Pediatric emergency medicine trisk 2907 2907

Clinical assessment. The initial assessment of a child with nephrotic
syndrome should focus on the adequacy of intravascular volume and
perfusion, respiratory status, and evaluation for evidence of complications
such as infection. There should be a thorough assessment of recent fluid
balance, with specific inquiries to diuretic use, urine output, and
gastrointestinal losses. As some patients with nephritis will have
concomitant nephrotic syndrome (secondary nephrotic syndrome), accurate
measurement of blood pressure should be documented to screen for
associated hypertension.
Laboratory investigation should include confirmation of nephrotic
syndrome, identification of associated electrolyte abnormalities, and an
evaluation for possible underlying etiologies, if clinically indicated by
evidence of systemic disease. A serum albumin of less than 2.5 g/dL is
suggestive of nephrotic syndrome. A freshly obtained urine sample should
confirm heavy proteinuria by dipstick and be inspected for the presence of
macroscopic hematuria, which may suggest glomerulonephritis. Nephrotic
range proteinuria in children is defined as protein excretion greater than 50
mg/kg/day or 40 mg/m2/hr, though this would depend upon a timed 24-hour
urine collection, which is prone to inaccuracies and not feasible in the ED.
Alternatively, a urine protein to creatinine ratio can be obtained on a spot
urine sample to quantify the degree of proteinuria. A normal ratio is less
than 0.5 in children 6 to 24 months and less than 0.2 in older children and
adults. Generally, a ratio more than 2 to 3 is consistent with nephrotic range
proteinuria. Idiopathic nephrotic syndrome is typically associated with
bland urine sediment.
Serum electrolytes may reveal hyponatremia secondary to decreased
intravascular volume and stimulation of ADH release. Hyponatremia in the
edematous child does not reflect total body sodium depletion but water
excess that is greater than sodium excess. Renal function studies may be
abnormal and reflect decreased intravascular volume or the underlying renal
disease. Complete blood cell counts may demonstrate elevated hemoglobin

and hematocrit due to hemoconcentration. Hyperlipidemia including
elevated total serum cholesterol, triglycerides, and total lipids is typical.
Studies to distinguish the cause of nephrotic syndrome should be
considered based on the patient’s presentation. Serum complements may
identify disorders associated with complement consumption such as