Question 1

Where malnutrition is common, how do you tell nephrotic syndrome apart from malnutrition, and can the two coexist?

Dr. Shraddha Lohia · Accepted Answer

Malnutrition and nephrotic syndrome are completely different, and clinical acumen separates them, although the two can coexist. A child with oedematous malnutrition can have swelling, but it is more towards the abdomen, with no periorbital puffiness, often with a pot belly from reduced muscle and the skin and hair changes of malnutrition. Serum albumin really helps: in malnutrition it is generally not below 2.5 g/dL. In nephrotic syndrome the albumin is low and there is oedema, and the parents give a clear history: it started around the eyes, then the face, then the hands and legs, then from the abdomen to the genitals, and the child has some difficulty walking and breathing.

Question 2

Where I work, we have no access to most of the drugs you mention. How can such patients be treated?

Dr. Shraddha Lohia · Accepted Answer

If you have a difficult nephrotic syndrome case and the drugs are not available, I can have them arranged and couriered for your patients, directly through the distributor, so that the patient gets them at a reasonable rate. Drugs and healthcare are relatively inexpensive in India, so the patient does not need to travel: you take care of the patient locally, and we can discuss and tailor the treatment together.

Question 3

Beyond the side effects like cataracts you mentioned, what is the broader developmental impact of long-term steroid-based therapy on growing children?

Dr. Shraddha Lohia · Accepted Answer

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.

Question 4

Can you summarise the indications for diuretics and albumin infusion?

Dr. Shraddha Lohia · Accepted Answer

The only child in whom I would use albumin infusion together with diuretics is one with resistant oedema. A child who has simply relapsed with a little periorbital swelling does not need diuretics. I treat the cause of the relapse first, for example an infection; if there is no clear cause, I treat with steroids at 2 mg per kg and review the child every third day to see whether a diuretic is needed or the child is going into remission. Children who are having a lot of difficulty with the swelling are the ones I start on diuretics, so that they do not acquire added infections: oedema is a perfect culture medium and I do not want a secondary bacterial infection. Some of these children have spontaneous bacterial peritonitis, and in them we use antibiotics, diuretics and albumin infusion.

Question 5

Does this mean that doctor partners in Africa with structured access to a specialist like you can manage most of these children locally, without the patient needing to travel to India?

Dr. Shraddha Lohia · Accepted Answer

Yes, absolutely. We do struggle sometimes: some parents call to say the child is swelling and they need an infection ruled out, some cannot reach a doctor, and some receive only medicines without a letter explaining what happened. Different parts of the world have different issues. Working with local doctors is the best way: it costs the patient less, they do not have to come to India to buy the drugs or see me, and they are treated by a local doctor who can actually follow them up. Once there is a plan, for example that one year of levamisole is complete and it is time to move to MMF, we can prepare: arrange the medication, brief the doctor on what to watch for in the blood work, and review the reports whenever the doctor wants to share them.

Question 6

Can you explain what causes pleural effusion in nephrotic syndrome?

Dr. Shraddha Lohia · Accepted Answer

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.

Question 7

Can you say more about abdominal pain and ascites in nephrotic syndrome?

Dr. Shraddha Lohia · Accepted Answer

Abdominal pain has several causes. The first is spontaneous bacterial peritonitis, for which antibiotics, generally a third-generation cephalosporin, help. An ascitic tap is no longer recommended, because the child generally leaks from the site, acquires a superadded infection and ultimately develops sepsis. The second is stretching of the liver capsule. The third is that children are not used to a large abdomen: when it suddenly increases, it causes not only discomfort but pain, and they become restless because walking, play and daily activity become very difficult. The amount of ascites is like going from not pregnant to five, seven or even nine months pregnant, which makes almost any task impossible; some children cannot distinguish discomfort from pain and simply become irritable. The intestines are swollen too, which causes diarrhoea and further pain.

Question 8

Could you re-explain the indications for diuretics and albumin infusion in nephrotic syndrome?

Dr. Shraddha Lohia · Accepted Answer

Children who come in immediately after a relapse with minimal periorbital oedema will respond to steroids and do not need diuretics. Children with anasarca, lower albumin, and no response to oral diuretics are the ones who need albumin infusion. You can identify them clinically: they have anasarca, with an abdomen so bloated that it causes respiratory embarrassment, or genital oedema. Their albumin is around 1.5, and they need albumin infusion with diuretics, to which they respond very well. If they have abdominal pain, add a third-generation cephalosporin, whichever is available: the amount of oedema makes a very good culture medium, and they often have subclinical infection. Oral diuretics are for children who come 7 to 10 days after a relapse, have not responded to primary management, and are on steroids at 2 mg per kg but whose facial oedema is beginning to spread. On 2 mg per kg for about 10 to 14 days such a child will go into remission, but the oedema is causing discomfort, so these children need oral diuretics.

Question 9

How should amyloidosis be approached?

Dr. Shraddha Lohia · Accepted Answer

Amyloidosis is very rare in children and is generally seen in adults, especially in the third decade. A renal biopsy confirms it, and then there is just medical management; there is not much more that can be done.

Live Discussion with Dr. Shraddha Lohia