Mycophenolate mofetil is inferior to tacrolimus in sustaining remission in children with idiopathic steroid-resistant nephrotic syndrome.
Studies of nephrotic syndrome show that substitution of calcineurin inhibitors by mycophenolate mofetil (MMF) enables sustained remission and corticosteroid sparing and avoids therapy associated adverse effects. However, controlled studies in patients with steroid resistance are lacking. Here we examined the effect of switching from therapy with tacrolimus to MMF on disease course in an open-label, one-to-one randomized, controlled trial on children (one to 18 years old), recently diagnosed with steroid-resistant nephrotic syndrome, at a referral center in India. Following six months of therapy with tacrolimus, patients with complete or partial remission were randomly assigned such that 29 received MMF while 31 received tacrolimus along with tapering prednisolone on alternate days for 12 months. On intention-to-treat analyses, the proportion of patients with a favorable outcome (sustained remission, infrequent relapses) at one year was significantly lower (44.8%) in the MMF group than in the tacrolimus group (90.3%). The incidence of relapses was significantly higher for patients treated with MMF than tacrolimus (mean difference: 1.05 relapses per person-year). While there was no difference in the proportion of patients with sustained remission, the risk of recurrence of steroid resistance was significantly higher for patients receiving MMF compared to tacrolimus (mean difference: 20.7%). Compared to tacrolimus, patients receiving MMF had a significantly (71%) lower likelihood of a favorable outcome and significantly increased risk of treatment failure (frequent relapses, steroid resistance). Thus, replacing tacrolimus with MMF after six months of tacrolimus therapy for steroid-resistant nephrotic syndrome in children is associated with significant risk of frequent relapses or recurrence of resistance. These findings have implications for guiding the duration of therapy with tacrolimus for steroid-resistant nephrotic syndrome.
Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
Aditi
A
Sinha
Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
Aarti
A
Gupta
Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India.
Mani
M
Kalaivani
Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
Pankaj
P
Hari
Department of Pathology, All India Institute of Medical Sciences, New Delhi, India.
Amit K
AK
Dinda
Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India. Electronic address: arvindbagga@hotmail.com.
Arvind
A
Bagga
D000293:Adolescent; D000367:Age Factors; D002648:Child; D002675:Child, Preschool; D057915:Drug Substitution; D004359:Drug Therapy, Combination; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use*; D007194:India; D007223:Infant; D053208:Kaplan-Meier Estimate; D008297:Male; D009173:Mycophenolic Acid / Q000009:adverse effects / Q000627:therapeutic use*; D009404:Nephrotic Syndrome / Q000151:congenital* / Q000175:diagnosis / Q000188:drug therapy / Q000276:immunology; D011239:Prednisolone / Q000627:therapeutic use; D011446:Prospective Studies; D012008:Recurrence; D012074:Remission Induction; D016559:Tacrolimus / Q000009:adverse effects / Q000627:therapeutic use*; D013997:Time Factors; D016896:Treatment Outcome
D005938:Glucocorticoids; D007166:Immunosuppressive Agents; D011239:Prednisolone; D009173:Mycophenolic Acid; D016559:Tacrolimus
calcineurin inhibitor; focal segmental glomerulosclerosis; minimal change disease