How can I effectively manage the complications associated with nephrotic syndrome in primary care?

Effective management of complications associated with nephrotic syndrome in primary care involves several key strategies:

• Monitor and manage proteinuria and kidney function: Measure albumin-to-creatinine ratio (ACR) and estimated glomerular filtration rate (eGFR) regularly. Refer to nephrology if ACR is 70 mg/mmol or more, and consider specialist advice if ACR is between 30-70 mg/mmol. For persistent proteinuria, offer an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) titrated to the highest tolerated dose to reduce proteinuria and protect kidney function ¹,²,³.
• Control blood pressure: Aim for blood pressure targets based on ACR levels: below 140/90 mmHg if ACR is under 70 mg/mmol, and below 130/80 mmHg if ACR is 70 mg/mmol or more. Individualize targets in frail patients or those with comorbidities ³.
• Manage cardiovascular risk: Offer atorvastatin 20 mg for primary or secondary prevention of cardiovascular disease (CVD) in chronic kidney disease (CKD) patients, adjusting dose according to lipid targets and renal function. Also consider antiplatelet therapy for secondary prevention of CVD ¹,².
• Address oedema and fluid overload: Although not detailed in the provided guidelines, standard practice includes salt restriction and use of diuretics as appropriate, with monitoring of renal function and electrolytes.
• Prevent and manage infections: Offer immunizations against influenza and pneumococcal disease to reduce infection risk, as nephrotic syndrome patients are immunocompromised ¹,³.
• Support self-management and education: Provide patients and carers with clear, jargon-free information about their condition, risks, and treatment options. Encourage lifestyle modifications such as smoking cessation, healthy weight, and exercise ¹,³.
• Monitor for complications of therapy: When using renin-angiotensin system antagonists, monitor serum potassium and eGFR before and after initiation or dose changes to avoid hyperkalaemia and acute kidney injury ³.
• Consider sodium-glucose cotransporter-2 (SGLT2) inhibitors: For patients with type 2 diabetes and CKD, consider SGLT2 inhibitors as add-on therapy to ACE inhibitors or ARBs if appropriate, to reduce progression of kidney disease ¹,².