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correspondence

Indian Pediatr 2013;50: 1065-1066

How to Treat Inadequately Treated First Episode of Nephrotic Syndrome


Jyoti Sharma

Email: [email protected]


A 2-year-old female child diagnosed as Nephrotic syndrome 1
st episode was put on daily steroid therapy as per IAP guidelines for the steroid sensitive nephrotic syndrome [1]. She went into remission during the first half of 2nd week of daily steroid therapy. Parents complied with the treatment till continuation of daily steroid therapy i.e. 6 weeks. Despite medical advice parents did not put the child on alternate day steroid therapy for the erroneous impression of complete cure of the disease. Within ten days of discontinuing steroids child had recurrence of the disease. On restarting the daily steroids child went into remission during initial 3 days only. As per consensus guidelines shall we treat this child as first relapse of nephrotic syndrome or as the continuation of first episode of nephrotic syndrome? Since the child did not receive alternate day steroids at all, she does not fulfill the criteria of relapse exactly as per IAP consensus guidelines. Type and duration of steroid therapy will vary according to this distinction.

Reference

1. Consensus Statement of Management of Steroid Sensitive Nephrotic Syndrome. Indian Pediatric Nephrology Group, Indian Academy of Pediatrics. Indian Pediatr. 2008;45:203-14.


Reply


The above situation described by the author is an interesting and often faced dilemma in pediatric nephrology practice. Since this child has already received 6 weeks of daily steroids and went into remission, the relapse should be technically treated as the first relapse. Most regimens for treatment of initial episode have recommended 4-6 weeks of daily steroids followed by alternate day therapy for another 6 weeks only, as longer durations predispose to more adverse effects [1,2]. We should treat this episode as first relapse and give the child daily prednisolone (2mg/kg/d) till 3 days of remission and then continue on alternate day (1.5 mg/kg/d) of oral prednisolone for another 4 weeks. This means that the child would receive at least another 5-6 weeks of steroids and she had already missed 6 weeks of alternate day steroids during the treatment of initial episode. Even if we consider this episode as continuum of the initial episode the child would still merit 6 weeks of alternate day steroid therapy that she had missed. However since the child relapsed after gaining remission it should be labeled as a relapse. The definition of relapse as per the guideline is "Urine albumin 3+ or 4+ (or proteinuria >40 mg/m2/h) for 3 consecutive early morning specimens, having been in remission previously" [1]. The definition of first relapse or subsequent relapses is not any different. The subsequent treatment of this child would be decided by the disease course on follow-up.

Mukta Mantan

Associate Professor,
Department of Pediatrics, Maulana Azad Medical College,
New Delhi 110 002, India.
Email: [email protected]

References

1. Consensus Statement of Management of Steroid Sensitive Nephrotic Syndrome. Indian Pediatric Nephrology Group, Indian Academy of Pediatrics. Indian Pediatr. 2008;45:203-14.

2. Lombel RM., Gipson DS, Hodson EM. Treatment of steroid-sensitive nephrotic syndrome: new guidelines from KDIGO. Pediatr Nephrol. 2013;28:415-26.

 

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