Difficult cases - Case scenarios
Under Category :  Case scenarios
Posted By :  Dr.  SUSHIL KUMAR
Posted On : 1/24/2013 7:59 PM
a 15 yr old male with IDDM, taking insulin from last 10 year admitted with generalized swelling, ascites and hypertension {BP 150, 100}. urine examination show nephrotic range proteinurea` no RBC. S. cholestrol was 350, total protein 6g, dl, s.albumin 1.6g, dl. normal level of urea and serum creatinine.we make a diagnosis of nephrotic syndrome. what should be the further management of this child_?_?.what is your experience in using steroid in a case of diabetes_?_?.
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We have one patient now at about 7 years female child who is on treatment for both nephrotc syndrome and type 1 diabetes. Actually this is just the reverse case` initially presnting with nephrotic syndrome and developed diabetes while on treatment dor nephrotic sndrome. She is at present on insulin and we treat relapse with steroid with slight increase in insulin requirement
Dr. Sanjay Kumar says,
8/13/2013 8:30:55 PM
5/11/2013 7:30:24 PM
At the end , sharing my experience
i dont have experience of diabetic with nephrotic syndrome .. Many cases of nephrotic syndrome and acute leukemia developed diabetic state while on management .. In acute leukemia especiallly as multiple drugs are diabetogenic in the regime...eg L asparaginase....None of the case we stopped management of these conditions , we continue steroid and start insulin , titrae according to need.. In case of ALL we stopped L asparaginase for few cycles...All cases we could complete the treatement and the diabetic state reversed.
Here the case is a bit different..He had diabetis for the last ten years.. I feel he needs extensive workup for both the conditions..,,
a. What is the over all controll status.. HbA1c..
b.End organ damage.. ,, eye,, ..peripheral nerve...About the renal status .. is it diabetic nephropathy or NS._? albuminuria ,, ok this massive less likely.. High cholesterol , one may argue it is part of metabolic syndrome in an adolescent..But hypoalbuminemia .and a normal renal function , diabetic nephropathy is unlikely ..it is NS ..
But what type of NS..
So more work up of NS also before you decide about management ..
Occasionally you may get a paradoxical response.. A diabetic patient on high insulin requirement with insulin antibodies , stroid may reduce the requirement of insulin . This is but an academic curiosity rather than practically helpful point
Most of us faces dielmas like this in patient management...but dont share these , i appreciate the Dr.Sushilkumar to bring this discussion..

This is not about steroid only , Treatment for an entity is causing adverse problems , at the same time that is in evitable in the management .. The level of one arm of each side will decide whether you can use it and continue ,, or stop it altogether.......
similar situation we had earlier ,, like Acute leukemia patients while on initial work up found out to be hepatitis B positive..., few of them diabetic at the beginning and on treatment ..
Here how to take a decision..
1. Confirm diagnosis ...without doubt..., assess the extent of the problem ,,and decide whether you can postpone the management a short while , or it is something which spontenusly remit with time . . so that you can buy some time for the management of an entity which takes shorter time to finish ...{This statement is not applicable for the above case,, but may be applicable for certain other situations like this ....}. The problem with
2.The other side...is there a management option other that the drug which is likely to worsen the primary condition .. How effective it is to controll it compared to the drug of choice..If the second option of drug is safe { wont worsen the primary disease ..},, it can be chosen even if the efficiency is not comparable ,, or a little less effective than the drug of choice.. ie efficiency sixty percent of the drug of choice is acceptable in this context....How this decision modifies the disease course of the recent illness should be considered , not only on a short term basis , but long term also..
eg ,,in this case ,,can you avoid steroid {which is the drug of choice for NS... }..and replace it with another like cyclophosphamide., calcineurins etc..There are clear cut guidelines for using this drug ..They can not be used as first line drug .
In this case as Dr Susan pointed out , this is very u nlikely to be MCNS.. you have to investigate beyond nephrotic syndrome ANA profile... Renal biopsy are a must ,.. before starting treatment .. { not after one month of treatment...}.. In case it turns out to be one of the complicated type of histopathology also . you have more justifications to go for the management options...other than steroid ie skippins steroid..I agree , even in those cases trial with high dose steroids to be the first line...
3 Third option . when there is no other choice for treatment .. Only one Drug of choice.. ,,no other drug with with comparable efficieny ..You are forced to use the drug ..{ or leave alone the patient , to take the course of disease or death or leave to another system with totally different way of approach .
If you opt for this choice.. you are sure the basic disease will flair up .. So be vigilant about that and manage aggressively ,, ie in a case like this the insulin dose to be stepped up , with close and strict monitering..
5/11/2013 7:29:44 PM
Dr. susan said says,
5/11/2013 1:40:10 PM
Mostly this is a case of secondary nephrotic syndrome investigate for SLE ` hepatitis and renal biopsy We use steroid in diabetic if needed but insulin requirements usually increase
renal biopsy
Dr. othman helmy says,
5/11/2013 3:39:29 AM

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