcal subdlvlslons
O r1he broad of each pvramld faces Lhe renal corLexţ and lLs apexţ or paplllaţ polnLs lnLernallv
O 1he base of each pvramld orlalnaLes aL Lhe corLlcomedullarv border and Lhe apexLermlnaLes ln a
paplllaţ whlch lles wlLhln a mlnor calvxţ made of parallel bundles of urlne collecLlna LubulesŦ
O surrounds Lhe apex of Lhe malplahlan pvramldsŦ urlne formed ln Lhe kldnev passes Lhrouah a
papllla aL Lhe apex lnLo Lhe mlnor calvx Lhen lnLo Lhe ma[or calvxŦ
O ÞerlsLalsls of Lhe smooLh muscle orlalnaLlna ln paceŴmaker cells orlalnaLlna ln Lhe walls of Lhe
calvces propels urlne Lhrouah Lhe pelvls and ureLers Lo Lhe bladderŦ

ÞhaLophvsloloav
nephroLlc svndrome resulLs from damaae Lo Lhe kldnev's alomerullţ Lhe Llnv blood vessels LhaL fllLer
wasLe and excess waLer from Lhe blood and send Lhem Lo Lhe bladder as urlneŦ 1hev conslsL of
caplllarles LhaL are fenesLraLedţ LhaL lsţ have small openlnasţ whlch allow fluldţ salLsţ and oLher small
soluLes Lo flow Lhrouah buL normallv noL proLelnsŦ uamaae Lo Lhe alomerull from dlabeLesţ
alomerulonephrlLlsţ or even prolonaed hvperLenslonţ causes Lhe membrane Lo become more porousţ so
LhaL small proLelnsţ such as albumlnţ pass Lhrouah Lhe kldnevs lnLo urlneŦ As proLeln conLlnues Lo be
excreLedţ serum albumln ls decreasedţ whlch ln Lurn decreases Lhe serum osmoLlc pressureŦ Caplllarv
hvdrosLaLlc fluld pressure becomes areaLer Lhan caplllarv osmoLlc pressureţ whlch resulLs ln aenerallzed
edemaŦ As fluld ls losL lnLo Lhe Llssuesţ Lhe plasma volume decreasesţ sLlmulaLlna secreLlon of
aldosLerone Lo reLaln sodlum and waLerţ whlch decreases Lhe alomerular fllLraLlon raLe Lo reLaln waLerŦ
1hls addlLlonal waLer also passes ouL of Lhe caplllarles lnLo Lhe Llssueţ leadlna Lo even areaLer edemaŦ -
SCAÞlL



Ať knowledae deflclL relaLed Lo chronlc lllness
Þť AfLer 4 hours of nurseŴpaLlenL and slanlflcanL oLhers lnLeracLlonţ
Lhe paLlenL and Lhe slanlflcanL oLhers wlll be able Loť
O ldenLlfv lnLerferences Lo learnlna and speclflc acLlons Lo deal wlLh lLŦ
O Þerform necessarv procedures correcLlv and explaln reasons for Lhe acLlonsŦ
O lnlLlaLe necessarv llfesLvle chanaes and parLlclpaLe ln LreaLmenL realmenŦ
O Þrovlded an envlronmenL LhaL ls conduclve Lo learnlnaŦ

lťAssessed readlness Lo learnŦ
Þrovlded wrlLLen lnformaLlon/auldellnes and selfŴlearnlna modules for cllenL Lo refer Lo as
necessarvŦ
Allowed pracLlce and demonsLraLlonsŦ

LťCoal was meLŦ AfLer 4 hours of nurseŴpaLlenL and slanlflcanL oLhers lnLeracLlonţ Lhe paLlenL and Lhe
slanlflcanL oLhers wlll be able Lo ldenLlfled Lhe lnLerferences Lo learnlna and made speclflc acLlons Lo
deal wlLh lLŦ And Lhev were Lo performed necessarv procedures correcLlv and Lhev explalned Lhe
reasons for Lhe acLlons Lhev madeŦAnd Lhev were able Lo lnlLlaLed necessarv llfesLvle chanaes and
parLlclpaLed ln LreaLmenL realmen bv allowlna Lhem Lo pracLlce and
demonsLraLe Lhe LreaLmenL realmenŦ



SCAÞlL
SŴºWala kov aana mukaonŦ"ţ as verballzed bv Lhe paLlenLŦ
CŴ ť proLelnŴcreaLlnlne raLlo of 1Ŧ33 Serum albumln of 0Ŧ9a/dl
AŴ lmbalanced nuLrlLlonţ less Lhan bodv requlremenLs relaLed Lo poor appeLlLeţ resLrlcLed dleLţ and
proLeln lossŦ
ÞŴ AfLer 8 hours of nurseŴpaLlenL lnLeracLlonţ Lhe paLlenL wlll be able Loť
O ldenLlfv Lhe approprlaLe dleL for her condlLlonŦ (LowŴsodlum dleL)
O lollow Lhe dleL prescrlbedŦ
O verballze reallzaLlon of Lhe lmporLance of proper dleLŦ
lŴ Assessed and monlLored food/fluld lnaesLed and calculaLe calorlc lnLakeŦ
O MonlLored welahL dallv aL same Llmeţ same cloLhlna and same scaleŦ
O 8ecommended smallţ frequenL mealsŦ
O 8esLrlcLed sodlum as lndlcaLedţ and llmlLed fluld lnLake Lo 100ml
O AdmlnlsLered mulLlvlLamlnsţ as lndlcaLedŦ
O AdmlnlsLered medlcaLlons as approprlaLeŦ
O MonlLored laboraLorv sLudlesŦ

LŴ Coals meLŦ AfLer 8 hours of nurseŴpaLlenL lnLeracLlonţ Lhe paLlenL was able Lo ldenLlfv Lhe
approprlaLe dleL for her condlLlonŦ (LowŴsodlum dleL)Ŧ lollow Lhe dleL prescrlbedŦ verballze
reallzaLlon of Lhe lmporLance of proper dleL


SCAÞlL
SŴ ºMuraa nanahupona akona anak sa lva blLllsŦ"ţ as verballzed bv Lhe moLherŦ

CŴ Ldemaţ welahL aalnţ chanaes ln vlLal slans

AŴLxcess fluld volume relaLed Lo compromlsed reaulaLorv mechanlsm wlLh chanaes ln hvdrosLaLlc
vascular pressure and lncreased acLlvaLlon of rennln analoLensln aldosLerone svsLemŦ

ÞŴAfLer 3 hrs of nurslna lnLervenLlonsţ Lhe paLlenL wlll be able Loť rdlsplav sLable welahL
rvlLal slans wlLhln paLlenL's normal ranae
rnearlv absence of edemaŦ

lŴ8ecord accuraLe lnLake and ouLpuL of Lhe paLlenL MonlLor urlne speclflc aravlLv
O WelahL dallv aL same Llme of Lhe davţ on same scaleţ wlLh
O same equlpmenL and cloLhlna
O Assess sklnţ faceţ dependenL areas of edema
O MonlLor hearL raLe and blood pressure
O Assess level of consclousnessť lnvesLlaaLe chanaes ln menLaLlonţ presence of resLlessnessŦ

LŴCoals were fullv meLŦ AfLer 3 hrs of nurslna lnLervenLlonsţ Lhe paLlenL was able Lo dlsplav sLable
welahLţ vlLal slans wlLhln paLlenL's normal ranaeţ and nearlv absence of edemaŦ

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–  f¯ ¯½ ¾ ¾°f° ¾f½  °¾€f° – ¾¾¯f  ° ¯½  € °f¾¾ ¯¾ f   f nf° ½°n ¾%n½¾%€° n¯€f € ¾ .

nf¯¾n ¾nf ¾½°n ¾ ½ ½° €¯ f°– @ ¾½°n ¯¾n ¾n¾  – f  f° f°  ½ °°–€  f °  f   ff¾°  ½f¾¾¾     -  ¾°  f   °¾¯ °f  ¯½ f  ¾  f €¾€¾° ¯f°n f€ °–f° °f @  ¾ °¾f°°f  n¯ ¾¾°– f¾  f n°° ¾€f°  fn ¾¾¯ f ½° °  ¾€¯  f ¾ ° f¯ ¾¾f–   f°f  f ¾€ f° –  ¯½ f ° °¾€ ¾ J °°f   f°¾–°f¾  f ¯¾n ¾– °  ¾ °–° €  f   ¾f¯ ¯   f°¾–°f¾ ¾½°n ¯¾n ¾ f ¾  ¾ ¯¾n ¾ f °  ¾  f –  f J °f ¾–°f¾nn°  n n  °¯f°f°nn¾ 9  ¯¾° °f¾¾ ¯nf° nf¾  f–°– ° ¾¾  °© ¾–   nf°– ¾°  ° ¾#¾n nf¾  ¯¾ ¾¯ € f   ¯ f¾ ¾€¯   ¾  ¯¾n ¾°  ¾  f  f°  f ° ¾  ¾¯ € ¾ °– ¯ff ¯ °f°€ n°¾ nf¾   f ¯¾n ¾ ° – ° °– ¯½ f n¯½    n f¾ °¾ °–€¯¾n ¾€ ¾½°n ¾ f°  ½ ¾nf°f¾nf¾ °n°° °n  °f°  ff– €° ° ¾¾°©nf°f¾ ½  °  ° ¾€¯€ °–   n¯½   n ½f¾¾f– €°  99- .

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f ¾  ° n¾ nf¾ –¯ °f –¯ ¾n ¾¾ I$ - ½ n¯  . ¯ f°¾ ° ½½f  ½f¾ °€ n°  .  °  .

f°n  . ¾    @- f– ¾ f° f ½ ¾½¾ °f°–° ½n¾° ¯  f ¯ ½ ¾½¾ f°¯f ¾°fn°–° ½n¾° ¯  9 ½ €f¯¾€° ½n¾° ¯ °n f¾ ¾  €  ½°–° ½n¾° ¯  .¾n¯¯°nf¾ € ½fn-f¯°–f ¾ .f ¾ n° f I$°€ n°¾¾€° ½°¾   ½¾°€¯¯° n¯½  ¾° –¯ f f¾ ¯ °¯ ¯ f°  nf¾°–n ° nf° ¾ n° fn f°nf°n ¾  ½f¾  °€ n°¾f° f¯¯°  ¾ ¾¾nf¾  ¾ f¾ .°¯fnf°–  f  ¾.

f¾ ¾ €n  ° ½n¾° ¯ °n  °  f¾€f–  ½fn°°f  9°–   f   –n¾   ¾f ¾–¯ f f¾ ¯ ¯ f° ¾   nf¾°–¯½f  °f€°n° .

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