A 5-year-old boy presents with periorbital edema, massive proteinuria (urine protein:creatinine ratio 9), hypoalbuminemia (serum albumin 1.8 g/dL), and hypercholesterolemia. He responds completely to prednisolone. Two years later he relapses for the sixth time in 12 months while being tapered. Which agent is MOST appropriate for steroid-sparing in frequently relapsing nephrotic syndrome?

• A Rituximab 375 mg/m² IV one dose
• B Tacrolimus 0.1 mg/kg/day
• C Mycophenolate mofetil 600 mg/m² twice daily
• D Cyclophosphamide 2 mg/kg/day for 8 weeks ✓

Explanation

In frequently relapsing or steroid-dependent minimal change nephrotic syndrome (MCNS) in children, cyclophosphamide (CPM) 2–3 mg/kg/day orally for 8–12 weeks is the first-choice steroid-sparing agent; it induces sustained remission in ~40–60% of cases and is a one-time course. Alternative agents include levamisole, mycophenolate mofetil, and calcineurin inhibitors. Rituximab (anti-CD20 monoclonal antibody) is increasingly used for steroid-dependent/frequently relapsing nephrotic syndrome but is reserved for patients who fail or are intolerant of cyclophosphamide or calcineurin inhibitors — it is not first-line steroid-sparing. Tacrolimus and MMF are alternatives for steroid-dependent disease but are used when cyclophosphamide fails or is contraindicated.

Reference: Ghai Essential Pediatrics, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.