2. CASE SCENARIO A male child patient aged 6 yrs was admitted
in pediatric ward with: Present complains: Hematuria burning
maturation History of present illness: Subject developed dyspnea 2
days back and on the present day morning blood in urine was found.
Past family history: Not significant (NO ONE HAD HEMATURIA)
3. Investigations 1. CUE (COMPLETE URINE EXAMINATION): urine
proteins: 420 (0-8 mg/dl) creatinine: 39 (30-40 mg/dl) P/C ratio :
10.70 ( 40 mg/m2/hr First morning protein : creatinine ratio of
> 2-3 : 1
5. PATHOPHYSIOLOGY
6. PATHOPHYSIOLOGY 1. Edema
7. Incidence ( pediatric ) 2 7 cases per 100,000 children per
year Higher in underdeveloped countries ( South east Asia ) Occurs
at all ages but is most prevalent in children between the ages
1.5-6 years. It affects more boys than girls, 2:1 ratio
http://www.kidney.org/site/107/pdf/NephroticSyndro me.pdf
8. Etiology Genetic Secondary Idiopathic or Primary
12. Clinical Features Edema Mild to start with peri orbital
puffiness, lower extremities Progression to generalized edema,
ascites, pleural effusion, genital edema Decreased urine output
Anorexia, Irritability, Abdominal pain and diarrhea Absence of
Hypertension Gross hematuria
13. NO PEDAL EDEMA BUT FACIAL PUFFYNESS PRESENT
14. DIFFERENTIALS Protein losing enteropathy Hepatic failure
Heart failure Acute/Chronic Glomerulonephritis Protein
Malnutrition
15. Lab Investigations Urine Examination Complete Blood Count
& Blood picture Renal parameters : Spot Urine Protein :
Creatinine ratio Urinary protein excretion protein selectivity
ratio Liver Function Test Renal Biopsy ???
16. Continue Urinalysis - 3+ to 4+ proteinuria Renal Function
Spot UPC ratio > 2.0 UPE > 40 mg/m2/hr Serum Creatinine
normal or elevated Serum albumin - < 2.5 gm/dl Serum
Cholesterol/ TGA levels elevated Serum Complement levels Normal or
low - Nelson Textbook of Pediatrics, Vol 2, 19th Edition, page
1804
17. Additional Tests C3 and antistreptolysin Chest X ray and
tuberculin test Hepatitis B surface antigen Indications for Biopsy
Age below 12 months Gross or persistent microscopic hematuria Low
blood C3 Hypertension Impaired renal Function Failure of steroid
therapy
18. Management (Initial Episode) High protein diet Salt
moderation 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 )
19. Subsequent course Relapse Infrequent Relapsers : 3 or less
relapses per year Frequent Relapsers : 4 or more relapses per year
Steroid therapy Steroid dependant : relapse following dose
reduction or discontinuation Steroid resistant : Partial or no
response to initial treatment
20. Management of Relapse Parent Education Symptomatic therapy
for infections in case of low grade proteinuria Persistent
proteinuria ( 3 - 4+ ) Prednisolone ( 2mg/kg/day until protein is
negative for 3 days ) 1.5 mg/kg on alternate days for 4 weeks )
Ghai Essential Pediatrics,8th edition, page 479.
23. Nursing management Assessment Age, height and weight Vital
signs Past hospital admissions Immunization status Edema Urinary
output Presence of infections Dietary pattern Malnourishment
24. Nursing management Monitoring of Vital signs Intake output
Urinary protein Diet Weight Abdominal girth
25. Nursing management Diet High protein diet 2-3 gm/kg/day
Calories- 50- 70 kcal/kg/day No Added salt Protein rich food items
Egg Milk Fish Chicken Paneer Spourts Pulses & legumes
