Nephrotic Syndrome

Most people have two kidneys, one on either side of the body just beneath the ribcage. Healthy kidneys filter the blood and allow small particles of waste products and water to be excreted as urine. Kidneys also play important role in the control of blood pressure, maintenance of bone health and formation of red blood cells.

What is nephrotic syndrome?
Nephrotic syndrome occurs when the kidneys leak large amounts of protein (especially albumin) into the urine. It is these proteins which is mainly responsible for holding water in the blood vessels, and when they are lost in urine, their level decreases in the blood which causes the water to come out of the blood vessels and cause swelling (edema).

What causes Nephrotic Syndrome?
In most cases, the exact cause of nephrotic syndrome is not known. There is no relationship with diet or socioeconomic status of the family. It is non-infectious and does not transfer to other family members

What are the symptoms?
The most common symptom is swelling (edema). It first appears on the face, especially around the eyes which is most prominent in the morning when the child gets up and decreases by the evening.

Other symptoms include: Frothy urine, weakness and tiredness, passing less urine than usual, recurrent infections, diarrhoea.

What is the treatment?
Prednisolone (steroid) is the drug of choice when the child is first diagnosed. Most children respond to this drug with disappearance of the protein in the urine and loss of swelling within 1-2 weeks (we call this REMISSION). Other drugs like diuretics, ACE inhibitors, etc may be required for symptomatic treatment.

Those who do not respond to steroids are given second line drugs like Cyclophosphamide, MMF, Levamisole and other immunomodulators as decided by your doctor according to the individual patient profile.

Duration of treatment: First episode is treated for 3 months and subsequent episodes are treated as decided by your physician.

What are the side effects of the treatment?
Common Side Effects of Steroids are:

Decreased resistance to infections such as cough and cold
Increase in appetite
Flushed, swollen cheeks and stretch marks on the skin
Rise in blood pressure
Behavioral problems e.g temper tantrums, or mood changes.
However most of the side effects are reversible and wean off once the steroid is stopped.

Long term supervision and course of nephrotic syndrome
In most cases the child with nephrotic syndrome becomes completely well with prednisolone treatment, and there are very few who require second line treatment which includes immunomodulators and other drugs.

The child may remain well for several months or longer. During this period, the child should be regarded as being normal, and should not be made to feel different from other children.

In majority of cases, however, nephrotic syndrome recurs. The recurrence is indicated by appearance of swelling around the eyes, which, if untreated, gradually increases to involve the face, feet, legs and abdomen, and in such conditions, doctor should be consulted immediately. Relapses are common in early childhood but decrease with age.

More than 90% of children with nephrotic syndrome go into adulthood with their kidneys functioning normally.

What are parents expected to do at home?
Starting and stopping of medicines should be strictly done as advised by the doctor.
Daily urine protein monitoring by urine dipsticks till negative for three days then atleast thrice a week during remission.
Keep a diary of all urine results so that your doctor can review your child’s progress in clinic. The dose of Prednisolone and any other medications and other comments should also be recorded.
In remission phase immediately report to the doctor under following conditions:
Swelling around the eyes
Decreased urine output
Urine protein 1+ or more for persistent 2-3 days
Any sign of infection like cough, cold, coryza.

Dietary advice for your child:
The child should be given a diet with enough proteins. High protein food items include milk and milk products, dal, chana, soyabean, eggs, meat and fish.

If the child is edematous, the doctor might advise salt restriction. Once the swelling disappears, the child can have his usual diet. It must be understood that salt has no role in the causation of nephrotic syndrome. No benefit can be expected by prolonged restriction of salt unless advised by the doctor for some other reason (e.g., if the blood pressure is high).

When is kidney biopsy required?
Very few children require kidney biopsy. Certain conditions in which children do not respond to daily treatment or have persistent gross hematuria, persistent hypertension, low complement level (C3 / C4) require kidney biopsy.

What immunizations are necessary?
Children who are on steroid medications and other immunosuprressives can become very unwell if exposed to CHICKENPOX or MEASLES, therefore they should be immunized for the same and also receive pneumococcal vaccine.

Dr. Ameet Kishore - Best ENT Doctor in india
Dr (Prof) Ameet Kishore is a graduate of the AFMC (Pune) and was awarded the medal for ENT. He obtained his higher surgical training in ENT Surgery in the UK and attained Fellowships of the Royal College of Surgeons of Edinburgh as well as the Royal College of Physicians and Surgeons of Glasgow.

He has received special training and experience in Microscopic Ear surgery, Neuro-Otology, Cochlear Implants, Endoscopic Sinus Surgery and in Paediatric ENT at various centres in UK, Europe and USA.

He was trained at the National Centre for Cochlear Implantation (UK) since 1995 and thus has extensive experience in management of deafness and in cochlear implantation. He set up and is the lead surgeon for the cochlear and hearing implant programme (for children and adults) at Apollo Hospitals. He has over 1800 cochlear implant recipients in this programme.

His team is particularly experienced in management of complex cochlear situations and is the only active programme in North India for Auditory Brainstem Implantation.

This programme also provides Bone Anchored Hearing Aids (BAHA), Bonebridge and Vibrant Soundbridge middle ear implants as options for patients with hearing loss.

Dr Kishore has large experience in endoscopic nasal and sinus surgical procedures like Functional Endoscopic Sinus Surgery (FESS) and Balloon Sinuplasty. Also performs advanced endoscopic procedures such as orbital decompression, optic nerve decompression, dacryocystorhinostomy (DCR), endoscopic closure of CSF leaks and endoscopic pituitary tumour surgery.

He was trained at the Royal Hospital for Sick Children, Glasgow in the Paediatric ENT, and is competent in the management of the child with common ENT problems as well as complex conditions that affect the paediatric ear, nose, throat and airway.

Is experienced in the management of conditions and lumps of the head and neck, salivary and thyroid gland. Well versed in microlaryngeal surgery and phonosurgical techniques for hoarseness.

He held the post of Consultant and Sr Lecturer at the Glasgow Royal Infirmary University Hospital for a number of years before returning to India, having spent over 15 years overseas.

His academic profile includes 6 book chapters, over 30 articles in peer reviewed journals and numerous presentations at National and International Conferences.

With over 25 years of ENT experience, he is Sr Consultant in ENT & Neurotology at Indraprastha Apollo Hospital, New Delhi and the Founder Director & Lead Consultant of Adventis ENT, Head Neck & Cochlear Implant Clincs.

Hypospadias Surgery In Delhi

What is hypospadias?
Hypospadias is a birth defect in boys in which the opening of the urethra is not located at the tip of the penis. In boys with hypospadias, the urethra forms abnormally during 8-14 weeks of pregnancy. The abnormal opening can be anywhere, from just below the end of the penis to the scrotum. Depending on the site of the opening they are classified as distal (minor type)and proximal (major type).

Types of Hypospadias:
The types of hypospadias a boys has depends on location of the opening of the urethra:

Subcoronal: The opening of the urethra is located somewhere near the head of the penis.
Midshaft: The opening of the urethra is located along the shaft of the penis.
Penoscrotal: The opening of the urethra is located where the penis and scrotum meet.
Understanding the normal penis and urethra
The normal urethra is a tube through which that urine flows out of the bladder. It passes through the penis. The opening of the urethra (meatus) is normally at the end of the penis, partly covered by the foreskin.

What is the penis like in hypospadias?
The main problem is that the urethra opens on the underside of the penis instead of at the end of the penis. The opening can be anywhere from just below the normal position (mild) to as far back as the base of the scrotum (severe).

Hypospadias may also include the following:

A hooded appearance of the foreskin. This is because the foreskin does not develop on the underside of the penis.
Tightening of the tissues on the underside of the penis (called ‘chordee’). This pulls the penis down and it cannot fully straighten. This is commanly seen in severe hypospedias

What problems can hypospadias cause?
Problems are likely to occur if hypospadias is left untreated. The further back the opening of the urethra is, the more severe the problems are likely to be.

Passing urine is different to normal. A baby in nappies will have no problem. However, when older, the urine stream may not be able to be directed forward into a urinal. When going to the toilet the urine is likely to ‘spray’ backwards. Sitting on a toilet may be needed to pass urine without mess.
Chordee causes bending of the penis. This is more noticeable when the penis is erect. Sexual intercourse may be difficult or impossible in severe cases.
Psychological problems about being ‘different’ to normal are common.

How common is hypospadias and what causes it?
About 1 in 300 boys are born with some degree of hypospadias. It seems to be getting more common. The reason why the penis does not develop properly is still not clear. The development of the penis while the baby is growing in the womb (uterus) is partly dependent on the male sex hormones such as testosterone.

What is the treatment for hypospadias?
If the hypospadias is mild, with the opening of the urethra just a little down from normal and with no bending of the penis, no treatment may be needed. However, in most cases an operation is required to correct the hypospadias. This can usually be done in one operation. However, if the hypospadias is more complicated, two operations may be necessary. The operation is usually done when the child is around 6-18 months old. The goals of treatment are:

For urine to be passed in a forward way.
For the penis to be straight when erect.
For the penis to look as normal as possible.
The position of the opening of the urethra is altered. Also, if chordee is present then this is corrected to allow the penis to straighten. The foreskin is usually used during the operation to make the new urethra so it is important that a circumcision is not done before the corrective surgery is performed.depanding on the surgery of hypospedias surgeryes

The success of the operation and the ‘normality’ that can be achieved depends on the severity of the hypospadias done in single as two stage

What happens after the operation?
Your son will be brought back to the ward to recover. He will be able to eat and drink after 3 hours He will have a dressing on his penis and a tube draining away the urine. The patients are usually kept for 2 days in the hosptial and then discharged. The dressing and tube need to stay in place for 10 days, then you will need to come back to the Hospital to have them removed.

What are the risks of hypospadias repair?
All surgery carries a small risk of bleeding during or after the operation.

For about one in ten boys, the original hole opens up again, so that your son passes urine through two holes. This can occur at any time after the operation. If this happens, your son will need the operation again. Occasionally, the new hole at the tip of the penis is too small, so your son will need another operation to make the hole larger. The drainage tube can irritate the inside of the bladder, which is painful. This is called ‘bladder spasm’. To reduce this, your son will be given ‘bladder spasm medicine’ as well as pain relief.

When you get home
Your son will go home with the catheter and dressing in place. Staff on the ward will give you full details of how to care for these at home.

You should encourage, to drink plenty of water/fluids.
Your child may need some pain relief when you get home.
You should not have a bath or shower until after the dressing comes off.
Putting your son in two nappies at a time can protect the area from accidental knocks.
Your son should not ride a bicycle or any sit-on toy until the area has healed.
Try to avoid getting the dressing dirty when nappy changing. If this happens, dab any faeces off with a damp cloth.
As there is a small risk of infection, your son will need to take antibiotics until he returns for his outpatient appointment.

Chemical Peeling In Dwarka
Chemical Peeling is the most commonly used dermatologic procedure that can be carried out on an OPD basis, it helps in promoting the effect of other medicines and thus is highly recommended by dermatologists.

A chemical peel is a technique used to remove the outermost layers of the skin (in a controlled manner) with the help of a chemical solution.

The nature of the chemical used determines the depth of the peeling and also decides the indication of that peeling agent.

Most common indications of chemical peels are Acne, Acne Marks & Scars Hyperpigmentation problems like Melasma, Tanning and Freckles.

Dermaheal has developed its own peeling mechanism where different peeling agents are combined to give best results to our patients according to their skin problems. These have been designed specially for the Indian skin type.

Peeling for Acne
According to the severity and chronicity of the Acne, Acne Marks & Acne Scars for a particular patient, we use a 3 to 4 step sequential peeling mechanism to give desired results. Peels used for this indication are -

Black Peels (Theraderm Inc. Imported from South Korea)
Salicylic Peels
Pyruvic Peels
Retinol (Yellow) Peel
The aforementioned peels can be used in different combinations or solitarily depending on the severity of Acne, Acne Marks & Scars and Patient skin type.

Peeling for Hyperpigmentation (Melasma)
In Indian skin the most common hyperpigmentation problem is Melasma, which occurs in the butterfly region of the face surrounding the nose, most commonly observed in the females of reproductive age group. This condition is very resistant to conventional medical treatment. Peels have come a long way to help Melasma patients to improve their quality of life and their social interaction by acting on the deeper layers of the skin where most creams and lotions can't penetrate. Peels used for this indication are -

Pyruvic Peels
Phenol-TCA Combination Peels
Glycolic Peels
Retinol (Yellow) Peels
Lactic Peels
The aforementioned peels can be used in different combinations or solitarily depending on the patient skin type and ongoing treatment protocol.

Vitiligo Treatment In Dwarka
What is Vitiligo
Vitiligo is a form of a chronic skin disorder which can easily be diagnosed by its characteristic appearance of white patches on the skin as the skin begins to lose its pigmentation.

These blotches can occur on any part of skin, however most common areas are face, neck, hands, eyes, mouth and foot.

Vitiligo can be treated by medications, phototherapy, laser and in certain cases surgical transplantation (tissue grafting and cellular grafting) is also advisable.

What causes vitiligo?
Melanin is the pigment which determines the color of our skin and hair.
The cells responsible for producing melanin (Melanocytes) are unable to function in case of Vitiligo thus causing loss of color of skin.
These white areas can either be localized or can continue to grow and are easily noticeable.
Melanocytes can be reintroduced to the affected areas via various methods to treat vitiligo.

Impact Of Vitiligo On Patients
Though vitiligo does not cause any serious impact on patient’s overall physical health and life expectancy, it can adversely affect patient’s psychological well-being.
Patient’s often feel insecure and anxious about their appearance which results in the development of antisocial behavior.
Younger patients are under constant emotional stress.
Mixed emotions of shame and fear often leads to depression.


Role Of Phototherapy
Derma heal Skin and Hair Clinic offers its patients the latest and best possible treatment modalities
We are equipped with a Narrowband UV-B (NB-UVB) chamber which works on whole body upto a great extent in cases of Generalized Vitiligo.
NB-UVB is an upright in-office booth which has a number of lamps that emit ultraviolet light thereby inducing re-pigmentation.
This device can be used in cases of both adults as well as children and does not cause any major side effects.
This treatment procedure is safe for both adults as well as children and generally requires 2-4 sessions weekly.
Phototherapy when combined with medications yield satisfactory results. Usually, prolonged treatments are required to attain better results.

Benefits Of Phototherapy
Significant improvement in the quality of life has been observed in the patients of generalized vitiligo undergoing phototherapy when combined with medications.
With phototherapy going on, the required doses of medicines gradually decreases thus decreasing the chances of long term side effects of medicines.
Patients experience a boost in their self-esteem as they keep on witnessing better results per session.
Phototherapy aids to prevent the formation of new patches thereby helping patients regain the confidence to face the world.

EXCIMER THERAPY
Excimer Therapy is an advanced technology that helps to treat skin diseases like vitiligo, atopic dermatitis and psoriasis which are usually difficult to treat conditions as there are very limited treatment options available for such skin conditions. This therapy is gentle as well as effective when followed with strict continuation.

The Excimer laser delivers a concentrated beam of UVB light through a hand piece directly to the white patches on the patient’s skin.