Nephrotic Syndrome in Children: What to Do When Initial Glucocorticoid Therapy Did Not Achieve Complete Remission
This protocol applies when a child with nephrotic syndrome has completed a standard initial course of oral glucocorticoid therapy — typically 8 to 12 weeks — but did not reach the complete remission target within the first 4 weeks of daily treatment.
The prior line consisted of oral prednisone or prednisolone given over 8 or 12 weeks, structured as a daily-dosing phase followed by an alternate-day phase. The required outcome was complete remission within 4 weeks — defined as urinary protein-to-creatinine ratio at or below the accepted threshold on three or more consecutive days. Failure to achieve that endpoint is the trigger for this protocol.
This protocol uses an oral glucocorticoid (prednisone or prednisolone) given as a single daily dose until the remission criterion is sustained for the required number of consecutive days, then transitioned to a reduced alternate-day schedule.
Complete dosing, duration, and step-down criteria are contained in the structured protocol below.
Complete remission: absence of significant proteinuria (negative or trace dipstick, or urinary protein-to-creatinine ratio at or below the accepted threshold) confirmed on three or more consecutive days.
References
- The initial approach to relapse should include oral prednisone or prednisolone as a single daily dose of 60 mg/m² per day or 2 mg/kg per day (maximum 60 mg/d) until the child remits completely for ≥3 days.
- After achieving complete remission in patients with steroid-sensitive nephrotic syndrome treated for relapse, reduce oral prednisone/prednisolone to 40 mg/m² or 1.5 mg/kg (maximum 40 mg) on alternate days for 4 weeks.
- Complete remission: First morning urine or 24-h uPCR ≤200 mg/g (0.2 g/g or 20 mg/mmol or negative or trace dipstick or <100 mg/m² per day) on three or more consecutive days.