Steroid use in glomerular diseases: Friend or foe?

Glucocorticoids (GCs) remain cornerstone agents in the management of autoimmune and glomerular diseases, owing to their potent anti-inflammatory and immunosuppressive properties that significantly improve clinical outcomes. However, their use is frequently limited by substantial adverse effects, including increased susceptibility to infection and various metabolic complications such as hyperglycemia, hypertension, osteoporosis, and gastrointestinal complications. Consequently, strategies aimed at minimizing GCs exposure, supported by robust clinical evidence, have become a major therapeutic priority. These strategies encompass complete withdrawal or rapid tapering of GCs, the use of immunosuppressive agents that target distinct pathogenic pathways, and the development of alternative GCs formulations designed to deliver the drug preferentially to affected tissues while reducing systemic toxicity. This review provides a clinically oriented synthesis of GCs pharmacology, adverse effect profiles, and disease-specific management strategies, with a focus on renal conditions in adults, including Immunoglobulin A Nephropathy, antineutrophil cytoplasmic antibody-associated vasculitis, lupus nephritis, membranous nephropathy, and podocytopathies such as minimal change disease and primary focal segmental glomerulosclerosis, whereas emphasizing evidence from randomized controlled trials relevant to clinical practice.