title: Non-corticosteroid treatment for nephrotic syndrome in children.
abstract: BACKGROUND
  Eighty to 90% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. About half relapse frequently and are at risk of the adverse effects of corticosteroids. Non-corticosteroid immunosuppressive agents are used to prolong periods of remission in these children, however these agents have significant potential adverse effects. Currently there is no consensus as to the most appropriate second line agent in children who are steroid sensitive, but who continue to relapse.
  
  
  OBJECTIVE
  To evaluate the benefits and harms of non-corticosteroid immunosuppressive agents in relapsing SSNS in children.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, reference lists, conference abstracts and contact with known investigators. Search date: September 2007
  
  
  METHODS
  Randomised controlled trials (RCTs) or quasi-RCTs were included if they compared non-corticosteroid agents with placebo, prednisone or no treatment, different doses and/or durations of the same non-corticosteroid agent, different non-corticosteroid agents.
  
  
  METHODS
  Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as relative risk (RR) with 95% confidence intervals (CI).
  
  
  RESULTS
  We identified 26 studies (1173 children). Cyclophosphamide (RR 0.44, 95% CI 0.26 to 0.73) and chlorambucil (RR 0.15, 95% CI 0.02 to 0.95) significantly reduced the relapse risk at six to twelve months compared with prednisone alone. There was no difference in relapse risk at two years between chlorambucil and cyclophosphamide (RR 1.31, 95% CI 0.80 to 2.13). There was no difference at one year between intravenous and oral cyclophosphamide (RR 0.99, 95% CI 0.76 to 1.29). Cyclosporin was as effective as cyclophosphamide (RR 1.07, 95% CI 0.48 to 2.35) and chlorambucil (RR 0.82, 95% CI 0.44 to 1.53) and levamisole (RR 0.43, 95% CI 0.27 to 0.68) was more effective than steroids alone but the effects were not sustained once treatment was stopped. There was no difference in the risk for relapse between mycophenolate mofetil and cyclosporin (RR 5.00, 95% CI 0.68 to 36.66) but CI were large. Mizoribine and azathioprine were no more effective than placebo or prednisone alone in maintaining remission.
  
  
  CONCLUSIONS
  Eight week courses of cyclophosphamide or chlorambucil and prolonged courses of cyclosporin and levamisole reduce the risk of relapse in children with relapsing SSNS compared with corticosteroids alone. Clinically important differences in efficacy are possible and further comparative studies are still needed.
authors.affiliation: Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia, 2145. Elisah@chw.edu.au
authors.forename: E M
authors.initials: EM
authors.lastname: Hodson
authors.forename: N S
authors.initials: NS
authors.lastname: Willis
authors.forename: J C
authors.initials: JC
authors.lastname: Craig
mesh_terms: D000293:Adolescent; D001379:Azathioprine / Q000627:therapeutic use; D002648:Child; D002675:Child, Preschool; D002699:Chlorambucil / Q000627:therapeutic use; D003520:Cyclophosphamide / Q000627:therapeutic use; D016572:Cyclosporine / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D007223:Infant; D007978:Levamisole / Q000627:therapeutic use; D009404:Nephrotic Syndrome / Q000188:drug therapy* / Q000517:prevention & control; D016032:Randomized Controlled Trials as Topic; D012263:Ribonucleosides / Q000627:therapeutic use; D055502:Secondary Prevention
chemical_list: D007166:Immunosuppressive Agents; D012263:Ribonucleosides; D002699:Chlorambucil; D007978:Levamisole; C010052:mizoribine; D016572:Cyclosporine; D003520:Cyclophosphamide; D001379:Azathioprine