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How Long Should We Treat the Initial Episode of Childhood Nephrotic Syndrome?

Prednisolone therapy regimens lasting 8 weeks or 16 weeks showed no significant differences in time to relapse, number of relapses, or development of steroid unresponsiveness.

Although 90% of children with idiopathic nephrotic syndrome respond to prednisolone, the length of treatment for the initial episode has remained a matter of debate. These researchers conducted a controlled, double-blind, randomized, multicenter trial in the U.K. to compare the clinical response and stability of remission after either 8 or 16 weeks of prednisolone in 223 children with an initial episode of nephrotic syndrome (age range, 1–14 years; mean age, 4.9 years).

Both treatment regimens started with 60 mg/m2 daily for 4 weeks (to verify steroid sensitivity). Then, the shorter regimen provided 40 mg/m2 on alternate days for 4 weeks, followed by placebo, whereas the extended treatment involved 60 mg/m2 on alternate days with doses tapering by 10 mg/m2 every 2 weeks. Of the study participants, 80% had a relapse during 24 months of follow-up. The two treatment protocols showed no significant difference in the time to relapse (medians: 16-week protocol, 139 days; 8-week protocol, 87 days). The regimens also showed no statistical differences in adverse events, the number of relapses, or the number of children who developed frequently relapsing or prednisolone-resistant nephrotic syndrome. Overall, the 16-week plan was slightly more cost-effective and provided a small improvement in quality of life.

COMMENT

This study shows that extending prednisolone therapy to provide a tapering period does not improve outcomes in the initial episode of nephrotic syndrome. I had previously changed from an 8-week protocol to a 16-week one. Now I will return to the 8-week regimen.

CITATION(S): Webb NJA et al. Long term tapering versus standard prednisolone treatment for first episode of childhood nephrotic syndrome: Phase III randomised controlled trial and economic evaluation. BMJ 2019 May 23; 365:l1800. (https://doi.org/10.1136/bmj.l1800)