13 year old girl presented with complantis of facial puffiness-3wks,abdominal distension for 2wks,weakness and body pain lasting for 6-7 months. there is no history of hematuria or polyuria. there is no h/o breathlesness,chestpain,cough. there is no h/o jaundice,bleeding manifestations,abdominal pain,diarrhoea,vomitting. there is no h/o tuberculosis in past. o/e there is severe pallor,nolymphadenopathy,no icteruus,anasarca. there is tense ascites and no other significant findings. investigations revealed: hb 5gm% tc 12800 dc p 35 l65 e0 m0 esr 70 mm urine alb ++++ pus full field rbc abs casts abs se.sugar(r) 87 mg% se.bili T 0.9 mg% D 0.2 mg% AST 34 IU/L ALT 35 IU/L ALK PHOS 133 IU/L S.PROTEIN total 2.0 gm% alb 0.8 gm% urine culture was sterlie. blood culture was sterile. perip.smear showed rbc microcytic,hypochromic,target cells. wbc lymphocytosis. platelets 1.7 lakhs/ retic count 17% SICKLING TEST was positive. USG ABDOMEN reveals normal liver texture,gross ascites and renal parenchyma disease grade 1.ovaries normal. chest XRAY shows b/l pleural effusion and pericardial effusion. pt was started with antibiotis and oral prednisolone. fresh FFP was transfused for 7 days. BT was given for 3 units. even after 3 weeks of steroid urine alb remains ++++ and ascites remained same. diagnostic tap revealed. prot. 0.3 gm% glucose 40 mg% cells 5,800/mm3 lymphocytes 100% A D A 1.4 u/L repeated urine cultures sterile. PUS cells remains full field. HIV SCREENING neg. RESPECTED SENIORS, i just want to have your advice reg. how to procede with the case. there are features of haemolytic anemia(SICKLE CELL),nephrotic syndrome and sterile pyuria. can we proceed with starting ATT drugs or go for UROGRAMS OR GO FOR RENAL BIOPSY TO FIND OUT RENAL PATHOLOGY. yours sincerely, a junior resident in pedia.