What is the appropriate treatment and management plan for a 7-year-old patient presenting with symptoms of nephrotic syndrome?

SOAP Note for 7-Year-Old with Nephrotic Syndrome

Subjective

• 7-year-old child presenting to Pediatric ER with symptoms consistent with nephrotic syndrome
• Likely presenting with edema, particularly periorbital edema and lower extremity swelling
• Possible complaints of decreased urination, fatigue, and abdominal discomfort

Objective

Physical Examination

• Vital signs: Check for hypertension, tachycardia (signs of volume overload or hypovolemia)
• Weight: Document current weight (important baseline for treatment monitoring)
• Generalized edema: Periorbital, lower extremities, possibly ascites
• Respiratory: Assess for pleural effusions, respiratory distress
• Cardiovascular: Evaluate for signs of hypovolemia or hypervolemia

Laboratory Tests

• Urinalysis: Heavy proteinuria (>3+)
• Serum albumin: Decreased (<2.5 g/dL)
• Lipid panel: Elevated cholesterol and triglycerides
• BUN/Creatinine: To assess kidney function
• CBC: Rule out infection
• C3, C4: Normal in minimal change disease
• Urine protein/creatinine ratio: Quantify proteinuria

Assessment

• Nephrotic syndrome, likely steroid-sensitive (minimal change disease is most common in this age group)
• Rule out secondary causes: infections, medications, systemic diseases

Plan

Immediate Management

1. Initiate high-dose glucocorticoid therapy with prednisone at 60 mg/m²/day (maximum 80 mg/day) for 4-6 weeks, followed by alternate-day therapy at 40 mg/m²/day for 4-6 weeks 1, 2

2. Fluid management:

   • Restrict sodium intake
   • Fluid restriction only if severe edema present
   • Monitor weight daily

3. Diuretics (if significant edema):

   • Furosemide 0.5-2 mg/kg/dose (up to 6 times daily, maximum 10 mg/kg/day) 1
   • If potassium-sparing diuretic needed, prefer amiloride over spironolactone 1

4. Albumin infusion (20-25%, 1 g/kg) only if:

   • Signs of hypovolemia (oliguria, tachycardia, hypotension)
   • Severe edema causing respiratory distress
   • Consider furosemide 0.5-2 mg/kg at end of infusion 1

Monitoring

• Daily weights and urine dipstick
• Electrolytes, BUN/creatinine every 1-2 days initially
• Blood pressure monitoring
• Monitor for steroid side effects
• Watch for signs of infection, thrombosis

Patient/Family Education

• Explain disease process and expected course
• Importance of medication adherence
• Dietary sodium restriction
• Signs of relapse (edema, foamy urine)
• When to seek immediate medical attention

Follow-up

• Outpatient follow-up within 1 week of discharge
• Continue monitoring for response to steroids
• Plan for steroid taper based on response

Relapse Management

• If relapse occurs, restart prednisone at 60 mg/m²/day until urine is protein-free for 3 consecutive days, then alternate-day therapy 2
• For frequent relapses or steroid dependence, consider steroid-sparing agents:
  • Cyclophosphamide: 2 mg/kg/day for 8-12 weeks (maximum cumulative dose 168 mg/kg) 1, 2
  • Levamisole: 2.5 mg/kg on alternate days 2
  • Calcineurin inhibitors: Cyclosporine (3-5 mg/kg/day) or tacrolimus 1, 2
  • Mycophenolate mofetil: 600-1200 mg/m²/day in 2 divided doses 2

Complications Prevention

• Pneumococcal vaccination if not up-to-date
• Annual influenza vaccination
• Defer live vaccines until prednisone dose <1 mg/kg/day 2
• Consider thromboprophylaxis if high risk (severe hypoalbuminemia, history of thrombosis)

Discharge Criteria

• Decreasing edema
• Stable vital signs
• Family understands medication regimen and follow-up plan