NEPHROTIC SYNDROME

PREPARED BY:MANISHA PRAHARAJ

MSC. NURSING 2ND YEAR

DEFINITION Nephrotic syndrome is a primary glomerular disease characterized by proteinuria, hypoproteinemic edema and hypercholesterolemia hypoalbuminemia, hyperlipidemia. Because of gross proteinuria serum albumin is low ( <2.5 g/dl).

TYPES1. Idiopathic NS:In childhood, the vast majority belongs to category it is regarded as a sort of autoimmune phenomenon, especially since it responds well to immunosuppressive therapy. It is two types:a. Minimal change NS – this predominant type, seen 86% of the cases.b. Significant change NS – this is infrequent. Mesangial proliferation is seen in 5% cases and focal sclerosis in 10% of cases.

2. Secondary NS:• It occurs in children (about 10%) of all cases.• This condition may occur due to some form of chronic glomerulonephritis, or due to diabetes mellitus, SLE, malaria, malignant hypertension, hepatitis B, infective endocarditic, HIV/AIDS, drug toxicity, lymphomas syphilis etc.

3. Congenital NS:• It is rare but a serious and fetal problem usually associated with other congenital anomalies of kidney.• It is inherited as autosomal recessive disease.• Severe renal insufficiency & urinary infections along with this condition result is poor prognosis.

4. Infantile NS: • The term is applied to NS occurring in infants between 4 – 12months of age. Its major causes are: A. NPHS2B. Diffuse mesengial sclerosis (DMS)

ETIOLOGY1. Primary renal cause• Minimal change nephropathy• Glomerulosclerosis• Acute post streptococcal glomerulonephritis• Immune complex glomerulonephritis.

2. Systemic cause• Infections• Toxins – mercury, bismuth, gold• Allergic – bee sting, inhaled pollen, food allergy• Cardiovascular – sickle cell disease, renal vein thrombosis, congestive heart failure• Malignancies – leukemia• Others – systemic lupus erythematous, anaphylactic purpura

PATHOPHYSIOLOGYAlteration in glomerular basement

membrane

Decreased colloidal osmotic pressure

Decreased vascular volume

Decreased renal blood flow

Increased loss of protein in urine

Altered glomerular protein permeability

Increased secretion of aldosterone

Edema

Tubular Na and H2O reabsorption

CLINICAL MANIFESTATIONFour main symptoms of nephritic symptoms:-• Protein urea• Hypoalbuminemia• Hyperlipidemia• Edema

OTHERS:• SOB (Shortness of

breath)• Mild headache• Fever, rash, joint

pain• Weakness• Malaise• Anorexia• Weight gain

• Periorbital edema• Irritability• Ascites• HTN• Anemia due to loss

of RBCs• Flank pain• Fatigue.

DIAGNOSISo PALPATION: Due to edema and ascites kidney cannot be palpable.o Urine analysis Haematuria 24 hour urinary total protein estimation – urine sample shows proteinuria (>3.5 g per liter per 24 hours)o Blood test BUN S.creatinine S.protein Desreases Lipid profile shows high level of S. cholesterol- 200mg.

• Comprehensive metabolic panel(CMP) shows hypoalbuminemia, albumin level is <2.5g/dl

Needle biopsy of kidney ECG KUB – X.ray Renal ultrasound Renal scan Intravenous urogram (IVU).

MANAGEMENTMEDICAL MANAGEMENT:• The goal of medical management is reduction of

protein excretion.• If causative agent is streptococcal then treated with

penicillin antibiotics.• Prednisolone is the drug of choice.Daily dose of 2mg/kg/day orally in divided doses for 6 weeks is given, • Thereafter 1.5 mg/kg as single dose on alternate days

for 6 weeks, after which treatment is discontinued.

• Proteinuria disappears within the first week of therapy and negative dipstick test for 2 consecutive days shows positive response to treatment.

• Frequent relapses are treated by alkylating agents such as cyclophosphamide (2 mg/kg daily for 12 weeks), nitrogen mustard, cyclosporine or levamisole.

• Diuretic and salt poor albumin may be indicated in presence of severe edema.

• Frusamide (1-44 mg/kg/day in 2 divided doses) may be prescribed.

DIETARY MANAGEMENT• Children should take a well-balanced diet rich in protein. Sodium is restricted when marked edema is present.• Provide high protein and high carbohydrates diet to patient.• If disease in advance stage then avoid protein intake because it is affected to kidney.• Water restriction may be indicated if decreasing salt intake does not control edema.

NURSING MANAGEMENTNURSING DIAGNOSIS:• Risk for infection related to immunosuppressive drugs.• Fluid and electrolyte imbalanced related to edema.• Impaired skin integrity related to disease process.• Altered nutrition related to Anorexia.• Altered kidney function related to disease condition.• Knowledge deficit related to disease process.

Care during hospitalization:• Child is hospitalized from initial therapy.

Patient may not understand importance of hospitalization because initially the child is symptomless. During hospitalization parents should be involved in child care and goal setting.

• Nurses should regularly monitor the vital signs and check the Childs daily weight.

• Monitor signs of infection and edema.• Detailed chatting of intake/output most be

done to monitor child’s response to medical therapy.

• Daily urine examination for albumin is required.

B. Administer the prescribed medications:o Children with nephritic syndrome are receiving steroids so the nurse most be aware of the side effects of these drugs. Patient should be observed for gastrointestinal bleeding, gastro intestinal ulcers, hyperglycemia and cataract.o Steroid is continued till the child is protein free, thereafter the drug dose in decreased gradually.

Maintain fluid and electrolyte balance:• Nurses should monitor serum sodium level

of the child.• Fluid intake either oral or I/V should be

strictly monitored.• Child is assessed for venous stasis, ascites

and pulmonary edema.• Daily weight of child is accurately

documented.

Prevention of infection:• The child is on corticosteroid therapy

(immunosuppressant) and there is loss of immunoglobulin in urine, so these children are the greater risk of infection.

• Strict aseptic technique should be used during invasive procedures.

• Monitor vital signs for early signs of infection.

• Isolate the child as he is on immunosuppressive therapy.

Promote rest:• Provide passive play to the child as

tolerated e.g, watching TV, reading story books, etc.

• Allow a period of rest after activities.• Limit visitors during acute phase of

illness.

Provide emotional support:• Explain parents about the disease and its treatment • Allow the patients and child to express their

feelings.• Due to sudden weight gain and disturbed body

image, child may manifest with behavioral changes, may refuse to look at mirror and has decreased interest in appearance.

• Enhance the body image of the child.• Encourage child to wear own clothes rather than

hospital clothes as this make the child feel good.

Discharge plan• Explain to patients about treatment

programmed, follow up and risk of relapse.• Encourage patients to measure child’s

weight weekly in order to identify early fluid retention.

• Tell then to contact doctor if any unusual symptoms appear.

• Increase intake of fruits and vegetables. No potassium and phosphorus restriction in necessary.

o Explain about the medications to be continued at home and their side effects like cushingoid appearance, gastrointestinal bleeding and sodium retention. If the child is on corticosteroid therapy for very long time, fundus checkup should be done because prednisolone causes cataract.o Dietary modifications should be explained to the parents.o Ask them to avoid saturated fats such as butter, cheese, fried foods, and fatty cuts of red meat and egg yolks and increase unsaturated fat intake including olive oil, canola oil, peanut butter, and nuts. The child can eat low fat desserts.

SUMMARY