3. T 36 BP 140/90 HR 80
Not pale, no jaundice, pitting edema 4+
Heart no gallop rhythm
Lung no crepitation
L i i
Abdomen no palpable mass, fluid thrill
Positive, no superficial vein dilatation
4.
5.
6. CBC Hb 13.0 WBC 8500 PMN 70 L30
platelet 240,000
UA sp gr 1020, protein 4+, RBC 3-5
WBC 0-1, oval fat body 1-2, no cast
0 1, 1 2,
spot UPCR = 4
TP 70 G/L, Albumin 20 G/L,
Chol
Ch l 350 mg/dl, Triglyceride 300 mg/dl
/dl T i l id /dl
BUN 10 mg/dl, Serum Cr 1.2 mg/dl
7.
8. What should you do next ?
1. Screen for ANA, anti DNA,C3, C4, CH 50
, , , ,
2. Bed rest and furosemide 40 mg/day
g y
3.
3 Start prednisolone 1 mg/kg/day
4. Collect
4 C ll t 24 h
hour urine protein
i t i
9.
10.
11.
12. other
3% 3% 3% 4% IgA
IgM
19%
Membranous
29% ain
cgn
10% dn
fsgs
6% lupus
4% 1% 18%
mes gn
minimal change
Figure 3: Renal Histopathology of
patients with nephrotic range proteinuria (N=217)
13. Percent of Secondary Glomerulonephritis
post inf
100%
lupus
80%
henoch-sc
60% MM
40% light_c
20% DN
0% Cryo
Anti GBM
<20 20-40 40-60 >60
Amyloidos
Age group (yrs)
Figure 2: Secondary glomerulonephritis by age (n=391)
14. ผล ANA negative, anti DNA negative
C3, C4 and CH 50 within normal limit
HBsAg negative, anti HCV negative,
g g , g ,
Anti HIV (with consent) negative
CXR no pulmonary infiltration
Stool examination ; no p
parasite found
ผูปวยยังมีอาการบวม และน้าหนักขึ้น 2 กิโลกรัม ใน 1 week
ู ํ
15. What should you do next ?
1. Bed rest and furosemide 40 mg/day
g y
2. Start prednisolone 1 mg/kg/day
3.
3 Advise renal biopsy
4. Repeat serum creatinine
4 R t ti i
16. Percent of Primary GN
100%
mini
80% Membranous
60% fsgs
mes gn
40%
IgM
20% IgA
mpgn
0%
crescentic gn
<20 20 40
20-40 40 60
40-60 >60
Age group (yrs)
Figure 1: Primary glomerulonephritis by age (n=568)
17.
18. The patient deny renal biopsy and
received prednisolone 50 mg/daily for 4
weeks.
How can you characterize the response
to corticosteroid ?
1.
1 Diuresis
2. Decrease body weight
3. Decrease proteinuria
3 D t i i
4. Increase serum albumin
5. Decrease serum cholesterol
19. Clinical findings that strongly against
the diagnosis of MCNS
1. RBC cast
2. Hypocomplementemia
3. Gross hematuria
4.
4 Severe uncontrolled hypertension
5. Rapidly progressive renal failure
6.
6 Organomegaly
O l
20.
21.
22.
23.
24.
25. The patient received prednisolone 50
mg/daily for 8 weeks.
Spot UPCR decrease to 1.5
p
Serum albumin = 25 G/L.
What should you do next ?
1.
1 Continue prednisolone 50 mg/daily to
16 weeks
2.
2 Add cyclophosphamide 100 mg/day
l h h id /d
3. Add cyclosporin 150 mg/day
4. Advise renal biopsy
26.
27.
28.
29. The patient agree for renal biopsy at
8 weeks, the results are shown here.
What is your diagnosis ?
30.
31.
32.
33. After renal biopsy, the patient receive
prednisolone 30-40 mg/daily and
cyclophosphamide 100 mg/day for
y p p g y
another 8 weeks.
At 16 weeks, proteinuria is 2+
spot UPCR = 0 5
0.5
Serum albumin increase to 38 G/L
What should you do next ?
34. 1. Increase prednisolone to 40 mg/day and
continue cyclophosphamide 100 mg/day for
another 4 weeks
2. Add cyclosporin ; keep trough level
75-120 ng/dl
3. Continue low dose of Prednisolone and
cyclophosphamide and add ACEI keep BP <
130/80
4. Repeat renal biopsy
35.
36. Response to therapy of MCNS
1. Complete remission:
Proteinuria trace or negative X 2
24 hour Proteinuria < 300 mg/day
i i /
2.
2 Partial remission:
Proteinuria < 1-2 gram/day
g y
Proteinuria < 50 % of baseline with normal
serum albumin
37. Steroid non responsive (resistance) MCNS
1. Proteinuria > 3 5 gram /d after 16 weeks
1 P t i i 3.5 /day ft k
2.
2 Patients who do not have criteria for partial
remission after adequate therapy
q py
38. If renal biopsy shows FSGS :
What is the different approach ?
39.
40.
41.
42.
43.
44.
45.
46.
47.
48. If renal biopsy shows
Membranous
glomerulonephritis :
What is the different approach ?
49.
50.
51.
52.
53.
54.
55.
56.
57. SUMMARY
1. The prediction of renal pathology from
clinical setting is not accurate
2. The long term prognosis of p
g p g patient with
nephrotic syndrome is generally good
3. Over immunosuppression should be
avoided
