Understanding Nephrotic Syndrome: Diagnosis and Classification

It follows the same mechanism as the rest of the oedema: low albumin causes fluid to shift into dependent spaces in the body, and the right lung is affected somewhat more often than the left. The underlying pathophysiology is hypoalbuminaemia driving fluid out of the vascular space into surrounding tissue, known as third spacing.

Abdominal pain in these children usually has a few overlapping causes: spontaneous bacterial peritonitis, treated with a third-generation cephalosporin, since a diagnostic ascitic tap is no longer recommended because the puncture site tends to leak and add a further infection risk; stretching of the liver capsule; and simply the physical discomfort of a child's abdomen suddenly distending, similar in scale to a late-term pregnancy, which makes walking and daily activity very difficult. Swelling of the intestines themselves also contributes to the pain and can cause diarrhoea.

Children who present soon after a relapse with only mild eyelid swelling respond to steroids alone and do not need diuretics. Children with full-body swelling, low albumin around 1.5 or below, and no response to oral diuretics need albumin infusion alongside diuretics, and are identifiable clinically by severe swelling causing breathing difficulty or genital oedema. Oral diuretics alone are for children who have been on steroids for 10 to 14 days, are heading into remission, but still have uncomfortable, spreading facial swelling.

Monitoring has to cover growth, charting height and weight and adjusting diet if the child is faltering, immunisation status, since immunity is lower on immunosuppressants and needs support, and the eyes, since cataracts and raised intraocular pressure can develop and fundus changes can reflect hypertension. Blood pressure itself needs care to interpret correctly: parents are asked to record home readings at different times of day along with the child's position and activity, since white-coat hypertension can otherwise be mistaken for the real thing. Longer term, children with frequent relapses can also develop hair loss, hypothyroidism and visible skin changes, all of which need specific follow-up.

Yes, that is exactly right, and it is the better model in most cases: it costs the patient far less, and a local doctor who can actually follow the child up in person, combined with specialist input from India, including guidance on when to move from one drug to the next and what blood work to watch, generally serves the patient better than travel. Medicines can also be shipped through distributors once a clear treatment plan and prescription exist from both sides, since India's role as a manufacturing hub keeps costs down.

Nephrotic-range proteinuria, generally more than 1 g per square metre of body surface area or a urine protein-to-creatinine ratio above 40 mg per square metre per hour, together with hypoalbuminaemia and oedema. Hypercholesterolaemia is no longer a required criterion.

An infrequent relapser has fewer than two relapses in six months or three in a year. A frequent relapser has three or more relapses in a year. Steroid dependence means two consecutive relapses occur while tapering steroids or within 14 days of stopping them.