Pediatric emergency medicine trisk 2906 2906
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losses, and restricted intake. Signs of decreased effective circulating volume
include tachycardia, peripheral vasoconstriction, and oliguria.
In addition to overall volume excess with or without intravascular
depletion, complications resulting from nephrotic syndrome include
infection and thromboembolism. Children with nephrotic syndrome are at
increased risk of developing serious bacterial infection, particularly
infections with encapsulated bacteria, because of urinary losses of
immunoglobulins and alternative complement pathway factors B and D.
Children who are treated with immunosuppressive agents will have
additional risk. Furthermore, ascites and pleural effusions increase the risk
for peritonitis, pneumonia, and empyema. Other potential complicating
infections include sepsis, meningitis, cellulitis, urinary tract infection, upper
respiratory tract infection, and severe acute gastroenteritis.
Thromboembolic complications are reported in 2% to 9% of children
with nephrotic syndrome and may occur in either the arterial or venous
circulation. The actual incidence may be higher, however as
thromboembolic events may be asymptomatic. The risk may be higher in
children with steroid-resistant disease. Nephrotic syndrome results in a
hypercoagulable state due to urinary losses of antithrombin III, protein S,
and plasminogen and increased circulating fibrinogen, factors V and VII as
well as increased platelet activation. Though many embolic events are
silent, cerebral venous thrombosis, pulmonary embolism, and renal vein
thrombosis may result in significant morbidity. Though a much less
frequent occurrence in children than in adults with nephrotic syndrome,
renal vein thrombosis should be suspected in cases of sudden-onset
macroscopic hematuria and flank pain.
Triage considerations. Children with nephrotic syndrome may present
acutely ill with signs and symptoms of fluid overload. Patients may require
support of lung function due to pulmonary edema. Hypertension, if present,
can be symptomatic and may require emergent management. They are at
risk for serious bacterial infections as well as both venous and arterial
thrombosis and may require emergent evaluation and treatment for these
conditions. Other patients may present with mild symptoms related to
edema and will be managed with gentle diuresis with fluid and salt
restriction.
