CHP. 22. Nephrotic Syndrome 167.
Treatment
In nephrotic syndrome the goals of treatment are to relieve symptoms,
correct urinary loss of protein, prevent and treat complications and
protect the kidney. Treatment of this disease usually lasts for a long
period (years).
1. Dietary advice
The dietary advice/restriction for a patient with swelling differs once the
swelling disappears with effective treatment.
- In a patient with swelling:Restriction of dietary salt and avoidance
of table salt as well as foods that are high in sodium content, so as to
prevent fluid accumulation and edema. Restriction of fluid is usually
not required.
Patients receiving high doses of daily steroids should restrict salt
intake even in the absence of swelling to decrease the risk of
developing hypertension.
For patients with swelling, adequate amounts of proteins should be
provided to replace the urine protein loss and prevent malnutrition.An adequate amount of calories and vitamins should also be provided
to these patients.
- In symptom- free patients:The dietary advice during the symptom-
free period is a normal healthy diet. Unnecessary dietary restrictions
should be avoided. Avoid restriction of salt and fluid. Provide an
adequate amount of proteins. Avoid moderately high protein diets
to prevent kidney damage and restrict protein intake in the presence
of kidney failure. Increase intake of fruits and vegetables. Reduce
the intake of fat in diet to control blood cholesterol levels.
In patients with swelling, salt restriction is necessary but during
symptom-free period avoid unnecessary dietary restrictions.
2. Drug therapy
A. Specific drug treatment
- Steroid therapy: Prednisolone (steroid) is the standard treatment
for inducing remission in nephrotic syndrome. Most children respond
to this drug. Swelling and protein in the urine disappear within 1-4
weeks (urine free of protein is labeled as a remission).
- Alternate therapy:A small group of children who do not respond
to steroid treatment and continue to lose protein in their urine need
further investigation such as a kidney biopsy. Alternate drugs used in
such patients are levamisole, cyclophosphamide, cyclosporin,
tacrolimus and mycophenylate mofetil (MMF). These alternate drugs
are used along with steroid therapy and help to maintain remission
when the dose of steroid is tapered.
B. Supportive drug treatment
- Diuretic drugs to increase urine output and reduce swelling. They
should be used only under supervision by a doctor as excessive use
may cause kidney failure.
- Antihypertensive drugs such as ACE inhibitors and angiotensin II
receptor blockers to control blood pressure and to reduce the urinary
loss of protein.
- Antibiotics to treat infections (e.g. bacterial sepsis, peritonitis,
pneumonia).
- Statins (simvastatin, atorvastatin, rosuvastatin) to reduce cholesterol
and triglycerides and prevent the risk of heart and blood vessel
problems.
- Supplement calcium, vitamin D and zinc.
- Rabeprazole, pantoprazole, omeprazole or ranitidine for protection
against steroid induced stomach irritation.
- Albumin infusions are generally not used because their effects last
only transiently.
- Blood thinners such as warfarin (Coumadin) or heparin, may be
required to treat or prevent clot formation.
3. Treatment of underlying causes
Meticulous treatment of underlying causes of secondary nephrotic
syndrome such as diabetic kidney disease, lupus kidney disease,
amyloidosis etc. is important. Proper treatment of these disorders is
necessary to control nephrotic syndrome.
Prednisolone (steroid) is the standard first
line treatment of nephrotic syndrome.