2 Case 1-2020: Answers to the questions
Question 1: Based on chief complaints, medical history, physical examination, what initial diagnosis can we suspect?
Answer to Question 1: Based on the chief complaints of low urine output and edema along with heavy proteinuria and hypoalbuminemia, a diagnosis of nephrotic syndrome was made initially.1 Nephrotic syndrome was suspected due to the presence of the classical triad of edema, proteinuria, and hypoalbuminemia.2
Question 2: Which findings in the above lab investigations are confirmatory to reach the final diagnosis?
Answer to Question 2:
- According to the literature, the diagnosis of nephrotic syndrome includes:
- Heavy proteinuria (dipstick 3–4+ or urine protein/creatinine ratio >0.2 g/mmol = >200 mg/mmol)
- Hypoalbuminemia (<25 g/L) .2
- In this case study, the presence of heavy proteinuria in the urine dipstick test along with urine protein/creatinine ratio 7.3 g/mmol (Normal range: <0.2 g/mmol) and hypoalbuminemia <2.5 g/L (Normal range: 3.5- 5.5 g/dl) are confirmatory features for diagnosing nephrotic syndrome.1
Question 3: What is the main cause of the final diagnosis?
Answer to Question 3:
- While idiopathic, or unknown, diseases are the most common cause of primary childhood nephrotic syndrome, researchers have linked certain diseases and some specific genetic changes that damage the kidneys with primary childhood nephrotic syndrome.7
- The incidence of idiopathic nephrotic syndrome (INS) is 1.15–16.9 per 100 000 children, varying by ethnicity and region.1
- The cause of secondary childhood nephrotic syndrome is an underlying disease or infection. Called a primary illness, it’s this underlying disease or infection that causes changes in the kidney function that can result in secondary childhood nephrotic syndrome.7
- Most children with nephrotic syndrome have “minimal change disease”. This means that their kidneys appear normal or nearly normal if a tissue sample is studied under a microscope. But changes to the tissue sample can be seen if it’s studied under an extremely powerful electron microscope. The cause of minimal change disease is unknown.3
- Based on these clinical presentations and lab investigations, the nephrotic syndrome was confirmed.
Treatment and Prognosis 1
- After establishing the diagnosis, optimal supportive treatment including Enalapril p.o., Prednisolone p.o., intravenous albumin, furosemide, low salt intake, high caloric, and protein diet were given along with Ceftriaxone and Ascoril-LS. The urine output and blood pressure were monitored. Successful control of peripheral edema with the administration of albumin and diuresis with furosemide was seen. Peri-orbital edema and leg swelling reduced, and there was a concomitant increase in serum protein levels. The lipid levels also gradually decreased in due course of time without any medication.
