SEVERE HYPONATREMIA AND METABOLIC ACIDOSIS IN A TODDLER WITH STEROID RESISTANT NEPHROTIC SYNDROME FOLLOWING ACUTE GASTROENTERITIS

ABSTRACT Background

Steroid-resistant nephrotic syndrome (SRNS) accounts for 3-15% of childhood nephrotic syndrome and is associated with significant morbidity, progression to chronic kidney disease, and susceptibility to complications. Intercurrent infections, such as gastroenteritis, may precipitate severe fluid and electrolyte derangements, including hyponatremia and metabolic acidosis, which can be life-threatening in pediatric SRNS.

Case Presentation

We report a 3-year-old male with SRNS and underlying minimal change nephropathy who presented with acute gastroenteritis, complicated by severe hyponatremia (Na 120 mEq/L) and metabolic acidosis (HCO, 13.9 mEq/L). The child developed vomiting and watery diarrhoea without fever or oliguria. Laboratory investigations confirmed critical electrolyte disturbances despite preserved renal function. Management involved prompt intravenous fluids, cautious electrolyte correction, intravenous hydrocortisone, and broad-spectrum antibiotics, followed by supportive therapy. The child's condition stabilized by Day 5, allowing transition to oral therapy, including alternate-day prednisolone, enalapril, atorvastatin, calcium carbonate with vitamin D, zinc, folic acid, nitazoxanide, loperamide, co-trimoxazole prophylaxis, and probiotics.

Discussion

This case underscores the complexity of SRNS with minimal change nephropathy during intercurrent infections. Severe hyponatremia and metabolic acidosis compounded by diarrheal losses and hypoalbuminemia highlight the need for vigilant monitoring. Notably, corticosteroids were continued without additional immunosuppressive agents, reflecting individualized clinical decision-making in real-world practice, which may diverge from guideline recommendations advocating calcineurin inhibitors in SRNS.

Conclusion

Children with SRNS are particularly vulnerable to electrolyte crises during infections. Early recognition and correction of hyponatremia and metabolic acidosis are crucial to prevent fatal complications. This case emphasizes the importance of tailored therapeutic strategies and highlights the gap between guidelines and real-world management in pediatric SRNS