Management of idiopathic nephrosis in adults, including steroid-resistant nephrosis

The initial management of idiopathic nephrotic syndrome with steroids alone is often reserved for patients with the highly responsive lesion of minimal change disease. This disease can be seen in up to 30% of adult patients, and appears to portend the same favorable prognosis as it does in children. However, adults respond more slowly to steroids than children, and therefore need a longer course of treatment to attain a remission rate similar to that of children. Patients with the lesion of focal segmental glomerular sclerosis do not respond so well to steroids; clinicians are often reluctant to treat such patients, particularly adults. Fourteen to 80% of adults with idiopathic nephrotic syndrome have this lesion, including the majority of black patients. Despite the previously poor results with steroids, remission rates of up to 60% have recently been reported with prolonged courses of therapy. Given these findings for minimal change disease and focal segmental glomerular sclerosis, steroid resistance in adults should perhaps be assumed only after failure to respond to a 4-month course of daily steroid therapy. Prospective trials are needed to confirm these data.