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Q. How do you monitor the patient?

A. Since the total course of prednisolone is for 2-3 months, weekly examination of urine to detect its effect on protein loss is important. Once the protein loss is controlled, once every 2-4 weeks the urine test should be done to diagnose recurrence of the disease or relapse which is diagnosed by reappearance of 3+ to 4+ proteins in urine. B.P.record, weight of the child, urine output also should be checked periodically.

Q. What precautions does the patient take?

A. The main precautions to be taken are avoidance of infection because infections are known to cause relapses and in severe cases death. Boiling the drinking water, avoiding contact with patients with infections like chickenpox, jaundice, typhoid etc. and giving vaccinations against the above mentioned diseases are important steps to prevent infections in NS. There is increased risk of complications in a child with NS due to infections which may be mild in healthy children.

Q. What are the chances of recurrence?

A. Chances of recurrence or relapse of NS is as high as 50-75% in a Nephrotic child.

Q. What to do in case of a relapse ?

A. In case of relapse the first step is contact your doctor to treat the infection which might be responsible for the relapse.

Q. How do you treat a relapse?

A. Then again oral prednisolone therapy may be needed. The duration of course of prednisolone therapy for relapse is shorter (6-8 weeks).

Q. When do you start steroids in a relapse?

A. If a child has proteinuria of 2+ or more for 2-3 weeks even if there is no swelling or edema it is safer to start steroids rather than wait, because all the complications of NS are related to edema.

Q. When is a kidney biopsy required?

A. If the patient does not respond to oral prednisolone therapy within the prescribed time a kidney biopsy is a must.

Q. What is the role of levamisole & when do you start & how to give?

A. Levamisole is a drug, which is useful if NS relapses frequently i.e. more than 3 relapses within 1 year or patient relapses while on steroids i.e. Steroid dependent NS. Levamisole can control proteinuria, which is reduced by steroids sparing effect so that fewer doses of steroids is needed and in some cases steroids can be omitted.

Levamisole is started when prednisolone has produced remission (ie. urine albumin shows nil or trace for 3 days consecutively). The dose recommended is 2.5 mg/kg on alternate day for 6-18 months with tapering dose of steroids. It is to be given after dinner at bedtime.

Q. What is the role of Enalapril in NS?

A. Tab. Enalapril is used to reduce proteinuria in selected cases of NS with infections like hepatitis, peritonitis etc. in whom steroids are contraindicated.

Q. If the child is Hbs Ag+ve do you give steroids? What is the treatment?

A. With HbsAg +ve, steroids are not indicated and may be harmful. Tab.Enalapril can be tried in such cases.