Question: My daughter was diagnosed with Minimal Change Nephrotic Syndrome in XXXXXXX 2015 and being treated since then.
She is 6 years 3 months old with 114 cm height and 19.4 kg weight.
Initially she was having Urine Albumin (+++) and 24 hours Urine protein 2495 mg/24 hrs. She was being treated with Prednisolone (Omnacortil Forte) 6ml twice daily (36mg) and achieved remission in about 12 weeks’ time. She was also detected with MANTOUX +ve (Tuberculin PPD, Induration 15mm x 10mm) and treated for ATT (Pyzina 500mg, R-cin 300mg) for 6 months in parallel to Nephrotic Syndrome. ANA result was Negative, BP was normal through the course of treatment and blood test (Serum albumin, Serum cholesterol) being done on regular interval with S-cholesterol was 295 mg/dl when urine albumin was (+++) and reduced to 169 mg/dl when achieved remission. Similarly, S-albumin increased from 3.2 mg/dl to 4.3 mg/dl.
However, she had frequent relapses after remission and being observed that she had relapse at a high daily dose of Prednisolone (Omnacortil ) 21mg. The pediatric nephrologist suggested that it’s a Steroid Dependent Nephrotic Syndrome. At this point (Oct 2015) she was administered with Mycophenolate mofetil (MyCept S – 360 mg daily) along with Prednisolone and achieved complete remission in 3 weeks, followed by tapered dose of Prednisolone along with MMF. The ATT was stopped in Nov 2015 and after that she was on remission at a lower dose of Prednisolone (2.5mg alt day) and MMF (360 mg daily) until XXXXXXX 2016.
The first relapse after a long remission occurred again in XXXXXXX 2016 with Prednisolone 2.5 mg + MMF 360mg and the Prednisolone dose was increased to 36 mg daily with a tapered regime in every 2 weeks provided the Urine Albumin is –ve or trace.
She was in remission for almost 2 months and the second relapse occurred in Mar 2016. Again the same regime was followed with 36 mg of Prednisolone daily + MMF (increased to 540 mg/day). She achieved remission in 2 weeks and sustained remission until Aug 2016. She was also off steroid from Jun 2016.
The third relapse occurred in Aug 2016 [ Urine Albumin = (+), Albumin/Creatinine = 31.45 , S Cholesterol =280 mg/dl , S – Albumin = 3.6 mg/dl ) . At this point she was advised for a Renal Biopsy with LM + IF + EM.
The Light Microscopy report suggests that,
Nineteen glomeruli are identified. None are globally sclerotic. They appear normocellular. Capillary loops ae open and have delicate contours. No spike or duplication or duplication of glomerular basement membranes seen. No segmental sclerosis is identified in any of the glomeruli included. No significant inflammation or fibrosis are seen in interstitium.



and Immunofluorescence report suggests that,

12 glomeruli are present for evaluation. The sections are stained for IgG, IgM, IgA, C3, Clq, Kappa & Lambda light. All stains are negative.
Final results suggests that ,
Features are consistent with Minimal Change Disease
Currently my daughter is in remission with 5mg Prednisolone alt day and 540 mg of MMF daily.
Based on the biopsy report, the treating pediatric nephrologist has given me an option to go with Rituximab or Tacrolimus based therapy.
My daughter is paranoid with hospitalization and Rituximab therapy would require atleast a day care admission with supervised slow infusion.
I am currently confused in terms of which option to go with. I have gone through the following journals to understand the efficacy of both the drugs.
Short-term efficacy of rituximab versus tacrolimus in steroid-dependent nephrotic syndrome – By XXXXXXX A., Bagga, A., Gulati, A. et al. Pediatr Nephrol (2012) 27: 235)
Efficacy and safety of rituximab in children with difficult-to-treat nephrotic syndrome (Aditi Sinha1, XXXXXXX Bhatia1, XXXXXXX Gulati1, XXXXXXX Rawat1, XXXXXXX K. Dinda2, XXXXXXX Hari1 and XXXXXXX Bagga1)
Requesting your guidance in understanding the best option to go with.