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is a group of symptoms that include: proteinuria, hypoalbuminemia, hyperlipidemia, and marked edema Caused by different disorders that damage the kidney which leads to the release of too much protein in the urine.

inflammation within the glomeruli that typically manifests as hematuria and proteinuria Renal function may be normal or reduced, depending on the severity of the acute condition or the presence of chronic glomerular injury

Hematuria
Macroscopic (visible) or microscopic Dysmorphic RBCs and RBC casts

Proteinuria Hypertension Edema Renal insufficiency

Name: DT Age: 37 Gender: Female Height: 1155cm Weight: 82 kg Admission Date: Dec. 9, 2012 Room no.: 208B Services: Medicine Ward

Magpapa-renal biopsy (for Renal Biopsy)

16 days PTA
(+) tea-colored urine, (-) dysuria, flank pain, polyuria, nocturia, oliguria, anuria, fever No consult done and no medications taken, thought to be related to menstruation

14 days PTA
(+) nape pain spontaneously relieved by rest, (-) headache, dizziness, chest pain Still no consult done and medications taken

12 days PTA
(+) edema L foot, BP 160/120mmHg Opted consult at Ospital ng Tondo: (-) headache, dizziness, chest pain; BP at hospital: 130/80 mmHg Patient went home with no assessment and no medications prescribed

11 days PTA
(+) edema whole face and bipedal edema Prompted consult at Fabella Hospital: assessed to have Nephrotic Syndrome Prescribed with Amlodipine 10mg/tab OD CBC, Urinalysis showed normal results. Blood chemistry showed: elevated BUN (36.89mg/dl) and elevated uric acid levels (14.67mg/dl)

10 days PTA
Experienced right orbital pain which was relieved by rest Went to Fabella hospital to show her lab results Prescribed with: Furosemide + Potassium (Diumide) 40mg/tab, Amlodipine 10mg/tab, Clonidine HCl (Catapres) 75mcg/tab and Diclofenac Compliant to all except Diclofenac

5 days PTA
CBC with Platelet Urinalysis Turbid urine Proteinuria ++++ RBC >100hpf WBC 15-20hpf 24-hour Urine test Protein/ Albumin Blood Chemistry Creatinine

Hemoglobin Hematocrit

ECG showed sinus bradycardia

Ultrasound of KUB

Chest

X-Ray

Anti-strptolysin O serology

Normal Results
Blood Chemistry Hepatitis Profile (Na, K, C3 integra)

Patient went to NKTI for consult Prescribed with Simvastatin 20mg/tab ODHS and Furosemide (Lasek) 40mg/tab TID to replace the Diumide 40mg/tab

3 days PTA

went to NKTI and was suggested to have renal biopsy

2 days PTA
Sought consult for second opinion Decided to undergo renal biopsy at USTH CBC with platelet, urinalysis, blood chemistry and coagulation assay were requested

1 day PTA

Coagulation assay and CBC with platelet showed normal results.

Urinalysis pH Albuminuria Leukocytes RBC Pus cell Squamous cell Bacteria 6.0 +++ + over 100hpf 20-30hpf +++ +++

Amorphous urate crystals ++ Blood Chemistry Hypoalbuminemia 3.05g/dl

2010: Cholelithiasis Laparascopic Cholecystectomy Cesarean Section: 2000, 2001, 2012 July 2012: Tubal Ligation Newly Diagnosed 2012: HTN

Diet: Mixed Smoking: 1 pack year Alcohol: Not an alc. Beverage drinker Substance: No illicit drug use

(+) HTN: Father (+) Gout/ Other Arthritides, (+) Kidney disease (Secondary to NSAID nephropathy: Siblings (-) DM (-) Thyroid disease

Name of medication Amlodipine

Dose 10mg

Route PO

Frequency Last dose taken OD NDA

Indication Hypertension

Simvastatin
Furosemide + Potassium (Diumide) Clonidine HCl (Catapres) Furosemide (Lasek)

20mg

PO

OD HS

NDA
NDA

Hypertension

40mg/tab PO

75mcg 40mg

PO PO TID

NDA NDA

Vital Signs
Temperature Pulse Rate Blood Pressure Respiratory Rate
LMP

36.5C 72 bpm 160/110 mmHg 20 cp

PMP

Normal Regular, Normal Full High Regular

Nov. 25-28, 2012

Oct. 25-28, 2012

HEENT

Skin

Lungs

Heart

Abdomen

Extremities

Neurologic

Hematopoietic

All Normal Results

Blood Chemistry Creatinine Total Protein Albumin

Dec. 8, 2012

8:36AM

1.39mg/dL 6.23g/dL 3.05g/dL

Globulin H/G
Coagulation Assay Dec. 8, 2012 Plt

3.20g/dL 1.00
8:36AM

10.5 secs

Normal Control

10.4 secs

Urinalysis Dec. 8, 2012 Leukocytes Erythrocytes

8:36AM + +

RBC
Pus Cells Squamous Cells Bacteria

Over 100 hpf

20-30 hpf +++ +++

Amorphous Wab

+++

COURSE IN THE WARD

12/09 MEDICATION 4:18 PM Remarks Given Insert Heplock Start PNSS 1L to run at 80mL/hr for 12 hours prior to procedure Continue Medications: Amlodipine 5mg/tab 1 tab OD Simvastatin 20mg/tab OD HS Ferrous Sulfate 1 tab OD Lab done as Out Patient (CBC, Coagulation Assay, and Urinalysis)

LABORATORY

12/10
ANCILLARY 7 AM Ultrasound Guided Renal Biopsy scheduled 11am today

THERAPEUTICS Patient instructed to be flat on the bed with 1 PM pressure at site using 5lbs sand bag. Watch out for pain. Patient biopsy at the site

Nephrotic Syndrome Glomerulonephritis Hypertension

Date and Time Started

12/09 4:25 PM 12/09 8:00PM 12/09 4:25PM

Drug, Dose, Route, Frequency

Amlodipine 5mg/tab PO OD Simvastatin 20mg/tab PO OD Ferrous sulfate 1 tab PO OD

Indication

Remarks

Hypertension Hyperlipidemia Iron supplement

On-going treatment On-going treatment On-going treatment

Date and Time Started 12/09 4:20 PM

Drug, Dose, Route, Frequency PNSS 1L IV 80 cc/ hr for 12 hrs

Indication

Remarks

Hydration

On-going treatment

Amlodipine 5 mg/tab PO OD

-Antihypertensive agent -Not recommended for hypertensive patients with proteinuria

Simvastatin 20 mg/tab PO ODHS

-Antihyperlipidemic

Ferrous sulfate 1 tab OD

Iron supplement

Relief and improve of the symptoms:

Hypoalbuminemia Proteinuria Edema

Prevent complications and delay kidney damage Prevent cardiac complications and possible infections

Management Guideline Typical clinical and laboratory features are sufficient to establish the diagnosis 1. Patient history 2. Urinalysis 3. Random urine protein/ creatinine ratio 4. Serum creatinine and albumin 5. 24-hr urine test 6. Lipid profile 7. Renal biopsy

Actual Management Diagnostics 1. Patient History 2. Urinalysis 3. CBC with platelet 4. Serum creatinine and albumin (Blood Chemistry) 5. 24-hr urine test 6.Renal biopsy

Treatment Guideline Diuretics are the mainstay of nephrotic syndrome Diuresis should aim for a target weight loss of 1 to 2 lb (0.5 to 1 kg) per day to avoid acute renal failure or electrolyte disorders. Large doses loop diuretics are often required (e.g., 80 to 120 mg of Furosemide) to be given IV

Actual Management Prescribed with Furosemide + Potassium (Diumide) 40mg/tab but was not continued nor shifted to IV after admission

Source: KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012); American Academy of Family Physicians: Nephrotic Syndrome (2009)

Treatment Guideline

Actual Management

Low serum albumin levels No diuretic administered during (hypoalbuminemia) limit diuretic admission effectiveness and necessitate higher doses. Thiazide diuretics, potassiumsparing diuretics, or Metolazone may be useful as adjunctive or synergistic diuretics

Source: KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012); American Academy of Family Physicians: Nephrotic Syndrome (2009)

Treatment Guideline

Actual Management

Angiotensin-converting enzyme No ACE inhibitors or ARBs (ACE) inhibitors and ARBs have prescribed to the patient been shown to reduce proteinuria and reduce the risk of progression to renal disease in persons with nephrotic syndrome The recommended dosage is unclear but Enalapril (Vasotec) dosages from 2.5 to 20 mg per day were used in a study of Radhakrishnan J, et.al.

Source: KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012); American Academy of Family Physicians: Nephrotic Syndrome (2009)

Is a complication of any kidney disease particularly, glomerulonephritis Stage II Hypertension with: SBP>160; DBP>100

Prevent other cardiovascular events of hypertension To delay progressive loss of GFR Achieve and maintain a BP:

Hypertension Stage 2

130/80 mmHg

Treatment Guideline
Angiotensin Converting Enzyme Inhibitors (ACE-I) and Angiotensin Receptor blockers (ARB) to be first-choice therapy for hypertension-associated with renal disease Serum Creatinine levels will be used as basis for proper dose adjustments.

Actual Management
Anti-hypertensive medications of the patient were continued: Amlodipine 5mg/tab PO OD and Simvastatin 20mg/tab PO OD

Source: KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012); Lexicomp

Nape pain, tea-colored urine, edema whole face, bipedal edema

BP 160/120 mmHg; BUN (36.89 mg/dL); Creatinine: 1.39 mg/dL

Uric Acid levels (14.67mg/dl)

Hypertension is a complication of glomerulonephritis

Give Losartan initial dose: 25mg OD, then 50-100 mg BID. Monitor BP, maintain at 130/80 mmHg.

Source: KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012); Lexicomp

Tea-colored urine

O A P

Proteinuria (+++), 24-hr urine test : Urine protein (1800 mg/24 hrs )

Proteinuria is a common symptom of glomerulonephritis

Give Losartan initial dose: 25mg OD, then 50-100 mg BID. Complete remission: <0.3 g urine protein per 24 hours

Source: KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012); Lexicomp

Edema of the whole face, bipedal edema

O A

Creatinine 1.39 mg/dL; BUN (36.89 mg/dL); BP 160/120 mmHg

Nephrotic edema

Give Furosemide initial dose 20-80 mg/dose; if response is not adequate, may repeat dose or increase in increments of 20-40mg/dose every 6-8hrs. Usual maintenance dose interval is once or twice daily.

Source: KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012); Lexicomp

Tea-colored urine, nape pain, edema of the whole face, bipedal edema

Creatinine 1.39 mg/dL; BUN (36.89 mg/dL); BP 160/120 mmHg Ultrasound-guided renal biopsy was not yet released and viewed

Ultrasound-guided renal biopsy is the ultimate differential diagnosis for renal disease (glomerulonephritis and nephrotic syndrome)
Management and treatment would be based on the results of the ultrasound-guided renal biopsy

Source: KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012); Lexicomp

Check results of patients creatinine, albumin, and lipid levels regularly Create a negative sodium balance by:

Limiting salt intake of 1.5-2g daily Restricting fluid intake to less than approximately 1.5 L per day

Low in saturated fat and cholesterol diet to avoid hyperlipidemia Pneumococcal vaccine to avoid infections

KDIGO Clinical Practice Guidelines for Glomerulonephritis (2012) American Academy of Family Physicians: Nephrotic Syndrome (2009) http://kidney.niddk.nih.gov/kudiseases/pubs/nephrotic/ www.merckmanuals.com/professional/genitourinary_disorders/gl omerular_disorders/nephrotic_syndrome.html. Lexicomp and Medscape