Diagnosis of relapse:

After completion of the treatment of first episode, weekly urine examination for proteinuria is advised for 1 month and subsequently every 2-4 weekly or whenever edema recurs. If urine shows proteinuria of 3+ to 4+ in 3-4 urine examinations in a week, a relapse is diagnosed. Many relapses occur with infections.

Treatment of relapse :

Look for focus of infection (throat, skin, urine etc) and treat with appropriate antibiotics e.g. Amoxycillin, Cephalexin etc for 6-7 days.

After 1 week if urine shows 3+/4+ protein after the infection is controlled, steroid therapy should be started as oral prednisolone 2mg/kg/day in 2 - 3 divided doses till 3 consecutive urine samples show absent or trace proteinuria, after which the dose of prednisolone is reduced to 1.5mg/kg as a single dose on alternate day for 4 weeks. If urine is cleared of proteins, steroid therapy is stopped.

If urine protein shows less than 2+ after control of infection, steroids should be withheld and child should be kept under close observation to detect presence of edema and proteinuria for next 2-3 weeks during which either proteinuria clears or increases to 3+ to 4 requiring steroids therapy for relapse.

Each relapse should be treated as above. If more than 2 relapse occur within 6 months after initial therapy, the child is diagnosed as frequent relapser.

The treatment of frequent relapsers or steroid dependent (relapse occurring while tapering steroids or within 2 weeks of stopping steroids) cases should be done by experienced pediatric nephrologist because this includes need for prolonged steroid therapy which is fraught with severe side effects; use of cytotoxic drugs like cyclophosphamide or chlorambucil and newer immunomodulatory drugs like levamisole or cyclosporin A. Severe life threatening infections like peritonitis, septicemia, meningitis etc. occur in frequent relapses.

All through the course of steroid therapy, the primary pediatrician should advise the parents as regards diet (salt restriction in edematous state, no need to increase protein in the diet), prevention of infections and immunizations (Chickenpox; Hib and pneumococcal vaccine are given 4 - 6 weeks after completion of steroid therapy; DPT can be given while tapering prednisolone dose but oral polio vaccine is given after stopping steroids for 1 - 2 months).

Even when the child is in remission i.e. no proteinuria regular follow up once every 4 - 12 weeks is required for at least 1 - 5 years before a child with nephrotic syndrome is said to be well controlled.

Good response to steroids is the best marker of good outcome and 75 - 80% nephrotic children with onset between 2 - 7 years respond to oral prednisolone therapy, do not require kidney biopsy (because minimal change N.S. is the commonest histologic diagnosis in this age group), continue to have renal function, normal B.P. and good quality of life.

Last created on 22-01-2002
Last updated on 01-07-2006