Nephrotic Syndrome: Relapse

Evaluation and management of patients with relapse of previously diagnosed nephrotic syndrome (NS)

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Definition of relapse

Steroids per KDIGO guidelines:
- Prednisone 2 mg/kg/day (or 60 mg/m²/day, max of 60 mg/day) until dipping negative/trace x3 days in a row, then
  - OK to divide into two doses
- 1.5 mg/kg/day (or 40 mg/m²/day, max of 50 mg/day) every other day for 4 weeks
  - Do not divide; give as a single daily dose to reduce steroid side effects and risk of adrenal insufficiency
- Also prescribe H2 blocker as steroid gastritis prophylaxis
Dietary/fluid restrictions:
- 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

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

[[When indicated?]]

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