Nephrotic Syndrome: New-Onset

• CMP

  • Evaluate for severe hypoalbuminemia, electrolyte derangements

• CBC

  • More data to evaluate degree of hemoconcentration

• Other potential causes of glomerular disease (if risk factors):

  • Syphilis, HIV, hepatitis B (HBV), and hepatitis C (HCV)

Indications for kidney biopsy

• Steroid resistance

• Impaired kidney function with normal volume status

• Macroscopic hematuria

• Persistent microscopic hematuria in setting of hypertension

• Onset <6 months of age

• Low C3

• Elevated ANA screen

• If patient is at high risk for latent tuberculosis, send QuantiFERON-TB Gold or place PPD before starting steroids

• Steroids per KDIGO guidelines:

  • Prednisone 2 mg/kg/day (or 60 mg/m²/day, max of 60 mg/day) daily for 6 weeks, then

    • OK to divide into two doses

  • 1.5 mg/kg/dose (or 40 mg/m²/dose, max of 50 mg/dose) every other day for 6 weeks

    • Do not divide; give as a single daily dose (if able to tolerate) to reduce steroid side effects and risk of adrenal insufficiency

  • Also prescribe H2 blocker as gastritis prophylaxis

• Dietary/fluid restrictions (until in remission):

  • Fluid restrict: 1 L/m²/day

  • Low sodium diet (2 grams Na/day)

    • Won't be able to adhere fluid restriction without Na restriction

  • Continue restrictions until in remission and edema improved

• Teaching by nephrology RNs if applicable

• Ensure vaccinations are up to date

Indications for hospitalization

• Significant hemoconcentration

• Significant AKI

• Poor enteral intake

• Concern for sepsis

• Social factors (e.g., need for patient/family education)

• If diagnosis other than minimal change disease is suspected, admission is often necessary for additional evaluation and management

• Consider using IV methylprednisolone in lieu of PO steroids, given the potential for gut edema and poor absorption of PO prednisone

• If albumin ≥2, generally try Lasix (furosemide) without albumin to see if responsive before using combination

• If albumin <2, consider Albumin + Lasix in combination:

  • 0.5-1 g/kg IV 25% albumin (rounded to increment of 12.5 g) over 8 hours

  • 0.5-1 mg/kg IV Lasix at 4 hours and again at 8 hours

  • Prefer to do during daytime - at least initially - in case of complication (i.e., flash pulmonary edema)

  • Repeat PRN based on exam and weight