Nephrotic syndrome medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

Treatment of Edema

There are currently no guidelines for the management of edema associated with nephrotic syndrome. The slow reversal of edema is important at a rate of 0.5-1 kg daily to prevent electrolyte disturbances, hypovention, ischemic acute tubular necrosis, and hemoconcentration associated with aggressive diuretic therapy.

IV Loop diuretics, like furosemide or bumetanide, are mostly used as first line diuretics. The use of oral medications is generally avoided due to poor absorption in cases of interstinal edema and due to presence of hypoalbuminemia Addition of thiazide-type diuretics, metolazone, or potassium-sparing diuretics are also reasonable options. There are currently no guidelines to outline the appropriate dosages and drug selection.

IV albumin, although generally not recommended for hypoalbuminemia due to its transient effects, has been shown to have synergistic effects with diuretics for an increased delivery of protein-bound diuretics to sites of action. Nonetheless, albumin is still not widely recommended, and its risks may at times outweigh the benefits because it is associated with anaphylaxis, hypertension, and pulmonary edema.

Treatment includes:

General Measures (Supportive)

• Monitoring and maintaining euvolemia (the correct amount of fluid in the body)
  • Monitoring urine output, BP regularly
  • Fluid restrict to 1L

• Diuretics (IV furosemide)

• Monitoring kidney function
  • Do EUCs daily and calculating GFR

• Prevent and treat any complications [see below]

• Albumin infusions are generally not used because their effect lasts only transiently.

Specific Treatment of Underlying Cause

• Immunosupression for the glomerulonephritides (steroids, cyclosporin)

• Standard ISKDC Regime for first episode: Prednisolone -60 mg/m² /day in 3 divided doses for 4 weeks followed by 40mg/m²/day in a single dose on every alternate day for 4 weeks.

• Relapses by prednisolone 2mg/kg/day till urine becomes negetive for protein. Then,1.5mg/kg/day for 4 weeks.

• Frequent Relapses treated by: cyclophosphamide or nitrogen mustard or cyclosporin or levamisole.

• Achieving stricter blood glucose control if diabetic

• BP control. ACE inhibitors are the drug of choice. Independent of their blood pressure lowering effect, they have been shown to decrease protein loss.

Dietary Recommendations

• Limit high protein animal foods to 1 oz per meal (preferably lean cuts of meat, fish, and poultry)

• Limit high phosphorous foods such as cheese, cooked dried beans and peas, nut butters, soy, tofu, and yogurt, including cokes and colas.

• Limit high potassium vegetables and fruits such as artichokes, avocado, bamboo shoots, beets, brussels sprouts, chard, greens (such as beet and collards), kohlrabi, okra, parsnips, potatoes, pumpkin, rutabagas, spinach, sweet potatoes, tomatoes, tomato juice, tomato sauce, wax beens, winter squash, yams. Fruits include, apricots, bananas, dates, honey dew, nectarines, orange juice, oranges, prune juice.

• Avoid saturated fats and eat unsaturated fats in moderation.

• Eat low-fat desserts only.

• Monitor fluid intake which includes all fluids and foods that are liquid at room temperature.