Q: My 6-year-old son is under treatment for nephrotic syndrome for the past 1 year. Last year he had puffiness on the face and tummy. The urine albumin was found to be 5+ and since then he has been under treatment. The doctor prescribed him Wyslone 10 mg X 5 tablets (50mg) a day and this was gradually reduced to 4, 3, 2, 1 tablet per day. After the course was over, he was well for 1 month but relapsed. He is still continuing his treatment in the same way. But the doctor has now added Vermisol tablet also. What is the root cause of this problem? What precautions should be taken to prevent relapse? What diet should be given? Can he take fresh fruits and juices? Can milk be added in his diet? Will kidney be affected by this in any manner?

A:Your 6 year old has what is called Minimal Change Disease that results in excessive leakage of proteins in the urine. The cause of this condition in children is largely unknown, but it may sometimes be preceded by viral infection, allergic reactions, or recent immunizations. Prednisone or steroids (which he is on) is the mainstay of therapy and children usually respond very well to it. Minimal change disease does not reduce the amount of urine produced. Fortunately, it rarely progresses to kidney failure. Minimal change disease usually responds well to medical treatment, with response to corticosteroids usually within the first month. Relapse may occur but often responds to prolonged treatment with corticosteroids and immunosuppressive medications. Levamisole (Vermisol) is considered second or third line of agent in the setting of failure of steroid therapy. If there is edema should be treated by salt restriction and sometimes diuretics. To control protein leakage in urine, a group drugs known as ACE inhibitors have been shown to be very effective although their role is only supportive and do not cure the disease. Nephrotic children are at increased risk of infection, particularly peritonitis, due in part to the loss of certain proteins in the urine. Prophylactic antimicrobials are not recommended, but infections that do occur should be promptly treated. Another potential complication of loss of certain proteins in the urine is risk of developing blood clots. Prevention of this problem in children includes such simple measures as mobilization, avoidance of dehydration, and early treatment of sepsis or dehydration. Another feared risk of this disease in children includes growth retardation and the pediatrician should closely observe the growth chart to detect this. Finally, use of long term steroids can result in complications such as weight gain, elevated pressures, diabetes, puffiness of face (as you have described), easy bruising etc. High-protein diets are of debatable value for symptoms of nephrotic syndrome. In many patients, reducing the amount of protein in diet produces a decrease in urine protein. In most cases, a moderate protein diet (1 gram of protein per kilogram of body weight per day) is usually recommended. Sodium (salt) may be restricted to help control edema (swelling). Vitamin D (milk is good source of it!) may need to be replaced if the nephrotic syndrome is chronic and unresponsive to therapy. A dietitian may assist you with configuring right diet for him. Yes, he surely can have fruits, juices and milk etc. If he has swelling and elevated blood pressure restriction of fruits or juices that are particularly high in sodium e.g. tomatoes, watermelon would be recommended. On the other hand fruits such as oranges and bananas which have low sodium content may be well suited.