Steroid treatment for the first episode of childhood nephrotic syndrome: comparison of the 8 and 12 weeks regimen using an individual patient data meta-analysis

Early Rituximab as an Add-On Therapy in Children With the Initial Episode of Nephrotic Syndrome

Introduction

The approximately 70% 12-month relapse in children experiencing the initial episode of steroid-sensitive nephrotic syndrome (SSNS) is a significant concern, with over 50% developing frequent relapses or steroid-dependent nephrotic syndrome (FRNS/SDNS). There is a lack of strategies to reduce relapse after the onset. Whether early administration of rituximab, which effectively reduces relapses in FRNS/SDNS, may be a solution has not been evaluated.

Methods

A prospective, multicenter, open-label, single-arm trial was conducted in China, with a 12-month follow-up. Children aged 1 to 18 years with the first episode of nephrotic syndrome (NS) were screened for eligibility. Proteinuria was evaluated daily using dipsticks. A dose of 375 mg/m2 of rituximab was intravenously infused within 1 week after achieving corticosteroid-induced remission. The main outcome was 12-month relapse-free survival.

Results

Out of the initially 66 children screened, 44 were enrolled and received rituximab, with all but 1 participant completing the 12-month follow-up. The median age at diagnosis was 4.3 years (interquartile range [IQR]: 3.4-5.9), and 33 (77%) of the participants were male. In the rituximab group, the 12-month relapse-free survival was significantly higher compared to historical controls (32 of 43 [74.4%] vs. 10 of 33 [30.3%]; P < 0.001; hazard ratio [HR], 3.76; 95% confidence interval [CI], 1.80-7.81). The post hoc analysis revealed a higher 24-month relapse-free survival and a lower incidence of FRNS/SDNS at the 12-month follow-up. Treatment with rituximab was well-tolerated.

Conclusion

Our findings support that early administration of rituximab may be associated with a higher 12-month relapse-free survival and a reduced incidence of FRNS/SDNS in children experiencing the initial episode of SSNS.

Treatment of idiopathic nephrotic syndrome at onset: a comparison between 8- and 12-week regimens in everyday clinical practice

BACKGROUND

Optimal steroid treatment at onset of idiopathic nephrotic syndrome is still debated. The aim of this study was to analyze the clinical outcome at 24 months of follow-up in patients admitted to our unit for the first episode of steroid-sensitive nephrotic syndrome comparing two different steroid regimens.

METHODS

We collected data on patients treated from 1992 to 2007 with prednisone according to the International Study on Kidney Diseases in Children 8-week regimen and since 2008 according to the Arbeitsgemeinschaft fur Padiatrische Nephrologie 12-week regimen. The primary outcome was to evaluate cumulative prednisone dosage at 12 and 24 months of follow-up in the two groups. As secondary outcomes, we considered mean relapse rate per patient; number of children without relapses at 6, 12, and 24 months; and number of patients who developed frequent relapses and steroid-dependent disease.

RESULTS

Data were collected on 127 patients. Sixty-one subjects received the 8-week regimen and 66 the 12-week regimen. The mean cumulative prednisone dose at 12 and 24 months was not different, and the rate of patients without relapses was lower at 6 and 12 months in patients treated with the 8-week course, while no difference was observed at 24 months.

CONCLUSIONS

Despite the limitations of a retrospective study with limited follow-up, our data indicate that switching treatment from a shorter to a longer scheme did not improve the clinical outcome at 24 months of observation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Protocol for an open-label, single-arm, multicentre clinical study to evaluate the efficacy and safety of rituximab in the first episode of paediatric idiopathic nephrotic syndrome

INTRODUCTION

Rituximab (RTX) effectively prevents relapses in patients with complicated steroid-sensitive nephrotic syndrome (SSNS). The 1-year relapse-free survival rate is approximately 30% in children after the first episode of SSNS treated with standardised corticosteroids. Whether the benefits of RTX extend to the first relapse are unknown. The efficacy and safety of RTX in the first episode of paediatric idiopathic nephrotic syndrome (RTXFIRPedINS) trial (NCT04783675) will assess its effect on the risk of subsequent relapse.

METHODS AND ANALYSIS

RTXFIRPedINS is an open-label, single-arm, multicentre trial targeting patients aged 1-18 years with a first episode of SSNS. All patients will receive standardised corticosteroid treatment for 12 weeks. A sample size of 44 patients provides 80% power to detect a 20% increase in the 1-year relapse-free rate, assuming a dropout rate of 10%. After obtaining informed consent and screening, eligible patients will be treated with a single intravenous infusion of 375 mg/m² RTX within 1 week after achieving remission. Trimethoprim-sulfamethoxazole will be administered for 3 months after RTX administration to prevent Pneumocystis carinii infection. The follow-up period will be 1 year. The primary outcome is the 1-year relapse-free survival rate after RTX infusion. The secondary study outcomes are the number of days from the infusion of RTX to the occurrence of the first relapse, 6-month relapse-free survival rate, the B cell recovery time and treatment-related adverse events. Immunological factors will be studied as predictors of response.

ETHICS AND DISSEMINATION

This trial was approved by the Ethics Committee of the Children's Hospital of Fudan University and seven local ethics committees. We will publish our study results in peer-reviewed journals and present them at international scientific meetings.

TRIAL REGISTRATION NUMBER

NCT04783675.

Treatment-Associated Side Effects in Patients with Steroid-Dependent Nephrotic Syndrome

Introduction:Nephrotic syndrome is one of the most extensively studied pediatric diseases for a nephrologist. Treatment for patients suffering from it has greatly improved the prognosis and reduced the mortality rate to 3% or less. Steroid medication is the first line, but non-steroid immunosuppressive drugs are useful in limiting steroid side effects and maintaining long-term remission. Objective: The aim of the study is to choose the best treatment for each patient in order to minimize long-term effects of corticosteroid therapy, taking into account the child's age, gender and other factors to optimize the quality of life. Materials and methods:Materials and methods: This is a retrospective study of pediatric patients older than one year and younger than 18 years of age diagnosed with idiopathic corticosteroid nephrotic syndrome. Study participants were treated in the Department of Pediatric Nephrology of "M. S. Curie" Emergency Clinical Hospital for Children, Bucharest, Romania, between January 2013 and December 2020. Thirty-seven subjects with steroid-dependent nephrotic syndrome from a total of 125 patients diagnosed with nephrotic syndrome were included in the present study. All study participants underwent clinical examination and laboratory tests and were regularly monitored. Results and discussion: Long-term corticosteroid therapy can lead to unwanted complications such as hypertension, short stature, behavior disturbances, or osteopenia. To minimize certain side effects, a second line steroid-sparing agents can be used due to their ability to induce complete remission and maintain it in patients with steroid-dependent nephrotic syndrome. Conclusion: Our study describes the most frequent side effects encountered in the Department of Nephrology in patients with steroid-dependent nephrotic syndrome. The purpose was to emphasize that pediatric patients' quality of life depends on limiting long-term corticosteroid treatment and preventing adverse reactions or complications.