Nephrotic Syndrome

This is an abbreviated version of the full GGC Guideline on Nephrotic Syndrome which can be accessed here.


Nephrotic syndrome is defined clinically by:

  • Urinary protein losses of >3g/day (~urine protein:creatinine ratio >300mg/mmol)
  • Serum Albumin <30g/L
  • Oedema (may be mild)


Initial assessment:

  • Dipstick urinalysis
  • Clinical history
  • Consider and investigate potential causes (Box 1)

Box 1 - Common causes of nephrotic syndrome

Common causes of nephrotic syndrome
  • Multisystem disorders – e.g. Diabetes or Systemic Lupus Erythematous
  • Chronic inflammatory disorders (e.g. Inflammatory bowel disease, Rheumatoid arthritis)
  • Primary Glomerulonephritis (GN)
  • Secondary Glomerulonephritis due to obesity, hypertension or certain drugs
  • Malignancy including multiple myeloma

Clinical examination:

  • Review patient observations: blood pressure is often high and oxygen saturations low.
  • Outside of critical care areas, measurement of fluid intake/urinary output are often inaccurate. Weigh daily during admission whilst adjusting treatment, ideally using the same scales each time.
  • Examine daily for pulmonary oedema. Be wary of skin integrity and risk of infection.


  • Urinary protein:creatinine ratio
  • GN screen - ANCA, ANA, anti-GBM antibody, rheumatoid factor and C3/C4
  • Myeloma screen (in those aged >60 years) - serum electrophoresis, immunoglobulins and Bence-Jones protein
  • Virology testing (HCV, HBV, HIV)
  • Renal tract ultrasound

Nephrotic syndrome complications: protein malnutrition, hypovolaemia (often iatrogenic), acute kidney injury, thromboembolism and infection.


General principles

All cases of nephrotic syndrome should be referred to renal to discuss the need for a renal biopsy.


  • Salt restrict to <2g daily, fluid restrict to <1.5L daily.
  • Loop diuretics. IV administration is often necessary as absorption can be inhibited by generalised oedema.
  • Aim to lose ~1-2kg of body weight per day, using patient-predicted 'dry' body weight as a target.
  • Examples of diuretic regimes can be seen below in table 1.

Table 1: Diuretics - initial dose suggestions

Drugs Initial dose suggestion Cautions

Currently on diuretics

Give usual dose as a stat IV dose, then give usual daily dose (e.g. 80mg daily, give 80mg IV daily).

Inadequate response options:

  • Increase dose
  • Add further bolus at ~2pm
  • Commence continuous infusion

Diuretic naive:

eGFR >60ml/minute: 40mg daily

eGFR 30-60ml/minute: 80mg daily

eGFR <30ml/minute: 120mg daily

Ototoxicity, hypokalaemia, hypovolaemia, acute renal decline.
  • Only commence on specialist/senior advice.
  • Addition of bendroflumethiazide 2.5mg or metolazone 5mg on alternate or each day.
Profound hypovolaemia, hypokalaemia, hyponatraemia.


  • Weak diuretic effect, beneficial in preventing hypokalaemia.
  • Amiloride 5mg daily
Hypovolaemia, hyperkalaemia.


  • Commence anti-hypertensives if necessary to control blood pressure (<140/90mmHg).
  • New or uncontrolled hypertension requires further investigations, see GGC Nephrotic Syndrome guidance.
  • Examples of anti-hypertensive regimens are shown in table 2.

Table 2: Antihypertensives - initial dose suggestions

Drug Initial dose suggestion

ACE inhibitors

  • Avoid whilst using high dose diuretic due to risk of hypovolaemia induced AKI.
  • Ramipril 2.5mg daily


  • Bisoprolol 2.5mg daily

Calcium channel blockers

  • Amlodipine 5mg daily


  • Refer patient to dieticians for protein and fat intake advice. 
  • Commencing lipid-lowering therapy for nephrotic syndrome is not generally recommended in the absence of confirmed aetiology.


  • The greatest risk of venous thrombus occurs when serum albumin is <20g/L. Use mechanical measures to reduce risk of DVT in all patients
  • Do NOT commence anticoagulation without discussing with renal as this may delay, or substantially increase the risk from, performing a renal biopsy

Other information

  • All unexplained uPCR results >100mg/mmol should be discussed, non-urgently with renal; out-patient follow-up may be required
  • Transient proteinuria often occurs in association with a systemic inflammatory response. A repeat sample in convalescence can clarify


Guideline reviewed: February 2023

Page last updated: March 2023