Treatment in adults

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The general management of the nephrotic syndrome includes:

• dietary modification:
  • low sodium
  • high protein and high calorie diets are not of proven value
• adults with MCD are edematous and often hypertensive
  • first-line therapy is diuretic therapy for fluid removal
    • diuretics:
      • furosemide e.g. 80-160 mg per day PO; other diuretics may also be indicated e.g. metolazone or spironolactone
      • electrolyte concentrations should be monitored
  • if antihypertensive therapy is still required, use of an angiotensin converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) seems a reasonable option for blood pressure reduction, and may have the added benefit of reducing urinary protein excretion
  • ACE inhibitors or ARBs to prevent progression or statin therapy for hyperlipidemia are not required in normotensive glucocorticoid-sensitive MCD
• use of oral steroid treatment
  • oral prednisone at an initial daily dose of 1 mg/kg of body weight (maximum dose 60 to 80 mg per day), which is continued for 12 to 16 weeks and is subsequently progressively tapered to discontinuation over the following six months
  • shorter treatment courses are often complicated with relapses
  • for the therapy of infrequent relapses in steroid-sensitive patients who do not have significant steroid-related side effect then often an abbreviated course of high dose oral prednisone is used
  • for patients with frequent relapses but no significant steroid-related side effects, a prolonged course of low-dose oral prednisone (approximately 15 mg on alternate days) to maintain a steroid-induced remission
• penicillin may be given prophylactically to prevent pneumococcal infection
• subcutaneous heparin, for the prevention of venous thromboses if very low albumin; warfarin is indicated for symptomatic thrombosis
• treatment of infections
• treatment of hyperlipidaemia - may resolve with treatment of nephrotic syndrome but may require specific lipid lowering medication
• second line agents include cyclophosphamide, cyclosporin and tacrolimus
  • cyclosporin combined with low dose prednisolone may achieve remission in relapsed disease (2)
  • evidence supports the use of rituximab for reducing the relapse rate of nephrotic syndrome (3)

Reference:

• 1) UptoDate - Treatment of minimal change disease in adults (September 2012)
• 2) Kodner C. Diagnosis and Management of Nephrotic Syndrome in Adults. Am Fam Physician. 2016 Mar 15;93(6):479-85.
• 3) Isaka Y, Sakaguchi Y, Shinzawa M, et al. Rituximab for Relapsing Nephrotic Syndrome in Adults: A Randomized Clinical Trial. JAMA. Published online November 05, 2025