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Nutritional management paediatric nephrotic syndrome

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Title: Nutritional management paediatric nephrotic syndrome


1
Nutritional management paediatric nephrotic
syndrome
  • Dr.

2
Introduction
  • 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
3
Introduction
  • 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
4
Introduction
  • 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
5
Introduction
  • 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

6
Introduction
  • 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

7
Initial 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

8
Initial advice
  • Supportive Care
  • Forms an important aspect of managing children
    with NS
  • Includes
  • Diet
  • Patient and parent education

9
Nutritional 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
10
Nutritional 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
11
Nutritional 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
12
Nutritional 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
13
Nutritional 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
14
Nutritional 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.

15
Nutritional 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

16
Nutritional 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
17
Nutritional 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
18
Nutritional 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
19
Nutritional 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
20
Nutritional 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

21
Nutritional management NS
  • A leaflet/booklet on healthy eating should be
    available to the family

22
Nutritional 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.

23
Nutritional 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

24
Nutritional 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.
25
Nutritional 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

26
Nutritional 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

27
Nutritional 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.

28
Nutritional 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

29
Nutritional 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

30
Nutritional management NS
  • Congenital nephrotic syndrome
  • The losses of protein can be reduced by
    unilaterial or bilateral nephrectomy combined
    with early dialysis and transplantation

31
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