Nephrotic Syndrome in Children ✅

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🧒 Nephrotic syndrome (children) occurs when podocyte injury leads to heavy protein loss in urine 🩸➡️💧. Loss of albumin lowers plasma oncotic pressure → oedema 💧, while effective circulating volume may be low. The liver responds with hyperlipidaemia 🧈, and loss of anticoagulants (e.g., antithrombin) increases thrombosis risk 🩸.

✅ Definition (typical paediatric nephrotic syndrome)

• Generalised oedema 💧
• Nephrotic-range proteinuria: urine PCR >200 mg/mmol 🧪
• Hypoalbuminaemia: albumin <25 g/L ⬇️
• Hyperlipidaemia 🧈 (supportive, not required for diagnosis)

⚠️ Causes (childhood)

• Idiopathic nephrotic syndrome (mostly Minimal Change Disease) ✅
• Secondary: infection, SLE/HSP, drugs, malignancy (less common)
• Other glomerular diseases with nephrotic-range proteinuria ± nephritic features

🧾 Clinical pattern categories

• ✅ Steroid-sensitive (SSNS) – remission with standard prednisolone course (1–4 weeks)
• ♻️ Steroid-dependent (SDNS) – relapse during taper or soon after stopping steroids
• ❌ Steroid-resistant (SRNS) – failure to remit with initial steroid course; specialist pathway/biopsy required

🤒 Symptoms & signs

• Oedema: periorbital 👁️ → generalised (legs, ascites, scrotal/vulval)
• Weight gain ⚖️, lethargy, reduced urine output 🚱
• Frothy urine ☁️ (protein)
• Red flags: abdominal pain, fever, breathlessness, severe headache, cool peripheries 🚨

🔬 Investigations (first presentation)

• Urine: PCR/ACR, dipstick (blood), culture if febrile; microscopy as indicated
• Bloods: U&E/creatinine, albumin, cholesterol, FBC, CRP; LFTs if needed
• Atypical feature screen: complement (C3/C4), ANA, infection screens as indicated
• Renal biopsy: atypical features, steroid resistance, age extremes, systemic features (specialist decision)

🩺 General management (key points)

• Early paediatric nephrology involvement 👩‍⚕️👨‍⚕️
• Salt restriction 🧂⬇️ (effective for oedema)
• Fluid management 💧 – assess intravascular volume carefully
• Diuretics 💊 – specialist-guided only (risk of hypovolaemia/AKI)
• Albumin infusion 💉 – severe/refractory oedema under specialist protocol
• Daily weight ⚖️ and oedema charting
• Avoid NSAIDs 🚫 (renal perfusion risk)

💊 Prednisolone for first presentation (common UK regimen)

• 60 mg/m²/day (max 60–80 mg) for 4 weeks
• 40 mg/m² alternate days for 4 weeks
• Taper: 5–10 mg/m² alternate days weekly over ~4 weeks 📉
• Most SSNS children achieve remission early ✅

🧯 Relapse & escalation

• Relapses are common; management guided by relapse frequency & steroid toxicity
• Frequent relapses / SDNS: steroid-sparing agents (levamisole, cyclophosphamide, calcineurin inhibitors) via nephrology
• SRNS: specialist pathway + biopsy; consider ACEi/ARB for proteinuria reduction

⚠️ Complications to monitor

• Infections 🦠 (pneumococcal, cellulitis, peritonitis)
• Hypovolaemia / shock 🚨 (tachycardia, cool peripheries, abdominal pain, oliguria)
• AKI 🩺 (from hypovolaemia, sepsis, nephrotoxins)
• Thrombosis / VTE 🩸 (abdominal pain, haematuria, chest symptoms, limb swelling)

💉 Vaccines & infection prevention (UK)

• Routine immunisations up to date ✅
• Annual influenza vaccine 🦠➡️💉
• Pneumococcal vaccination/boosters per local pathway 💉
• Check varicella status; manage exposure carefully if immunosuppressed
• Avoid live vaccines during high-dose steroids & shortly after stopping

📚 References

• NHS Greater Glasgow & Clyde (NHS Scotland). Idiopathic nephrotic syndrome: management in children. View guideline
• infoKID (UK paediatric kidney information). Nephrotic syndrome. View infoKID page