We read with interest the editorial by Arvind Bagga on Steroid Resistant nephrotic syndrome (SRNS) in the January issue of Indian Pediatrics(1). The same issue also featured our experience with 136 biopsy proven cases SRNS over the last 12 years published as a "brief report"(2). We agree with the observation that the outcome of early steroid resistance (initial nonresponders - INR) is better than children who have late steroid resistance (secondary nonresponders - SNR). In our study we had compared children with Minimal Change disease with non-MCD subtypes. We had observed that the distribution of the number of children who were INR and SNR was similar in the 2 groups. Hence we had commented that the better outcome in MCD was accounted for by the underlying histopathology, rather than the type of steroid resistance. We did not imply that the type of steroid resistance has no effect on the outcome and our results seem to have been misinterpreted. To further clarify this point we are reporting here a subgroup analysis of children with SRNS who were INR as compared to those with those who were SNR.

In our study of the 136 children with SRNS, 94 had early steroid resistance while 42 had late steroid resistance. They were treated with a variety of immunosuppressive protocols (intravenous cyclophosphamide, cyclo-sporine, dexamethasone). The mean age of onset of symptoms in INR was significantly greater than in SNR (9.4 + 5.05 vs 6.7 + 4.99 yrs, P = 0.004). The clinical and biochemical features at onset were similar in the 2 groups. Focal segmental glomerulosclerosis was the commonest histopathologioc subtype in both INR ( 55/94) as well as SNR (25/42). However all the children with Membranous NS (n = 6) as well as those with Mesangiocapillary glomerulo-nephritis (n = 2) were INR. After a mean follow-up of 45.5 + 26.6 months, a significantly greater number of SNR children were in remission as compared to INR (29/42 vs 38/94, P = 0.4). The mean serum albumin on followup was also significantly greater in SNR as compared to INR ( 3.2 + 1.0 vs 2.8 + 0.9 g/dL, P = 0.04).

Hence, we reiterate that children with SNR have a better outcome as compared to children with INR. Further studies are required to analyze the confounding effect of histopathology i.e., whether children with MCD and INR have a better outcome than children with FSGS and SNR.

Sanjeev Gulati,
Alok Kumar,
Department of Nephrology,
Sanjay Gandhi Post Graduate Institute
of Medical Sciences, Raebareli Road,
Lucknow 226 014,
India. 

1. Bagga A. Steroid resistant nephrotic syndrome: Recent developments. Indian Pediatr 2006; 43: 9-13.

2. Gulati S, Sengupta D, Sharma RK, Sharma A, Gupta RK, Singh U, et al. Steroid resistant nephrotic syndrome. Indian Pediatr 2006; 43: 55-60.