Case on nephrotic syndrome
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ORATOR: RAYAZ AHMAD BHAT
STUDENT NIPER, GUWAHATI, ASSAM
MODERATOR: DR. (Mrs.) MANGALA LAHKAR
CAC, NIPER, GUWAHATI, ASSAM
MENTOR HOSPITAL: GUWAHATI MEDICAL COLLEGE AND HOSPITAL
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CASE: NEPHROTIC SYNDROME
Deptt. Of Nephrology
Guwahati Medical College And Hospital
Assam
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PATIENT DETAILS
NAME: XYZ
SEX: MALE
AGE: 82yrs
DOA: 10/09/2016
Deptt. Regd. No: 4654/16
BED NO. 04
MRD NO. 59868
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CHIEF COMPLAINTS
Swelling of both legs from last 2 months
Lower urinary tract symptoms from last 15 days
Respiratory difficulty with on/off cough from last 15 days
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PATIENT HISTORYSOCIAL HISTORY
SMOKER: NO
ALCOHOLIC: NO
MEDICAL HISTORY
No history of T2DM or Hypertension
H/o of pain killer for knee joint pain (B/L) 1 month prior to swelling
No H/o intake of herbal medication
No H/o Haematemesis or Melena
No H/o renal calculi, burning micturation or fever.
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ON PHYSICAL EXAMINATIOM
PULSE RATE: 86/MIN
CVS : S1 S2 -Normal
PALLOR: +
OEDEMA: +
CHEST: VESICULAR BREATH SOUNDS were audible
Bp: 110/80
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LAB INVESTIGATIONS
INVESTIGATIONNORMAL VALUE/RANGE
10/09/16D1
12/09/16
D3
15/09/16D6
20/09/16
D11
Sodium 137-145 mmol/l 127 128 124
Potassium 3.5-5.1 mmol/l 3.7 2.4 3.2
Calcium(total) 8.4-10.2 mg/dl 6.9 6.6
AST 17-59 u/l 61
ALT 21-72 u/l 40
WBC 4000-11000 7900 8500
Hemoglobin 13-17 g/dl 10.1 9.0
Neutrophills 37-72 % 46 87.3
Lymphocytes 20 -40 % 35 10
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INVESTIGATION NORMAL VALUE/RANGE D1 D3 D6 D11
Monocytes 2 – 10 % 7 2.1
Eosinophills 1 – 6 % 12 6
Prothrombintime/INR
12-16 sec/.8-1.5 18.7/1.7
TSH 0.465-4.68mIU/L 300
Cholesterol <200mg/dl 369
Triglycerides 50-150mg/dl 401
Albumin 3.5-5mg/dl 1.8 1.5
Total Protein 6-8g/dl 4.84
Urea 10-45mg/dl 48.3 1O2.9
Creatinine 0.80-1.50 mg/dl 2.06 2.83
Iron 65-180ug/dl 55
TIBC 240-450 mcg/dl 183
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INVESTIGATION NORMAL VALUE/RANGE
D1 D3 D6
RandomGlucose
79-140mg/dl 124.4
Fasting Glucose
70-110mg/dl 95
Hb1Ac 0-6% 5.50
tPSA 0-4ng/dl 0.365
Urine Protein(24hr)
24-141mg/24hrs
336
CPK 55-170u/l 439
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USG REPORT12/09/16
RESULT
Bilateral renal parenchymal changes and
Right kidney cyst
Liver
Gall bladder
COMMON BILE DUCT
PORTAL VEIN
SPLEEN
NORMAL
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SERUM PROTEIN ELECTROPHORESIS SHOWED
HYPERGAMAGLOBULINEMIA (POLYCLONAL)
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Other Tests
HIV-I and II-------Non-reactive
Hep-B and C------Non-reactive
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RENAL BIOPSY (NEEDLE) REPORT25/09/16
RESULT
RENAL AMYLOIDOSIS WITH GLOMERULAR AND VASCULAR DEPOSITION OF AMYLOID
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DIAGNOSISNEPHROTIC SYNDROME
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EPIDEMIOLOGY
Nephrotic syndrome is relatively rare but importantmanifestation of kidney disease with a incidence of 3new cases per 100,000 each year in adults and hasserious complications , caused by a number ofprimary and secondary glomerular diseases
Reference : PatientPLUS , Document ID-2505(v24)
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MEDICATIONS CHARTDRUG ROA DOSE RREQ DAYS 10/09/16 0nwards
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
TORASEMIDE
(DYTOR)
ORAL 10mg BD
PANTOPRAZOLESODIUM
(PANTACID)
ORAL 40mg ODAC
ATORVASTATIN AND FENOFIBRATE
(ATORLIP-F)
ORAL 10/160mg
OD HS
FUROSEMIDE
(LASIX)
I.V 60mg BD
PIPERACILLINANDTAZOBACTAM
(PIPZO)
I.V 4/0.5g OD
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DRUG ROA DOSE RREQ DAYS 10/09/16 0NWARDS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
TRYPSIN,BROMELAIN AND RUTOSIDE
(ENZOMAC)
ORAL 40mg,90mg,100mg
TD
TRAMADOLI.M 50mg S0S
LEVOTHYROXINE
(THYRONORM)
ORAL 50mg OD AC
TRANEXIMIC ACID
(TRANOSTAT)
I.V 1 AMP STATIM
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DRUG ROA DOSE RREQ DAYS
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PREDNISOLONE
(OMNACORTIL)
ORAL 10mg BD
CALCIUM CARBONATEAND VITAMIN D
(SHELCAL)
ORAL 500mg OD
ATORVASTATIN
(ATORLIP)
ORAL 10mg ODHS
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Patient was discharged on request on 26/09/16
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DISCHARGE MEDICATIONS TABLET OMNACORTIL (PREDNISOLONE) 20mg 2 tab for
one week
• Followed by 20mg 1 and half tab for 0ne week
• Followed by20 mg 1 tab for 1 week
• Followed by 10mg 1 tab for 10 days
TABLET THYRONORM 75mg OD
TABLET PANTACID 40mg OD BBF
TABLET ATORLIP 20mg OD
TABLET LASIX 60mg BD till swelling subsides
FOLLOW UP
HEMATOLOGY AND NEPHROLOGY OPD EVERY 2 WEEKS
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PHARMACEUTICAL ISSUES AND SUGGESSIONS
Concurrent use of statins and fibrates increase the risk of Rhabdomyolysis and Myopathy and the risk is more in elderyand renal disease patients
SUGGESTIONCREATINE KINASE levels should be monitored regularly
As a general rule any patient given a statin and fibrate should be told to report any signs of myopathy and possible RHABDOMYOLYSIS( unexplained muscle pain, tenderness, weakness or dark urine)
If Myopathy does occur the statin should be stopped immediately or dose adjusted and monitored closely.
Generally a lower dose of statin with fibrate is recommended
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•CYP3A4 inhibitors like macrolide antibiotics , azole antifungals if required should be prescribed very cautiously for a patient on statins –High risk of rhabdomyolysis
Monitoring of liver function is recommended for all statins to rule out any toxicity to liver
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High dose of any corticosteriod can produce hypokalemia via mineralocorticoid action which is further increased by concurrent administration of Ferusemide and may produce symptoms of muscle pain/cramps, confusion , dizziness etc
SUGGESTION
• Increase dietary intake of potassium
• Supplements of Potassium chloride
• Concurrent use of Potassium sparing diuretic
• Dose adjustment
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PREDNISOLONE may elevate serum TG and LDL levels if used for prolonged period
SUGGESTION
Close monitoring of lipid levels and dose titration
PREDNISOLONE may also increases blood coagulability
SUGGESTION
Since the patient is already at risk of thromboembolism due to loss of anthithrombin-III close monitoring of PT is necessary to prevent any complication
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Response to Prednisolone should be closely monitored because there are variations in response to Corticosteroids which include:
Corticosteroid sensitive patients
Corticosteroid resistant patients or Late steroid responders
Corticosteroid intolerant patients
Corticosteroid dependent patients
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One of the complication of disease is immune deficiency due to leakage of immunoglobulin's and loss of proteins in general making the patient prone to infections ,so, the patient should be prescribed appropriate antibiotics and should not stop taking antibiotic unless told because the patient is taking PREDNISOLONE which has IMMUNOSUPRESSANT action further increasing risk of infections.
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Concurrent administration of Levothyroxinewith calcium containing products (SHELCAL) reduces its oral bioavailability by nonspecific adsorption of levothyroxine to calcium carbonate at acidic pH
SUGGESTION
Patient should be advised to take Levothyroxine with a gap of at least 4 hours after or before any calcium and iron containing products, sucralfate,PPIs
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Patient was given Tranostat I.V after renal biopsy to watch for haematuria
SUGGESTION
TRANSTAT being antifibrinolytic and given I.V may increases the risk of thrombus formation since the patient is already at risk of thromboembolismtherefore it should be given cautiously and the patient should be monitored closely for any thromboembolic complication.
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Other Suggestions
Chances of embolism increases at rest so, Doctor should consider this
Patient could be recommended DOPPLER ULTRASOUND to check any thromboembolic complication
Growth retardation occurs due to loss of proteins and steroid therapy so the patient should be prescribed suitable supplements
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LIFE STYLE MODIFICATIONS Low fat , low cholesterol diet
limitation of saturated and trans fats
salt restriction
Lean sources of protein
Exercise to prevent thromboembolic complications
Patient should be advised not to take any other medication without doctors or pharmacists consultation since there are various complications of the SYNDROME which restricts the use or require close monitoring of various drugs
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