nephrotic syn with thromboembolism
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DEPARTMENT OF PEDIATRIC NEPHROLOGYDEPARTMENT OF PEDIATRIC NEUROLOGYMEHTA’S CHILDREN HOSPITAL
Complications of NS are1.Infection2.Acute renal failure3.Dyselectrolytemia4.Fluid overload disorders5.Bone mineral loss6.Stunted growth 7.Hypertension8.Thromboembolism
3⅟₂ years old, MaleDiagnosed as NS in April 2008Remission after 12 weeks of oral
prednisolone therapy1st relapse in March 2009 responded
to daily prednisolone therapy
Two weeks later when in remission on alternate day prednisolone therapy came with
Headache Poor oral intakeProgressively increasing lethargy
Mild dehydrationHR: 98/min, volume goodBP: 100/70Fundus normalSystemic examination: essentially
normal
Urine albumin: NegSerum albumin: 3.7g/dlCreatinine: 0.5mg/dlSodium: 137meq/lCalcium: 9.4mg/dlWBC count: 11,500 cmmPolymorphs 60%, Lymphocytes 37%Hb 14, PCV 40%Platelet count: 5.04lacs/cmm
In absence of DyselectrolytemiaHypertension Hypovolemia CT Brain was done
Thrombosis of superior sagital sinus with possible extension to Right transverse sinus
Protein C: 204 (67-195%)Protein S: 101 (77-143%)Anti Thrombin III: 158 (70-122%)
Low molecular weight Heparin IV Diuretics for raised ICPOral anticonvulsants
After 1 week of treatment he did not improve symptomatically
MRI Brain with MR Venogram was done
Thrombosis of superior sagital sinus, torcula, Right transverse sinus and Right sigmoid sinus
Oral anticoagulants with dose adjustment was done to maintain INR between 2-3 and was discharged
COMPLETE RECOVERY OF RIGHT LATERAL RECTUS PALSY
Incidence of Thromboembolism in children with NS is 1.8-5%
Bryce A, et al. Epidemiology and risk factors for thromboembolic complications of childhood nephrotic syndrome: A midwest pediatric nephrology consortium study. J Pediatr 2009;155:105-10
Mahmoodi BK, ten Kate MK, Waanders F, Veeger NJ, Brouwer JL, Vogt L. High absolute risks and predictors of venous and arterial thromboembolic events in patients with nephrotic syndrome: results from a large retrospective cohort study. Circulation. Jan 15 2008;117(2):224-30.
Platelet hyper-aggregabilityHypercoagulation Decreased endogenous anti-
coagulantsDecreased activity of fibrinolytic
systemEndothelial cell injury
Hyperviscosity HyperlipidemiaRBC hyperaggregation
Renal vein thrombosis (30-40%)Deep vein thrombosis (15-20%)Pulmonary embolismMesenteric vein thrombosisCerebral venous thrombosis (1-2%)Arterial thrombosis
Children >12 years of ageCongenital NSSevere proteinuriaPrevious episodes of thrombosis/DVTCentral line accessSLE
HypertensionHypovolemiaDyselectrolytemiaAcute renal failureCNS infectionThromboembolism