A 4-year-old boy has had 5 relapses of nephrotic syndrome in 18 months, each requiring oral corticosteroids. He is currently on prednisolone and has cushingoid features. The BEST strategy to achieve steroid-free remission and prevent further relapses in a frequently-relapsing steroid-sensitive nephrotic syndrome is:
- A Increase prednisolone dose and add calcium + vitamin D
- B IV cyclophosphamide pulse therapy for 6 monthly pulses
- C Add oral mycophenolate mofetil as a steroid-sparing agent ✓
- D Levamisole 2.5 mg/kg alternate days for 12 months
Explanation
In frequently relapsing (≥4 relapses in 12 months) steroid-sensitive nephrotic syndrome (SSNS) with steroid toxicity (Cushingoid features), steroid-sparing agents are indicated. Mycophenolate mofetil (MMF) is an effective, relatively well-tolerated second-line agent that reduces relapse frequency and allows steroid tapering. MMF is increasingly preferred over cyclophosphamide due to a better long-term safety profile (no gonadotoxicity). Cyclophosphamide (oral 2-2.5 mg/kg/day for 12 weeks or IV pulses) is an alternative but has alkylating agent toxicity including gonadotoxicity in cumulative doses. Levamisole is used in low-resource settings but has agranulocytosis risk and requires frequent CBCs. Increasing prednisolone worsens cushingoid features.
Reference: Ghai Essential Pediatrics, 10th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.