Corticosteroid therapy in childhood nephrotic syndrome: a meta-analyis of randomised control trials.
Jonathan C Craig, Elisabeth M Hodson, Narelle S Willis, John F Knight
Centre for Kidney Research, Royal Alexandra Hospital for Children, Sydney, NSW, Australia.
Introduction. Oral corticosteroid therapy is the treatment mainstay
in children with nephrotic syndrome, with a response rate of 95%. The optimal
dose and duration however, have not been established. This meta-analysis aims
to assess the benefits and harms of different corticosteroid regimes in preventing
relapse in children with steroid responsive nephrotic syndrome (SRNS).
Methods. Published and unpublished randomised controlled trials were
identified from the Cochrane Controlled Trials Register, Medline (1966-1998),
Embase (1988-1998), reference lists of articles, abstracts from proceedings
and contact with known investigators in the area. Two reviewers independently
reviewed all eligible studies for inclusion, assessed study quality (concealment
allocation, intention to treat, completeness of follow-up and blinding of outcome
assessment) and extracted data. A random effects model was used to estimate
summary effect measures after testing for heterogeneity.
Results. Twelve trials including 2 in abstract form were identified.
Significantly fewer children who received at least 12 weeks of prednisone (total
induction dose > 2900mg/m2) had relapsed within 2 years (relative risk 0.73;
95% CI 0.60,0.89) or had become frequent relapsers (relative risk 0.67; 95%
CI 0.48,0.93) than those who received 8 weeks of therapy (total dose: 2240mg/m2).
There was an inverse correlation between the risk for first relapse and total
duration (r2 = 0.66) and total dose of steroid therapy (r2 = 0.69). Mean relapse
rate/patient/year was lower in children who received more than 12 weeks therapy
(weighted mean difference -0.31; 95% CI 0.51, -0.12). There was no increase
in reported side effects in children treated for 12 weeks or more.
Conclusions. The likelihood of prolonged remission following the first
episode of SRNS is increased with higher total doses and longer durations of
steroid therapy without an increase in side effects of therapy.
Presented at the 33rd Annual Meeting of the American Society of Nephrology, Toronto, October 2000
Correspondence
Elisabeth Hodson
ElisaH@chw.edu.au