What is the recommended dose of prednisone (corticosteroid) for a patient with nephrotic syndrome?

Recommended Steroid Dosing for Nephrotic Syndrome

For initial presentation of childhood nephrotic syndrome, start prednisone at 60 mg/m²/day (or 2 mg/kg/day, maximum 60 mg) as a single daily dose for 4-6 weeks, followed by 40 mg/m²/dose (or 1.5 mg/kg, maximum 40 mg) on alternate days for 2-5 months with gradual tapering, for a total treatment duration of at least 12 weeks. 1

Initial Episode Treatment Algorithm

Daily Phase (Weeks 1-6)

• Dose: 60 mg/m²/day OR 2 mg/kg/day (maximum 60 mg/day) 1
• Administration: Single morning dose (not divided doses) 1, 2
• Duration: Continue for 4-6 weeks 1

Critical dosing consideration: The 60 mg/m² and 2 mg/kg formulations are NOT equivalent in children weighing <30 kg—the weight-based dosing delivers approximately 15% less medication. 3 Use body surface area calculation (60 mg/m²) for more accurate dosing in younger children. 3

Alternate-Day Phase (Weeks 7-16)

• Dose: 40 mg/m²/dose OR 1.5 mg/kg/dose (maximum 40 mg on alternate days) 1
• Administration: Single morning dose every other day 1
• Duration: 2-5 months with tapering 1
• Tapering schedule: After 6 weeks of alternate-day therapy, taper by 10 mg/m² per week down to 5 mg on alternate days 1

Total treatment duration: 12-16 weeks minimum 1

Relapse Treatment

Infrequent Relapses

• Daily phase: 60 mg/m²/day (maximum 60 mg) until remission achieved (urine dipstick trace/negative for 3 consecutive days) 1
• Alternate-day phase: 40 mg/m²/dose on alternate days for at least 4 weeks after remission 1

Frequent Relapses or Steroid-Dependent Disease

• Daily phase: 60 mg/m²/day until remission (3 consecutive days) 1
• Alternate-day phase: 40 mg/m²/dose on alternate days for at least 3 months 1
• Maintenance: Use lowest dose on alternate days to maintain remission without major adverse effects 1

Alternative for selected frequent relapsers: Lower doses (0.2-1.5 mg/kg/day) may successfully induce remission in some patients, reducing cumulative steroid exposure. 2, 4 However, this approach requires close monitoring as response time may be delayed (10 days vs. 7 days with standard dosing). 4

Important Clinical Pitfalls

Age-Related Considerations

• Children <1 year: Do NOT use standard protocols—these patients likely have genetic causes and should be managed differently with kidney biopsy before treatment 1
• Children >12 years: Consider kidney biopsy before initiating therapy as secondary causes become more common 1

Response Monitoring

• Expected response time: 9-11 days in children for initial episode 2, 5
• Adults: May require up to 16 weeks to respond 5
• Steroid resistance definition: No remission after 8 weeks of appropriate therapy 1

Dose Adjustments NOT Required

• Prednisone does not require dose adjustment based on GFR levels, even in advanced CKD 6, 7
• Standard dosing maintained even when GFR <50 mL/min 6, 7

When to Consider Alternative Therapy

Steroid-sparing agents indicated when: 1

• Significant steroid-related adverse effects develop
• Frequent relapses (≥2 relapses in 6 months or ≥4 relapses in 12 months)
• Steroid dependence (relapse during tapering or within 2 weeks of stopping)

First-line steroid-sparing options: 1

• Levamisole (if available)
• Cyclophosphamide (2-3 mg/kg/day for 8-12 weeks) 5
• Calcineurin inhibitors (cyclosporine 3-5 mg/kg/day) 7, 5

Essential Supportive Care

Prophylaxis requirements during high-dose therapy: 7

• Pneumocystis pneumonia prophylaxis when prednisone ≥0.5 mg/kg/day
• Gastroprotection per local guidelines
• Bone protection per local guidelines

Monitoring parameters: 6, 7

• Serum creatinine and GFR
• Proteinuria (daily urine dipstick)
• Potassium levels
• Blood pressure