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CLINICAL CASE REPORT

NEPHROTIC SYNDROME (N0.4) IN A 10 YEARS OLD BOY

Mirantika Audina
I4061172033
Supervisor
dr. Hilmi Kurniawan Riskawa, Sp.A, M.Kes

Pediatric Unit of Medical Education Course

Tanjungpura University
Kartika Husada’s Hospital
Kubu Raya Region
2018

Patient’s Identity
FA, An 10 years old boy with medical
record number 143336, was admitted in
pediatric ward of Kartika Husada’s
Hospital for 3 days since 31st July 2018 till
2nd August 2018.
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Subjective Findings
Present Complain
• Edema
History Of Present Ilness
• An 10 years old boy presented with edem for
4 years on his face. Edema firstly located on
his palpebra then it was spread to both of his
fingers.
• Others complain such as fever, cough,
dispnea, headache, sore throat, dan
abdominal pain was denial. There was no
complain both on his urination or defecation.
• His appetite and drink was normal.
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Subjective Finding Objective Finding

 Past Illness History Vital Sign
He had similar complaint when he was • General status: moderate sickness
6 years old • Awareness : compos mentis
 Family History • Blood pressure: 130/100
• Heart rate: 100 x/minutes, regular rhytm, palpable
There was no similar compain in his
• Respiratory rate: 30x/minutes
family
• Temperature : 37 º C
 Medical History • Spo2 : 98%
On the first day of his complain, he Nutritional Status
went to a health center and was found
• Weight : 28 kg
blood on his urine (+++) on the
• Height: 134 cm
examination.
• BMI : 15,59
• Status : normal
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Objective Finding

 Eyes : Anemic Conjunctiva (-), icteric sclera (-), edema palpebra (+)
 Ear : mucus (-), tragus pain (-), deformity (-), hyperemic auricula(-), tympani
membrane intact
 Nose : mucus (-), hyperemic nasal mucosa (-)
 Mouth : Mucosa of the mouth dan lips moist, leukoplakia (-)
 Throat : hyperemic Pharyng (-)
 Neck : lymph node enlargement (-),
 Lung
• Inspection : Symmetric shape and motion, retraction subcostae
• Palpation : Same tactile fremitus of right and left lung
• Percution : Sonor in both lung fields
• Auscultation: bronchovesicular breath sound, wheezing (-/-), slime (+/+)
 Cor : Heart sound S1 and S2 single, regular, murmur (-) and gallop (-)
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Objective Finding

 Abdomen
• Inspection : Flat, no mass
• Auscultation : Bowel sound normal
• Percution : Timpani in all region of abdomen
• Palpation : Liver and spleen not palpable, there is no tenderness and ascites
 Anus and genitalia : were not examined
 Extremities : Warm, Capillary Refill Time < 3”, cyanosis (-), edema (+) et region
digiti manus dextra and sinistra
 Laboratory Finding 6

30th July 2018 31st July 2018

Urinalisis Complete Blood Examination
• Colour : yellow • Leukocyte : 11.500/mm3 (Normal : 5.000-17.000
• Turbidity : clear /mm3 )
• pH : 8 • Eritrocyte : 4,55 juta/mm3 (Normal : 3.90-5.50
• Density : 1,010 juta /mm3)
• Leukocyte: (-) • Hemoglobin : 11,6 g/dl (Normal : 11,5-13,5 g/dl)
• Protein : (-) • Hematocryte : 35,2% (Normal : 34-40%)
• Glucose : (-) • Trombocyte : 336.000/mm3 (Normal : 150.000-
400.000 /mm3)
• Keton : (-)
• MCH : 25,6 pg (Normal : 23,1-28,2 pg)
• Bilirubin : (-)
• MCV : 77,4 fl (Normal : 71,6-83,5 fl)
• Urobilinogen: normal
• MCHC : 33,1 g/dl (Normal : 32,0-35,9 g/dl)
• Nitrit : (-)
• %Limfosit : 41,6% (Normal : 20-80%)
• Blood : +++
• %Granulosit 30,4% (Normal : 40-65%)
 Laboratory Finding 7

31st July 2018 1st August 2018

Serology chemical Complete blood examination
• SGOT : 21 u/l (Normal : ≤ 40 u/l) Colour : yellow
• SGPT : 8 u/l (Normal : ≤ 41 u/l) Turbidity : clear
• Ureum : 10 mg/gl (Normal : 15-45 pH :6
mg/dl)
Density : 1,010
• Creatinin : 0,48 mg/dl (Normal: L
0,9-1,3 mg/dl, P 0,6-1,1 mg/dl) Leukocyte: (-)
• Cholesterol total : 114 mg/dl Protein : (-)
(Normal < 200 mg/dl) Glucose : (-)
• Albumin: 3,9 g/dl (Normal : 3,4-4,8
g/dl) Keton : (-)
Bilirubin : (-)
Urobilinogen : normal
Nitrit : (-)
Blood : +++
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Differential Diagnose Working Diagnose

 Nephrotic Sundrome
Nephrotic Syndrome
 Glomerulonephritis
 Therapy 9

Bed rest Venflon

Non-
medicamentosa

Medicamentosa
Monitor of Diuresis Inj. Ampicillin 4 x 1 gr IV
Monitor of blood pressure/6 hours Oral Route
• Furosemid 2 x 20 mg tab
• Prednison 3-3-3 tab (3 x 15 mg)
• Captopril 2 x 6,5 mg tab
 Follow UP 10

Tgl S O A P

1/8-18 Edema (+) a/r face Awareness: ompos mentis Nephrotic syndrome Venflon
(SD 6 HD 2) and digiti manus BP: 110/80 mmHg Inj. Ampicillin 4 x 1 gr IV
dextra sinistra, fever HR: 90x/mnt Oral Route:
(-), cough (-), RR: 26x/mnt Furosemid 2 x 20 mg tab
dyspnea (-), T : 36,5oC, Prednison 3-3-3 tab (3 x 15
urination (+) norma, Weight : 28 kg, mg)
defecation (-) the edem palpebra (+), anemic conjungtive (-/-), Captopril 2 x 6,5 mg tab
latest day was 2 days S1S2 regular, murmur (-), gallop (-), crackles (- Bed rest
ago /-), wheezing (-/-), soeple, timpani, bowel Monitor of Diuresis
sound (+) N, abdominal pain (-), liver and Monitor of blood pressure/6 hours
spleen not palpable, edem a/r digiti manus
dextra sinistra (+)
2/8-18 Edema (+) a/r face Awareness: ompos mentis Nephrotic syndrome Venflon
(SD 7 HD 3) and digiti manus BP: 120/90 mmHg Oral Route:
dextra sinistra HR: 90x/mnt Ampicillin 3 x 1/2 tab
decreased, fever (-), RR: 24x/mnt Furosemid 2 x 20 mg tab
cough (-), dyspnea (- T : 36,5oC, Prednison 3-3-3 tab (3 x 15
), urination (+) Weight : 27,5 kg, mg)
norma, defecation (- edem palpebra (+) decreased, anemic Captopril 2 x 6,5 mg tab
) the latest day was 2 conjungtive (-/-), S1S2 regular, murmur (-), Hospital free-days
days ago gallop (-), crackles (-/-), wheezing (-/-), soeple,
timpani, bowel sound (+) N, abdominal pain (-
), liver and spleen not palpable, edem a/r
digiti manus dextra sinistra (+) decreased
 Prognosis
 Ad vitam : dubia ad bonam
 Ad functionam : dubia ad bonam
 Ad sanactionam : dubia ad bonam
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Discussion
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 Patients present with edema complaints. Some diseases that can cause it are from kidney,
liver, allergic and malnutrition. In edema caused by heart disease is starting from both legs
due to reduced backflow due to impaired return to the cor, the influence of force and
peripheral resistance on the high limbs, especially the popliteal fossa and inguinal.
 Next is the liver organ. This swelling begins from the stomach due to fibrosis of the liver
which aims to bend the vein back and occur portal hypertension, a decrease in protein
synthesis that occurs hypoalbuminemia which enters intravascular osmotic which causes
extravasation of fluid.
 In addition, allergies can also cause edema, but only in certain places which are non pitting
edema and do not last long.
 In malnutrition, swelling occurs throughout the body for no apparent reason and usually in
the kwashiorkor or marasmus kwashiorkor.
 In edema caused by kidney disorders is starting from the eyelids. It is because og the
gravitation. Eyelid is a network that contains a lot of connective tissue.

In this patient, edema starts from the
eyelids which continues to his fingers.
This shows that edema in these patients
leads to kidney disorders. To help
establish a diagnosis, a supporting
examination is needed in the form of a
complete blood laboratory test,
complete blood chemistry and
urinalysis
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Result of Laboratory examination obtained:
• From the results of laboratory examination obtained
proteinuri (-), albumin 3.9 g / dl, urea 10 mg / dl,
creatinine 0.48 mg / dl, and total cholesterol 114 mg / dl.
From the results of history, physical examination and
laboratory examination, these patients obtained
palpebral edema and edema of digiti manus dextra
sinistra, levels of albumin, cholesterol and proteinuria
within normal limits.
  Criteria for Nephrotic Syndrome based on 15

Consensus on Management of Idiopathic

Nephrotic
syndrome is a Nephrotic Syndrome in Children, 2012 Indonesian
collection of Pediatric Association:
clinical
manifestations Massive proteinuria (> 40 mg / m2LPB / hour or 50
characterized by mg / kg / day or urine protein / creatinine ratio at>
massive loss of 2 mg / mg or dipstick ≥ 2+);
urine protein
(albuminuria), Hypoalbuminemia <2.5 g / dL;
followed by
hypoproteinemia
(hypoalbuminemi
a) and eventually Hypoalbuminemia <2.5 g / dL;
results in edema.
And this is related
to the onset of
Edema;
hyperlipidemia,
hypercholesterole
mia and lipiduria.
Can be accompanied by hypercholesterolemia>
200 mg / dL
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This patient was diagnosed with new cases of nephrotic syndrome, not relapse nephrotic syndrome or steroid-
resistant nephrotic syndrome as stated in the referral diagnosis. Because what is meant by relapse is a state of
proteinuria (+2) + (proteinuria> 40 mg / m2 LPB / hour) 3 consecutive days within 1 week after steroid therapy,
while what is meant by resistance is no remission in full dose prednisone treatment (full dose) 2 mg / kg / day for
4 weeks. 8-9 In this case, the patient's parents did not know for certain the history of treatment at the beginning
of the first patient's illness

Therefore, I conclude that in these patients are new cases.

For treatment in these patients full steroid was administered according to ISKDC
(International Study on Kidney Diseases in Children) given prednisone 60 mg /
m2LPB / day or 2 mg / kgBW / day (maximum 60 mg / day in divided doses to
induce remission).

In this patient the BB is 28 kg, so the dose of prednisone given is 28 kg x 2 mg /

kgBW / day = 56 mg / day. However, this patient is given a dose of 45 mg / day
due to:

a. One tablet of prednisone contains 5 mg which makes it easier to

determine the number of tablets to be given and makes it easier to
consume drugs;

The rounding dose to 45 mg is still in safe doses of prednisone,

which is a maximum of 60 mg / day.
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Then,to overcome edema in

patients this is given diuretic
furosemide with a dose of 1-3
mg / kgBB / day so that the  In this patient albumin therapy was not given because
dose given to this patient is 28 of indications of albumin administration of 20% 1 g / kg
kg x 2 mg mg/ kgBW / day 56
mg / day divided into 2 doses body weight is if they did not respond to diuretic
of administration, so that the medication and albumin value <1. Whereas in this
dose given to this patient patient the albumin level was 3.9 g / dl and by giving
should be 14 mg / 12 hours
furosemid the patient had responded, so albumin
but in cases given 20 mg / 12
hours.This administration of administration was not needed.
furosemide is indicated for
severe edema as occurs in
these patients.

 Children with clinical manifestations of nephrotic
Diet for patients with nephrotic
syndrome is 35 cal / kg / day,
mostly consisting of
carbohydrates. A diet low in
salt (1-2 grams / day) and low
in fat should be given. In
patients with nephrotic
syndrome protein intake is
limited to 0.8-1 g / kg / day
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syndrome for the first time, should be hospitalized with
the aim of speeding up examination and evaluation of
dietary settings, overcoming edema, starting steroid
treatment, and parenting education.7 These patients
were hospitalized for 3 days and monitored for
therapeutic responses assessed by increased diuresis,
reduced edema, decreased urine protein, and weight
loss.
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 For three days, the patient's body weight was originally

28 kg to 27.5 kg and edema both on the patient's face
and fingers decreased. This proves that the patient still
gives a good response to therapy so that patients are The right diagnosis in the case of
advised to do outpatient care. In this case the prognosis
new cases of nephrotic
syndrome and the selection of
is dubia ad bonam because the patient diagnosed with appropriate therapies can
Nephrotic Syndrome who in the course of his illness is provide good success.
still sensitive to steroid treatment is characterized by
the condition of the patient to go home to experience
improvement.
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 TERIMAKASIH