An 8-year-old boy with steroid-sensitive nephrotic syndrome (SSNS) has had 4 relapses in the past 18 months. He is currently on alternate-day prednisolone. His mother is concerned about steroid toxicity — height velocity has declined, and he has developed cataracts. Which agent should be considered to induce and maintain remission while reducing cumulative steroid dose?

• A Cyclophosphamide pulse therapy (IV)
• B Rituximab (anti-CD20 monoclonal antibody) ✓
• C Levamisole
• D Tacrolimus

Explanation

Rituximab has emerged as a steroid-sparing agent for frequently relapsing and steroid-dependent nephrotic syndrome in children. It depletes B cells and appears to target abnormal T-cell regulation in MCNS. Multiple RCTs (PREDNOS-2, RITURNS, MENTOR) demonstrate that rituximab maintains remission duration and reduces relapse rates, allowing prednisolone to be withdrawn or significantly reduced. Levamisole is used for frequently relapsing but not steroid-dependent NS. Cyclophosphamide is used as a second-line agent but has significant gonadotoxicity and cumulative risks.

Reference: Ghai Essential Pediatrics, 10th ed.

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