Nephrotic syndrome

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1. Peer Group Presentation Subject – Medical Surgical Nursing Topic - Nephrotic Syndrome Presented by Mr. Hari Singh Nagar M.Sc Nursing 1 st year

2. Nephrotic Syndrome Introduction –The syndrome is apparent in any condition that seriously damage the glomerular capillary membrane that results in increase glomerular capillary permeability to plasma proteins. Although liver is capable of increasing the production of protein. It can’t keep up with the daily loss of albumin through the kidney. Thus hypoalbuminemia results.

3. Definition It is a clinical disorder that is characterized by proteinuria, hypoalbuminemia , edema and hyperlipidemia. This occurs due to excessive leakage of plasma proteins in urine because of increase capillary permeability of the glomerulus.

4. Etiology Glomerulonephritis DM SLE Amyloidosis o kidney Sarcoidosis Cancer Trauma Infection Drugs Renal thrombosis

5. Pathophysiology ----------------------------------------- Decrease plasma oncotic pressure Compensatory synthesis of protein including lipoprotein by liver Due to E/F Glomerular damage Increased permeability of glomerulus capsule to protein Proteinuria (3.5 gm/24 hours) Increase renal catabolism albumin Hypoalbuminemia (less then 3.4 mg/DL)

6. Hyperlipidemia Fluid escape into the tissue Decrease plasma volume Edema Decrease GFR Increase Aldosterone Sodium and water Retention Generalized edema (Anasarca or dropsy) Decrease lipid catabolism due to low level of protein

7. Clinical manifestation Proteinuria Hypoalbuminemia Edema – Periorbital edema, pitting edema, ankle edema, Ascites, pleural effusion, Weight gain, hypertension Fatigue, headache, malaise and irritability Foamy appearance of urine (decrease surface tension by severe proteinuria) Hematuria Thrombophilia (clot formation) Lipiduria Dyspnoea Anaemia

8. Diagnostic evaluation History Physical examination Urinalysis - 24 hours urine Serum chemistry Creatinine clearance test Needle biopsy of kidney

9. Management Symptomatic treatment Edema – Rest – not for prolong time Nutrition – 1 gm protein/kg/day, not more that, sodium restriction, water not greater then the level of diuresis. Medication – Loop diuretics (furosemide) Hypoalbuminemia – moderate intake of protein, rich in animal protein. Hyperlipidemia – low saturated fat, high unsaturated fat, if unresponsive to nutrition therapy then take hypolipidemic drugs such as statin.

10. Thrombophilia – Heparin Infection – Antibiotics ACE inhibitors – to control hypertension Achieve better blood glucose level Kidney damage Corticosteroid – prednisone Immunosuppressant – Cyclophosphamide

11. Complication Infection Thromboembolic complication Pulmonary edema Hypovolemia Growth retardation Altered drug metabolism ESRD

12. Nursing management Nursing diagnosis – excessive fluid volume related to damage glomeruli as evidence by I/O chart, edema and weight gain. Nursing goal – To maintain fluid volume Intervention – Assess fluid status, Monitor I/O ratio. Limit fluid and sodium intake to prescribed volume. Explain to patient and family rational for fluid resuscitation. Oral hygiene is to be encouraged. To provide the diuretics

13. 2. Nursing diagnosis – risk of infection related to edema & altered immune response as evidence by weight gain, I/O chart, taking temperature. Nursing goal – To prevent from infection Intervention - Limit fluid intake Provide meticulous skin care To monitor I/O chart. To check daily weight. To check the TPR. Use strict aseptic technique To provide the diuretics and antipyretics.

14. 3. Nursing diagnosis – Disturbed thought process related to effect of uremic toxin on CNS as evidence by confusion, LOC, impair ability to process external stimuli. Nursing goal – To stabilise the thought process Intervention – assess the extent of impairment in thought process. Orient to time, place and person. To provide diuretic, antibiotics to the patient. Preserving neurological functioning. Use seizure precaution.

15. Encourage the patient to turn & in any type of activity as due to drowsiness and lethargy. Give psychological support. Prepare for haemodialysis.

16. Chlorambucil Treatment of Frequently Relapsing Nephrotic Syndrome Chlorambucil, in combination with prednisone, was compared with prednisone alone in a randomized controlled trial in 21 children to assess its effect on the duration of remission (improvement) and the rate of relapse (deterioration after improvement). All control patients treated with prednisone alone continued to relapse at the same rate, with all patients experiencing a return of proteinuria by seven months. Conversely, those who received the same prednisone therapy along with chlorambucil for six to 12 weeks remained in complete remission, without further medication, during 12 to 34

17. months of follow-up observation. Complications were minimal. Immediate Side effects commonly reported with cyclophosphamide were not seen with chlorambucil. Comparison with published reports also suggests that remission induced by chlorambucil is more stable than that after cyclophosphamide. Chlorambucil appears to be of value in the frequently relapsing nephrotic patient, adding an effect that is unattainable with prednisone alone. (N Engl J Med 295:746–749, 1976)

18. The effects of corticosteroids on behaviour in patient with nephrotic syndrome The objective of this study was to measure the frequency and severity of the behavioural effects of high-dose oral steroid therapy in children with nephrotic syndrome. We conducted a prospective assessment of the behaviour of 12 children using a standardized psychological questionnaire at the time of diagnosis and again after 4 weeks of steroid therapy. A group of control children was also assessed. There was a significant increase in the total behaviour score ( P =0.03) and specifically in aggressive and poor attention behaviour items in

19. the group of nephrotic children compared with the control group. Four of the children with nephrotic syndrome developed abnormal behaviour in the clinical range compared with none of the controls. In conclusion, children with nephrotic syndrome treated with high-dose oral steroids are at risk of developing clinically relevant behavioural changes