Renal Module Treatment of Nephrotic & Nephritic Syndrome PDF

Al Azhar University Faculty of Medicine for Girls Renal Module  Module Code :IMP-07-20318  Phase : 1  Year : 2nd year...

Al Azhar University Faculty of Medicine for Girls Renal Module  Module Code :IMP-07-20318  Phase : 1  Year : 2nd year  Semester : 3 Credit hours : 5 hours Subject: Pharmacology.  Lecture 5 Treatment of nephrotic and nephritic syndrome ILOs: The student should be able to: 1-Recognize the dietary regimen of nephrotic and nephritic syndrome 2-Identify the drug treatment of nephrotic syndrome. 3-Point out the role of corticosteroids in treatment of nephrotic syndrome. 4-Identify treatment for relapses and treatment of steroid resistant cases of nephrotic syndrome. 5-Explain the role of cyclophosphamide and cycloserine in steroid resistant cases of nephrotic syndrome. 6-Enumerat indications of immediate dialysis in case of nephritic syndrome. 7-Recognize the suitable antibiotic in for treatment of nephritic syndrome.  A-Nephrotic syndrome Definition: It is a clinical state characterized by: *Heavy proteinuria: >3.5gm/d/1.73m2 *Hypoproteinemia *And often associated with: -Edema. - -Hypercholesterolemia& dyslipidemia. -Hypocalcemia &hypokalemia. Treatment: A-Diet: H2O: decrease, to avoid dilusional hyponatremia. Na: decrease, for prevention and treatment of edema. K: increase Proteins: Moderate protein restriction is advised particularly in case of renal impairment. B-Drugs: 1-For edema: a-Diuretics: - Furosemide: - Spironolactone: may be added. b-Albumin: in cases of severe hypoalbuminemia. 2-For hypercoagulability: a-Oral anticoagulants: warfarin. b-Antiplatelets: low dose aspirin or dipyridamole. 3-For infection: -Pneumococcal &varicella vaccination. -Early detection and treatment of infection. 4-For hyperlipidemia: e.g. Atorvastatin. 5-Steroid therapy: e.g. prednisolone or prednisone. It is the cornerstone for management for most cases. The initiation of therapy may be delayed for a week as spontaneous remission occurs in 5% of cases within a week. The role of corticosteroids in treatment of nephrotic syndrome: Immunosuppression by: 1- Suppression of T-cell function & inhibition of T cell mediated factor involved in pathogenesis of the disease. 2-They may act directly to stabilize podocyte cytoskeleton. Doses of oral prednisolone: 60mg/m2/day for 4 weeks. Until urine protein is 0, trace or + for three consecutive days. Then weaning regimen is given 40mg/m2/day every other day for 2 weeks. Then, 20mg/m2/day every other day for 2 weeks. Then, 15mg/m2 /day every other day for 2 weeks. Then, 10mg/m2 /day every other day for 2 weeks. Then, 5mg/m2 /day every other day for 2 weeks. Patient who have persistent proteinuria one week after this treatment is considered steroid resistant. A renal biopsy is performed. 6-Treatment of relapses: Relapsing nephrotic syndrome: is defined as steroid-sensitive nephrotic syndrome with 2 or more relapses within 6 months. -Cyclophosphamide. -Cyclosporine. The role of cyclophosphamide: acts by immunosuppressive effect on T-cells. The role of cyclosporine: 1-Inhibit T- activation. 2-It may directly target podocytes and stabilize actin cytoskeleton responsible for maintaining cell shape. 7-Treatment of steroid resistant cases: * Cyclophosphamide. * ACEIs e.g. captopril or ARBs e.g. losartan: The role of ACEIs: a-Reduce the arterial blood pressure. b-May decrease intraglumerular hydrostatic pressure and thus can decrease urinary protein losses, particularly in diabetic nephropathy. 8-Treatment of the cause; in case of secondary nephrotic syndrome, e.g. SLE.  Nephritic syndrome Definition: It is a clinical syndrome characterized by acute onset of: Hematuria, oliguria, hypertension, edema and mild or moderate proteinuria.  B-Treatment of nephritic syndrome. I-General: a-Rest: in the early stage till hypertension, edema and hematuria subside. b-Regular measurement of blood pressure. c-Diet: is low in Na, K, water and proteins, but high in CHO. II-Drugs: 1-Antibiotics: Oral penicillin V: 500mg/12 hours for 10 days: to ensure eradication of streptococcal infection. Erythromycin: 40mg/kg/d for 10 days in case of penicillin allergy. -Single dose of long acting penicillin: benzathine penicillin (1.2 million units): to avoid recurrence of streptococcal infection and to avoid its complications. 2-For edema: Salt restriction and loop diuretics. 3-For hypertension: Calcium channel blockers e.g. nifedipine, ACEIs e.g. capoten or vasodilators e.g. hydralazine. 4- Immediate dialysis: is indicated in: a-Severe hyperkalemia. b-Acute renal failure. c-Acidosis. d-Uncontrolled hypertension. e-Pulmonary edema.