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losses, and restricted intake Signs of decreased effective circulating volume include tachycardia, peripheral vasoconstriction, and oliguria In addition to overall volume excess with or without intravascular depletion, complications resulting from nephrotic syndrome include infection and thromboembolism Children with nephrotic syndrome are at increased risk of developing serious bacterial infection, particularly infections with encapsulated bacteria, because of urinary losses of immunoglobulins and alternative complement pathway factors B and D Children who are treated with immunosuppressive agents will have additional risk Furthermore, ascites and pleural effusions increase the risk for peritonitis, pneumonia, and empyema Other potential complicating infections include sepsis, meningitis, cellulitis, urinary tract infection, upper respiratory tract infection, and severe acute gastroenteritis Thromboembolic complications are reported in 2% to 9% of children with nephrotic syndrome and may occur in either the arterial or venous circulation The actual incidence may be higher, however as thromboembolic events may be asymptomatic The risk may be higher in children with steroid-resistant disease Nephrotic syndrome results in a hypercoagulable state due to urinary losses of antithrombin III, protein S, and plasminogen and increased circulating fibrinogen, factors V and VII as well as increased platelet activation Though many embolic events are silent, cerebral venous thrombosis, pulmonary embolism, and renal vein thrombosis may result in significant morbidity Though a much less frequent occurrence in children than in adults with nephrotic syndrome, renal vein thrombosis should be suspected in cases of sudden-onset macroscopic hematuria and flank pain Triage considerations Children with nephrotic syndrome may present acutely ill with signs and symptoms of fluid overload Patients may require support of lung function due to pulmonary edema Hypertension, if present, can be symptomatic and may require emergent management They are at risk for serious bacterial infections as well as both venous and arterial thrombosis and may require emergent evaluation and treatment for these conditions Other patients may present with mild symptoms related to edema and will be managed with gentle diuresis with fluid and salt restriction
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