Treatment of Nephrotic Syndrome
The treatment of nephrotic syndrome should include edema management with diuretics, ACE inhibitors or ARBs for proteinuria reduction, statins for hyperlipidemia, and anticoagulation in high-risk patients, with disease-specific therapy determined by the underlying cause. 1
Definition and Diagnosis
Nephrotic syndrome is characterized by:
- Heavy proteinuria (>3.5g/24h)
- Hypoalbuminemia (<3.0g/dL)
- Edema
- Hyperlipidemia 1
Treatment Approach
1. Supportive Care
Edema Management:
- Fluid and sodium restriction 1, 2
- Loop diuretics (e.g., furosemide) as first-line therapy 1
- For severe cases, consider combination therapy with thiazide or potassium-sparing diuretics 1
- Avoid intravenous fluids and saline 1
Antiproteinuric Therapy:
- ACE inhibitors or ARBs to reduce proteinuria 1, 3
- Hold these medications during periods of volume depletion (diarrhea, vomiting, excessive sweating) 1
- Avoid dihydropyridine calcium channel blockers (amlodipine, nifedipine) as they may worsen edema and proteinuria 1
Hyperlipidemia Management:
- Statins for hyperlipidemia 1
2. Disease-Specific Therapy
Primary Focal Segmental Glomerulosclerosis (FSGS):
- High-dose oral glucocorticoids (1mg/kg/day) as first-line therapy 1
- Continue until complete remission or maximum of 16 weeks
- Maintain for ≥6 months in responders
- Consider calcineurin inhibitors for steroid-resistant cases 1
Membranous Nephropathy:
- Immunosuppressive therapy based on risk stratification
- Monitor for spontaneous remission in low-risk patients 3
Minimal Change Disease:
- Corticosteroids as first-line therapy 4
3. Management of Complications
Thrombotic Complications:
- Anticoagulation for high-risk patients 1
- Unfractionated or low-molecular-weight heparin or warfarin preferred 1
- Avoid factor Xa inhibitors and direct thrombin inhibitors due to albumin binding and urinary loss 1
Infection Risk:
- Vaccination against encapsulated organisms 1
- Consider trimethoprim-sulfamethoxazole prophylaxis when using prednisone ≥20mg daily 1
- Screen for latent infections (tuberculosis, hepatitis B/C, HIV, syphilis) 1
Cardiovascular Risk:
- Aggressively manage cardiovascular risk factors 1
- Control hypertension, hyperlipidemia, and diabetes mellitus 1
Special Populations
Pediatric Patients:
- Corticosteroids are the cornerstone of treatment 4
- Monitor growth velocity as it may be affected by corticosteroid therapy 5
- Consider steroid-sparing agents for frequent relapses: levamisole, mycophenolate mofetil, calcineurin inhibitors, anti-CD20 antibodies, cyclophosphamide 4, 6
Elderly Patients:
- Use caution with corticosteroids due to increased risk of diabetes mellitus, fluid retention, and hypertension 5
- Start at lower doses and monitor closely 5
Monitoring and Follow-up
Regular monitoring of:
- Renal function
- Proteinuria
- Blood pressure
- Edema
- Growth velocity in children 1
Response assessment:
- Complete response: return of serum creatinine to baseline and UPCR <500-700 mg/g
- Partial response: stabilization or improvement of serum creatinine but UPCR still >500-700 mg/g 1
Important Caveats
Renal biopsy may be necessary to confirm underlying disease or identify idiopathic disease likely to respond to corticosteroids 2, 3
Avoid routine prophylactic antibiotics and prophylactic anticoagulation without specific indications 2, 3
Intravenous albumin is not routinely recommended 2
Consult nephrology for guidance on immunosuppressive therapy, anticoagulation, and need for renal biopsy 3
Monitor for adverse effects of corticosteroids, particularly in pediatric and elderly patients 5, 4