Management of Nephrotic Syndrome: A Step-by-Step Clinical Guide

Management of Nephrotic Syndrome: A Step-by-Step Clinical Guide

Question.  Outline the management of Nephrotic Syndrome.
Answer.

Management of nephrotic syndrome involves:

• Scientific treatment of underlying morphology or causative disease
• General measures to control nephritic complications
• Treatment to reduce proteinuria
  Non-specifi measures that may reduce proteinuria include ACE and NSAIDs.
  ACE­I and ARBs (angiotensin­receptor blockers) reduce proteinuria and slows the rate of progression of rate of renal failure by lowering intraglomerular pressure and preventing development of hemodynamically mediated focal segmental *glomerulosclerosis.

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• Edema: Advice patient to take low sodium diet i.e.1 to 2 g/day. In mild edema thiazide induce gentle diuresis.
  In moderate edema frusemide in doses of 80 to 120 mg/day or torsemide 20 to 40mg/day is given.
  In patients with severe edema frusemide 20 to 40mg/day is combined with spironolactone 100 to 200mg/day for complete resorption of sodium throughout the nephron.
• Hypercholesterolemia: It is treated by the lipid lowering agent specially statins. Atorvastatin 20 mg OD or BD
  Anticoagulation is needed for patient with deep vein thrombosis, arterial thrombosis and pulmonary embolism.
• Antiplatelet agents and warfarin could be advocated.
• Diet: Restricted protein diet is advised since high protein diet accelerates progression of nephritic syndrome.
• Vitamin D supplementation is advisable.

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• Antibiotics: Aggressive antibiotic therapy is given in nephrotic syndrome as chances of sepsis are always present. Mainly cephalexin are given
• Corticosteroids: Produce rapid and complete remission with clearing of proteinuria in 90% cases.
  Dose -Prednisolone 1 mg/kg/day, maximum 80 mg/ day. Remission usually occurs between days 7 and 14, though some patients need up to 16 weeks therapy to achieve complete remission.
  Prednisolone dose is reduced to 0.5 mg/kg/day and then tapered slowly.
  An attmpt to stop treatment should be made after 8 weeks.
  In patients who relapse, course of prednisolone should be repeated.
• Immunosuppressive drugs: In steroid­resistant patients, or in those in whom remission can only be maintained by heavy doses of steroids, cyclophosphamide 1.5–2 mg/kg/ day for 8–12 weeks with concomitant prednisolone 7.5–15 mg/day.
• Levamisole: In corticosteroid­dependent children 2.5 mg/ kg to maximum 150 mg on alternate days is useful in maintenance of remission.