Title: Nutritional management paediatric nephrotic syndrome
1Nutritional management paediatric nephrotic
syndrome
2Introduction
- Nephrotic syndrome (NS)
- Commonest glomerular disease affecting children
- Frequently encountered in general paediatrics
- Characterised by
- Significant proteinuria (early morning urine
protein to creatinine ratio gt 200mg/mmol) leading
to - Hypoalbuminaemia (plasma albumin of lt 25g/l)
Paediatrics and child health 201020(1)36-42
3Introduction
- NS defined by the clinical triad of
- Oedema
- Nephrotic range proteinuria and
- Hypoalbuminaemia
- Typically accompanied by
- Dyslipidaemia with elevated plasma cholesterol
and triglycerides
Paediatrics and child health 201020(1)36-42
4Introduction
- NS can be
- Congenital or acquired
- Congenital disease
- May be due to a genetic mutation or secondary to
a congenital infection - Acquired disease
- More common and is usually idiopathic
- Categorised according to the response to
corticosteroid treatment as - Either steroid sensitive or steroid resistant
disease
Paediatrics and child health 201020(1)36-42
5Introduction
- Majority of children with NS have a
- Steroid sensitive condition (SSNS) that is
associated with minimal histological changes in
the glomeruli (MCNS) - Initial management involves
- Control of oedema and prevention of infection
while awaiting the response to corticosteroids
6Introduction
- If the child does respond to prednisolone with
infrequent relapses, then there are likely to be
a few long term dietary problems - However, children who frequently relapse and are
- Steroid dependent may require long term dietary
advice to monitor and maintain nutritional status
and prevent obesity. - Growth and endocrine function are important
issues in the long term management of such
patients
7Initial advice
- Growth parameters should always be recorded and
dry weight estimated, as surface area is used to
calculate the prednisolone dosage - A dietitian should be involved in the initial
management both to review the dietary history as
well as advising on the practicalities of the
moderate fluid restriction that is - Often required in the initial oedematous phase
while awaiting the response to steroids
8Initial advice
- Supportive Care
- Forms an important aspect of managing children
with NS - Includes
- Diet
- Patient and parent education
9Nutritional management NS
- Both high- and low-protein diets have been
advocated in the past for children with NS. - Apart from salt restriction and general healthy
eating, no specific dietary advice is currently
considered necessary for children with SSNS
Current Paediatrics 200212551-60
10Nutritional management NS
- Diet
- A balanced diet, adequate in protein (1.5-2 g/kg)
and calories is recommended - Patients with persistent proteinuria should
receive 2-2.5 g/kg of protein daily - lt 30 calories should be derived from fat and
saturated fats avoided
Revised guidelines for management of SSNS.
Indian J Nephrol 20081831-9
11Nutritional management NS
- Pathogenesis of oedema in NS
- Hypoalbuminaemia leads to an imbalance of
Starling equilibrium by reducing the oncotic
pressure, causing retained fluid to escape from
the circulation into the interstitial space and
leading to progressive oedema - This fall in oncotic pressure also causes a
contraction of the circulating blood volume,
resulting in maximal salt and water retention - Sodium retention will cause further extracellular
fluid expansion with exacerbation of generalize
oedema - A no added salt diet is therefore an
appropriate measure
Paediatrics and Child health 2008 188 369-74
12Nutritional management NS
- A no added salt diet is advisable in view of
the salt and water overload - There is no evidence for use of a high protein
diet - Children should be encouraged to have a normal
healthy diet
Paediatrics and Child health 2008 188 369-74
13Nutritional management NS
- While salt restriction is not necessary in most
patients with steroid-sensitive nephrotic
syndrome, reduction of salt intake (1-2 g per
day) is advised for those with persistent edema
Revised guidelines for management of SSNS.
Indian J Nephrol 20081831-9
14Nutritional management NS
- No added salt diet
- Can be done by omitting the addition of salt to
food at the table and reducing the intake of
highly salted manufactured foods, particularly
snack foods such as crisps - Salt should not be added to salads and fruits,
and snacks containing high salt should be avoided - Very low sodium diets and the use of low sodium
specialist products should not be necessary.
15Nutritional management NS
- No added salt diet
- This advice can produce conflict within families
and possible confusion - Follow up dietetic review in the clinic will help
reinforce previous advice and help ensure that
the diet is practical and not unnecessarily
restrictive
16Nutritional management NS
- Since treatment with corticosteroids stimulates
appetite, parents should be advised regarding - Ensuring physical activity and preventing
excessive weight gain
Revised guidelines for management of SSNS.
Indian J Nephrol 20081831-9
17Nutritional management NS
- Parental
- Motivation and involvement is essential in the
long-term management of these children - They should be provided information about the
disease, its expected course and risk of
complications
Revised guidelines for management of SSNS.
Indian J Nephrol 20081831-9
18Nutritional management NS
- Normal activity and school attendance should be
ensured - The child should continue to participate in all
activities and sports
Revised guidelines for management of SSNS.
Indian J Nephrol 20081831-9
19Nutritional management NS
- Dyslipidemia is an expected finding in children
with NS and - May resolve when patients are in remission.
- Children who have refractory nephrosis often have
persistent dyslipidemia - Treatment includes
- Dietary counseling to limit dietary fat to 30 of
calories, saturated fat to 10 of calories, and
300 mg/day dietary cholesterol
Pediatrics 2009124747-757
20Nutritional management NS
- Fat intake
- The use of monounsaturated or polyunsaturated
margarines and oils are also advocated as part of
the general healthy eating advice with a
reduction of a saturated fat intake - Attempts at dietary manipulation of lipids in the
diet may be more relevant in the child with a
chronic nephrotic state
21Nutritional management NS
- A leaflet/booklet on healthy eating should be
available to the family
22Nutritional management NS
- Weight control
- Prednisolone treatment undoubtedly stimulates the
child's appetite and dietary advice about the
prevention of excessive weight gain is important - Many children and their parents become upset with
changes in body image, and this is particularly
true with adolescents.
23Nutritional management NS
- Weight control
- In between meal snacks such as biscuits, crisps,
and fizzy (high sugar) drinks should be avoided
with low energy alternatives promoted - Healthy eating advice should again be reinforced
- Occasionally contact with the nursery or school
may be necessary as part of the psychosocial
support required in some families
24Nutritional management NS
- Food allergy
- As the aetiology of MCNS is unknown, there are
some parents who become concerned that dietary
factors may be responsible especially as MCNS is
commoner in atopic families - There are reports suggesting food
hypersensitivity, particularly to - Milk and dairy products, may be aetiological
factors in the glomerular damage in both young
and adult patients
Lancet 1987 i 1315-6.
25Nutritional management NS
- Food allergy
- If a trial of a few foods diet is contemplated it
should be under close dietetic supervision. - One should be aware that some families may seek
advice from alternative medicine sources,
especially if they have concerns about the use of
corticosteroids
26Nutritional management NS
- Steroid resistant nephrotic syndrome
- This group of patients is usually very
heterogenous with an underlying renal pathology
that does not respond to at least four weeks of
daily prednisolone treatment - Prolonged initial steroid dosage combined with
oedema, 'anorexia, and catabolic state may
require a period of nutritional support either
with oral or nasogastric tube fed supplements
27Nutritional management NS
- Steroid resistant nephrotic syndrome
- Vitamin supplementation and iron treatment may
also be indicated - Such children are often hospitalised for long
periods and the clinical course may be
complicated by diarrhoea and other nosocomial
infections from the ward.
28Nutritional management NS
- Congenital nephrotic syndrome
- This is a rare condition that in the past was
associated with failure to thrive, progressive
renal failure, and eventual death - If such patients are to survive they require
intensive dietetic support because of the
anorexia that is complicated by fluid restriction
29Nutritional management NS
- Congenital nephrotic syndrome
- A protein intake of 2-4 kglbody weight/day with
maximum energy intake within the fluid allowance
may be indicated - Nutritional supplements will be essential to
achieve nutritional requirements and
administration by the nasogastric or preferably
gastrostomy route will be indicated should the
child fail to meet their nutritional requirements
orally
30Nutritional management NS
- Congenital nephrotic syndrome
- The losses of protein can be reduced by
unilaterial or bilateral nephrectomy combined
with early dialysis and transplantation
31Thank You!