A 35-year-old woman with nephrotic syndrome secondary to minimal change disease has been on prednisolone for 10 weeks with no response (steroid-resistant nephrotic syndrome). What is the next treatment step?

• A Cyclophosphamide
• B Rituximab as first alternative
• C Mycophenolate mofetil plus low-dose steroids
• D Cyclosporine or tacrolimus (calcineurin inhibitor) ✓

Explanation

In adults with steroid-resistant minimal change disease (MCD) — defined as no remission after 16 weeks of adequate steroids — calcineurin inhibitors (cyclosporine or tacrolimus) are the recommended next-line agents per KDIGO 2021 guidelines, achieving remission in 70–80% of steroid-resistant cases. Rituximab is increasingly used in frequently relapsing or steroid-dependent MCD rather than steroid-resistant MCD. Cyclophosphamide is used in frequently relapsing MCD. MMF has less evidence in MCD compared to FSGS.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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