First Episode Nephrotic Syndrome

1. Nephrotic syndrome is diagnosed in patients with significant edema, nephrotic range proteinuria (dipstix 3+/4+ proteinuria; spot protein to creatinine ratio >2.0 mg/mg) and hypoalbuminemia (<2.5 g/dl). Blood levels of creatinine are normal; persistent hematuria and hypertension is unusual.
2. Infections, if present, are treated before initiating therapy with corticosteroids. Patients who show a positive tuberculin test, but no evidence of systemic tuberculosis, should receive prophylaxis with INH for six months.
3. The first episode is treated with prednisolone at a dose of 2 mg/kg per day (maximum 60 mg in one or divided doses) for 6 weeks, followed by 1.5 mg/kg (maximum 40 mg) on alternate days as single morning dose for next 6 weeks. Therapy beyond 12-weeks results in steroid toxicity, without benefit on long-term course of the illness.
4. Parents should monitor urine protein at home (dipstick, boiling method). Most patients do not require therapy with antacids, acid blockers or calcium supplements. Prednisolone is best given after food.
5. After starting treatment, patient is evaluated at 2-4 weeks for remission (urine protein negative, trace for 3 consecutive days). Failure of remission despite 4-weeks' prednisolone therapy suggests the presence of steroid resistance. Such patients must be referred to specialists for further management.

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