Nephrotic syndrome is a primary
glomerular disease characterized by
proteinuria, hypoproteinemic edema and
hyperlipidemia. Because of gross
proteinuria serum albumin is low ( <2.5
1. Idiopathic NS:
In childhood, the vast majority belongs to
category it is regarded as a sort of autoimmune
phenomenon, especially since it responds well to
immunosuppressive therapy. It is two types:
a. Minimal change NS – this predominant
type, seen 86% of the cases.
b. Significant change NS – this is infrequent.
Mesangial proliferation is seen in 5% cases and
focal sclerosis in 10% of cases.
2. Secondary NS:
• It occurs in children (about 10%) of all
• This condition may occur due to some
form of chronic glomerulonephritis, or due to
diabetes mellitus, SLE, malaria, malignant
hypertension, hepatitis B, infective
endocarditic, HIV/AIDS, drug toxicity,
lymphomas syphilis etc.
3. Congenital NS:
• It is rare but a serious and fetal problem
usually associated with other congenital
anomalies of kidney.
• It is inherited as autosomal recessive
• Severe renal insufficiency & urinary
infections along with this condition result is
4. Infantile NS:
• The term is applied to NS occurring in
infants between 4 – 12months of age. Its
major causes are:
B. Diffuse mesengial sclerosis (DMS)
Alteration in glomerular basement
Decreased colloidal osmotic
Increased loss of protein in urine
Altered glomerular protein
Increased secretion of aldosterone
Tubular Na and
Four main symptoms of nephritic
• Protein urea
• SOB (Shortness of
• Mild headache
• Fever, rash, joint
• Weight gain
• Periorbital edema
• Anemia due to loss
• Flank pain
o PALPATION: Due to edema and ascites kidney cannot
o Urine analysis
24 hour urinary total protein estimation – urine
sample shows proteinuria (>3.5 g per liter per 24 hours)
o Blood test
Lipid profile shows high level of S. cholesterol-
• The goal of medical management is reduction
of protein excretion.
• If causative agent is streptococcal then treated
with penicillin antibiotics.
• Prednisolone is the drug of choice.
Daily dose of 2mg/kg/day orally in divided doses
for 6 weeks is given,
• Thereafter 1.5 mg/kg as single dose on
alternate days for 6 weeks, after which
treatment is discontinued.
• Proteinuria disappears within the first
week of therapy and negative dipstick test
for 2 consecutive days shows positive
response to treatment.
• Frequent relapses are treated by alkylating
agents such as cyclophosphamide (2 mg/kg
daily for 12 weeks), nitrogen mustard,
cyclosporine or levamisole.
• Diuretic and salt poor albumin may be
indicated in presence of severe edema.
• Frusamide (1-44 mg/kg/day in 2 divided
doses) may be prescribed.
• Children should take a well-balanced diet
rich in protein. Sodium is restricted when
marked edema is present.
• Provide high protein and high
carbohydrates diet to patient.
• If disease in advance stage then avoid
protein intake because it is affected to kidney.
• Water restriction may be indicated if
decreasing salt intake does not control edema.
• Risk for infection related to immunosuppressive
• Fluid and electrolyte imbalanced related to
• Impaired skin integrity related to disease
• Altered nutrition related to Anorexia.
• Altered kidney function related to disease
• Knowledge deficit related to disease process.
Care during hospitalization:
• Child is hospitalized from initial therapy.
Patient may not understand importance of
hospitalization because initially the child is
symptomless. During hospitalization
parents should be involved in child care and
• Nurses should regularly monitor the vital
signs and check the Childs daily weight.
• Monitor signs of infection and edema.
• Detailed chatting of intake/output most be
done to monitor child’s response to medical
• Daily urine examination for albumin is
B. Administer the prescribed medications:
o Children with nephritic syndrome are
receiving steroids so the nurse most be aware
of the side effects of these drugs. Patient
should be observed for gastrointestinal
bleeding, gastro intestinal ulcers,
hyperglycemia and cataract.
o Steroid is continued till the child is
protein free, thereafter the drug dose in
Maintain fluid and electrolyte balance:
• Nurses should monitor serum sodium level
of the child.
• Fluid intake either oral or I/V should be
• Child is assessed for venous stasis, ascites
and pulmonary edema.
• Daily weight of child is accurately
Prevention of infection:
• The child is on corticosteroid therapy
(immunosuppressant) and there is loss
of immunoglobulin in urine, so these
children are the greater risk of infection.
• Strict aseptic technique should be used
during invasive procedures.
• Monitor vital signs for early signs of
• Isolate the child as he is on
• Provide passive play to the child as
tolerated e.g, watching TV, reading story
• Allow a period of rest after activities.
• Limit visitors during acute phase of illness.
Provide emotional support:
• Explain parents about the disease and its
• Allow the patients and child to express their
• Due to sudden weight gain and disturbed body
image, child may manifest with behavioral
changes, may refuse to look at mirror and has
decreased interest in appearance.
• Enhance the body image of the child.
• Encourage child to wear own clothes rather than
hospital clothes as this make the child feel good.
• Explain to patients about treatment
programmed, follow up and risk of relapse.
• Encourage patients to measure child’s
weight weekly in order to identify early
• Tell then to contact doctor if any unusual
• Increase intake of fruits and vegetables. No
potassium and phosphorus restriction in
o Explain about the medications to be continued
at home and their side effects like cushingoid
appearance, gastrointestinal bleeding and sodium
retention. If the child is on corticosteroid therapy for
very long time, fundus checkup should be done
because prednisolone causes cataract.
o Dietary modifications should be explained to
o Ask them to avoid saturated fats such as
butter, cheese, fried foods, and fatty cuts of red meat
and egg yolks and increase unsaturated fat intake
including olive oil, canola oil, peanut butter, and nuts.
The child can eat low fat desserts.