| 1. Renal problem: nephrotic syndrome, nephritic syndrome
2. cardiac problem: heart failure
3. liver problem: hypoalbuminemia
4. Allergic reaction - angioedema | 3 years old with 1 week history of swollen face and hands. Patients have normal development.
The parent was well.
3 causes of facial puffiness? |
| 1. nephrotic - proteinuria (frothy urine), oedema, hypoalbuminemia, cx: ascites
2. nephritic - hypertension, oliguria (urine output), haematuria (blood during micturition), sore throat
3. heart failure: sob? reduced effort tolerance, failure to thrive
4. allergy: snake bites, food allergy | 3 years old with 1 week history of swollen face and hands. Patients have normal development.
The parent was well.
5 question you would like ask patient. |
| Nephrotic syndrome | Patient had history of passing frothy urine. Investigation result given.
i. LFT: hypoalbuminemia
ii. Urine: proteinuria, no hematuria
Most likely diagnosis |
| 1. Monitor I/O chart
2. Nephrotic chart - BP, albumin, urine dipstick, daily weight
3. Oral prednisolone 60mg/m2/day for 4 weeks --> every alternate day 40mg/m2/day 4 weeks --> reduce 25% by 4 weeks --> stop
4. Diuretics IV Frusemide - gross oedema
5. C Penicillin /Penicillin V as prophylaxis for spontaneous bacterial peritonitis
6. Human albumin | Management of nephrotic syndrome. |
| Spontaneous peritonitis secondary to nephrotic syndrome | Patient has had one relapse and currently come with complaint of abdominal pain and high grade fever.
State provisional diagnosis. |
| 1. FBC
2. Aspirate peritoneal fluid
3. Check urine for proteinuria | Patient has had one relapse and currently come with complaint of abdominal pain and high grade fever.
How do you confirm your diagnosis. |
| Patient
- absence from school, unable to perform at school, affect learning curve
Family
-mother has to take care of him and not the other children (neglect)
-mother has to bring him everytime replapse
-treatment cost is a burden to family | Patient is now 8 years old. He presented with relapse. He has had 12 relapses in the past 5 years.
What are psychological burden of chronic illness on patient and family? |
| Give cyclophosphamide.
Monitor side effect of it : alopecia, neutropenia, haemorrhagic cystitis, gonadal toxicity | Patient is now 8 years old. He presented with relapse. He has had 12 relapses in the past 5 years. How do you manage |
| Neprotic syndrome: oedema, hypoalbuminemia, proteinuria
Nephritic syndrome: hypertension, oligouria, haematuria
in nephrotic syndrome, cx is hypoalbuminemia.
in nephritic syndrome, cx is hyperalbuminemia. | Triad of nephrotic syndrome?
Triad of nephritic syndrome?
(hyperalbuminemia/hypoalbuminemia)
in nephrotic syndrome, cx is _________.
in nephrotic syndrome, cx is _________. |
| Renal failure, spontaneous peritonitis, hypovolemic shock. | Cx of nephrotic syndrome |
| 1. oedema - common
2. proteinuria
>40mg/m2/hour or >1g/m2/day or
early morning urine PCI of >200 mg/mmol
3. hypoalbuminemia (<25g/l)
4. hypercholesterolaemia | Diagnosis of nephrotic syndrome (criteria) |
| 1. FBC
2. Urinalysis/ urine dipstick test
3. RP - urea, creatinine, electrolyte
4. LFT - albumin
5. serum cholesterol
6. ASOT
7. Serum compliment (C3,C4)
8. Urine PCI (Quantitative urinary protein excretion) | investigations in nephrotic syndrome. |
| 1. Primary: common: minimal changes
2. Secondary: post streptococcal glomerulonephritis /SLE | Aetiology of Nephrotic Syndrome. |
| Steroid resistant nephrotic syndrome (failure to achieve remission despite 4 weeks of adequate corticosteroid therapy) | When is renal biopsy is done? |
| T. Prednisolone
60mg/m2/day until remission,
40mg/m2/day every alternate day 4 weeks,
taper down 25% 4 weeks,
and stop. | What is the prednisolone regime for relapsed nephrotic syndrome? |
| >> 2 relapse within 6 months from initial diagnosis or
>> 4 relapse within 1 year from initial diagnosis. | What is definition of frequent relapse? |
| T. Prednisolone
60mg/m2/day until remission,
40mg/ m2/day every alternate day 4 weeks,
taper down over 4 weeks,
keep low dose alternate day 0.1-0.5 mg/kg/dose for 6 months.
should pt relapsed while on low dose EOD, reinduce prednisolone as relapse. | What is the prednisolone regime for frequent relapse? |
| >> 2 consecutive relapse occuring during steroid taper or within 14 days of the cessation of steroids. | What is steroid dependent nephrotic syndrome. |
| if pt is non steroid toxic, consider reinduce with steroid and maintain as low dose of alternate day as possible.
if pt is steroid toxic, consider steroid sparing agents. Begin therapy when in remission after induction with corticosteroids. | what is the treatment for steroid dependent nephrotic syndrome. |
| cyclophosphamide
2-3mg/kg/day for 8-12 weeks (cumulative dose 168mg/kg) | Example of steroid sparing agents. |
| asx proteinuria.
Usually trigger by intercurrent infection.
In maintainance alternate day prednisolone, increase the dose from alternate to every day 3-5 days to reduce risk of relapse.
not require cortisteroid induction if asx, remains well and resolve after resolution of infection.
however, if proteinuria persist, treat as relapse. | what is breakthrough proteinuria? |
