L. Indumathi*
Nurse Educator, Kauvery Hospital, Salem, Tamilnadu, India
*Correspondence: indumaya1986@gmail.com
Nephrotic syndrome: A case report
Abstract
Childhood Nephrotic syndrome is characterized by severe proteinuria and hypoalbuminemia, with edema as the most common presenting symptom. The majority, of more than 90%, children with Nephrotic syndrome would have minimal change disease and achieve remission of proteinuria from treatment with glucocorticoids. While the goal of initial therapy is to maximize the proportion of patients with sustained remission, many patients experience relapses (range of 1 to 20) during childhood that can lead to significant morbidity. We report a case of 7-year-old child brought here with a history of on and off generalized body swelling for the past 6 months. She had a history of fever, cold, cough, and frothy micturition for the past 4 days. Laboratory investigations showed protein in urine and reduced serum albumin levels. The child was mainly treated with furosemide, prednisolone, augmentin and levamisole. Urine I/O charting was done daily until optimal results was obtained.
Keywords: Nephrotic syndrome, Proteinuria, Hyperlipidemia, Hypoalbuminemia, Albuminuria
Background
Nephrotic syndrome (NS) is the most common glomerular disease in childhood. As a clinicopathological entity, it is characterized by abnormal glomerular basement membrane permeability to plasma proteins (mainly albumin) resulting in massive proteinuria (albuminuria), and varying degrees of hypoalbuminemia, edema and hyperlipidemia. 70- 80% of children with the nephrotic syndrome attain complete remission with various corticosteroid regimens and are labeled as steroid sensitive.
Case Presentation
A 7-years-aged child was brought by the parents to pediatric OPD with the complaints of on and off swelling of the body (anasarca) for 6 months, and with scrotal swelling, cold, cough, and fever for four days. He had history of frothy micturition for 3 days. He was initially treated at a hospital and was diagnosed to have bilateral Hydrocele and minimal Ascites.
He was admitted to Kauvery Hospital, Salem, on 12/05/2022 at 12.50 pm, to general ward for further management.
On Clinical Assessment
| Blood Pressure | Pulse rate | Respiration | SpO2 | Temp |
| 100/80 mmHg | 94 beats/min | 20 breath/min | 100% | 100o F |
Physical Examination revealed that child was alert, febrile, and with facial puffiness and pedal edema. Urine output was less than 30 mL/day; Weight was 22 kg on admission.
Abdominal Examination on arrival: child had abdominal distension 31cms and scrotal edema
Abdominal scan report
Mild as cites, bilateral minimal pleural effusion, edematous gallbladder wall, bilateral normal kidney with raised renal cortical echogenicity.
Urine routine report
Urine protein: 3941 mg/L
Protein/Creatinine Ratio = 25.6
Urine Creatinine – 153.6 mg/L
Albumin +++/Later-Negative
Acetone – Trace/Later Negative
Bile Pigment ++/Later negative
Pus Cell = 6-8/hpf, Later 3-5/hpf
Initial blood report
| S.no | Investigation | Result | Reference value |
| 1 | HB | 12.9 g/dl | 13-17 g/dl |
| 2 | Total count | 11150 cel/cumm | 4000-10000 cel/cumm |
| 3 | Platelet | 4.08 lakhs | 1.5-4 lakhs |
| 4 | Urea | 42.3 mg/dl | 19-43 mg/dl |
| 5 | Creatinine | 0.3 mg/dl | 0.66-1.25 mg/dl |
| 6 | Potassium | 4.8 mmol/L | 3.5-5.1 mmol/L |
| 7 | Sodium | 131 mmol/L | 137-145 mmol/L |
| 8 | CRP | 04 mg/dl | 0-10 mg/dl |
| 9 | Total protein | 3.3 g/dl | 6.3-8.2 g/dl |
| 10 | Total bilirubin | 0.3 mg/dl | 0.2-1.3 mg/dl |
| 11 | SGOT | 27 U/L | 17-59 U/L |
| 12 | SGPT | 12 U/L | 21-72 U/L |
| 13 | Albumin | 1.3 g/dl | 3.5-5 g/dl |
| 14 | Globulin | 2.0 g/dl | 1.5-3.5 g/dl |
| 15 | GGTP | 6 U/L | 12-73 U/L |
Management
Child was initially treated with IV fluids 40 mL/h, Inj. Frusemide 10 mg, Tab. Prednisolone 60 mg/m2/day, placed later on Tab. Augmentin 375 mg BD, Tab. Wysolone 45 mg OD, Tab. Levamisole 50 mg OD and Syrup. Cetzine 5 ml BD.
The Child was prescribed with high caloric and protein diet (1200 kcal per day) with a low salt intake. The urine output and blood pressure were monitored. Successful control of edema with the administration of diuretic furosemide was seen. The scrotal edema and leg swelling were reduced and there was a concomitant increase in the protein levels.
Input/output/weight chart
| S.No | Date | Urine output (mL/day) | Input (mL/day) | Weight (kg) | Abdominal girth (cm) |
| 1 | 12/5/22 | 30 | 200 | 22 | 31.0 |
| 2 | 13/5/22 | 760 | 990 | 22.9 | 31.5 |
| 3 | 14/5/22 | 640 | 450 | 24.1 | 30.5 |
| 4 | 15/5/22 | 1900 | 700 | 22.1 | 29.0 |
| 5 | 16/5/22 | 1320 | 890 | 20.3 | 28.5 |
| 6 | 17/5/22 | 1730 | 725 | 18.5 | 26.0 |
Nursing care
(a). When the child got admitted in the hospital, he had fever so sponging was given and the fever got reduced to 98.6oF. Child achieved stable vital sign.
(b). Steam inhalation given twice a day to relieve cold.
(c). Fluid intake and output chart was accurately monitored by the nurses every day.
(d). Nutritional status of the child was enhanced with high protein diet and daily weight was monitored and it was reduced from 22 to 18 kg on the day of discharge as the facial puffiness, leg swelling, scrotal edema and abdominal ascites was reduced. Abdominal girth of the child was reduced from 31 to 26 cm on the day of discharge.
(e). Calm and quiet environment given for the child to promote sleeping hours. Psychological support is given for the parents and reassurance was given continuously as they were so much worried about the child’s health.
(f). Child was engaged with fun and game activity during the hospital stay and was involved in all his care for his full cooperation.
(g). Hand washing techniques and strict medical asepsis techniques were taught to the child and the care givers to protect the child free from infection.
Discussion
Nephrotic syndrome can affect people of any age, it’s usually first diagnosed in children aged between 2-5 years old. It affects more boys than girls. Around 1:5000 children are diagnosed with the condition every year. Common primary causes of nephrotic syndrome are minimal -change nephropathy and focal glomerulosclerosis. Secondary causes include systemic diseases such as diabetes mellitus, lupus erythematosus and amyloidosis.
Main features associated with Nephrotic syndrome are edema formation and urinary features are proteinuria and frothy micturition.
Most children respond well to treatment with prednisolone, with the protein often disappearing from the urine and the swelling going down within a few weeks. This clinical state is known as remission.
Parents are advised to seek immediate medical advice if their child has come into contact with someone who has chickenpox or measles and is not immunized against the diseases as the risk of infection may be increased in child with nephrotic syndrome because of low immunoglobulin IgG levels.
Conclusion
Nephrotic syndrome is a common renal disease worldwide and an important chronic renal disease in children. This case report was undertaken to assess clinical presentation, associated complications, investigative profile and therapeutic response in children with nephrotic syndrome. Nephrotic Syndrome is neither a single disease nor even a heterogeneous group of disease. Rather it is a clinical state characterized by heavy proteinuria and hypoalbuminemia, often associated with edema, hypercholesterolemia and hyperlipidemia. Delay in diagnosis may increase the risk for child to suffer the complications.
The best prognosis is for patients with minimal change nephropathy, who have few relapses and less than 5% require long-term corticosteroids. The long-term risk of renal failure in these patients is low. Patients who show a poor response to steroids usually have a poor outcome. For those who develop nephrotic syndrome due to a secondary cause, the morbidity is primarily related to the cause. Diabetic patients who respond to ACE inhibitors may develop slowing down of proteinuria and stabilize renal function. Those who develop amyloidosis usually have a guarded prognosis.
Reference
[1] Hodson EM, Willis NS, Craig JC. Interventions for idiopathic steroid-resistant nephrotic syndrome in children. Cochrane Database Syst Rev. 2019.
[2] Nephrotic syndrome in children: A report of the International Study of Kidney Disease in Children. Kidney Int. 1978;13(2):159-65.
[3] Eddy AA, Symons JM. Nephrotic syndrome in childhood. Lancet 2003;362(9384):629-39.
[4] McLean TLK RH, Rasoulpour M. Intravenous methylprednisolone treatment of steroid responsive nephrotic syndrome. Pediat Res. 2019;14(8):1006.
L. Indumathi
Nurse Educator