Treatment of nephrosis
Two kinds of medications are used commonly in the treatment of nephrosis. Some children have such massive swelling of the body that it is necessary to use diuretic medications (“water pills”) to coax the kidney into excreting more salt and fluid. One such medication that is commonly used is Lasix™ (generic name, furosemide). However, this treatment does not improve the problem of the kidney's leakage of protein.
One medication that does clear up the leakage of protein is called prednisone. This medication resembles hormones (steroids) produced by the adrenal glands, such as cortisone. Up to 90% of children with minimal-change nephrotic syndrome treated with this medication have complete disappearance of protein from the urine and of the swelling of the body. If the urine remains free of protein for several days, this response to treatment is called a remission. The loss of swelling, accompanied by an increased urine output usually occurs 7 to10 days after starting prednisone treatment, leading to a sudden weight loss and a noticeable change in the appearance of the child.
A remission (meaning a “negative” or “trace” reaction for protein in the urine using a dipstick) may occasionally may take as long as 6 weeks. However, a small number of children with nephrosis, perhaps up to 10 to 15%, do not respond to prednisone and may never achieve a remission. This is referred to as steroid-resistant nephrotic syndrome. In such children, diuretic medications may control the fluid retention but they will continue to spill protein into the urine for long periods of time. Nephrosis is not treated by surgery.
How to check the urine at home for protein
Using a special test strip, which is dipped in the urine, you can check to see if your child is spilling protein. The amount of protein in the urine can be determined by comparing the color change on the test strip with a chart on the bottle. Normal urine gives a “negative” or “trace” (very pale green-yellow) reaction .With increasing amounts of protein in the urine, the shades of color change from + (one plus, “30”), ++ (two plus, “100”), +++ (three plus, “300”) to ++++ (four plus, dark blue-green, greater than “2000”) .The numbers refer to the concentration of protein in the urine. The first urination of the morning should be checked and your physician notified if the test result is greater than 1+ for three consecutive days. If your child is spilling protein, this test should be done each morning and the results written down on a calendar and brought as part of an appointment so that the physician is aware of them.
Side effects of prednisone treatment
For prednisone to be effective it must be used in high doses; side effects may become obvious within a few weeks of starting treatment. The first change is an increased appetite and rapid weight gain due to an actual increase in fat tissue .This weight gain is not due to fluid retention. The appearance of the child after treatment with prednisone for several weeks is sometimes referred to as a "moon face." It is often accompanied by a flushed appearance and an accumulation of fatty tissue in the cheeks.
If prednisone is continued at high doses for a long period of time, there may be other side effects, such as a slowing of growth, some increase in fine body hair, stretch marks, and loss of calcium from bones (osteoporosis). Side effects occurring less often include increased blood pressure and changes in mood or behavior. In most children, however, the initial course of daily treatment is relatively short (4 weeks), and the dose is subsequently tapered over a period of time to levels at which the side effects are less of a problem.
The tendency to develop these side effects is most pronounced in those children who have several closely-spaced relapses and therefore require several courses of treatment with prednisone. Most side effects are not permanent. As the prednisone dose is reduced, most of the side effects gradually disappear and the child eventually regains a normal appearance. However, perhaps the most troubling side effect, the gain in weight, is the most persistent effect. A calorie-restricted diet for several months may be necessary.
Other possible medications
There are other medications for children who have experienced serious side effects from prednisone treatment. A medication called cyclophosphamide (Cytoxan™) is used for certain children with frequent relapses. Research has shown that it is effective in decreasing the number of relapses. However, because the use of cyclophosphamide requires frequent blood tests and special instructions for use, it is reserved for certain children who relapse frequently or who develop significant side-effects from prednisone. If the physician believes this medication may help your child, you will receive a detailed explanation at that time. Other medications that may be used either in conjunction with prednisone or in its place include Neoral™ (cyclosporine), Prograf™ (FK-506 or tacrolimus), or CellCept™ (mycophenolate mofetil or MMF). Like cyclophosphamide, these medications affect the immune system and are reserved for steroid-resistant or difficult steroid-dependent cases.