Nephrotic syndrome

Presenter: -
Amit Mann
M.Sc. Nursing 1st year
College of Nursing
AIIMS,NEWDELHI
 CASE STUDY
 A 2-year-old male toddler weighing 15 kg presented with a
history of fever which is high grade continuous type associated
with chills and rigors.
 The patient had cough (wet cough more in amount) whitish
colour sputum not foul smelling.
 Swelling over face was present which initially started around
peri-orbital (which is more during morning) and gradually
progressed to face which decreases by evening.
 The toddler had decreased urine output.
CASE STUDY Contd.
 The baby was delivered by C-section and weighed 2.75 kg
after birth.

 On examination pitting type of oedema was present over lower

limbs and swelling over face was present.

 Laboratory investigations showed protein in urine, reduced

serum albumin (2.0 g/dL) with elevated lipid levels.
Nephrotic syndrome

• It is characterized by heavy proteinuria(more than 3.5 gm /day),

hypoalbuminemia (serum albumin <2.5 mg/dl) and edema.
Incidence
• 2-4 per 100,000 children worldwide.
• 9-10 per 100,000 children in India.
• More frequent 2-6 years of age.
• More common in males than females.
Etiology
1. Idiopathic nephrotic syndrome (90%)
- Minimal change disease - MCNS (85%)
- Focal segmental glomerulosclerosis (10%)
- Mesangial proliferation (5%)
2. Glomerulonephritis;Membranous nephropathy; and
membranoproliferative glomerulonephritis (10%)
Secondary Causes
• Genetic
• Hepatitis B, Hepatitis C,
• HIV,
• SLE
• Malignancies
Pic credit -Wikipedia
Minimal change disease
The individual foot processes can
no longer be made out- it is like
they have all just “melted”
together into a single thin layer.
This important barrier in the
filtration process can no longer
keep protein from being filtered
out of the blood and into the
urine.

Pic credit –
UNC Kidney centre
Do u see any difference?

Pic credit –
UNC Kidney centre
And in this one

Pic credit –
UNC Kidney centre
PATHOPHYSOLOGY

Brunner and Suddarth’s

Textbook of Medical
Surgical Nursing
Pic Credit –
Clinical reference MSK
Signs & Symptoms

Edema Hematuria Oliguria

Respiratory distress
Clinical manifestations
• Foamy urine
• Weight gain due to retaining too much fluid
• Tiredness
• Anorexia
Continued…
• Ascites
• Pleural effusion
• Labial or scrotal swelling
• Edema of intestinal mucosal possibly causing
diarrhea, anorexia ,poor intestinal absorption
Hyperlipidemia
• The hyperlipidemia associated with the syndrome is primarily
due to abnormal lipoprotein homeostasis that results in an
increase in synthesis and decrease in catabolism.
• Patients usually have elevations of total plasma cholesterol,
triglyceride, very-low-density lipoprotein (VLDL), and low-
density lipoprotein (LDL)
Hypercoagulability
• Caused by an increased urinary loss of antithrombin III,
increased hepatic synthesis of fibrinogen, and increased
platelet aggregation.

• Increased risk of spontaneous thrombosis and embolism.

• The patient with acute renal vein thrombosis can present with
sudden onset of flank or abdominal pain, gross hematuria
Anemia
• Patients with nephrotic-range proteinuria have a tendency to
lose different types of proteins in the urine, including binding
proteins.

• Transferrin loss due to proteinuria, patients present with an iron-

resistant microcytic hypochromic anemia.

• Anemia may result from decreased renal synthesis of

erythropoietin.
Investigations at the first episode of NS

Essential If required
Urinalysis: proteinuria,red Antistreptolysin O titre
cells casts Chest X ray (positive tuberculin
Essential

If test,history
required of contact with
Bloodproteinuria,red
 Urinalysis: levels ofcells casts  Antistreptolysin O titre
 Blood levels of urea ,creatinine albumin, cholesterol  tuberculosis)
 urea,creatinine, albumin, Chest X ray (positive tuberculin test,history of
CBC contact
Hepatits b surface antigen
with tuberculosis)
cholesterol
 Tuberculin test  Hepatits b surface antigen
Antinuclear
 Antinuclear antibodies
antibodies –if features of–if
SLE
Complete blood count  Urine culture-if clinical feature of UTI present
features of SLE
Tuberculin test Urine culture-if clinical feature of
UTI present
Dipstick test
• Nephrotic-range proteinuria will be apparent by 3+ or 4+ readings on
the dipstick. A 3+ reading represents 300 mg/dL of urinary protein or
more, which correlates with a daily loss of 3 g or more and thus is in
the nephrotic range.
24-hour urine collection
For this test, you will need to collect urine samples over 24
hours.
Discard the first sample taken at 7am and collect urine for
next 24 hrs till next day at 7am.
Blood investigations

• Serum Albumin level is < 2.5 gm/dl (Hypoalbuminemia)

• Serum cholesterol is > 250mg/dl (Hypercholestremia)
• Serum Triglyceride is > 200 mg/dl (Hypertriglyceridemia)
• Serum sodium level is < 135 mg/dl (Hyponatremia)
• Serum urea level are usually within normal limits in MCNS.
Indications for Renal Biopsy
Indicated at the age of onset if a cause other than minimal
change NS is likely eg:
• Age at onset less than 1 year or more than 16 years
• Gross or persistent microscopic hematuria
• Patients who fail to show remission despite 4 weeksof daily
treatment with prednisolone (steroid resistance)
• High blood levels of Urea or creatinine
• Sustained hypertension
MEDICAL MANAGEMENT
Initial Episode
• Massive edema or any infection should be controlled before
starting corticosteroid therapy.
• Prednisolone - 2 mg /kg day (maximum 60 mg )in single or
divided doses for 6 weeks , followed by 1.5 mg/kg/day
maximum 40 mg as a single morning dose on alternate days
for the next 6 weeks.
• Therapy with corticosteroid is then stopped.
Important definitions
Remission - Protein-free urine (urine protein negative/trace; or <4
mg/m2 /hr) for 3 consecutive days
Relapse - Proteinuria (urine protein 3+ or more) for 3 consecutive days
 Infrequent relapser - Responder, but with 3 or less relapses within one
year
Frequent relapser - Relapser who has >2 relapses within 6 months of the
initial episode; or >3 relapses in any 12 months period
Steroid dependent - Occurrence of two consecutive relapses during
alternate day prednisolone therapy, or within 2 weeks of its discontinuation
Initial resistance - Absence of remission despite 4-weeks of initial steroid
treatment
Late responder - Patient with initial resistance, who responds later
Late resistance - Initial responder, who subsequently fails to respond to
steroid therapy.
Medical management contd.
Therapy for relapse
• Prednisolone-2 mg/kg/day until urine protein is trace or nil for 3
consecutive days (remission) which usually takes 8-12 days.
• And subsequently as a single morning dose of 1.5 mg/kg on
alternate days for 4 weeks and then stopped.

• Treatment for relapse usually lasts for 5-6 weeks.

Medical management contd.
Therapy for Frequent relapses and steroid dependence

 Long Term , Alternate day steroids

Following treatment of a relapse , Prednisolone is tapered to a
dose of 0.3 - 0.7 mg/kg on alternate days ,which is given for 9 to
12 months.
Steroid sparing agents
Alternate agents are recommended if features of corticosteroid
toxicity (growth failure, hypertension and cataract ) appears.
Medical management contd.
Steroid sparing agents
 Levamisole
1. Dose and duration-2-2.5 mg/kg on alternate days for 12-24
months.
2. A/E-flu like symptoms ,neutropenia, hepatoxicity, convulsions,
skin rash.
3. Monitoring-monitor total and differential leukocyte count every 3-
4 months.
4. Concomitant steroid therapy-dose of prednisolone is tapered to
0.25 -0.5 mg/kg on alternate days.
Medical management contd.
 Cyclophosphamide
• Dose and duration-2-2.5 mg/kg/day for 8 -12 weeks along
with Prednisolone 1.5 mg/kg on alternate days.
• A/E-leukopenia , alopecia , vomiting hemorrhagic cystitis,
gonadal toxicity ,malignancies.
• Monitoring-cumulative dose should not exceed 168 mg/kg,
repeat courses are avoided.
• Leukocyte counts should be monitored every 2 weeks.
• Cyclophosphamide is stopped if leukocyte is less than
3000/mm3.
• Fluid intake should be increased and patient are encouraged
to void frequently.
Medical management contd.

 Mycophenolate mofetil

• Dose – 30mg/kg/day in two divided doses for 12-14 days

• A/E- gastrointestinal discomfort, diarrhea and leukopenia

• Monitoring-leukocyte counts are monitored every 1-2 months,

treatment is withheld if counts falls below 4,000/mm 3
Medical management contd.
Cyclosporine A
• It is used in patients who do not benefit significantly from
levamisole or cyclophosphamide ,continue to relapse and show
significant signs of toxicity.
• Dosage is 4 - 5 mg/kg/day for 12 – 36 months daily along with
alt. day prednisolone upto 12 -24 weeks.
• Side effects- Hirsutism ,gum hyperplasia and hypertension,
nephrotoxicity.
• A renal biopsy is advisable before commencing treatment with
these agents.
Medical management contd.
Rituximab
• Monoclonal antibody
• It is used in steroid dependent & Frequently relapsing nephrotic
syndrome.
• 375 mg/m2 IV once in a week (2-3 doses)
• A/E- fever, rash, bronchospasm , neutropenia.
Other concerns
VACCINATION
All children with NS should receive vaccine against pneumococcal
infections.

Administration of live vaccine is contraindicated in steroid therapy.

(measles ,mumps ,rubella,opv)

• 2doses of varicella vaccine are given 4 weeks apart ,while the

child is in remission form and off immunosuppressants.
• Other injections like pneumococaal, Hepatitis b can be given.
Complications
1.Edema-
Daily administration of corticosteroids results in diuresis within 2-
4 days or diuretics.

• Short term therapy –fresumide 1-3mg/kg/day ± thiazide

diuretics

• Refractory edema- IVfrusemide bolus (1-3mg/kg/dose,infused

over 15-20 min) or infusions (0.1-1mg/kg/hour)
Complications..
2. Hypovolemia-
marked by elevated ratio of blood urea to creatinine ,rising
hematocrit and urine sodium less than 20mEq/L .

• Treatment-rapid infusion of NS (10-20ml/kg over 20-30 minutes.

• who don’t respond-2 saline boluses should receive infusion of
5% (10-15ml/kg)
Complications……
3.Thrombosis
Heparin /low molecular weight heparin initially followed by oral
anticoagulants
4. Increased risk of infections
Antibiotics and vaccinations
5. Hyper lipidemia
Treatment-atorvastatin (10-20 mg/day )
6. Calcium, Vit. D metabolism
Urinary loss of 25-Hydroxyvitamin D3
Hypoalbumenia
Eat plenty of ……
Say no to…..
 Nursing management
 Nursing Assessment
 Nursing Diagnosis
 Nursing Goals
 Nursing Intervention
 Nursing Evaluation
Nursing Assessment
• Edema :-
Observe for edema when performing physical examination of the child with
nephrotic syndrome.
• Weigh and measure :-
Weigh the child and record the abdominal measurements to serve as a
baseline.
• Vital signs :-
Obtain vital signs, including blood pressure.
• Pitting edema :-
Note any swelling about the eyes or the ankles and other dependent parts.
• Skin :-
Inspect the skin for pallor, irritation, or breakdown; examine the scrotal area of
the male child for swelling, redness, and irritation.
Nursing diagnosis 1

Excess fluid volume related to fluid accumulation in tissues and

third spaces.
Interventions
Record accurate intake and output of patient.

Weight daily at same time of the day, on same

scale , with same equipment and clothing.
Measure the child’s abdomen daily at the level
of the umbilicus.
Assess skin , face and dependent areas for
edema.
Administer diuretics as prescribed.
Nursing diagnosis 2
Risk for imbalanced nutrition: less than body requirements related to
anorexia.

Interventions
Offer a visually appealing and nutritious diet.

Consult the child and the family to learn which foods are
appealing to the child.
Serving six small meals may help increase the child’s total
intake better.
Nursing diagnosis 3
Risk for impaired skin integrity related to edema.

Interventions
Inspect all skin surfaces regularly for breakdown.
Turn and position the child every 2 hours.
Protect skin surfaces from pressure by means of pillows and
padding.
Protect overlapping skin surfaces from rubbing by careful
placement of cotton gauze.
Bathe the child regularly.
Nursing diagnosis 4
Risk for infection related to immunosuppression.

Interventions
Protect the child from anyone with an infection
i.e. Staff, family, visitors and other children

Handwashing and strict medical asepsis are

essential.

Observe for any early signs of infection.

Administer antibiotics as prescribed.

Take home message

• Nephrotic syndrome is not a disease itself, but the manifestation of many

different glomerular diseases resulting in proteinuria, hypoalbuminemia
edema and hyperlipidemia.

• Prednisone is the first-line therapy for children with nephrotic syndrome

(NS).

• Other immunosuppressive medications may be useful in those whose

symptoms fail to respond to standard corticosteroid therapy or in those
who have frequent relapses.
Summary
Definition

Etiology

Pathophysiology

Types

Clinical features

Diagnosis
Management – medical &
nursing
Queries ?????
MCQ 1

A nurse is assessing a client with nephrotic syndrome and

notes frothy, foamy urine output. What is the rationale for this
characteristic urine appearance?

A Increased glucose levels in the urine due to insulin resistance.

B Presence of blood in the urine from glomerular damage.
C Excessive protein excretion in the urine.
D Elevated creatinine levels indicating kidney dysfunction.
MCQ 2
A nurse is caring for a client with nephrotic syndrome who is
prescribed diuretics. What should the nurse monitor closely
while the client is on diuretic therapy?

A Serum potassium levels

B Blood glucose levels
C Serum calcium levels
D Blood pressure readings
MCQ 3
A nurse is caring for a client diagnosed with nephrotic
syndrome who presents with edema, proteinuria,
hypoalbuminemia, and hyperlipidemia.
What is the priority nursing intervention for this client?

A. Assess for signs of infection and initiate appropriate treatment.

B. Monitor blood glucose levels to detect potential hyperglycemia.
C. Provide dietary education to increase protein intake.
D. Administer diuretics to manage edema.
MCQ 4
A nurse is assessing a client with nephrotic syndrome
for signs of hypoalbuminemia. What clinical
manifestation should the nurse expect to observe?

A Elevated blood pressure and fluid overload.

B Muscle weakness and fatigue.
C Hyperactivity and restlessness.
D Pallor and cold extremities.
MCQ 5
A nurse is educating a client with nephrotic syndrome
about self-management strategies. Which statement
by the client indicates the need for further teaching?

A "I will monitor my blood pressure regularly at home."

B "I will restrict my fluid intake to prevent edema."
C "I will report any signs of infection to my healthcare provider."
D "I will weigh myself daily and keep track of any sudden weight
changes."
 Bibliography

• Pediatric nephrology , 5th edition, RN Srivastava & Arvind Bagga

pp 195-235

• O P Ghai, V K Paul, Arvind Bagga, “Essential Pediatrics”, 8 th Edn,

Pg 450 -54

• medind.nic.in/maa/t09/i1/maat09i1p4.pdf

• www.icmr.nic.in/ijmr/2005/july/0701.pdf
Thank you