A 30-year-old woman develops nephrotic syndrome with massive proteinuria, hypoalbuminaemia, and oedema. Kidney biopsy shows effacement of foot processes on electron microscopy without immune deposits or hypercellularity. Initial treatment with prednisolone 1 mg/kg/day is initiated. She is classified as 'steroid-sensitive' after achieving complete remission. She now has her third relapse within 1 year of stopping steroids. What is the most appropriate next step?
- A Continue alternate-day prednisolone indefinitely
- B Cyclosporine A for at least 1–2 years as steroid-sparing therapy
- C Mycophenolate mofetil lifelong therapy
- D Cyclophosphamide course for 8–12 weeks ✓
Explanation
This patient has frequently relapsing, steroid-dependent minimal change disease (MCNS). For such patients, cyclophosphamide (2–2.5 mg/kg/day for 8 weeks) induces more prolonged remissions than steroids alone, often achieving sustained remission in 50–75% of patients for years. Cyclophosphamide is preferred for the first steroid-sparing treatment in adults with FSGS/MCNS due to its potential for long-term remission. Cyclosporine is also effective but relapses frequently occur upon discontinuation (calcineurin inhibitor-dependent disease). MMF is an alternative with fewer gonadotoxic side effects. Indefinite alternate-day prednisolone does not address the underlying frequent relapsing pattern and has long-term steroid toxicity.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.