Nephrotic Syndrome (Childhood Nephrosis)
This handout has been written to help you learn about nephrotic syndrome and how to take care of your child at home. If you have any questions, please be sure to ask your doctor or nurse. Our staff is here to help you.
What do the kidneys do?
The kidneys are two fist-sized organs found in the lower back. When they are working well, they clean the blood, and rid the body of waste products, excess salt, and water. When diseased, the kidneys may leak red blood cells and protein into the urine. Blood and protein are usually not found in the urine of a person whose kidneys are healthy and working well.
What is nephrotic syndrome?
This is an illness where proteins leak through the kidney into the urine. These proteins would normally stay in the blood where they work to keep fluids from leaking into the nearby body tissues. As time goes by, if the protein losses in the urine are greater than the body can keep up with, the blood protein levels will drop and fluid will then leak out of the blood vessels into the tissues. This leads to swelling which is most often seen in the eyelids in the mornings. It may also be seen in the feet and legs, hands, face, belly or scrotum. While your child has nephrotic syndrome, he will not pass urine as often as he normally does, and the urine will look very concentrated (dark yellow).
It is often young children between the ages of 18 months and 5 years that develop this illness. Although a person at any age can get this, it happens twice as often in boys than in girls. The most common cause in this age range is Minimal Change Nephrotic Syndrome (MCNS). Children with MCNS tend to respond well to treatment and, in the long run, do very well. There are other kidney diseases that cause nephrotic syndrome. If your child does not respond to our early treatments, we may need to look further to make a diagnosis. This can be a serious chronic disease that will need special attention over the years. Despite this, many children outgrow this illness over time with no lasting harm to the kidneys.
What is the treatment?
It is not known what causes nephrotic syndrome or how long your child may have the illness. It may be a problem with your child's immune system. This problem only affects the kidneys. Therefore, your child will not be more likely to get infections.
Our goal with treatment is to try to control the swelling and to stop the leakage of protein in the urine.
The best way for you to try to control your child's swelling is to limit the amount of salt she eats and drinks. Even normal amounts of salt will cause the body to retain fluid. A dietitian will work with you to help plan a low-salt diet for your child and explain how to reduce salt in the diet. This is a very important part of the treatment. You should never attempt to restrict your child's fluid intake. Her swelling is not affected by the amount of fluids taken in, but rather by salt intake.
Patients are given corticosteroids. The most common form is prednisone. In nephrotic syndrome, prednisone is usually given when:
- a large amount of protein is present in the urine
- swelling is present
- the patient gains weight
Prednisone is similar to a hormone produced in the body. It is a very strong medicine that has a number of side effects. Some of these side effects are:
- increased appetite
- acne (pimples) in teens on the face, back and shoulders
- mood swings
- increased risk of infection
- upset stomach, increased stomach acid
For children who are taking prednisone for a long time (months), there are more side effects to watch for such as:
- slowing of the growth rate
- cataracts (all children taking prednisone for long periods should have their eyes carefully checked once a year)
- weakening of the bones (osteoporosis)
- hip and knee problems
- severe headaches
- high blood pressure
- increased risk of infection
Some children who have this illness are at risk of forming blood clots during the time they are in relapse. Your doctor may have your child take a daily baby aspirin. This will help prevent any clots from forming. Taking the baby aspirin is only needed while your child is in relapse. While your child is taking the aspirin, if he gets a viral illness, especially chicken pox, you should stop the aspirin. If your child has not had either chicken pox or the chicken pox vaccine and he has contact with someone with chicken pox while he is taking prednisone, please call your doctor right away. If your child has severe pain in an arm or leg, uneven swelling of an arm or leg, or changes in the color or temperature of an arm or leg, you should also call your doctor right away.
Children who have this illness are at risk for certain infections while they are in relapse. Two of these are peritonitis (infection in the abdomen) and sepsis (infection in the blood stream). We can lower the risks by giving your child a vaccination called Pneumovax, and by prescribing penicillin to be taken twice a day while in relapse. If your child develops a fever or belly pain while nephrotic, you should call your doctor right away. These can be signs of life-threatening illness, and your child's condition can get worse quickly.
Sometimes, we will prescribe a diuretic "water pill" for your child to help control the swelling. These pills can be hard to use safely in children with nephrotic syndrome, so we do not use them often.
Monitoring In order to keep track of the amount of protein in your child's urine and her response to treatment, we will ask you to test her urine at home using urine dipsticks. We will teach you how to perform and record the results of this test. Your child's response to prednisone is very important in helping the doctor adjust the dose. We will ask you to record the results on the sheets we have given you.
A remission is a response to treatment with a decrease in the protein in the urine. A remission is defined as your child's urine is trace or negative for protein for three days in a row.
A relapse is when protein returns to your child's urine. It is sometimes hard for you to know when your child is having a relapse. It is safest to call our office when your child's urine protein is greater than trace to discuss further treatment.
Treatment does not cure this illness. It only treats the symptoms. Most children (80%) will have a return of protein in their urine and this is called a relapse. Relapse can occur:
- if your child has an infection
- if the prednisone is not taken as prescribed
- for unknown reasons
How will you know if your child is having a relapse?
1. Weigh your child at least once a month to have an idea of what his normal weight is. Record the weight on the attached sheets.
2. Watch for signs of swelling
- sudden weight gain
- swelling around the eyes--most often seen in the morning
- ankle swelling--often seen before bedtime after the child has been up all day
- swelling in the legs, hands, belly, and genitalia
3. Routine monitoring of the urine
You should check your child's urine for protein at least once a week even when in a long remission. The reason for monitoring is to "catch" a relapse early before swelling occurs. If you are not checking the urine and your child has a relapse, the only way for you to be aware of this is when he becomes swollen. Once swelling occurs, it becomes much harder to get rid of the excess fluid that your child's body is retaining. It is much easier to care for your child if you are aware of the relapse early, and tell us before the swelling happens. If your child develops a viral illness, you should check the urine more often since an infection can trigger a relapse.
What to do when your child has swelling and protein in the urine?
1. Follow a salt-restricted diet. If you have any questions or concerns about the diet once you are home, feel free to call the outpatient dietitian, Fran Kittel, RD, MS at (608) 270-5609.
2. Give medicine as prescribed, and keep track on the record sheets included at the back of this handout.
3. Weigh your child at the same time each day. Record the weight on the record sheet. Continue to weigh your child every day, and watch for a sudden increase in weight.
4. We suggest that you test the urine for protein once a day while symptoms are present. It is best to check in the morning. Record the results of the test on the attached sheet.
5. Protect skin: Swelling not only puts excess pressure on the skin, but will also make the skin look shiny and stretched. As a result, the skin is fragile and can easily break open. To protect the skin:
- Avoid constant pressure on swollen areas. For example: do not sit or lie in one position for a long time.
- Avoid tight clothing, especially tight elastic around ankles and wrists.
- Remove watches, rings, belts, or other items that could constrict the skin.
- For boys, briefs are the preferred underwear because they give more support than loose fitting boxer shorts.
6. Watch for swelling, redness and any infections, such as a cold, ear infection, etc. If swelling or infections occur, call your local doctor. If your doctor does not find an obvious cause for the fever or other complaints, call the pediatric renal clinic at (608) 265-6020.
Does this disease ever go away?
Children who have MCNS may have different outcomes after their first treatment. Roughly 1/3 will never have a return of their illness (a relapse). Another one third will have a relapse of their illness a few times a year. Sadly, the other 1/3 will have frequent relapses. They will need prolonged use of prednisone to keep their illness in remission. This group of children is the most challenging to care for. Many children no longer relapse once they enter puberty.
Regardless of which pattern your child develops, it is important to treat your child like a normal child. Your child needs to have a routine, such as going to school and seeing friends.
Can my child receive immunizations?
While your child is nephrotic and taking prednisone, it is best to avoid immunizations. All live vaccines such as varicella (chickenpox), MMR and oral polio must be avoided since your child's immune system is suppressed by the prednisone. She would be at risk of getting an infection from the vaccine. Also, it is best to avoid even killed, inactive vaccines, since the prednisone would most likely affect your child's ability to respond to these vaccines. You should wait until your child is in remission and off prednisone for at least 2-4 weeks before she receives any immunizations.
The information provided should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed physician should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Any duplication or distribution of the information contained herein is strictly prohibited.
Last Updated: 07/26/2011
Copyright © 07/26/2011 University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing. HF#4327
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