In nephrotic syndrome management, when is a kidney biopsy recommended relative to initiating steroids or other immunosuppressive therapy?

• A. Kidney biopsy before starting steroids or other immunosuppressive therapy
• B. Initiate steroids first and biopsy only if response is poor
• C. Biopsy only if there is active infection
• D. Biopsy is never required

Answer: (A)

Histologic confirmation via kidney biopsy before starting steroids or other immunosuppressive therapy is recommended in nephrotic syndrome because the exact glomerular disease dictates the most appropriate treatment and prognosis. Nephrotic syndrome encompasses several pathologies (for example, minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, and secondary causes), and their responses to steroids or immunosuppressants vary widely. A biopsy establishes the precise lesion, helps exclude secondary processes, and guides therapy to avoid giving immunosuppression when it won’t help or when alternative treatments are needed. While there are some pediatric cases where a steroid trial might be used empirically, in general the biopsy-before-treatment approach provides the most accurate basis for management.