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).
TYPES
1. 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. NPHS2
B. Diffuse mesengial sclerosis (DMS)
ETIOLOGY
1. 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
PATHOPHYSIOLOGY
Alteration in glomerular basement
membrane
Altered glomerular protein
permeability
Increased loss of protein in urine
Decreased
vascular Decreased colloidal osmotic
Edema
volume pressure
Decreased Tubular Na and
Increased secretion of aldosterone
renal blood H2O reabsorption
flow
CLINICAL MANIFESTATION
Four main symptoms of nephritic
symptoms:-
• Protein urea
• Hypoalbuminemia
• Hyperlipidemia
• Edema
OTHERS: • Periorbital edema
• SOB (Shortness of • Irritability
breath) • Ascites
• Mild headache • HTN
• Fever, rash, joint • Anemia due to loss
pain of RBCs
• Weakness • Flank pain
• Malaise • Fatigue.
• Anorexia
• Weight gain
DIAGNOSIS
o 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).
MANAGEMENT
MEDICAL 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 MANAGEMENT
NURSING 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.
