Clinical Scenario:
A 5-year-old boy with steroid-sensitive nephrotic syndrome (SSNS) presents with generalized edema and abdominal pain. He has been receiving prednisolone 2 mg/kg/day for the last 7 days following a relapse. On examination, he is afebrile, pulse 118/min, blood pressure 88/56 mmHg, and has tense ascites with marked pedal edema. Urinalysis shows 4+ proteinuria. Laboratory investigations reveal: serum albumin 1.6 g/dL, serum creatinine 0.5 mg/dL, hematocrit 45%, and urine protein/creatinine ratio 8 mg/mg. He has passed only 0.4 mL/kg/hour of urine over the past 12 hours despite adequate fluid intake.
What is the most appropriate next step in management?
A. Administer 20% albumin infusion followed by intravenous furosemide
B. Increase the dose of oral prednisolone to 4 mg/kg/day
C. Initiate continuous intravenous furosemide infusion alone
D. Restrict oral fluids to 50% of maintenance and observe
E. Start intravenous normal saline bolus (20 mL/kg)
Correct answer & Explanation
Correct Answer : A
This child has intravascular volume depletion (hypovolemia) despite severe edema, suggested by:
Hypotension
Oliguria
Hemoconcentration (hematocrit 45%)
Severe hypoalbuminemia
Preserved renal function
In hypovolemic nephrotic syndrome, the recommended treatment is 20% albumin (0.5–1 g/kg over 2–4 hours) followed by intravenous furosemide (1–2 mg/kg) near the end of the infusion to mobilize edema while restoring intravascular volume.
Why the other options are incorrect
B. Increasing steroid dose does not correct acute hypovolemia and is not indicated.
C. Diuretics alone may worsen hypovolemia and precipitate acute kidney injury.
D. Fluid restriction alone is inadequate and may further compromise renal perfusion.
E. Normal saline alone provides only transient intravascular expansion and is generally less effective than albumin in severe hypoalbuminemia unless albumin is unavailable.
Learning Point:
Before prescribing diuretics in nephrotic syndrome, always assess intravascular volume status. Children with edema may still be hypovolemic, and treating them with diuretics alone can worsen renal perfusion and precipitate acute kidney injury.
