A Case Presentation - Nephrotic Syndrome

Moderator Presenter
Dr. Sreelekha Rajesh Kavitha K C
Professor, Dept of Pediatric Nursing, TGNIE 2nd Year, PBSC, TGNIE Pune
Pune.
 History

Name: Adiv Ahaan

Age: 3 years
Sex: Male
Religion: Hindu
From: Pune
Patient Id: 2724478

• On 24/ 9/2021 3:00 PMReported to the pediatric emergency with the chief complains of
generalized swelling of the body X 5 days
• Swelling started from the face followed by swelling of abdomen , upper and lower limbs.
• No h/o of rash , fever, sore throat, fast breathing
• Patient was taken to the local hospital and some medicine was given, a USG was done and
referred to RubiHall Clinic.
 History of present illness

• The patient was apparently well 5 days back when his mother noticed swelling of his
face, which was acute in onset and gradually progressing towards the abdomen and
bilateral upper and lower limbs.
• The swelling is painless and pitting in nature.
• The overlying skin was normal and there is no history of itching and rashes.
• No h/o frothy urine ,yellowish discoloration of urine
• No h/o cough, chest pain
• No h/o abdominal pain, loss of appetite, vomiting.
• No h/o fever , joint pain, photosensitivity and oral ulcers
• No h/o altered bowel habit and bladder
• No h/o passage of frank blood in the urine
• No h/o crying at micturition , yellowish discoloration of the body
• No h/o any skin infection
• No h/o petechia, purpura.
Past history:
• h/o throat infection 2-3 months back
• No h/o of similar illness
• No h/o TB, asthma, HTN, DM
• No h/o fever with rash, neck swelling.
Antenatal:
• Regular ANC visits
• TT vaccine taken on time
• Iron and calcium taken on time
• No h/o fever, rashes, lymphadenopathy
• No h/o excessive vomiting, increased frequency of
micturition
• No h/o burning micturition, increased urgency
• No h/o PV bleeding, spotting
• No h/o headache, blurring of vision, epigastric
pain.
Perinatal history:
• Normal term, spontaneous vaginal delivery at (
patient not sure of exact date)
• Baby cried at birth.
• Baby weight:-2.0 kg
• Breast feeding at 4 hours of life.
Post natal history:
• No h/o Excessive bleeding
• No other complications
Family history:
• No h/o similar illness in family
• No h/o consanguineous marriage
• No h/o TB, DM, Kidney deases
• No h/o HTN
Dietary History:
• Tea+ 1 kotori rice+ 1 kotori daal+ 1 kotori potato curry
• Not significant history given by mother.
Immunization history:
• Immunization as per EPI schedule with strictly all vaccines given to child
Developmental History
• H/o normal developments
• Explore drawers, runs ups and
downstairs
• Vertical and circular strokes
• Asks for food , toilets
• 2-3 word sentence, short sentences
 On Examination

General condition:
• facial puffiness +ve
• Edema +ve, bilateral pitting
edema of limbs
• No any scar marks of infection
Vitals
• Pulse: 110/min; regular, normal vol and character,
• RR: 22/min
• Temp: 98 F
• BP: 90/60 on rt arm in sitting
position
GPE
• Pallor
• Icterus
• Lymphadenopathy
• Dehydration
Anthropometry
• Weight: 13.5 kg
 Physical examination

GIT
Abdomen distended, umbilicus central, all quadrant moving symmetrically with
respiration, no venous prominence, no scar marks, hernia site are intact.

On palpation: no local rise in temp

no tenderness
no any lump and organ
On percussion: shifting dullness present
Chest
Bilateral Equal Chest Expansion;B/L Normal
vesicular breath sounds ; no added sounds, Trachea Central
CVS
S1S2-normal, No added sounds

Preliminary Diagnosis

Probably a case of nephrotic syndrome. Mostly Minimal change Disease (as per
incidence and geography).
Investigation
Contd…
Hematological parameters
 Final Diagnosis

• With the clinical sign and symptoms , lab diagnosis, age as well as other no secondary
diseases associated.
• Nephrotic syndrome with some hematuria. Most probably minimal change disease
nephrotic syndrome for the confirmation renal biopsy is preferred.
Treatment Given
Nephrotic Syndrome
Incidence (Paediatric ) ?
Pathophysiology : Minimal change disease
Pathophysiology
How changes occurs?
 Clinical features

• Puffiness of face which also appear in abdomen and lower extremities

• Pitting Edema resulting respiratory distress and diarrhoea due edema of interstitial
mucosa
• Irritability and anxiety
• Weight gain
• Proteinuria
• Hyperlipidaemia
• Pleural effusion may also occur
 Lab Investigations

• Urine Examination
• Complete Blood Count & Blood picture
• Renal parameters :
• Spot Urine Protein : Creatinine ratio
• Liver Function Test
• Renal Biopsy ???
• Urinalysis - 3+ to 4+ proteinuria
• Renal Function
• UPE > 40 mg/m2/hr
• Serum Creatinine – normal or elevated
• Serum albumin - < 2.5 gm/dl
• Serum Cholesterol–elevated
 Management

• Treatment of infections
• If significant edema – diuretics Aldosterone antagonist (Fursemide, spironolactone)
• Corticosteroid therapy with Prednisolone or prednisone
• (2mg/kg per day for 6 weeks followed by 1.5 mg/kg single morning dose on alternate
days for 6 weeks)
• Administration of Albumin
• Calicium supplements
 Complications

• Edema
• Infections
• Thrombotic complications
• Hypovolemia and Acute renal Failure
• Steroid Toxicity
 Diet management

• In diet management, diet should contain adequate protein

• Saturated fat must be avoided
• Salt restriction is usually not required excessive edema is present salt restriction should be
done
• Calcium, Vitamin D3 and Zinc must be supplemented
 Parent education

• Should be explained about diseases and the usual outcomes

• Their cooperation is ensured
• If possible they are taught how to examine urine for protein
• Which should be done periodically to detect relapse early
Thank You