Nephrotic Syndrome in Children

Explanation

This is classic idiopathic nephrotic syndrome of childhood, almost certainly minimal change disease given the age of 1 to 10 years, absent hematuria, normal blood pressure, normal renal function, and normal complement. Corticosteroids are the definitive treatment and the most effective way to abolish proteinuria: about 80 to 90 percent of children achieve complete remission, typically within 2 to 4 weeks of starting oral prednisolone at 60 mg/m2 per day (maximum 60 mg) for 4 to 6 weeks followed by alternate-day tapering. Steroids act on the podocyte and on T-cell mediated permeability factors to restore the glomerular filtration barrier, which removes the cause of proteinuria rather than merely mitigating its consequences. Because the presentation is typical, renal biopsy is not required before starting steroids and is reserved for age under 1 year or over 12 years, macroscopic hematuria, hypertension, low complement, impaired renal function, or steroid resistance after 4 to 6 weeks of adequate therapy. Furosemide only removes salt and water and can precipitate hypovolemia and thrombosis in a child with a serum albumin of 17 g/L, so it is used cautiously and only for symptomatic edema. ACE inhibitors reduce intraglomerular pressure and lower proteinuria by perhaps 30 to 40 percent and are valuable in steroid-resistant disease or chronic proteinuric kidney disease, but they are not first-line for a new steroid-sensitive presentation and carry a risk of hyperkalemia and acute kidney injury in hypovolemia. Intravenous albumin is a temporary measure for symptomatic hypovolemia or severe refractory edema and produces no lasting reduction in protein loss. Key complications to anticipate are pneumococcal peritonitis, venous thromboembolism from urinary antithrombin loss, and hypovolemic acute kidney injury.

Why each option

A.

Furosemide treats edema only and can worsen intravascular volume depletion and thrombotic risk without reducing protein loss.

B.

Correct. Oral corticosteroids induce complete remission of proteinuria in 80 to 90 percent of children with idiopathic nephrotic syndrome.

C.

ACE inhibitors give a modest antiproteinuric effect and are used in steroid-resistant disease, not as initial therapy for a typical presentation.

D.

Albumin infusion transiently expands plasma volume for severe symptomatic edema and does not alter urinary protein excretion.

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