A 5-year-old boy presents with periorbital edema, heavy proteinuria (protein:creatinine ratio 8), hypoalbuminemia (serum albumin 1.8 g/dL), and hypercholesterolemia. His blood pressure is normal. He is started on prednisolone 60 mg/m²/day (maximum 60 mg/day). After 4 weeks of daily prednisolone, the urine protein remains negative for 3 consecutive days. What is the correct next step per ISKDC guidelines?
- A Stop prednisolone immediately as the child is in remission
- B Switch to oral cyclophosphamide for 12 weeks
- C Continue prednisolone 40 mg/m² alternate day for 4 weeks, then taper ✓
- D Add tacrolimus and reduce prednisolone to 20 mg/m²/day
Explanation
Per ISKDC (International Study of Kidney Disease in Children) guidelines for the initial episode of nephrotic syndrome, after achieving remission (urine protein negative for 3 consecutive days) with daily prednisolone (60 mg/m²/day for 4–6 weeks), the regimen is changed to alternate-day prednisolone at 40 mg/m² (maximum 40 mg) for 4 weeks, followed by tapering. This two-phase regimen reduces relapse rates while minimizing steroid toxicity. Abrupt cessation after remission increases relapse rates. Cyclophosphamide and calcineurin inhibitors are reserved for frequently relapsing or steroid-dependent nephrotic syndrome.
Reference: Ghai Essential Pediatrics, 10th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.