A 4-year-old boy presents with generalized edema, urine protein 3+ on dipstick, serum albumin 1.6 g/dL, serum cholesterol 380 mg/dL, and normal blood pressure. Serum C3 is normal. He is started on prednisolone and achieves remission within 4 weeks. He has 3 more relapses within 12 months, each requiring prednisolone. He now develops significant cushingoid features. What is the MOST APPROPRIATE next pharmacological step?
- A Increase prednisolone dose and continue for 2 years
- B Perform renal biopsy immediately and start cyclophosphamide empirically
- C Add levamisole as a steroid-sparing agent for frequently relapsing nephrotic syndrome ✓
- D Switch to alternate-day prednisolone alone, as frequently relapsing NS does not require steroid-sparing agents
Explanation
This child has frequently relapsing steroid-sensitive nephrotic syndrome (FRNS: ≥2 relapses in 6 months or ≥4 in 12 months) with steroid toxicity (cushingoid features). In FRNS, steroid-sparing agents are indicated to maintain remission while minimizing steroid dose. Levamisole (an immunomodulator) is the first-line steroid-sparing agent in FRNS as per IAP guidelines, effective in maintaining remission when added to low-dose alternate-day prednisolone. Renal biopsy is indicated in steroid-resistant NS (no remission after 4 weeks of prednisolone), not FRNS. Cyclophosphamide is used in steroid-dependent NS or FRNS failing levamisole.
Reference: Ghai Essential Pediatrics, 10th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.