Treatment of Severe Nephrotic Edema with Albumin and Furosemide

Treatment of Severe Edema in Children with Nephrotic Syndrome with Diuretics Alone — A Prospective Study

“…In contrast to adults, children are often more severely hypoalbuminemic and edematous, necessitating hospitalization and IV albumin administration. Albumin is routinely used in children because of (1) low serum oncotic pressure due to hypoalbuminemia, (2) reports of diuretic resistance and decreased efficacy in NS (1)(2)(3)(4), (3) increased diuresis when diuretics are given after IV albumin (1,5,6), and (4) a reluctance to treat patients with diuretics only because of concerns about dehydration and increased risk of thromboembolic complications.…”

Nephrotic Edema: Etiopathogenic and Therapeutic Considerations

“…The cause and treatment of severe edema accompany ing the nephrotic syndrome (NS) have been subjects of controversy for many years [1][2][3][4], Although a certain serum albumin level is supposed to accompany or induce edema, no absolute correlation exists with serum albu min and clinical presentation, histology, glomerular fil tration rate (GFR, or its equivalent, serum creatinine) [5,6], serum electrolytes, or hematocrit -blood volume [4,7], In addition, there is no correlation between serum albu min and response to the administration of albumin and furosemide (Lasix®) [8], Even though the administration of 'salt poor' albumin does not aim to raise the serum albumin, this occurs transiently in many patients. The unpredictability of diuresis in response to the combined use of albumin and furosemide, and even more to albu min [ 1 ] or diuretics [1,6] given alone, further supports the notion that factors other than, or in addition to, hypoproteinemia are responsible for the sodium retention and edema of nephrotic patients [5,7,9,10], Recently it was postulated that the hyperlipidemia of these patients could be the result of an initial glomerular capillary wall damage leading to urinary loss of lipopro tein lipase activators, increase in serum lipids (low densi ty and very low density lipoproteins) which bind with glycosaminoglycans of the capillary basement mem brane and further increase its permeability [11], The per sistence of these findings in NS children after several years in remission [12], may lend support to the hypothe sis that an abnormal lipid metabolism is responsible for the initiation of NS and progression of glomerular and tubulo-interstitial disease [II], Similarly, excessive pro tein intake in the diet has been ascribed the main role in the progression of glomerular renal disease through chronic renal vasodilation [13], and food manipulation induced either remission or relapse in half of the NS children studied [14].…”

“…Since the above drugs have not been proven uniformly efficacious [1,4] and have been implicated in the develop ment of vascular thrombosis [3,4], their indications need further evaluation, especially in patients with decreased circulating volume and increased blood hematocrit and thrombogenic factors [3,4]. In those patients, diuretic therapy should be administered intravenously and preceeded by infusion of a volume expander such as human serum albumin [8]; other solutions used successfully in clude mannitol [20], plasma protein fractions, dextran, and hydroxyethyl starch (Hespan®) and other polymers of high molecular weight [4]. Albumin alone induced only a transient diuresis [1].…”

“…Mannitol, dextran, diuretics and fluid restriction may worsen a pre-existing state of hemoconcentration [20]; albumin or Plasmanate infusion may be associated with hypotension [4]; albumin may worsen glomerular histopathology or function [8] and induce hematuria [4]; and administration of any solution aimed at inducing a diuresis maybe followed by hypertensive [8] and congestive heart failure episodes [1] (probably in the NS patients with increased blood volume).…”

“…Until more is known about the pathophysiology of NS and its edema, the cautious administration of albumin followed by furosemide [8] seems to be the best approach [4,21], Research in alternative methods of treatment of NS and its edema should be encouraged, including food manipulation, with careful attention to lipids (especially fatty acid composition and their ratio of saturated to unsaturated) and protein, head-out immersion in warm water [22,23], and others. Hopefully, this vexing problem eventually will be solved for the benefit of the patients and their families who suffer so much, and the medical and paramedical personnel who become so frustrated in their unsuccessful attempts to help these children.…”