ORIGINAL ARTICLE 177 P J M H S VOL.3 NO.2 APR – JUN 2009 Frequency of Peritonitis in children with Nephrotic Syndrome JUNAID RASHID, RASHID MEHMOOD, JAMIL AHMAD, SUMAIR ANWAR, M. TARIQ BHATTI ABSTRACT Objective: This prospective descriptive study was aimed at determining the frequency of peritonitis in children with Nephrotic Syndrome. Methods: It was carried out in Department of Pediatrics, Jinnah Hospital, Lahore from Jan 2005 to Jan 2006. All patients admitted with the diagnosis of Nephrotic syndrome either (new or known) excluding those with congenital nephrosis were included. Peritonitis was primarily a clinical diagnosis with CBC, Peritoneal tap and abdominal ultrasound as supportive investigations Results: Out of 100 of nephrotic syndrome patients, 19 had peritonitis with male to female ratio of 2:1. Peritonitis was more common in patients with relapse (n=16; 84%) as compare to newly diagnosed cases (n=3; 15%). All presented with abdominal distension, pain (94%), tenderness (94%), fever (63%) and vomiting (52%). Ascitic fluid, morphology & cytology was positive in 17 patients (89%), culture & sensitivity was positive in only 4 patients (21%) with growth of Pneumococcus in 3 patients (15%) and E. coli in one patient (5%). 12 developed peritonitis within the first year of diagnosis of nephrotic, 5 patients after first year of establishing the diagnosis and two patients after two years of diagnosis of nephrotic syndrome. Conclusion: 19% of nephrotic syndrome (mostly known cases with relapse within the first year of diagnosis) presented with peritonitis with male predominance. Most common presentation of peritonitis in nephrotics is abdominal distension and abdominal pain. Ascitic fluid is positive for peritonitis in 89 % with positive culture in only 21% (mainly Pneumococcus). Keywords: Nephrotic syndrome, peritonitis. INTRODUCTION Nephrotic Syndrome is one of the most common diseases in children, which is characterized by proteinuria, hypoalbuminemia, hypercholesterolemia and edema. According to the underlying histological lesion the nephrotic syndrome is classified as minimal change, focal glomerulosclerosis (segmental / global), mesangial proliferative glomerulonephritis, diffuse mesangiocapillary glomerulonephritis, diffuse membranous glomerulonephritis and chronic glomerulonephritis. Minimal change disease is the commonest lesion in Nephrotic Syndrome. 1 Minimal change disease occurs predominantly between 2-8 years of age and it is responsive to steroid in 90%of cases. Focal segmental is the second most common lesion and it is usually steroid resistant 1 . 1 Peritonitis is an important complication in Nephrotic Syndrome 2 . Streptococcus pneumonie (Pneumococcus) has been found to be primarily responsible organism in most cases of peritonitis. E.coli is the other bacterium found in these patients. Although Nephrotic Syndrome is well known as a predisposing factor to bacterial infections in children including peritonitis, urinary tract infections, skin infections, sepsis, respiratory tract infections and ----------------------------------------------------------------------- Department of Paediatrics, Allama Iqbal Medical College/ Jinnah Hospital, Lahore Correspondence to Dr. Junaid Rashid, Associate Professor, Email: doc_junaid@hotmail.com Cell No. 0321 8864444 osteo-myelitis, but data on the frequency of peritonitis is limited. Peritonitis is defined as the inflammation of peritoneal lining of the abdominal cavity. In the pre- antibiotic era fatal peritonitis and sepsis have led to 40-50% mortality but now with the use of antibiotics and steroids, this mortality has decreased to 1.5- 4.6% only. The diagnosis of peritonitis is usually clinical 3 . Essentially, all patients present with some degree of abdominal pain. Anorexia and nausea are frequently present and may precede the development of abdominal pain by some time. Vomiting may occur because of the underlying visceral organ pathology (i.e., obstruction) or secondary to the peritoneal irritation. Most patients with intra-abdominal infections demonstrate leukocytosis (>11,000 cells/mm 3 ) with a shift to the immature forms on the differential cell count. Blood chemistry findings are often within the reference range initially, but they may show evidence of dehydration with elevated BUN and altered electrolyte concentrations caused by protracted vomiting, diarrhea, renal dysfunction, and ascites. When assessing a peritoneal fluid sample for peritoneal infection, it generally demonstrates low pH that is more pronounced in mixed infections and severe bacterial contamination, with increased numbers of anaerobic bacteria in these circumstances and glucose as well as elevated protein and LDH levels. 3 In SBP, a WBC count of