MCD causing approximately 77% of cases and focal segmental glomerulonephritis (FSGS) and MPGN the majority of the remaining occurrences Children typically present between the ages of and years, and the reported ratio of boys to girls who are diagnosed at a younger age is as high has 2:1 The gender ratio is closer to 1:1 in those who present later in childhood or as adolescents Goals of Treatment Many children with nephrotic syndrome present to the ED with signs of fluid overload Initial management should focus on improving fluid balance while monitoring for signs of intravascular volume depletion Children should also be assessed for underlying complications of nephrotic syndrome such as infection and thrombosis If a diagnosis of nephrotic syndrome has not been established in the past, an initial workup for potential underlying causes may be initiated Clinical Considerations Clinical recognition Nephrotic syndrome results when there is increased permeability across the glomerular filtration barrier It is characterized by hypoproteinemia, edema, hyperlipidemia, and massive proteinuria exceeding 50 mg/kg/day Hypertension may be present, especially in the setting of FSGS, but is often absent in MCD Edema, often the most noticeable clinical manifestation of nephrotic syndrome, is the result of excessive salt and water retention Periorbital edema is often the initial finding and may be misdiagnosed as signs of allergy The associated edema is gravity dependent and therefore will vary in location based on patient position and activity Upon awakening, edema may be more marked in the face and then shift to the lower extremities with ambulation It may also be notable in the scrotal or vulvar regions Other complications of third spacing, such as ascites, pulmonary edema, and pleural effusions, may also occur Although children with nephrotic syndrome and edema have total body sodium and water excess, some will present with evidence of intravascular depletion This is more likely to occur in those with severe hypoalbuminemia and will be exacerbated by diuretic use, gastrointestinal