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Education And Debate

Lesson of the Week: Nephrotic syndrome in childhood complicated by life threatening pulmonary oedema

BMJ 1996; 312 doi: (Published 06 January 1996) Cite this as: BMJ 1996;312:36
  1. C J D Reid, senior registrara,
  2. M J Marsh, consultantb,
  3. I M Murdoch, consultantb,
  4. G Clark, senior lecturera
  1. a Department of Paediatric Nephrology, Guy's Hospital, London SE1 9RT
  2. b Department of Paediatric Intensive Care, Guy's Hospital
  1. Correspondence to: Dr Reid.
  • Accepted 5 June 1995

A consensus statement on nephrotic syndrome from the British Association for Paediatric Nephrology has recently recommended intravenous 20% albumin for the management of hypovolaemia in this condition.1 The suggested dose is 1 g/kg over one to two hours followed by frusemide. Caution is required with this treatment, however, as considerable fluid shift may occur.2 We describe three children who were transferred to our paediatric intensive care unit because they had developed life threatening fluid overload and pulmonary oedema after receiving an excessive dose or too rapid infusion of 20% albumin.

Beware of infusing too much 20% albumin too quickly in children with nephrotic syndrome

Case 1

A 4 year old girl presented to her local hospital with a 10 day history of periorbital and lower limb oedema, a three day history of diarrhoea and vomiting, and oliguria for the past 24 hours. Urine analysis showed heavy proteinuria. The plasma albumin concentration was 15 g/l, urea concentration 11.6 mmol/l, creatinine concentration 41 μmol/l, haemoglobin concentration 120 g/l, and urinary sodium concentration 11 mmol/l. Nephrotic syndrome was diagnosed, and oral prednisolone was started. Oliguria persisted and her weight increased. There was no response to intravenous frusemide. She was given 20% albumin at a dose of 3.5 g/kg ideal body weight over four hours. During the infusion she became breathless, cyanosed, and had a generalised seizure followed by respiratory arrest. At intubation pink frothy sputum welled from the trachea. Initial arterial blood gas tensions when she was ventilated with 100% oxygen were pH 6.87, Pco2 8.7 kPa, Po2 5.9 kPa, base excess -24.6. Central venous pressure was +20 cm H2O. …

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