Hypo- and hypervolemic edema in children with steroidsensitive nephrotic syndrome

Abstract

Background/aim: The mechanism of edema formation in nephrotic syndrome is still poorly understood. We aimed to evaluate the volume status in children with steroid-sensitive nephrotic syndrome (SSNS) and to emphasize the importance of echocardiography in demonstrating of volume changes.Materials and methods: Thirty-two SSNS patients and 30 healthy children were enrolled in this study. The volume statuses of patients were evaluated by clinical and laboratory features, including fractional sodium excretion (FENa) and distal sodium/potassium exchange (UK/UNa+K ratio). Inferior vena cava collapsibility index (IVCCI), left atrial diameter (LAD), aortic diameter (AD), and left ventricular mass index (LVMI) were measured using conventional echocardiographic methods.Results: FENa was lower in children with NS; however, the distal K/Na ratio of the patient and control groups did not differ. In addition, IVCCI, LAD, AD, and LVMI were not different among groups. When evaluating the volume status of patients, 8 patients (25%) were hypovolemic while 24 patients (75%) were nonhypovolemic (normovolemic or hypervolemic). LAD was significantly lower in hypovolemic patients. Conclusion:The majority of children with SSNS are normovolemic or hypervolemic and echocardiography is an easy and valuable method for the evaluation of volume status in these patients.

Inferior Vena Cava Collapsibility Index: A Precise Non-invasive Tool for Evaluation of Edema in Children with Nephrotic Syndrome.

“…However, in phase 2 of their study, the FeNa% criterion for the volume status was modi ed and patients with FeNa% of < 0.2% were identi ed with volume contraction which we have applied in addition to clinical assessment to differentiate edema types. In the current work,73.3% of the studied patients were non-hypovolemic; the same observation was noted by Buyukavci and colleagues [7] who reported that 75% of their patients were non-hypovolemic and another study also in 2015, by Ozdemir [9] studied NS subgroups (relapse-edematous, relapse-edema free and remission), were compared. They found nonsigni cant difference between groups as regard to IVCCI.…”

“…Some literatures relied on the presence or absence of hypovolemic symptoms and signs [4] or radioactive labeling techniques [5]. Later researches explored the roles of inferior vena cava collapsibility index (IVCCI) and left atrial diameter (LAD) assessed by echocardiography (ECHO) [6,7] and over hydration (OH) value assessed by bioimpedance spectroscopy (BIS) technique such as body composition monitor (BCM) [8] for volume burden assessment. IVCCI has strong correlation to central venous pressure so it decreases with increased intra vascular volume and have been widely used for volume status assessment in hemodialysis and critically ill patients and less frequently in INS [9][10][11][12].…”

“…Donmez et al; [6] studied the value of IVCCI, to determine the volume load in children with minimal lesion nephrotic syndrome and noted that IVCCI in nephrotic edematous patients was less than nephrotic non-edematous group and healthy control group, indicating hypervolemic state in edematous patients. On the other hand, In 2015, Buyukavci and his coworkers[7] studied SSNS children versus healthy control; IVCCI didn't differ among both groups. Furthermore, IVCCI was not signi cantly different between hypovolemic and nonhypovolemic subgroups within the active NS group.…”

Steroid Sensitive Nephrotic Syndrome: Revised Guidelines

“…Patients with severe edema have marked hypoalbuminemia (serum albumin <1.5 g/dL), along with ascites and anasarca that interferes with daily activities [97,98]. Intravascular volume depletion is common in patients with moderate or severe edema [99,100], and should be assessed before instituting therapy with diuretics.…”

“…2). Subsequently, patients are managed with IV and oral hydration, and IV albumin (20%; 0.5-1 g/kg over 3-4 hr) [97,99,101].…”