A 5-year-old boy presents with periorbital puffiness, massive proteinuria (4+ on dipstick), hypoalbuminemia (1.8 g/dL), and hypercholesterolemia. He has no hematuria and blood pressure is normal. He is started on prednisolone. After 8 weeks of adequate corticosteroid therapy, proteinuria persists. What is the NEXT step?

• A Renal biopsy ✓
• B Cyclosporine immediately without biopsy
• C Increase prednisolone dose to 2 mg/kg/day
• D Add enalapril and furosemide and continue steroids for another 4 weeks

Explanation

Steroid-resistant nephrotic syndrome (SRNS) is defined as persistent proteinuria after 8 weeks of adequate daily prednisolone therapy (2 mg/kg/day × 4 weeks followed by 1.5 mg/kg/alternate days × 4 weeks). SRNS requires renal biopsy to identify the underlying histopathological diagnosis (most commonly focal segmental glomerulosclerosis — FSGS — in this age group) before initiating second-line immunosuppressants (cyclosporine, tacrolimus). Proceeding to cyclosporine without biopsy is inappropriate as histology guides management and prognosis. Increasing prednisolone is not evidence-based after steroid resistance is established.

Reference: Ghai Essential Pediatrics, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.