What is the treatment for edema in Nephrotic Syndrome (NS)?

From the Guidelines

The treatment of edema in nephrotic syndrome primarily involves diuretic therapy, with loop diuretics being the first-line option, as recommended by the KDIGO 2021 clinical practice guideline for the management of glomerular diseases 1.

Key Recommendations

• Loop diuretics, such as furosemide, should be used as the first-line treatment for edema in nephrotic syndrome, with twice daily dosing preferred over once daily dosing, and the dose increased to cause clinically significant diuresis or until the maximally effective dose is reached 1.
• For resistant edema, switching to a longer-acting loop diuretic, such as bumetanide or torsemide, may be necessary 1.
• Dietary sodium intake should be restricted to less than 2.0 g/d to complement diuretic therapy and enhance its effectiveness 1.
• Combining loop diuretics with other mechanistically different diuretics, such as thiazide diuretics, may be beneficial for synergistic treatment of resistant edema 1.
• Monitoring for adverse effects of diuretics, such as hypokalemia, hyponatremia, and impaired GFR, is crucial 1.

Additional Considerations

• Albumin infusions followed by intravenous furosemide may be considered for severe, refractory edema, although this approach provides only temporary benefit 1.
• Potassium-sparing diuretics, such as amiloride, may be preferred over mineralocorticoid inhibitors, such as spironolactone, in patients with nephrotic syndrome 1.
• The underlying mechanism of edema in nephrotic syndrome involves hypoalbuminemia leading to decreased oncotic pressure, which causes fluid shift from the intravascular to the interstitial space, triggering the renin-angiotensin-aldosterone system and promoting sodium and water retention 1.

From the FDA Drug Label

Furosemide tablets are indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome. Spironolactone tablets are indicated for the management of edema in the following settings: ... Nephrotic syndrome when treatment of the underlying disease, restriction of fluid and sodium intake, and the use of other diuretics produce an inadequate response.

Treatment of edema in nephrotic syndrome can be managed with:

• Furosemide 2, which is indicated for the treatment of edema associated with renal disease, including the nephrotic syndrome.
• Spironolactone 3, which is indicated for the management of edema in nephrotic syndrome when other treatments are inadequate.

From the Research

Treatment Options for Edema in Nephrotic Syndrome

• The management of edema in nephrotic syndrome can be achieved through various methods, including the use of loop diuretics, such as frusemide, as stated in 4.
• In cases of intractable edema, additional measures can be taken, including salt restriction, treatment with intravenous frusemide, and the use of thiazide and potassium-sparing diuretics, as mentioned in 4.
• Other treatment options for edema in nephrotic syndrome include ultrafiltration and head-out water immersion, which can be beneficial for patients who are unresponsive to other measures, as noted in 4.

Pathophysiology and Management of Edema

• The pathogenesis of edema in nephrotic syndrome can occur through various mechanisms, including intravascular volume underfilling and overfilling, and management should be directed towards the underlying pathophysiology, as discussed in 5.
• The treatment of edema in nephrotic syndrome should take into account the individual patient's pathophysiology, and a systematic approach to management is recommended, as stated in 6.

Use of Diuretics in Nephrotic Syndrome

• Diuretics play a significant role in the treatment of edema in nephrotic syndrome, and various classes of diuretics exist, each with a unique mode of action, as mentioned in 6.
• The use of diuretics in nephrotic syndrome should be guided by the underlying pathophysiology and the individual patient's response to treatment, as discussed in 7.

Clinical Considerations

• Nephrotic syndrome is a complex condition that requires a comprehensive approach to management, including the treatment of edema and other complications, as noted in 8.
• The primary care physician should be aware of the common causes of nephrotic syndrome and the importance of establishing a cause and treating the underlying condition, as stated in 8.