11-08-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[11-08-2025 16:21] PPM 1: @PPM3 we haven't added the patient advocate here yet?
[12-08-2025 17:00] PPM 1: EMR summary:
Age/Gender : 17 Years/Female
Address :
Discharge Type: Relieved
Admission Date: 29/07/2025 08:53 PM
Name of Treating Faculty
[HOD]
(PGY1)
Diagnosis
NEPHROTIC SYNDROME
FSGS
Case History and Clinical Findings
CHIEF COMPLAINTS :
C/O BILATERAL PEDAL EDEMA SINCE 20 DAYS
FACIAL PUFFINESS SINCE 20 DAYS
HOPI :
PATIENT WAS APPARENTLY ASYMOTOMATIC 20 DAYS BACK THEN AFTER WAKING UP IN
THE MORNING SHE OBSERVED FACIAL PUFFINESS , DECREASED IN THE EVENING ,
INCREASED IN THE MORNING , THEN AFTER 2 DAYS SHE DEVELOPED BILATERAL PEDAL EDEMA , INSIDIOUS IN ONSET, PROGRESSIVE [ FROM ANKLE NOW EXTENDING UPTO THE SHIN], PITTING TYPE ,.
NO C/O SOB, ORTHOPNOEA , PND INCREASE IN MORNING , DECREASE AT NIGHT .
NO C/O FEVER , NAUSEA , VOMITINGS
H/O BURNING MICTURITION FOR 2 -3 DAYS [RESOLVED],
H/O DECREASED URINE OUTPUT 17 DAYS BACK.
NO C/O GIDDINESS , CHEST PAIN , PALPIATIONS .
C/O COUGH SINCE 17 DAYS , PRODUCTIVE , WHITISH , NO DIURNAL VARIATION , NO
POSTURAL VARIATION.
H/O BURNING SENSATION AT ABDOMEN AFTER FOOD INTAKE
H/O FEVER AND MYALGIA 2-3 MONTHS BACK
Page-2
KIMS HOSPITALS
H/O RING WORM INFECTION 1 YEAR BACK
N/K/C/O DM, HTN, CVA, CAD, TB, EPILEPSY, THYROID DISORDERS
PERSONAL HISTORY: UNMARRIED, MIXED DIET, REGULAR BOWEL AND BLADDER
MOVEMENTS , NO KNOWN ALLERGIES AND ADDICTIONS
FAMILY HISTORY - NOT SIGNIFICANT
GENERAL EXAMINATION:
NO PALLOR , NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, PEDAL EDEMA,
MALNUTRITION
VITALS:- TEMP: 98.0 F, BP: 120/80MMHG, RR: 18 CPM, PR: 80 BPM, SPO2: 99% AT RA
SYSTEMIC EXAMINATION :
CVS - S1 S2 +, NO MURMURS
RS - BAE +, NVBS
PER ABDOMEN - SOFT , NON TENDER
CNS - NFND , HIGHER MENTAL FUNCTIONS INTACT
Investigation
COMPLETE URINE EXAMINATION (CUE) 29-07-2025 09:14:PMCOLOUR Pale
yellow APPEARANCE Clear REACTION Acidic SP.GRAVITY 1.010ALBUMIN +++SUGAR Nil BILE SALTS Nil BILE PIGMENTS Nil PUS CELLS 5-6 EPITHELIAL CELLS 3-4 RED BLOOD CELLS Nil CRYSTALS Nil CASTS Nil AMORPHOUS DEPOSITS Absent OTHERS Nil
HEPATITIS- B SURFACE ANTIGEN (HBSAg) RAPID TEST 29-07-2025 09:14:PM Negative ANTI
HCV ANTIBODIES (Rapid Test)RAPID 29-07-2025 09:14:PM Non Reactive
BLOOD UREA 29-07-2025 09:16:PM 27 mg/dl SERUM CREATININE 29-07-2025 09:16:PM 1.1 mg/dl
SERUM ELECTROLYTES 29-07-2025 09:16:PMSODIUM 135 mmol/LPOTASSIUM 4.4
mmol/L CHLORIDE 102 mmol/L LIVER FUNCTION TEST (LFT) 29-07-2025 09:16:PMTotal Bilurubin 0.51 mg/dl Direct Bilurubin 0.19 mg/dlSGOT(AST) 33 IU/LSGPT(ALT) 19 IU/LALKALINE
PHOSPHATASE 166 IU/LTOTAL PROTEINS 4.9 gm/dl ALBUMIN 1.77 gm/dl A/G RATIO 0.57
BLOOD UREA 01-08-2025 08:30:AM 25 mg/dl SERUM CREATININE 01-08-2025 08:30:AM 1.0 mg/dl
SERUM ELECTROLYTES 01-08-2025 08:30:AMSODIUM 134 mmol/LPOTASSIUM 4.0
mmol/LCHLORIDE 102 mmol/L
HAEMOGLOBIN 9.4 gm/dl TOTAL COUNT 9,600 cells/cumm LYMPHOCYTES 35 % EOSINOPHILS
05 % MONOCYTES 06 % BASOPHILS 00 %PCV 28.7 vol % M C V 77.8 fl M C H 25.5 pg M C H C
32.8 % RDW-CV 20.2 % RDW-SD 57.9 fl RBC COUNT 3.69 millions/cumm PLATELET COUNT 4.00
lakhs/cu.mm
SMEARRBC microcytic hypochromic
Page-3
KIMS HOSPITALS
HEMOGRAM ON 1/8/25
HAEMOGLOBIN 9.5 gm/dl TOTAL COUNT 7,700 cells/cumm NEUTROPHILS 55 %
LYMPHOCYTES 35 % EOSINOPHILS 04 % MONOCYTES 06 % BASOPHILS 00 % PCV 29.8 vol %
M C V 79.9 fl M C H 25.3 pg RDW-CV 23.6 % RDW-SD 68.1 fl RBC COUNT 3.73 millions/cumm
PLATELET COUNT 3.48 lakhs/cu.mm SMEARRBC Normocytic normochromic Light Microscopy WBC With in normal limits Light Microscopy PLATELETS Adequate in number
Blood Urea - 25 mg/dl
SERUM ELECTROLYTES
Serum Creatinine 1.0 mg/dl
SODIUM 134 mmol/L CHLORIDE 102 mmol/L CALCIUM IONIZED 1.21 mmol/L
Prothrombin Time 16 Sec INR 1.11
SPOT UPCR ON 29/7/25
SPOT URINE PROTEIN-172 mg/dl. SPOT URINE-CREATININE -78.0 mg/dl. RATIO 2.20
24 HR URINARY PROTIEN:
24 HOURS URINARY PROTEIN-1,920 mg/day. 24 HOURS URINE VOLUME -800 ml
USG WAS DONE ON 29/7/2025- NO SONOLOGICAL ABNORMALITY DETECTED
Urinary Creatinine 0.8 g/day
RENAL BIOPSY WAS DONE ON 1/8/25
Treatment Given(Enter only Generic Name)
FLUID RESTRICTION,2L/DAY
SALT RESTRICTION ,2GM/DAY
INJ METHYLPREDNISOLONE 1GM IV/OD IN 100ML NS OVER 30 MINS
INJ LASIX 40MG IV/TID 8AM--2PM--5PM
ALBUMIN RICH PODER 2TPSP IN GLASS OF WATER
Advice at Discharge
FLUID RESTRICTION,2L/DAY
SALT RESTRICTION ,2GM/DAY
ALBUMIN RICH PODER 2TPSP IN GLASS OF WATER
TAB. PREDNISILONE 30 MG PO/BD FOR 10 DAYS
TAB .LASIX 40 MG PO/BD FOR 10 DAYS 1-X-1
Follow Up
REVIEW WITH BIOPSY REPORT TO NEPHRO OPD
When to Obtain Urgent Care
Page-4
KIMS HOSPITALS
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR ORATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact:
08682279999 For Treatment Enquiries Patient/Attendant Declaration : - The medicines prescribed
and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been
explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER
SIGNATURE OF PG/INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
Discharge Date
Date:
Ward: CKD
Unit:
[12-08-2025 19:27] PPM 1: @PPM 4 will you be able to talk to this patient's advocate and then make him her talk to the patient advocate of 22F who also has nephrotic syndrome?
This participatory medical cognition exercise may help the patients to make better informed decisions at their non clinical (external medicine) level? @PPM5 @PPM6 @PPM7?
The patient here has already cleared her mpc inter and was about to take admission in B tech when this illness started. Now she has put that on hold. She's quite intelligent and WhatsApp savvy.
We know with FSGS the prognosis is such that she may land up needing a renal transplant soon and we need to guide and empower both these two patients with the adequate support they need.
[14-08-2025 07:06] PPM 1: @PPM4 we need to convey a few things to them when you try to make that phone connect.
1a) Never to share patient identifiers online. We will delete the face photo and try to upload the eyelids again.
1) They need to share regularly here about her diet plates and hourly activities so that we can track the reason for such failures.
2) They need to understand that the biopsy suggests that she has FSGS which is a more advanced disease, less amenable to therapy than what we may have witnessed in our lupus nephritis patient with whom you were supposed to introduce them.
3) We may need to add azathioprine to reduce her current dose of steroids and keep our Nephrologist in the loop through @PPM9 @PPM3
3) Eventually if the medicines don't work she may need a transplant for which they need to prepare mentally from now on
4) Lastly the morning edema around the eyes is maximum in the morning because of the fact that while asleep the total body water in the third space gravitated toward the eyes.
[14-08-2025 07:10] PPM 1: మీ ఫోన్ కాల్ కనెక్ట్ చేయడానికి ప్రయత్నించే సమయంలో వీరకి కొన్ని విషయాలు伝ించాలని ఉంది.
1a) ఆన్లైన్లో రోగి గుర్తింపు వివరాలు ఎప్పుడూ పంచుకోవద్దు. మేము ముఖంలో ఉన్న ఫోటోని తొలగించి, మళ్లీ కనువెళ్ళ ఫోటో అప్లోడ్ చేయడానికి ప్రయత్నిస్తాము.
1) వారి ఆహార ప్లేట్లు, గంటల వారీ కార్యకలాపాల గురించి ఇక్కడ రెగ్యులర్గా వివరాలు పంచుకోవాలి, తద్వారా ఆవిధమైన వైఫల్యాల కారణాలను ఏదైనా ట్రాక్ చేయగలుగుతాం.
2) బయాప్సీ ద్వారా ఆమెకు FSGS (ఫోకల్ సెగ్మెంటల్ గ్లోమెరులో స్క్లిరోసిస్) ఉందని అర్థం చేసుకోవాలి, ఇది ముందు మీరు పరిచయం చేయాల్సిన లుపస్ నెఫ్రైటిస్ రోగికి కన్నా ఎక్కువగా అభివృద్ధి చెందిన, చికిత్సకు తక్కువ ప్రతిస్పందించే వ్యాధి.
3) ఆమె ప్రస్తుత స్టెరాయిడ్ల డోస్ని తగ్గించడానికి అజాథియోప్రైన్ జోడించవలసి ఉంటుంది. మా నెఫ్రాలజిస్ట్ని @PPM9 @PPM3 ద్వారా సమాచారంలో ఉంచండి.
3) చివరగా మందులు పనికిరాకపోతే ఆమెకు ట్రాన్స్ప్లాంట్ అవసరం కావచ్చు, అందుకు మానసికంగా సిద్ధం కావటం ప్రారంభించాలి.
4) ఉదయం కనుమూల చుట్టూ వాపు ఎక్కువగా కనిపించడం ఎందుకంటే అందులోకి సొరగట్టు సమయంలో శరీరం మొత్తం నీరు కళ్లు వైపు వలసిపోతోంది.
అప్పటి తేదీ: గురువారం, ఆగస్టు 14, 2025, ఉదయం 7 గంటలు IST
[14/08, 07:07] Perplexity: Here’s the transliteration in English:
@ mee phone call connect cheyadaaniki prayatninche samayamlo veeraki konni vishayalu cherchali.
1a) Online lo rogi gurthinpu vivaralu eppudu panckovaddu. Memu mukhamlo unna photo ni tolaginchi, malli kanu vella photo upload cheyadaaniki prayatnistamu.
1) Vari aahaara plates, gantala vaari kaaryakalapaalu gurinchi ikkada regularly vivaralu panckovali, thadvaara aavidhamaaina vaiphalyala kaaranalanu eedaina track cheyagalugutam.
2) Biopsy dwara ame ku FSGS (Focal Segmental Glomerulo Sclerosis) undani artham chesukovali, idi mundu meeru parichayam cheyaalsina lupus nephritis rogi ki kanna ekkuva ga abhivruddhi chesina, chikitsa ku takkuva pratispandince vyadhi.
3) Ame prastuta steroid dose ni tagginchadaaniki azathioprine jodinchavalsi untundi. Maa nephrologist ni @PPM9 @PPM3 dwara samacharamlo unchandi.
3) Chivariga mandulu panikiraakapothe ame ku transplant avasaram kavachu, anduku maanasikanga siddham avadam praarambhinchali.
4) Udayam kanumuula chuttu vaapu ekkuvaga kanipinchadam endukante anduloki soragattu samayamlo shareeram mottham neeru kalllu vaipu valasipothundi.
Appati tedi: Guruvaaram, August 14, 2025, udayam 7 gantalu IST
[14-08-2025 08:37] PPM 9: Ok sir
[14-08-2025 10:14] PPM 1: @Meta AI what is the standard recommendation for re evaluation of 24 hour urine protein post steroid therapy? After how many days it needs to be repeated to check for remission and what is the effective frequency of this evaluation? Please share your statements with perplexity styled links to evidence based data
[14-08-2025 10:14] Meta AI: The standard recommendation for re-evaluation of 24-hour urine protein post-steroid therapy typically involves checking for remission after 6–8 weeks of initial therapy, as this is the timeframe during which steroid-sensitive nephrotic syndrome (SSNS) or steroid-resistant nephrotic syndrome (SRNS) responses are most evident. Complete remission is defined as urine protein nil-trace by dipstick for three consecutive days, or a protein-creatinine ratio (Up/Uc) of <0.2.¹ ²
For effective frequency, weekly or biweekly evaluations are often advised during the initial treatment phase to monitor response closely. Once remission is achieved, monitoring can be spaced out, but relapses or resistance should prompt closer follow-ups and potentially additional tests, such as spot protein/creatinine ratios for convenience.³
Would you like information on alternative monitoring methods or updated guidelines for specific conditions?
[14-08-2025 10:14] Meta AI: https://www.indianpediatrics.net/july2021/650.pdf
[14-08-2025 10:14] Meta AI: https://theipna.org/wp-content/uploads/2022/02/IPNA_SRNS_English.pdf
[14-08-2025 10:14] Meta AI: https://www.indianpediatrics.net/may2021/may-461-481.htm
[14-08-2025 10:17] PPM 1: Not sure why this was done after 5 days of starting treatment?
[14-08-2025 10:21] PPM 3: It was done before also sir,this is the recent one
[14-08-2025 12:27] PPM 4: will call them today evening sir..
[14-08-2025 13:05] PPM 1: That's what we are asking. Why was it needed unnecessarily again when it was already done a few days earlier
[14-08-2025 13:06] PPM 1: Was done on 27/6/25 as per discharge EMR summary
[15-08-2025 14:19] PPM 4: Talked to the patient sir @PPM1
talked about adherence to therapy and possible chances of success of steroid therapy.. and probability of transplantation/ dialysis within 5-6 years incase if the syndrome is steroid therapy resistant
introduced 22F Lupus Nephrotic syndrome patient to her. and added her to the group for inputs from patient's perspective.
17F patient will be sharing food plates images and daily activities and tablet intake message in the group from today here sir.
[15-08-2025 14:24] PPM 1: Wow! Amazing work!
Thanks a lot for encouraging steps to building this network to empower patients
[15-08-2025 18.59] PPM 4: A small correction.. @CR the patient is actually unmarried.
[15-08-2025 19:19] CR: Done
[15-08-2025 19:52] PPM 1: Thanks for the correction. Unfortunately will still remain in her paper discharge although it's good that we have corrected it in our online summary
[15-08-2025 21:27] PA: Patient Tablets veskunnaru mam
[15-08-2025 21:27] PA: Day motham intikade unnaru
[15-08-2025 21:28] PA: 6 to 8 walking chesaru
[16-08-2025 10:03] PPM 1: It's difficult to optimise the dose of this combination @PPM4
We can ask the patient to switch to tablet lasix (frusemide) and then ask her to take 80mg at 8:00AM and 40mg at 12:00 PM. Again this is just to address her cosmetic needs of reducing the skin edema.
For real remission we will need to wait for the immunosuppressives to take hold but again reducing the steroid dose even early at this juncture by adding an adjuvant azathioprine 50 mg and making the oral Prednisolone just 30 mg would be safer perhaps?
@Meta AI @PPM8 @PPM2 your inputs on best possible immuno suppression combination to manage nephrotic proteinuria in a 17 year old woman with normal creatinine but a biopsy showing focal segmental glomerulosclerosis? Please substantiate with perplexity styled references and single RCT evidences in PICO format mentioning absolute numbers and no percentages
[16-08-2025 10:03] Meta AI: Managing nephrotic proteinuria in a young patient with focal segmental glomerulosclerosis (FSGS) requires a tailored approach balancing efficacy and safety. Here's a breakdown of your query with relevant evidence and considerations:
---
### 1. Lasix (Frusemide) for Symptomatic Edema Management
- Proposed Plan: Switching to tablet Lasix and administering 80 mg at 8:00 AM and 40 mg at 12:00 PM is reasonable for diuretic control of edema. Dividing the dose avoids excessive diuresis at once and optimizes fluid removal.
- Considerations: Monitor for hypokalemia and volume depletion, especially in a young patient. Add potassium supplementation if needed or consider a potassium-sparing diuretic like spironolactone.
---
### 2. Steroid Dose Optimization
- Current Plan: Reducing oral prednisolone to 30 mg/day while introducing azathioprine (AZA) 50 mg/day as a steroid-sparing agent.
- Evidence:
- RCT Reference: Ponticelli et al. (1999) showed benefits of corticosteroids in idiopathic FSGS, but prolonged high-dose steroids increase side effects.
- Early tapering with adjunctive immunosuppressives is supported in steroid-dependent or resistant cases.
- Considerations: AZA is often used as a second-line agent, but its efficacy in FSGS is less robust compared to alternatives like calcineurin inhibitors (e.g., tacrolimus or cyclosporine).
---
### 3. Optimal Immunosuppressive Combination
- Primary Goal: Achieve remission of proteinuria and preserve renal function.
- Evidence-Based Options:
- Calcineurin Inhibitors (CNI): Tacrolimus or cyclosporine combined with low-dose steroids.
- RCT Evidence: CNI use in FSGS has shown remission rates of ~60% in steroid-resistant cases (PICO format below).
- Mycophenolate Mofetil (MMF): Potentially effective in steroid-dependent FSGS, especially in combination with low-dose prednisolone.
- Azathioprine: Less commonly first-line in FSGS, often used in milder cases or when CNIs are contraindicated.
- PICO Example:
- Population: 17-year-old with biopsy-proven FSGS and nephrotic proteinuria.
- Intervention: Tacrolimus + low-dose prednisolone.
- Comparison: Prednisolone monotherapy.
- Outcome: Complete or partial remission of proteinuria over 6 months.
- RCT Evidence: Randomized studies (e.g., Gipson et al., 2011) showed tacrolimus achieved remission in ~60-70% of patients compared to ~30% with steroids alone.
---
### 4. Additional Considerations
- Monitor: Proteinuria (urine protein-to-creatinine ratio), renal function, and side effects of immunosuppressive drugs.
- Lifestyle: Sodium restriction and adequate protein intake to manage edema and proteinuria.
- Long-Term Plan: Regular follow-ups to adjust therapy based on response and side effects.
---
Would you like further details on a specific immunosuppressive agent or monitoring strategy?
[16-08-2025 10:05] PPM 1: @Meta AI thanks
Please share the RCT evidence in absolute numbers and not percentages
[16-08-2025 10:05] Meta AI: ### Absolute Numbers from RCT Evidence for FSGS Management:
#### 1. Calcineurin Inhibitors (CNI) + Prednisolone
- Population: 54 patients with steroid-resistant FSGS (adults and children).
- Intervention: Tacrolimus + low-dose prednisolone.
- Comparison: Prednisolone monotherapy.
- Outcome:
- Tacrolimus group: 38 patients achieved remission (24 complete and 14 partial).
- Prednisolone group: 16 patients achieved remission (10 complete and 6 partial).
- Remission occurred within 6 months of therapy initiation.¹ ²
---
#### 2. Mycophenolate Mofetil (MMF) + Prednisolone
- Population: 34 patients with steroid-resistant FSGS.
- Intervention: MMF (2 g/day) + low-dose prednisolone.
- Comparison: High-dose prednisolone alone.
- Outcome:
- MMF + Prednisolone: 20 patients achieved remission (12 complete, 8 partial).
- Prednisolone monotherapy: 14 patients achieved remission (7 complete, 7 partial).
- Sustained remission was seen in 18 patients over 12 months.³ ⁴
---
#### 3. Rituximab + Mycophenolate
- Population: 13 children with CNI-resistant FSGS.
- Intervention: Dual therapy (Rituximab + Mycophenolate).
- Outcome:
- 11 children achieved sustained remission for at least 1 year (8 complete, 3 partial).
- 2 children showed no response.
- Relapse occurred in 2 of the 11 responders after 1–2 years.⁵
---
#### 4. Cyclophosphamide + Prednisolone
- Population: 54 patients with idiopathic nephrotic syndrome due to FSGS.
- Intervention: Cyclophosphamide + Prednisolone.
- Comparison: Prednisolone monotherapy.
- Outcome:
- Cyclophosphamide group: 29 patients achieved remission (14 complete, 15 partial).
- Prednisolone group: 19 patients achieved remission (11 complete, 8 partial).⁶
---
Let me know if you'd like more details on specific therapies or additional RCTs!
[16-08-2025 10:05] Meta AI: https://www.slideshare.net/slideshow/fsgs-251132432/251132432
[16-08-2025 10:05] Meta AI: https://indianjnephrol.org/rituximab-mycophenolate-combination-therapy-in-children-with-calcineurin-inhibitor-resistant-fsgs/
[16-08-2025 10:05] Meta AI: https://kdigo.org/wp-content/uploads/2018/08/Chap-6-FSGS-Evidence-summary_Final_V2_Profiles.pdf
[16-08-2025 10:05] Meta AI: https://www.kidneymedicinejournal.org/article/S2590-0595(22)00122-4/fulltext
[16-08-2025 10:05] Meta AI: https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2019.00178/full
[16-08-2025 10:05] Meta AI: https://www.nature.com/articles/nrneph.2012.289.pdf
[16-08-2025 10:07] PPM 1: @Meta AI no trials using azathioprine I guess?
[16-08-2025 10:07] Meta AI: It seems that robust randomized controlled trials (RCTs) specifically evaluating azathioprine for focal segmental glomerulosclerosis (FSGS) are limited or nonexistent. Most available evidence regarding azathioprine comes from case reports, observational studies, or its usage in combination therapy for steroid-sparing purposes in nephrotic syndrome.
For example, a case report highlighted azathioprine's role in managing nephrotic syndrome secondary to FSGS when steroids caused psychosis. In this scenario, azathioprine (50 mg daily) led to significant reductions in proteinuria (from 7.0 g/24 hours to 2.8 g/24 hours over two months) and resolution of edema, suggesting partial remission. However, this is anecdotal evidence rather than RCT-supported data.¹
Another source mentions that remission rates of prednisone plus azathioprine were comparable to other combinations, with a reported remission rate of 80% in a small cohort of patients with FSGS. However, this data was derived from non-randomized settings and lacks absolute numbers or detailed trial methodology.²
Azathioprine is often considered a secondary option in settings where calcineurin inhibitors (CNIs) or mycophenolate mofetil (MMF) are contraindicated or not tolerated. Its use in FSGS remains empirical and is primarily based on extrapolation from other glomerular diseases.
Would you like me to explore alternative immunosuppressive options or provide additional case-specific insights?
[16-08-2025 10:07] Meta AI: https://www.slideshare.net/slideshow/fsgs-251132432/251132432
[16-08-2025 10:07] Meta AI: https://pubs.sciepub.com/ajhr/4/1/3/index.html
[16-08-2025 10:09] PPM 1: @PPM4@PPM7 @PPM9 we can go with azathioprine. Please check the case report cited by meta.
Also please get her to switch to dose optimizeable frusemide and add tablet spironolactone separately without the combination
[16-08-2025 10:29] PPM 7: He was initiated for azathioprine due to steroid associated psychosis sir
[16-08-2025 10.32] PPM 7: 60 mg prednisolone
[16-08-2025 10:38] PPM 1: We are lucky our current patient is still alright with her 60 mgWhat was his weight?
[16-08-2025 10:46] PPM 8: Based on your query regarding immunosuppressive management of nephrotic-range proteinuria in a 17-year-old female with biopsy-proven FSGS and normal creatinine, I have synthesized evidence from clinical studies, RCTs, and consensus guidelines. The approach prioritizes remission induction while minimizing toxicity in this pediatric-adolescent transition population.
### Key Clinical Considerations
1. *Pathophysiology*: Primary FSGS is likely driven by a circulating permeability factor, with podocyte injury as the final pathway.
2. *Histologic Variants*: Tip variant has higher steroid responsiveness; collapsing variant carries worst prognosis (not specified in biopsy) .
3. *Baseline Therapy*: All patients require maximized ACEi/ARB therapy. In the referenced cohort, 94.4% (101/107) received ACEi/ARB.
---
### Evidence-Based Immunosuppressive Strategies
#### *First-Line: Corticosteroids*
- *KDIGO Recommendation*: Initial prednisone 1 mg/kg/day (max 80 mg) for ≥4 weeks; continue until complete remission or max 16 weeks.
- *Rationale*: 30-60% achieve remission, but adolescent response rates are lower than younger children. Steroid resistance is defined as failure to respond after 16 weeks.
#### *Second-Line for Steroid Resistance: Calcineurin Inhibitors (CNI)*
- *Cyclosporine (CsA) + Low-Dose Prednisone*
- *RCT Evidence (PICO Format)*:
- *P*: Adults/children with steroid-resistant FSGS
- *I*: CsA (3.5-5 mg/kg/day) + prednisone (0.15 mg/kg/day)
- *C*: Prednisone alone
- *O*: Complete/partial remission at 6 months
- *Results*: 8/10 achieved remission with CsA/prednisone vs 1/10 with prednisone alone (RR 8.85; 95% CI 1.22–63.92) .
- *Adolescent Data*: In 38 steroid-resistant FSGS patients, 44.7% (17/38) were CNI-resistant, while 55.3% (21/38) achieved remission.
- *Tacrolimus Alternative*
- *Study*: 44 adults with steroid-resistant FSGS treated with tacrolimus + prednisolone.
- *Results*: 38.6% (17/44) complete remission; 13.6% (6/44) partial remission.
#### *Alternative to CNI: Mycophenolate Mofetil (MMF) + Dexamethasone*
- *FSGS Clinical Trial (NIH-FSGS)*:
- *P*: Children/young adults (2-40 yrs) with steroid-resistant FSGS
- *I*: MMF (1200 mg/m²/day) + dexamethasone pulses (20 mg/m²)
- *C*: Cyclosporine alone
- *O*: Partial remission at 52 weeks
- *Results*: 37.0% (17/46) remission with MMF/dexamethasone vs 35.6% (16/45) with CsA .
- *Adverse Events*: MMF arm had fewer cases of hypertension (absolute numbers not reported) .
---
### Clinical Phenotypes & Tailored Therapy
Cluster analysis of 87 FSGS patients identified 3 phenotypes with therapeutic implications :
| *Cluster* | *Characteristics* | *Immunosuppression Benefit* | *Remission Rate* |
|-------------------------|-----------------------------------|-------------------------------|---------------------|
| Cluster 1 (n=26) | Heavy proteinuria (uPCR >350), albumin >30 g/L | Likely benefit | 57.7% (15/26) |
| Cluster 2 (n=43) | Non-nephrotic proteinuria | Minimal benefit | 37.2% (16/43) |
| *Cluster 3 (n=18)* | *Full nephrotic syndrome* | *Highest benefit* | *66.7% (12/18)* |
For this patient (nephrotic syndrome), immunosuppression is strongly indicated.
---
### Adverse Effect Monitoring
1. *CNI Nephrotoxicity*:
- Monitor creatinine monthly (rise >30% requires dose reduction) .
- In the tacrolimus study, 9% (4/44) developed irreversible nephrotoxicity.
2. *Infections*:
- MMF increased infection risk: 43.1% (19/44) with tacrolimus.
3. *Metabolic Effects*:
- Steroids: 22.7% (10/44) developed glucose intolerance with tacrolimus.
---
### Rescue Therapies for Refractory Cases
- *Rituximab*: Limited RCT evidence; consider if CNI/MMF fail.
- *Plasmapheresis*: Anecdotal response in recurrent FSGS post-transplant.
---
### Summary of Recommendations for This Patient
1. *Initiate high-dose prednisone* (1 mg/kg/day) for 4-16 weeks.
2. *If no remission by week 8*:
- Add tacrolimus (trough 5-8 ng/mL) or cyclosporine (trough 100-150 ng/mL).
- Alternative: MMF + dexamethasone pulses if CNI contraindicated.
3. *Continue ACEi/ARB* and monitor urine PCR monthly.
4. *Assess APOL1 status* if African ancestry (predicts progression).
> "Achieving remission (complete or partial) is the critical factor in renal survival for nephrotic FSGS" . In steroid-resistant adolescents, timely CNI use preserves renal function in >50%.
[16-08-2025 10:48] PPM 1: @PPM9 @PPM4 check if she's on ARB
[16-08-2025 11:01] PPM 7: 89.3kg bmi 30
@PPM7 is it mentioned in the discharge summary? If not you have another point for your study project @PPM5
[16-08-2025 11:54] PA: Weight 62
[16-08-2025 11:54] PA: Height 5.4
[16-08-2025 11:55] PPM 4: EE tablet patient enni veskuntunnaru
[16-08-2025 11:56] PA: Morning 8 ki okati veskuntunnaru sir
[16-08-2025 11:56] PPM 4: 1 day lo enni veskuntunnaru
[16-08-2025 11:56] PA: 2
[16-08-2025 11:58] PPM 4: Weight eppudu chuskunnaru? tablets vadatam start chesaka? cheyyakamundha?
[16-08-2025 12:00] PA: Chesaka sir
[16-08-2025 12:01] PPM 4: date pampinchandi
[16-08-2025 12:01] PA: 13
[16-08-2025 12:03] PPM 4: She's not on ARB sir. She is using only diuretics and prednisolone
[16-08-2025 12:05] PPM 4: Weight: 62 kgs, height: 163 cm, BMI: 23.3 as of 13 august 2025
[16-08-2025 13:09] PPM 1: Yes so @PPM9 @PPM10 @PPM3 please co-ordinate changing over to
Tablet Prednisolone 30 mg once daily
Tablet Azathioprine 50mg once daily
Tablet Telma 20 mg once daily
Tablet frusemide 80mg in the morning and 40mg in the afternoon
Tablet spironolactone 50 mg once daily
[16-08-2025 13:11] PPM 9: Ok sir
[16-08-2025 13.28] PA: 
[16-08-2025 13.32] PPM 10: Ok sir.
[16-08-2025 13:39] PPM 9: Spoke to patient sir and advised to get the tablet and post the pics of the tablets here.
[16-08-2025 14:41] PPM 1: Doesn't appear well balanced?
[16-08-2025 16:49] PPM 7: Yes sir
[16-08-2025 18:18] PPM 4: Fish chicken mutton sir
[16-08-2025 18:19] PPM 4: @PPM1 Sir is meat recommended for this patient sir.
[16-08-2025 18:20] PPM 4: This patient can include fish, chicken, and mutton in their meals, focusing on lean, well-cooked, low-salt preparations. Dietary advice should be personalized based on kidney function, proteinuria levels, and cholesterol profile. Connecting with a renal dietitian for tailored meal planning is highly recommended.
~perplexity.ai
[16-08-2025 18:21] PPM 4: @PA chicken, fish thinnochu. mutton monthly 1 time okay.
salt and oil ekkuva veyyakudadhu. idhi jagratha teeskovali.
[16-08-2025 18:47] PA: OK sir 20.22
[16-08-2025 21:18] PA: OK sir
Tablet frusemide 80mg in the morning and 40mg in the afternoon
Tablet spironolactone 50 mg once daily
[17-08-2025 07:08] PPM 1: If this is 60 mg currently, change to:
Tablet Prednisolone 30 mg once daily
Add
Tablet Azathioprine 50mg once daily
Tablet Telma 20 mg once daily
After coordinating with @PPM9
[17-08-2025 07:19] PPM 9: Ok sir
[17-08-2025 09:04] PPM 4: @PPM1 Sir @PPM9 sir is it possible for her to take medicines at hospital today as today is holiday?
[17-08-2025 09:13] PPM 9: Yes pharmacy will be open
[17-08-2025 09:55] PPM 1: All these should be available in a pharmacy shop near her home. Where does she live?
[17-08-2025 09:59] PPM 4: She's currently in Hyd it seems sir.. will ask her to get the medicines from a nearby pharmacy
[17-08-2025 12:09] PPM 1: Update:
[16/08, 11:14] Anonymous Pm: She is not on arb sir
[16/08, 13:16] Anonymous Pm: Sir they went to Nims
[16/08, 13:16] Anonymous Pm: Today
[16/08, 13:17] Anonymous Pm: I couldn't talk to them in detail, I'll let you know after that
[17/08, 12:07] Anonymous Pm: Sir they are admitted at Nims right now, the doctors there are trying to do electron microscopy for the already taken biopsy sample, so we are trying to find out, if we can retrieve the sample and give it to them
[17-08-2025 14.08] PA:
[17-08-2025 22:33] PA: [8/17, 22:22] pa: Biopsy chesina mukka kavali anttunaru sir
[8/17, 22:23] Pa: Unte koncham kavali esthara
@PPM1 Sir @PPM9 any update on biopsy sample slides sir..?
[17-08-2025 22:36] PPM 3: We talked to the lab, they said they will get the sample but it will take 10 days, need to confirm with them again tomorrow
[17-08-2025 22:36] PPM 4: okay sir.. is it possible to retrieve sooner?
[17-08-2025 22:37] PPM 3: We will try to talk again tomorrow
[18-08-2025 00.34] PA: Present chala tahginai sir ekkada nims ki vachaka treatment chestharu
[18-08-2025 10:37] PPM 1: @PPM4 ask her to share an image of the tablets wrapper she's getting or she can even ask the nurse for the name when the tablets are being administered 
[18-08-2025 11.46] PPM 1: Alright!
So that rapid recovery is the magic of expensive human albumin that may offer a brief respite of days but is going to be short lived and I guess the treating team there can afford it and by her second albumin she'll feel better subjectively at discharge.
So subjective relief is a big game changer for every patient project!
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