Mechanisms and management of edema in pediatric nephrotic syndrome
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EDUCATIONAL REVIEW
Mechanisms and management of edema in pediatric nephrotic syndrome Mahmoud Kallash 1,2
&
John D. Mahan 1,2
Received: 10 April 2020 / Revised: 18 August 2020 / Accepted: 11 September 2020 # IPNA 2020
Abstract Edema is the abnormal accumulation of fluid in the interstitial compartment of tissues within the body. In nephrotic syndrome, edema is often seen in dependent areas such as the legs, but it can progress to cause significant accumulation in other areas leading to pulmonary edema, ascites, and/or anasarca. In this review, we focus on mechanisms and management of edema in children with nephrotic syndrome. We review the common mechanisms of edema, its burden in pediatric patients, and then present our approach and algorithm for management of edema in pediatric patients. The extensive body of experience accumulated over the last 5 decades means that there are many options, and clinicians may choose among these options based on their experience and careful monitoring of responses in individual patients. Keywords Pediatric nephrotic syndrome . Children . Edema . Overfill . Underfill
Introduction Edema is a major component of nephrotic syndrome (NS) (defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines as having edema, urine protein/creatinine ratio ≥ 2 mg/mg, and hypoalbuminemia ≤ 2.5 g/dl). Edema is a late Middle English (modern Latin) word that originated from the Greek word: oidēma, from oidein, which means “to swell.” Most of the early writings on this subject in the Sumerian, Babylonian, Egyptian and Greek cultures centered on dropsy, likely cardiacinduced edema. The concept of “dropsy of the chest” began to attract attention sometime by the end of the seventeenth century and it was well appreciated by the eighteenth century. By the beginning of the nineteenth century, reports by John Blackall and Richard Bright provided new insights by differentiating dropsy into that of cardiac and renal origins [1, 2]. The role of salt, initially thought of in terms of its anion chloride, in the development of edema began to be appreciated
* Mahmoud Kallash [email protected] 1
Division of Pediatric Nephrology, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205, USA
2
The Ohio State University College of Medicine, Columbus, OH, USA
by the middle to the late nineteenth century. Its mobilization or removal, however, remained problematic for physicians at that time. The “cure de dechloruration,” which gained widespread acceptance by the end of the nineteenth century, was not always a successful undertaking. This treatment of dropsy, which centered on augmenting secretions (diaphoretics, purgatives) or mechanical removal of body fluids (bleeding, leeching, lancing), remained a frustrating and chancy undertaking while it was pursued for much of the eighteenth century and into the nineteenth century. The discovery of sulfanilamide-induced sodium bicarbonate diuresis in the late 1940s provided the first step in the new age of clinically effectiv
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