A new frontier in edema management: the potential of tolvaptan for refractory edema with hyponatremia in pediatric nephrotic syndrome.

BACKGROUND: Severe nephrotic edema in children often necessitates use of one or more diuretics. Moderate to severe hyponatremia co-exist in such patients. Tolvaptan, a vasopressin receptor antagonist, has shown promise in treating edema in adult as well as pediatric cases, however in children there is not much data. This study aims to explore the use of tolvaptan in severe nephrotic edema with hyponatremia in children. METHODS: Children with Nephrotic syndrome (1-12 years) with severe edema were screened for eligibility and received furosemide (2-4 mg/kg/d) for 48 h, those refractory to furosemide (weight loss < 3%) with hyponatremia (Na < 130mEq/L) were administered tolvaptan (0.3-1 mg/kg/d) for 48 h after excluding hypovolaemia, elevated liver enzyme and reduced eGFR (< 60 ml/min/1.73m2). Parameters were compared before and after 48 h of tolvaptan. RESULTS: A total of 60 (44 males, 16 females) patients were enrolled with mean age of 5.71 ± 2.16 years. After 48 h of tolvaptan administration, there was significant reduction in body weight (21.98 ± 6.33 to 21.02 ± 6.28 p < 0.001). and increase in 24-hour urine volume from 700 (400-1060) mL/day [1.56 ± 0.91 mL/kg/hour] to 1200 (900-1637.5) mL/day [3.17 ± 2.53 mL/kg/hour] (p < 0.001). The mean serum sodium level increased significantly from 125.87 ± 3.77 mEq/L to 131.18 ± 4 mEq/L (p < 0.0001). There was no significant change in liver enzymes after tolvaptan. CONCLUSIONS: Tolvaptan effectively reduces edema, increases urine output while improving serum sodium levels in pediatric nephrotic syndrome with refractory edema without any significant side effects.