Background and objective Corticosteroids induce remission in 80% of children with idiopathic nephrotic syndrome (INS). However 90% of steroid responders experience at least one relapse and 40% of them suffer from frequent relapses. The optimal treatment for the first episode of INS in terms of preventing subsequent relapses remains controversial.
Methods We conducted a systematic review and meta-analysis of randomised controlled trials (RCT). We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials without language restriction. We also searched proceedings from international conferences and we contacted investigators. We only included RCT which compared different regimens for the treatment of the first episode of INS in children.
Results 26 RCT were included. Nine studies compared the classic two-month steroid regimen with prolonged steroid courses ranging from three to seven months. Meta-analysis of those studies showed no difference in the number of children with frequent relapses [RR: 0.79, 95% CI (0.57, 1.08)] (Figure 1) and number of relapses per patient [WMD: –0.37, 95% CI (–0.85, 0.1)]. Cumulative steroid dose was significantly higher with prolonged courses [SMD: 0.48 95% CI (0.16, 0.81)] (Figure 2). Eight studies compared three months with six months of steroid treatment. Similarly there was no difference in frequent relapses [RR: 0.63, 95% CI (0.36, 1.10)] (Figure 3) and relapses per patient [WMD: –0.32, 95% CI (–0.65, 0.00)]. Three RCT explored the potential benefit of adding cyclosporine, azithromycin or sarei-to, a Chinese herb, to steroids. Only sarei-to was showed to improve frequent relapses and number of relapses per patient.
Conclusion This meta-analysis showed no sufficient evidence that prolonged steroid courses for the first episode of INS can prevent future relapses. The cumulative steroid dose was significantly higher with prolonged courses suggesting a potential for increased toxicity, even though the incidence of side effects was similar. In conclusion, the current evidence cannot support that prolongation of steroid treatment for the first episode of INS for more than two to three months is beneficial.
Abbreviations RR relative risk, CI confidence intervals, WMD weighted mean difference, SMD standardised mean difference
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