title: Assessment of Volume Status and Appropriate Fluid Replenishment in the Setting of Nephrotic Syndrome.
abstract: BACKGROUND
  When the permeability of the glomerular filtration barrier increases, leading to proteinuria, nephrotic syndrome (NS) occurs. First episodes or relapses of NS can be concurrent with acute gastroenteritis (AGE) infections. This condition can cause further deterioration of the hypovolemic state, as intravascular water is lost through both AGE-related vomiting/diarrhea and NS-related fluid shifting into the interstitium. In this case report, we wish to raise the issues about the difficult management of children presenting with both NS and AGE.
  
  
  METHODS
  We report two cases characterized by concurrence of NS and AGE. Despite our intervention, case #1 required dialysis, whereas in the case #2 we restored the patient's liquid homeostasis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: No guidelines helping general physicians in the management of children presenting with both NS and AGE are available in the literature. However, it is common for these patients to seek the first line of treatment at emergency departments. In these patients, restoring the liquid homeostasis is a challenge, but some key points can help the physicians with first-line management: 1) carefully evaluate the signs of hypovolemia (edematous state can be misleading); 2) bear in mind that-in hypovolemic, severely hypoalbuminemic (serum albumin levels < 2 g/dL) NS children-initial fluid administration should be followed by a 20% albumin infusion if oligoanuria persists; intravenous 4.5% albumin may be a valid alternative as a first-line therapy instead of crystalloid and 20% albumin; and 3) pay attention when using furosemide; it should only be administered after albumin infusion or after hypovolemia correction.
authors.affiliation: Department of Woman, Child and of General and Specialized Surgery, Seconda Università degli Studi di Napoli, Napoli, Italy.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Marzuillo
authors.affiliation: Department of Woman, Child and of General and Specialized Surgery, Seconda Università degli Studi di Napoli, Napoli, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Guarino
authors.affiliation: Department of Woman, Child and of General and Specialized Surgery, Seconda Università degli Studi di Napoli, Napoli, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Apicella
authors.affiliation: Department of Woman, Child and of General and Specialized Surgery, Seconda Università degli Studi di Napoli, Napoli, Italy.
authors.forename: Rosaria
authors.initials: R
authors.lastname: Marotta
authors.affiliation: Pediatric Emergency Department, Azienda Ospedaliera di Rilievo Nazionale Santobono-Pausilipon di Napoli, Napoli, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Tipo
authors.affiliation: Department of Woman, Child and of General and Specialized Surgery, Seconda Università degli Studi di Napoli, Napoli, Italy.
authors.forename: Laura
authors.initials: L
authors.lastname: Perrone
authors.affiliation: Department of Woman, Child and of General and Specialized Surgery, Seconda Università degli Studi di Napoli, Napoli, Italy.
authors.forename: Angela
authors.initials: A
authors.lastname: La Manna
authors.affiliation: Pediatric Nephrology and Dialysis Unit, Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Montini
mesh_terms: D000418:Albumins / Q000494:pharmacology / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D003967:Diarrhea / Q000209:etiology; D004487:Edema / Q000209:etiology; D004636:Emergency Service, Hospital / Q000458:organization & administration; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D005759:Gastroenteritis / Q000150:complications*; D006706:Homeostasis / Q000502:physiology; D006801:Humans; D034141:Hypoalbuminemia / Q000150:complications; D020896:Hypovolemia / Q000209:etiology*; D008297:Male; D009404:Nephrotic Syndrome / Q000150:complications*; D009846:Oliguria / Q000209:etiology; D013610:Tachycardia / Q000209:etiology; D014839:Vomiting / Q000209:etiology
chemical_list: D000418:Albumins
keywords: dehydration; furosemide; hypoalbuminemia; hypovolemic shock; nephrotic syndrome