The above situation described by the author is an interesting and often faced dilemma in pediatric nephrology practice. Since this child has already received 6 weeks of daily steroids and went into remission, the relapse should be technically treated as the first relapse. Most regimens for treatment of initial episode have recommended 4-6 weeks of daily steroids followed by alternate day therapy for another 6 weeks only, as longer durations predispose to more adverse effects [1,2]. We should treat this episode as first relapse and give the child daily prednisolone (2mg/kg/d) till 3 days of remission and then continue on alternate day (1.5 mg/kg/d) of oral prednisolone for another 4 weeks. This means that the child would receive at least another 5-6 weeks of steroids and she had already missed 6 weeks of alternate day steroids during the treatment of initial episode. Even if we consider this episode as continuum of the initial episode the child would still merit 6 weeks of alternate day steroid therapy that she had missed. However since the child relapsed after gaining remission it should be labeled as a relapse. The definition of relapse as per the guideline is "Urine albumin 3+ or 4+ (or proteinuria >40 mg/m2/h) for 3 consecutive early morning specimens, having been in remission previously" [1]. The definition of first relapse or subsequent relapses is not any different. The subsequent treatment of this child would be decided by the disease course on follow-up.

2. Lombel RM., Gipson DS, Hodson EM. Treatment of steroid-sensitive nephrotic syndrome: new guidelines from KDIGO. Pediatr Nephrol. 2013;28:415-26.