A 4-year-old child with idiopathic nephrotic syndrome (INS) is started on prednisolone 60 mg/m²/day. After 6 weeks of full-dose steroids, the child remains nephrotic (urine protein 4+ on dipstick, albumin 1.8 g/dL). The MOST appropriate next management step is:

• A Continue prednisolone for 2 more weeks before declaring steroid resistance
• B Kidney biopsy and start cyclophosphamide
• C Switch immediately to mycophenolate mofetil without biopsy
• D Kidney biopsy to confirm histology, then consider calcineurin inhibitor (CNI) or cyclophosphamide ✓

Explanation

Steroid-resistant nephrotic syndrome (SRNS) is defined by persistent nephrosis after 8 weeks of full-dose prednisolone therapy (or 4 weeks of full dose, depending on guideline version). Before initiating second-line immunosuppression, kidney biopsy is mandatory to establish histological diagnosis — focal segmental glomerulosclerosis (FSGS) is the most common finding in SRNS and influences therapy selection. Calcineurin inhibitors (tacrolimus or cyclosporine) are the first-line agents for SRNS in current ISKDC/IPNA guidelines. Cyclophosphamide is used in steroid-dependent/frequently relapsing disease. Mycophenolate without biopsy is not evidence-based in SRNS.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.