Paediatric Acute care Guidelines PMH Emergency Department

Background

Nephrotic Syndrome is characterised by: 

  • Oedema (patients generally present with this complaint)
  • Significant proteinuria (> 3+) on dipsticks or urine protein:creatinine ratio >200 mg/mmol)
  • Hypoalbuminaemia (<25g/L)
  • Hypercholesterolaemia

The majority (> 80%) respond to steroid treatment and are assumed to have minimal change in histology, with a good long term prognosis (though relapses are common)

Assessment

Clinical considerations:

  • There is often a history of weight gain and reduced urine output
  • Upper respiratory tract infection or diarrhoea may be precipitating causes
  • Look for peri-orbital, scrotal or labial oedema as well as peripheral oedema of the limbs and sacrum

Investigations 

  • Urinalysis
  • Urine – MC+S
  • UEC, LFT, Cholesterol
  • Streptococcal serology, complement levels (C3, C4) and ANF
  • Blood cultures if febrile or septic  

Management

  • Steroids: A number of regimens are advocated. These usually begin with prednisolone given daily or in divided doses at 60 mg/m2 (max. 80mg/day) of body surface area at least until remission (typically 1-2 weeks) calculated on ideal weight for height. (BSA formula is on PMH growth charts).
    • The starting dose usually approximates 2mg/kg/day (based on estimated non-oedematous weight)
  • Antibiotic prophylaxis (oral Cephalexin, penicillin or IV equivalents) while oedematous and taking daily steroids is generally recommended
  • Consider hospital admission for first attack, and in complicated relapses (e.g. gross oedema, hypertension, hypovolaemia, infection)
  • Strict fluid balance 
  • Daily weights
  • Daily urinalysis and/or urine protein:creatinine ratio
  • No added salt (but otherwise normal) diet without fluid restriction (at least initially)
  • IV albumin is indicated for hypovolaemia as evidenced by:
    • Anuria
    • Hypotension
    • Poor perfusion with skin mottling or poor capillary return, often with abdominal pain 
    • A urinary sodium of < 10 mmol/l is a useful investigation to confirm hypovolaemia
    • A low serum albumin alone is not an indication for intravenous albumin 
  • Give albumin only after discussion with the ED or Inpatient Consultant

Evidence of Hypovolaemia

  • Give 1 g/kg 20% albumin (5ml/kg) over 4-6 hours
  • Provided perfusion improves, give 1-2mg/kg of IV Frusemide mid-infusion
  • Beware of hypertension and pulmonary oedema

If clinically Shocked 

  • Consider 10ml/kg 4.5% albumin
  • Gross genital oedema may also be an indication, but infrequently in the ED setting
  • Frusemide 1-2 mg/kg IV should be considered mid infusion

References

External Review: Frank Willis (Consultant – Department of Nephrology): July 2015

We want your feedback!

Help us provide guidelines that are useful to you, the clinician.

Give feedback here