What discharge advice should be given to a nephrotic syndrome patient on high‑dose prednisone, furosemide, lisinopril, and atorvastatin, with low serum albumin (<2.5 g/dL) and prolonged steroid use (>4 weeks)?

Discharge Advice for Nephrotic Syndrome

Patients with nephrotic syndrome on high-dose prednisone, furosemide, lisinopril, and atorvastatin require comprehensive discharge counseling focused on medication adherence, monitoring for complications—particularly thromboembolism when albumin <2.5 g/dL—and recognition of steroid-related adverse effects.

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Medication Management

Prednisone (High-Dose Steroid Therapy)

• Never abruptly discontinue prednisone after >4 weeks of therapy, as this can precipitate adrenal crisis 1
• Take prednisone as a single morning dose to minimize insomnia and mimic physiologic cortisol rhythm 1
• Continue high-dose therapy until complete remission or for a maximum of 16 weeks, whichever comes first 1
• Expect gradual tapering by 5 mg every 1-2 weeks over 6 months once remission is achieved 1

Common steroid side effects to monitor:

• Hyperglycemia: Check fasting glucose weekly during high-dose phase; report values >126 mg/dL 1
• Mood changes, insomnia, increased appetite, and weight gain 1
• Increased infection risk: Avoid live vaccines and report fever >38°C immediately 1
• Bone loss: Ensure calcium 1200-1500 mg/day and vitamin D supplementation 1
• Gastric irritation: Take with food; report black stools or epigastric pain 1

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Diuretic Therapy (Furosemide)

• Take furosemide in the morning (or twice daily if prescribed) to avoid nocturnal urination 1
• Weigh yourself daily at the same time (after voiding, before breakfast); report weight gain >2 kg in 3 days 1
• Restrict dietary sodium to <2.0 g/day (<90 mmol/day) to enhance diuretic efficacy 1
• Monitor for signs of volume depletion: dizziness upon standing, decreased urine output, or excessive thirst 1
• Do not increase furosemide dose without physician guidance, as excessive diuresis can precipitate acute kidney injury 1

Electrolyte monitoring:

• Hypokalemia risk: Report muscle cramps, weakness, or palpitations 1
• Hyponatremia risk: Report confusion, nausea, or headache 1

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ACE Inhibitor Therapy (Lisinopril)

• Continue lisinopril even if serum creatinine increases up to 30% from baseline, as this represents hemodynamic adaptation 1
• Stop lisinopril immediately and contact your physician if you develop: 1
  • Angioedema (facial, tongue, or throat swelling)
  • Persistent dry cough interfering with daily activities
  • Serum creatinine increase >30% or refractory hyperkalemia (K+ >5.5 mEq/L)
• Avoid NSAIDs (ibuprofen, naproxen) and potassium supplements unless specifically prescribed, as these increase hyperkalemia risk 1
• Do not abruptly stop lisinopril during acute illness with vomiting or diarrhea; contact your physician for guidance on temporary discontinuation 1

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Statin Therapy (Atorvastatin)

• Take atorvastatin at bedtime for optimal cholesterol synthesis inhibition 2
• Hyperlipidemia in nephrotic syndrome increases cardiovascular risk fourfold; statin therapy is essential even if cholesterol normalizes with disease remission 1, 2
• Report unexplained muscle pain, weakness, or dark urine (signs of rhabdomyolysis) 2
• Avoid grapefruit juice, which increases atorvastatin levels and toxicity risk 2

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Critical Complication Monitoring

Thromboembolism Risk (HIGHEST PRIORITY with albumin <2.5 g/dL)

Your serum albumin <2.5 g/dL places you at 29% risk for renal vein thrombosis and 17-28% risk for pulmonary embolism 1

Seek immediate emergency care for:

• Sudden shortness of breath, chest pain, or hemoptysis (pulmonary embolism) 1
• Unilateral leg swelling, pain, or warmth (deep vein thrombosis) 1
• Sudden flank pain or gross hematuria (renal vein thrombosis) 1

Additional thrombosis risk factors to report:

• Prolonged immobilization (>4 hours of travel, bed rest) 3, 4
• Planned surgery or procedures 3, 4
• New diagnosis of atrial fibrillation or heart failure 3, 4

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Infection Risk

• Nephrotic syndrome increases susceptibility to bacterial infections, particularly cellulitis and spontaneous bacterial peritonitis 1
• Report immediately: Fever >38°C, abdominal pain with distension, spreading skin redness, or purulent drainage 1
• Ensure pneumococcal vaccination is up to date (discuss with physician before discharge) 1

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Acute Kidney Injury Warning Signs

• Contact your physician if: 1
  • Urine output decreases to <500 mL/day
  • Urine becomes dark, tea-colored, or bloody
  • Severe nausea/vomiting prevents medication intake
  • Progressive leg swelling despite diuretics

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Dietary and Lifestyle Modifications

• Sodium restriction <2.0 g/day is mandatory; avoid processed foods, canned soups, deli meats, and restaurant meals 1
• Maintain adequate protein intake (0.8-1.0 g/kg/day) unless otherwise instructed; excessive protein does not compensate for urinary losses 1, 5
• Avoid alcohol while on high-dose prednisone due to increased gastritis and hyperglycemia risk 1
• Elevate legs when sitting to reduce peripheral edema 1

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Follow-Up and Monitoring Schedule

First 2-4 Months (Active Treatment Phase)

• Laboratory monitoring every 2-4 weeks: 1, 3
  • Serum creatinine, BUN, electrolytes (Na+, K+, CO2)
  • Serum albumin
  • First-morning urine protein-to-creatinine ratio (UPCR)
  • Fasting glucose (while on high-dose prednisone)

After 4 Months (Maintenance Phase)

• Laboratory monitoring every 3-6 months if stable 3
• Continue monitoring for disease activity and treatment complications 3

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Medication Adherence and Tapering

• Do not adjust or discontinue any medications without physician guidance, even if edema resolves or you feel well 1
• Premature steroid discontinuation increases relapse risk to >50% within 6 months 1
• Proteinuria reduction is the primary treatment goal; complete remission (proteinuria <0.2 g/day) predicts long-term kidney survival 1

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When to Contact Your Physician Urgently

• Fever >38°C or signs of infection 1
• Sudden shortness of breath, chest pain, or leg swelling 1
• Severe headache, visual changes, or blood pressure >180/110 mmHg 1
• Persistent nausea/vomiting preventing medication intake 1
• Dark urine, decreased urine output, or flank pain 1
• Mood changes, confusion, or suicidal ideation (steroid-induced psychiatric effects) 1

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Prognosis and Long-Term Outlook

• Patients with proteinuria >3.8 g/day have a 35% risk of end-stage renal disease within 2 years if untreated, compared to 4% risk with proteinuria <2.0 g/day 1
• Achieving complete or partial remission significantly improves renal survival and reduces cardiovascular complications 1
• Prolonged steroid therapy (>4 weeks) requires gradual tapering over 6 months to prevent adrenal insufficiency 1