Nephrotic syndrome: complications and follow-up
Complications are 2o to the relative hypovolaemic
state and to impaired immunity.
Predisposition to infection is 2o
to decreased IgG levels, and to impaired opsonization due to steroid
immunosuppression. Bacterial peritonitis (especially Streptococcus pneumoniae) is an important complication and should
be considered in any child with nephrotic syndrome who com-plains of abdominal
pain. Urgent assessment, cultures, and IV antibiotic therapy are required.
Nephrotic syndrome produces a
hypercoagulable state and predisposition to both arterial and venous thrombosis
is recognized.
Suggested by development of
oliguria and or presence of low BP. Patients may also complain of abdominal
pain. If present, administration of an in-fusion of 20% human albumin solution
1g/kg over 2hr with furosemide (2mg/kg IV) should be given.
This
is pre-renal and 2o to hypovolaemia.
The majority of patients will have
MCD and will respond to steroids.
Biopsy is therefore reserved for
those with atypical features:
· Age <12mths or >12yrs.
·
Increased
BP.
·
Macroscopic
haematuria.
·
Impaired
renal function.
·
Decreased
C3/C4.
· Failure to respond after 1mth of
daily steroid therapy.
·
30%
single relapse.
·
30%
occasional relapses.
·
30%
steroid dependence.
·
Many
patients with steroid-sensitive nephrotic syndrome will relapse. A relapse is
defined as detection of urine dipstick ++ proteinuria for >3 days.
·
Frequent
relapse is defined as >2 relapses within 6mths of initial response or 4 or
more relapses in any 12mths.
Each relapse is treated with oral
steroids in a similar manner to above. Alternative strategies for frequent
relapsers include a trial of therapy with other agents such as:
·Cyclophosphamide.
·Levamisole.
·Ciclosporin A.
·Other agents including the
immunosuppressants tacrolimus, mycophenolate mofetil and anti-CD20 monoclonal
antibody (rituximab) may be considered.
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