A 4-year-old child with steroid-sensitive nephrotic syndrome has relapsed twice in the past year (frequent relapser). He has been on prednisolone for 8 months total. Which of the following is the most appropriate next step to reduce steroid toxicity and maintain remission?
- A Switch to mycophenolate mofetil as first steroid-sparing agent
- B Perform renal biopsy to guide therapy
- C Add levamisole 2.5 mg/kg on alternate days for 1–2 years ✓
- D Continue alternate-day prednisolone indefinitely
Correct answer: C. Add levamisole 2.5 mg/kg on alternate days for 1–2 years
Explanation
In frequent-relapsing steroid-sensitive nephrotic syndrome (SSNS), levamisole (2.5 mg/kg on alternate days) is recommended as the first-line steroid-sparing agent by ISKDC and IAP guidelines due to its immunomodulatory properties, good safety profile, and evidence of reducing relapse frequency. Mycophenolate mofetil is a second-line agent. Renal biopsy in uncomplicated SSNS is not routinely indicated before steroid-sparing therapy. Indefinite alternate-day prednisolone causes cumulative toxicity.
Reference: Ghai Essential Pediatrics, 10th ed.
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