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CHAPTER IV
DISCUSSION AND SUMMARY
4.1. Discussion
Nephrotic syndrome is the most common kidney disease that is found in
children. Incidence of nephrotic syndrome in children in USA and England is 2-7
per 100.000 per year and the prevalence is between 12 and 16 per 100.000. In
developing country, the number of incidence is higher. In Indonesia, its reported 6
per 100.000 per year for children less than 14 years old. The ratio boys and girls is
2:1.
PZ, 8 years 8 months, female, was admitted to RSUP HAM at August 12th
2014 and diagnosed with Nephrotic Syndrome and Gastritis. This diagnosis was
made based on history of previous illness and clinical findings such swollen face.
It happened since 2 weeks years ago and separated to the legs and hands.
The others symptom on this patient were fever abdominal pain . Feverwas
happened for 2 wweks. Patients had a history of transfussion 4 months ago and
got 525cc blood transfussion. At physical examination, conjunctiva palpebral
inferior is pale, which is asign of anemia. Then, on the lower extremities, there is
pitting edema. The lab result in IGD shows anemia normochromic normocytic,
proteinuria, hypoalbuminemia, increasing of RFT, and decreasing of Na+.
Nephrotic syndrome is diagnosed by some points. There are :

Massive proteinuria (> 40mg/m2 BSA/ hour or 50mg/ kgBW/ day

or dipstick urine +2 or ratio between protein and creatinin is >
2,5)

Hipoalbuminemia (<2,5 g/dL)

Oedema

Can be with hypercholestrolemia (> 200mg/dL)

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The patient has been diagnosed with Nephrotic Syndrome, based on

criteria, there was found the presence of 3symptomps on these patient
sare :Edema, proteinuria with dipstick urine +1, and hypoalbuminemia (1gr/ dL) .
The patient also diagnosed with anemia because of anemia sign and low Hb on
blood test.
Most of children with nephrotic syndrome have a form of primary or
idiopathic nephrotic syndrome. Glomerular lesion associated with idiopathic
nephrotic syndrome include minimal change disease (the most common), focal
segmental

glomerulosclerosis,

membranoproliferative

glomerulonephritis,

membranous nephropathy and diffuse mesangial proliferation.

Steroid resistant nephrotic syndrome is usually caused by Focal Segment
Glomerulonephritis (80%), MCNS, or mesangial proliferative glomerulonephritis.
The result of diagnose is from biopsy. But the patient didnt remember the type of
nephrotic syndrome from the biopsy.
The initial therapy for children with nephrotic syndrome without any
contraindication for steroid as ISKDCs (International Study of Kidney Disease in
Children) suggestion is given prednisone 60 mg/ m2 BSA/ day or 2 mg/kgBW/
day (max dose 80mg/ day) in divided dose, to induce remission. Prednisones
dose is calculated based on IBW (BW/BL). Initial full dose of prednisone is given
for 4 weeks. If there is remission in first 4 weeks, continued to second 4 weeks
with 40mg/m2 BSA/ day ( early dose) or 1,5 mg/ kgBW/ day, as alternating dose
(given distance a day) once a day after breakfast. If there isnt remission after 4
weeks of full dose prednisone, the patient is stated in steroid resistant nephrotic
syndrome.
After several weeks of previous treatment, the patient was diagnosed as
steroid resistant nephrotic syndrome. Patient was given maximaldose of steroid
(prednisone) for more than 4 weeks, but there isnt any remission from the
disease. Based on IDAI consensus, if patient dont get any remission for 4 weeks
after given full dose prednisone, then it can categorized as steroid resistant
nephrotic syndrome.

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Treatment

of

steroid

resistant

nephotic

syndrome

isnt

satisfy.

Cyclophosphamide (CPA), that is given orally, has been reported make remission.
For patient with resistant steroid nephrotic syndrome that get remission after
given CPA, can be given prednisone again, because it can be back to sensitive.
But, if there isnt remission after given full dose of steroid or become steroiddependent again, can be given cyclosporin.
4.2. Summary
It has been reported, an adolescent boy with the main complain of swollen and
was diagnosed with Nephrotic syndrome. The diagnose was established based on
history taking, clinical manifestation, laboratory finding, and bone marrow
puncture.The patient got PRC transfusion and still need to be followed up.