NEPHROTIC SYNDROME

BY:
Jaspreet Kaur Roar(110100430)
Christy Sitorus (110100492)
SUPERVISOR:
dr. Yazid Dimyati, Sp A (K)

INTRODUCTION

NEPHROTIC SYNDROME IS?

EPIDEMIOLOGY
In the United States, incidence of 2.7 cases per 100,000

children per year

Cumulative prevalence of 16 per 100,000 children
More common in boys than girls in younger age groups
but in adolescence, no significant difference between
genders
Most commonly seen at ages 3 to 5 years old.
In Indonesia based on a multicenter study in 20002004 involving seven pediatric institutions, the top
three kidney diseases affecting children in Indonesia
were nephrotic syndrome (35%), acute poststreptococcal acute glomerulonephritis (26%), and
urinary tract infections (23%)

PATHOPHYSIOLOGY

DIAGNOSIS

TREATMENT

COMPLICATIONS

PROGNOSIS
Mortality in minimal-change nephrotic syndrome

is approximately 2%, with the majority of deaths

due to peritonitis or thrombus
98% of children who have minimal change
nephrosis, most are steroid-responsive and can be
expected to return eventually to a normal state
Minimal-change nephrotic syndrome results in
relapses; about two thirds of patients experience at
least a single relapse, with another third possibly
developing a protracted series of such relapses over
many years

MEDICAL RECORD
Case
Name: DW
Age: 1 year 5 months
Sex: Male
Date of Admission: on 8th July at 21.00
BW: 14kg and BL: 86cm

Chief of Complain: Swelling

throughout the body
It has been experienced by patient for 17 days,

worsened in the last 4 days, swelling appeared mainly

on his testis, and it worsened everyday. History of
swelling on the eyelids (+), both legs (+), testis (+) and
body (+).
History of shortness of breath had been present 1 week
ago.
Fever (+) in the last 5 days, it was fluctuating fever and
reduced with fever medication. Nausea (-), vomit (-).
History of low urine output was found, lasted for 1
week, urine looked concentrated. Sandy deposit of
urine was not found. History of urine being the color of
meat wash water (-). Defecation within normal means.

 History of disease

DW was a patient of RS AFINA AZIZ diagnosed with Nephrotic

Syndrome that has been treated for 3 days.
History of medication:

Cefotaxim, Paracetamol
History of family:

History of family having same symptom and disease was not found.
History of feeding:

1 month of breast feeding.

 History of pregnancy :

Patients mother was 25 years old during pregnancy. The gestational age was
aterm. There was no illness during pregnancy.
History of birth :

Baby was spontaneously born and was assisted by a midwife, the baby cried
spontaneously. Body weight was 3000 gram at time of birth.
History of immunization:

Complete immunization for the past 1 year and 5 months

History of Growth and Development:

The patients mother said that DWs growth was normal and according to his
age. DW had begun sitting at the age of 6 months old, standing at the age
of 10 months old as well as walking at the age of 15 months old.

PHYSICAL EXAMINATION
General status
Body weight: 14 kg, Body length: 86 cm,
BW/A: Z score =3
BL/A: Z score >3
BW/BL: 2 < Z score < 3

Presens status
Sensorium
: Compos Mentis
Blood Pressure : 90/60 mmHg
Heart Rate
: 140 beats/min
Respiratory Rate
: 38 breaths/min
Body Temperature
: 36,5oC
Anemic (-), icteric (-), cyanosis (-),edema (-),
dyspnea (+)

Local status
Head :

Eyes : isochoric pupil, pale inferior palpebral conjunctiva (-/-),icteric sclera (-/-),
light reflexes (+/+), oedema superior palpebra (+/+)
Face : oedema (-), Bleeding (-/-)
Ears : within normal range
Nose: within normal range
Mouth: within normal range
Neck : JVP (-), lymph node enlargement (-)
Thorax : Symmetric fusiform; retraction (-); HR: 140 beats/min, regular, murmur (-);
RR: 38 breaths/min, regular, ronchi (-), breath sound: vesicular, additional sound (-)
Abdomen : Bigger appearance, umbilical protrusion, soepel, peristaltic (+) normal.
Kidney, liver and spleen undetermined, skin pinch returns quickly, shifting dullness (+).
Extremities :Pulse 140 times/min, regular, blood pressure 90/60 mmHg, adequate
pressure and volume, warm, CRT < 3. Oedema (+) at lower extremities.
Anogenital : Male. Scrotum Oedema (+).

LABORATORY FINDINGS
PARAMETERS

VALUE

Haemoglobin

10.2

Erythrocyte

3.93

Leucocyte

24,260

Hematocrit

33

Thrombocyte

376,000

Albumin

0.9

Blood glucose

82

Blood Urea Nitrogen (BUN)

15

Ureum

32

Creatinin

0.34

Sodium

125

Potassium

4.2

Chloride

103

DIPSTICK URINALYSIS
Color

Yellow

Glucose

Negative

Bilirubin

Negative

Ketone

Negative

Specific gravity

1.020

pH

6.5

Protein

Positive 4 (++++4)

Urobilinogen

Negative

Nitrite

Negative

Leucocyte

Negative

Blood

Negative

Differential Diagnosis

Nephrotic Syndrome
Glomerulonephritis

Working Diagnosis

Nephrotic Syndrome

Management

IVFD D5% NaCl 0,45% 10gtt/i micro

Inj. Ceftazidim 25mg/BW/12h=> 300 mg/ 12h (IV)

Inj. Lasik 1 mg/BW/12h => 12 mg/ 12h (IV)

Spironolacton 2 x 12,5 mg
Diet 1100 kcal with 10gr protein

Diagnostic Planning

Fluid balance/ 6 hours

Urine dipstick/ 6 hours

Lipid Profil
Chest X-Ray ( AP & L)

Follow Up
July, 9th 2016
S Oedema (+), Fever (-)
O Sensorium

CM, T: 36,9C

Head

Face: Oedema (-).

Eyes: isochoric pupil, pale inferior palpebral conjunctiva (-/-), icteric sclera (-/-),
light reflexes (+/+), oedema superior palpebra (+/+).
E/N/M are normal.

Neck

Lymph node enlargement (-)

Thorax

SF, retraction (-). Heart rate 120 beats/min, regular, Murmur (-). Respiratory rate
20 breaths/min, regular, ronchi (-/-)

Abdomen
Extremities

Bigger appearance, umbilical protrusion, soepel, peristaltic (+) normal. Kidney,

liver and spleen undetermined, shifting dullness (+)
Pulse 120 times/min, regular, blood pressure 100/60 mmHg, adequate pressure
and volume, warm, CRT < 3. Oedema (+) at lower extremities.

A Steroid Resistant Nephrotic Syndrome

P Management:

oIVFD D5% NaCl 0,9% 20 gtt/minute/micro

oInj. Ceftazidim 25 mg/BW/12h => 300 mg/ 12h (IV)
oInj. Lasik 1 mg/BW/12h => 12 mg/ 12h (IV)
oSpironolacton 2 x 12,5 mg
oDiet 1100 kcal with 10gr protein
oFluid Balance/6 hours
oMorning urine Dipstick

July, 10th 2016

S Oedema (+), Fever (-)
O Sensorium

CM, T: 36,9C

Head

Face: Oedema (-).

Eyes: isochoric pupil, pale inferior palpebral conjunctiva (-/-), icteric sclera (-/-),
light reflexes (+/+), oedema superior palpebra (+/+).
E/N/M are normal.

Neck

Lymph node enlargement (-)

Thorax

SF, retraction (-). Heart rate 120 beats/min, regular, Murmur (-). Respiratory rate
20 breaths/min, regular, ronchi (-/-)

Abdomen
Extremities

Bigger appearance, umbilical protrusion, soepel, peristaltic (+) normal. Kidney,

liver and spleen undetermined, shifting dullness (+)
Pulse 120 times/min, regular, blood pressure 100/60 mmHg, adequate pressure
and volume, warm, CRT < 3. Oedema (+) at lower extremities.

A Nephrotic Syndrome

P Management:

oIVFD D5% NaCl 0,9% 20 gtt/minute/micro

oInj. Ceftazidim 300 mg/ 12h (IV)
oInj. Lasik 12 mg/ 12h (IV)
oSpironolacton 2 x 12,5 mg
oDiet 1100 kcal with 10gr protein
oFluid Balance/6 hours
oMorning urine Dipstick

July, 11th 2016

S Oedema (+), Fever (+)
O Sensorium
Head

Neck
Thorax
Abdomen
Extremities

CM, T: 36,9C
Face: Oedema (-).
Eyes: isochoric pupil, pale inferior palpebral conjunctiva (-/-), icteric sclera (-/-),
light reflexes (+/+), oedema superior palpebra (+/+) .
E/N/M are normal.
Lymph node enlargement (-)
SF, retraction (-). Heart rate 118 beats/min, regular, Murmur (-). Respiratory rate
24 breaths/min, regular, ronchi (-/-)
Bigger appearance, umbilical protrusion, soepel, peristaltic (+) normal. Kidney,
liver and spleen undetermined, shifting dullness (+)
Pulse 118 times/min, regular, blood pressure 100/80 mmHg, adequate pressure
and volume, warm, CRT < 3. Oedema (+) at lower extremities.

A Nephrotic Syndrome

P Management:

oIVFD D5% NaCl 0,9% 20 cc/hours

oInj. Ceftazidim 300 mg/ 12h (IV)
oInj. Lasik 12 mg/ 12h (IV)
oSpironolacton 2 x 12,5 mg
oMilk diet 100cc/3 hours (Oral)
oFluid Balance/6 hours
oMorning urine Dipstick
oRecheck Complete Blood Count, Albumin, Electrolyte, Procalcitonin.
oUrine & blood Culture

CASE
The patient is a 3 years 11 months old boy.

DISCUSSION
Nephrotic syndrome often occurs in 93% in children
compared to adults.
Interstital edema is a common clinical expression of
nephrotic syndrome.

Patient was admitted to the hospital with a chief

complaint of swelling on the whole body

Patient was diagnosed with nephrotic syndrome due to

hypoalbuminemia.

Patient was diagnosed with nephrotic syndrome due to

Hypercholesterolemia (high level of cholesterol in the
blood).

Expansion of the interstital compartment is secondary to

the accumulation of sodium in the extracellular
compartment, due to an imbalance between oral or
parenteral sodium intake and urinary sodium output,
along with alterations of fluid transfer across the
capillary walls.

Hypoalbuminemia is a low level of albumin (a protein)

in the blood due to proteinuria. Low albumin in the
blood causes fluid to move from the blood into the
tissue, causing swelling. The kidney perceives the
decrease of fluid in the blood and aggressively retains as
much fluid and salt as it can. This contributes to the
body's fluid-overload state.

Hypercholesterolemia, high blood cholesterol, is

common in nephrotic syndrome). In addition to
albumin, other important enzymes involved in
cholesterol metabolism slip through the glomeruli,
which contribute to high blood cholesterol.

SUMMARY
DW, 1 years 5 months old, male, was admitted to the Pediatric

Departement of H. Adam Malik General Hospital on 8th July,

2016. With his main complaint is swelling throughout the body.
Based on anamnesis, physical examination, and laboratory
assesment, he was diagnosed with Nephrotic Syndrome and was
given treatment of the followings:
IVFD D5% NaCl 0,9% 20 gtt/min/micro
Inj. Ceftazidim 300 mg/ 12h (IV)
Inj. Lasik 12 mg/ 12h (IV)
Tab. Prednison 2-2-1
Spironolacton 3 x 12,5 mg
Milk diet 100cc/3 hours (Oral)