Case on nephrotic syndrome

A case presentation on Nephrotic Syndrome

1. PATIENT CASE STUDY PRESENTATION ORATOR: RAYAZ AHMAD BHAT STUDENT NIPER, GUWAHATI, ASSAM MODERATOR: DR. (Mrs.) MANGALA LAHKAR CAC, NIPER, GUWAHATI, ASSAM MENTOR HOSPITAL: GUWAHATI MEDICAL COLLEGE AND HOSPITAL

2. CASE: NEPHROTIC SYNDROME Deptt . Of Nephrology Guwahati Medical College And Hospital Assam

3. PATIENT DETAILS NAME: XYZ SEX: MALE AGE: 82yrs DOA: 10/09/2016 Deptt . Regd. No : 4654/16 BED NO. 04 MRD NO. 59868

4. 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

5. PATIENT HISTORY SOCIAL 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.

6. ON PHYSICAL EXAMINATIOM PULSE RATE: 86/MIN CVS : S1 S2 -Normal PALLOR: + OEDEMA: + CHEST: VESICULAR BREATH SOUNDS were audible Bp: 110/80

7. LAB INVESTIGATIONS INVESTIGATION NORMAL VALUE/RANGE 10/09/16 D1 12/09/16 D3 15/09/16 D6 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

8. INVESTIGATION NORMAL VALUE/RANGE D1 D3 D6 D11 Monocytes 2 – 10 % 7 2.1 Eosinophills 1 – 6 % 12 6 Prothrombin time/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

9. I NVESTIGATION NORMAL VALUE/RANGE D1 D3 D6 Random Glucose 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

10. USG REPORT 12/09/16 RESULT Bilateral renal parenchymal changes and Right kidney cyst Liver Gall bladder COMMON BILE DUCT PORTAL VEIN SPLEEN NORMAL

11. 2D ECHOCARDIOGRAPHY SHOWED MILD PERICARDIAL EFFUSION SERUM PROTEIN ELECTROPHORESIS SHOWED HYPERGAMAGLOBULINEMIA (POLYCLONAL)

12. Other Tests HIV-I and II------- Non-reactive Hep -B and C------ Non-reactive

13. RENAL BIOPSY (NEEDLE) REPORT 25/09/16 RESULT RENAL AMYLOIDOSIS WITH GLOMERULAR AND VASCULAR DEPOSITION OF AMYLOID

14. DIAGNOSIS NEPHROTIC SYNDROME

15. EPIDEMIOLOGY Nephrotic syndrome is relatively rare but important manifestation of kidney disease with a incidence of 3 new cases per 100,000 each year in adults and has serious complications , caused by a number of primary and secondary glomerular diseases Reference : PatientPLUS , Document ID-2505(v24)

16. MEDICATIONS CHART 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 TORASEMIDE (DYTOR) ORAL 10mg BD   PANTOPRAZOLE SODIUM (PANTACID) ORAL 40mg ODAC                 ATORVASTATIN AND FENOFIBRATE (ATORLIP-F) ORAL 10/160mg OD HS              FUROSEMIDE (LASIX) I.V 60mg BD                PIPERACILLIN AND TAZOBACTAM (PIPZO) I.V 4/0.5g OD               

17. 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                TRAMADOL I.M 50mg S0S  LEVOTHYROXINE (THYRONORM) ORAL 50mg OD AC                TRANEXIMIC ACID (TRANOSTAT ) I.V 1 AMP STATIM 

18. 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 CARBONATE AND VITAMIN D (SHELCAL) ORAL 500mg OD        ATORVASTATIN (ATORLIP) ORAL 10mg OD HS   

19. Patient was discharged on request on 26/09/16

20. 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

21. PHARMACEUTICAL ISSUES AND SUGGESSIONS Concurrent use of statins and fibrates increase the risk of Rhabdomyolysis and Myopathy and the ris k is more in eldery and renal disease patients SUGGESTION CREATINE 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. Concurrent administration of Levothyroxine with 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

28. 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 thromboembolism therefore it should be given cautiously and the patient should be monitored closely for any thromboembolic complication.

29. 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

30. 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