What is the recommended follow-up plan for a young adult patient with a history of steroid-sensitive nephrotic syndrome (SSNS) who has achieved remission?

Follow-Up Plan for Young Adults with Steroid-Sensitive Nephrotic Syndrome in Remission

Young adults with SSNS who have achieved remission should be monitored with regular urine dipstick testing for proteinuria at home and periodic clinical assessments, with the frequency and duration of follow-up determined by their relapse pattern and steroid dependence status. 1

Defining Remission and Monitoring Parameters

Remission is confirmed when urine dipstick shows trace/negative proteinuria for at least 3 consecutive days. 1, 2 For ongoing monitoring:

• Home urine dipstick testing should be performed regularly (at minimum weekly, more frequently during intercurrent illnesses) to detect early relapse 2
• Relapse is defined as ≥2+ proteinuria for 3 consecutive days on early morning urine or ≥2+ proteinuria with edema 1
• Monitor blood pressure at each clinical visit 2
• Assess for steroid-related adverse effects including growth, bone health, and metabolic complications 3, 4

Risk Stratification and Follow-Up Intensity

The follow-up plan must be tailored based on the patient's relapse history:

For Infrequent Relapsers (≤1 relapse in 6 months)

• Clinical follow-up every 3-6 months with assessment of growth, blood pressure, and review of home urine monitoring 4
• Continue home urine dipstick monitoring indefinitely, as relapses can occur years after initial presentation 3
• No routine laboratory monitoring needed if consistently in remission 4

For Frequent Relapsers or Steroid-Dependent Patients

• More intensive monitoring every 2-3 months during the first year after achieving remission 4
• If on steroid-sparing agents (levamisole, cyclophosphamide, or calcineurin inhibitors), monitor drug-specific toxicities 1
• For patients on calcineurin inhibitors who achieved complete remission, consider discontinuation after 12-24 months to reduce nephrotoxicity risk 1
• Monitor serum creatinine and estimated GFR to assess for CNI nephrotoxicity 1

Management of Intercurrent Illnesses

During upper respiratory tract infections or other illnesses, patients with frequent relapsing or steroid-dependent SSNS should receive daily prednisone at their maintenance dose to reduce relapse risk. 1 This is a critical preventive measure, as infections are the most common trigger for relapse 1.

Treatment of Relapses

If relapse occurs during follow-up:

• For infrequent relapses: Treat with prednisone 60 mg/m² (maximum 60 mg/day) daily until remission for at least 3 days, then 40 mg/m² on alternate days for at least 4 weeks 1
• For frequent relapses or steroid-dependent disease: After achieving remission with daily prednisone, switch to alternate-day therapy for at least 3 months 1
• Consider steroid-sparing agents (levamisole first-line, then cyclophosphamide or CNIs) if patients develop steroid-related adverse effects or meet criteria for frequent relapsing/steroid-dependent disease 1

Long-Term Prognosis Counseling

Most patients with SSNS will eventually achieve permanent remission with normal kidney function, making the primary concern the cumulative morbidity from immunosuppressive therapy rather than kidney failure. 3 This should guide treatment decisions toward minimizing drug toxicity while maintaining remission 3.

• Approximately 70-80% of patients will experience at least one relapse, with up to 50% developing frequent relapses or steroid dependence 4
• The goal is balancing different therapeutic agents to achieve sustained remission with the lowest cumulative side effects 3
• Long-term kidney function remains excellent in the vast majority of SSNS patients 3, 4

Critical Pitfalls to Avoid

• Do not assume permanent cure after initial remission - continued home monitoring is essential as relapses can occur unpredictably 3, 4
• Do not delay introduction of steroid-sparing agents in patients developing significant steroid toxicity or meeting criteria for frequent relapsing/steroid-dependent disease 1, 4
• Do not continue CNIs indefinitely - reassess need after 12-24 months of complete remission to minimize nephrotoxicity 1
• Do not use cyclophosphamide for steroid-resistant nephrotic syndrome if it develops - CNIs are first-line therapy 1, 5