ORATOR: RAYAZ AHMAD BHAT

STUDENT NIPER, GUWAHATI, ASSAM

MODERATOR: DR. (Mrs.) MANGALA LAHKAR

CAC, NIPER, GUWAHATI, ASSAM

MENTOR HOSPITAL: GUWAHATI MEDICAL COLLEGE AND HOSPITAL

CASE: NEPHROTIC SYNDROME

Deptt. Of Nephrology

Guwahati Medical College And Hospital

Assam

PATIENT DETAILS

NAME: XYZ

SEX: MALE

AGE: 82yrs

DOA: 10/09/2016

Deptt. Regd. No: 4654/16

BED NO. 04

MRD NO. 59868

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

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.

ON PHYSICAL EXAMINATIOM

PULSE RATE: 86/MIN

CVS : S1 S2 -Normal

PALLOR: +

OEDEMA: +

CHEST: VESICULAR BREATH SOUNDS were audible

Bp: 110/80

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

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

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

USG REPORT12/09/16

RESULT

Bilateral renal parenchymal changes and

Right kidney cyst

Liver

Gall bladder

COMMON BILE DUCT

PORTAL VEIN

SPLEEN

NORMAL

SERUM PROTEIN ELECTROPHORESIS SHOWED

HYPERGAMAGLOBULINEMIA (POLYCLONAL)

Other Tests

HIV-I and II-------Non-reactive

Hep-B and C------Non-reactive

RENAL BIOPSY (NEEDLE) REPORT25/09/16

RESULT

RENAL AMYLOIDOSIS WITH GLOMERULAR AND VASCULAR DEPOSITION OF AMYLOID

DIAGNOSISNEPHROTIC SYNDROME

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)

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

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

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

Patient was discharged on request on 26/09/16

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

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

•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

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

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

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

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.

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

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.

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

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