Understanding the association between the genetic and clinical phenotypes in children with nephrotic syndrome (NS) of different etiologies is critical for early clinical guidance. We employed whole-exome sequencing (WES) to detect monogenic causes of NS in a multicenter cohort of 637 patients. In this study

a genetic cause was identified in 30.0% of the idiopathic steroid-resistant nephrotic syndrome (SRNS) patients. Other than congenital nephrotic syndrome (CNS)

there were no significant differences in the incidence of monogenic diseases based on the age at manifestation. Causative mutations were detected in 39.5% of patients with focal segmental glomerulosclerosis (FSGS) and 9.2% of those with minimal change disease (MCD). In terms of the patterns in patients with different types of steroid resistance

a single gene mutation was identified in 34.8% of patients with primary resistance

2.9% with secondary resistance

and 71.4% of children with multidrug resistance. Among the various intensified immunosuppressive therapies

tacrolimus (TAC) showed the highest response rate

with 49.7% of idiopathic SRNS patients achieving complete remission. Idiopathic SRNS patients with monogenic disease showed a similar multidrug resistance pattern

and only 31.4% of patients with monogenic disease achieved a partial remission on TAC. During an average 4.1-year follow-up

21.4% of idiopathic SRNS patients with monogenic disease progressed to end-stage renal disease (ESRD). Collectively

this study provides evidence that genetic testing is necessary for presumed steroid-resistant and idiopathic SRNS patients

especially those with primary and/or multidrug resistance.