Management of Focal Segmental Glomerulosclerosis (FSGS) After High-Dose Prednisolone

Tapering Strategy

The American Journal of Kidney Diseases recommends tapering the dose of prednisolone by 5 mg every 1-2 weeks to complete a total treatment duration of at least 6 months after achieving remission with high-dose prednisolone in FSGS 1, 2
For patients who achieve complete remission rapidly, the Kidney International guidelines suggest continuing high-dose glucocorticoid treatment for 4 weeks or after the disappearance of proteinuria, whichever is longer, then reducing prednisone by 5 mg every 1-2 weeks to complete a total duration of 6 months 2
The total treatment duration must be at least 6 months even if remission occurs early, as recommended by the American Journal of Kidney Diseases 1, 4

For patients who achieve partial remission within 8-12 weeks, the Kidney International guidelines recommend continuing high-dose glucocorticoids until 16 weeks to determine whether further proteinuria reduction and complete remission may occur 2, 3
After 16 weeks, reduce prednisone by 5 mg every 1-2 weeks to complete a total duration of 6 months, as suggested by the Kidney International guidelines 2, 3

For patients who develop steroid-resistant or significant toxicities, the Kidney International guidelines recommend rapidly tapering glucocorticoids as tolerated and switching to alternative immunosuppression with calcineurin inhibitors (CNIs) 2, 3
The Kidney International guidelines suggest using cyclosporine at a dose of 3-5 mg/kg/day in 2 divided doses with a target trough level of 100-175 ng/ml 2, 3
The Kidney International guidelines also recommend using tacrolimus at a dose of 0.05-0.1 mg/kg/day in 2 divided doses with a target trough level of 5-10 ng/ml 2, 3

The American Journal of Kidney Diseases recommends monitoring serum creatinine regularly during the taper phase and reducing the dose of CNIs if serum creatinine increases but does not plateau or increases over 30% of baseline 1, 4
The Kidney International guidelines suggest monitoring proteinuria regularly to evaluate treatment response and adjusting the treatment plan accordingly 2, 3

The Kidney International guidelines recommend treating relapses with the same initial dose and duration of corticosteroids as the first episode 7, 8
The Kidney International guidelines suggest using prednisone at a dose of 1 mg/kg/day (maximum 80 mg) or an alternate-day dose of 2 mg/kg (maximum 120 mg) for a minimum of 4 weeks up to 16 weeks as tolerated or until complete remission 7, 8

The American Journal of Kidney Diseases recommends monitoring for diabetes, particularly in obese patients or those with a family history, and assessing bone health and considering prophylaxis for osteoporosis 1, 4
The Kidney International guidelines suggest targeting systolic blood pressure <120 mmHg using standardized office measurement and initiating ACE inhibitors or ARBs at maximally tolerated doses for proteinuria and blood pressure control 2, 3

The American Journal of Kidney Diseases recommends avoiding abrupt cessation of high-dose steroids and instead tapering gradually over 6 months total duration 1, 4
The Kidney International guidelines suggest avoiding continuation of high-dose therapy beyond 16 weeks if proteinuria is persistent and unremitting, especially with side effects 1, 2, 4