Nephrotic Syndrome

Nephrotic syndrome is associated with proteinuria in excess of 3-3.5 g/1.73 m² daily accompanied by hyperlipidaemia, oedema, hypoalbuminaemia, and hypercoagulable state.
Diuretics should be used with caution and not given as a routine in children with nephrotic syndrome.

Causes of Nephrotic syndrome

The causes of nephrotic syndrome are generally grouped into:

  1. Primary glomerular disease
  2. Infections
  3. Systemic diseases
  4. Drug related

1. Primary Glomerular Disease

  • Minimal change disease – common in children
  • Focal and segmental glomerulosclerosis
  • Membranous nephropathy
  • Membranous proliferative glomerulonephritis

2. Infections

  • Bacterial (Post streptococcal infection)
  • Viral-Hepatitis B and C, HIV
  • Parasitic (Plasmodium malariae, Schistosoma mansoni, Filaria sis)

3. Systemic Diseases

  • Diabetes mellitus
  • Systemic Lupus Erythematosus
  • Amyloidosis

4. Drug-related

  • Non steroidal anti-inflammatory drugs

Symptoms of Nephrotic syndrome

The following are the symptoms of nephrotic syndrome:

  1. Early morning facial puffiness
  2. Generalized body swelling
  3. Foamy appearance of urine
  4. Weight gain (unintentional)
  5. Poor appetite

Signs of Nephrotic Syndrome

Signs of nephrotic syndrome include the following:

  1. Periorbital, peripheral, genital oedema
  2. Ascites
  3. Pleural effusion
  4. Protein malnutrition particularly in children with long standing disease

Investigations

  • Urinalysis
  • BUE and creatinine
  • Serum albumin
  • Serum lipids
  • Fasting blood glucose
  • Serology – Hepatitis B, C, HIV Hb electrophoresis
  • Antinuclear antibody (ANA)
  • Ultrasound of kidneys

Treatment for Nephrotic Syndrome

Treatment objectives

The treatment objectives of nephrotic syndrome include the following:

  1. To relieve symptoms
  2. To treat underlying condition
  3. To prevent and manage complications
  4. To delay progressive kidney damage
  5. To improve the quality of life of the patient

Non-pharmacological treatment

  1. Restrict salt intake
  2. Adequate protein diet; 0.6-0.8 g/kg body weight of 1st class protein (eggs, meat, fish, dairy products) per day for adult and 2-4 g/kg per day for children

Pharmacological treatment

A. For control of oedema

1st Line Treatment
Evidence Rating: [C]
Furosemide, IV,
Adult: 40-80 mg 8-12 hourly (max. 160 mg daily)
Children: Refer to specialist.
Note

In children, furosemide is used in conjunction with albumin infusion only in servere oedema.

 
Or
Furosemide, oral,
Adult: 40 mg daily, increasing to 80 mg daily; max. 240 mg daily.
Children: Refer to specialist.

B. For control of resistant oedema

Furosemide, IV or oral.

  • (as above for adults and children)

And

Metolazone, oral,
Adults: 2.5-10 mg once daily
Children: Refer to specialist.
Note

Diuretics should be used with caution and not given as a routine in nephrotic syndrome in children.

C. For control of proteinuria

Lisinopril, oral,
Adult: 5-20 mg daily

And

Prednisolone, oral,
Adults: 1 mg/kg daily
Children: 60 mg/m2 or 2 mg/kg daily (max. 80 mg).
For long-term management, refer to a paediatrician.
Note

Corticosteroids should be given to children and selected adults with minimal change nephrotic syndrome by specialists only.

Referral Criteria

Refer all patients to a physician specialist, paediatrician or nephrologist immediately after diagnosis and stabilisation.