A 25-year-old woman develops nephrotic syndrome with 8 g/day proteinuria, hypoalbuminaemia, and oedema. Renal biopsy shows podocyte effacement on electron microscopy with no immune deposits on immunofluorescence. She is initially treated with prednisolone 1 mg/kg/day. After 16 weeks she remains non-responsive. Which is the next step per KDIGO 2021 guidelines?
- A Cyclosporine or tacrolimus as calcineurin inhibitor therapy ✓
- B Rituximab immediately as second-line
- C Repeat biopsy to rule out FSGS before changing therapy
- D Cyclophosphamide 2 mg/kg/day for 8 weeks
Correct answer: A. Cyclosporine or tacrolimus as calcineurin inhibitor therapy
Explanation
Minimal change disease (MCD; no deposits on IF, effacement only on EM) is usually steroid-responsive, but steroid-resistant cases (no remission after 16 weeks) per KDIGO 2021 should be treated with calcineurin inhibitors (cyclosporine or tacrolimus) as second-line therapy. Rituximab is an emerging option but not yet first-choice second-line in most guidelines. Cyclophosphamide is used for frequently relapsing or steroid-dependent disease in children, not routinely for steroid-resistant adult MCD.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.