The idiopathic nephrotic syndrome (NS) of childhood is a heterogenous disorder characterised by massive proteinuria, hypoalbuminemia, hyperlipidemia and edema. Histological characteristics are non-specific and range from minimal change disease, focal and diffuse mesangial proliferation to focal and segmental glomerulosclerosis (FSGS). Immunofluorescence is usually negative and electron microscopy shows fusion of the epithelial cell foot processes [1]. Over 80% of children presenting with an initial episode of NS respond to steroids (steroid sensitive), whilst the remaining 20% do not respond and are considered steroid resistant (SR) [2]. On follow up, 50-60% of children in the steroid responsive group have frequent relapses or develop steroid dependant disease. This group of children are at risk for extrarenal complications of NS as well as progression to end-stage renal disease necessitating renal replacement therapy. In these children who undergo transplantation, the overall risk for recurrence of the primary disease is about 25% [1]. The aim of therapy is to control the nephrotic state and thus prevent complications and to especially try and halt or delay progression to end-stage renal disease. To date the plethora of agents in our therapeutic armamentarium has failed to produce a drug that is the panacea for this condition. Thus management of SRNS therefore poses a major therapeutic challenge to the attending clinician.

There are certain clinical and histological characteristics that may predict the likelihood of steroid resistance. These include:

• Hypertension (50-60% likelihood)
 
• Hematuria (30%)
 
• Hypertension plus hematuria (20%)
 
• Elevated plasma creatinine
 
• Massive proteinuria (>10g/day)
 
• Age of first presentation in infancy, after 8 years or post puberty
 
• Tubulointerstitial disease on renal biopsy or collapsing FSGS and percentage of globally sclerosed glomeruli
 
• Black race
 
• Selectivity index >0.2
 
• Tubular proteinuria (Increase excretion of B2 -microglobulin retinol-binding protein, lysozyme [3].