Short-Term Steroid Regimen for Adult Steroid-Sensitive Minimal Change Disease

Abstract

Background: In pediatric patients with steroid-sensitive nephrotic syndrome, recent trials have revealed that a 2-month, short-term steroid regimen is not inferior to an extended steroid course. However, the optimal duration of initial steroid therapy for adult steroid-sensitive minimal change disease (MCD) remains unclear. Objectives: The aim of present study was to evaluate the effectiveness of a 2-month, short-term steroid regimen in the treatment of adult steroid-sensitive MCD patients. Method: This was a prospective observational study. Adult patients with steroid-sensitive MCD (n = 35) who were initiated on a short-term steroid regimen between January 2015 and June 2016 were included. The details of the regimen are as follows: (1) prednisolone was administered at an initial dose of 0.8–1.0 mg/kg/day and continued for 4–6 weeks and (2) dosage was reduced to 0.5–0.6 mg/kg/alternate day and continued for 4 weeks. Control patients (n = 140), who were treated using conventional steroid administration, were selected from our previous adult MCD cohort. All patients fulfilled the following criteria: biopsy-proven MCD, age ≥20 years, first episode of nephrotic syndrome, and attainment of complete remission within 4 weeks. The following parameters of patients who received short-term treatment regimen and control patients were compared: any relapse and frequent relapse, adverse events caused by steroid treatment and cumulative steroid dose. Results: Throughout the observation period (median: 17.3 months), 24 (68.6%) patients in the short-term group developed at least one relapse. The short-term regimen showed earlier occurrence of any relapse than the conventional regimen (adjusted hazard ratio [aHR] 2.45; 95% CI 1.51–3.97; p < 0.001), but there was no difference in frequent relapse (aHR 1.31; 95% CI 0.43–3.99; p = 0.63). None of the patients showed any symptoms of adrenal insufficiency after discontinuation of corticosteroids. The cumulative steroid dose during the observational period was significantly lower in the short-term group than in the conventional group. Conclusions: The short-term steroid regimen may represent an effective treatment option that ensures lower steroid exposure when treating adult steroid-sensitive MCD patients.

Incidence of remission and relapse of proteinuria, end-stage kidney disease, mortality, and major outcomes in primary nephrotic syndrome: the Japan Nephrotic Syndrome Cohort Study (JNSCS)

“…Several guidelines suggested longer corticosteroid therapy; the Kidney Disease Improving Global Outcomes (KDIGO) clinical guideline for glomerulonephritis suggested a daily dose of 1.0 mg/kg of prednisolone or an alternate-day single dose of 2 mg/kg tapered slowly over a total period of up to 6 months [12] and the Japanese evidence-based clinical practice guideline for nephrotic syndrome suggest 0.6-0.8 mg/kg of prednisolone tapered within 2 years [13]. Compared with these conventional long corticosteroid therapies, an intriguing Japanese observational study of adult patients with MCD suggested clinical advantages of a 2-month corticosteroid therapy, the lower incidence of adverse events, including diabetes and infection [31]. Because nephrologists might possibly maintain adult patients with MCD on corticosteroids for very long [32], an optimal immunosuppressive therapy should be explored in well-designed clinical studies to prevent critical events associated with immunosuppressive therapy, including infection.…”

Association of initial prednisolone dose with remission, relapse, and infectious complications in adult-onset minimal change disease

“…There were no differences in the time from the initiation of PSL to relapse and in the relapse rate between the two groups [ 11 ]. Similar protocols have also been compared in adults where a 2-month short-term steroid regimen resulted in a higher relapse rate and shorter time to relapse than the conventional steroid regimen with a similar initial therapy dosage (0.8–1.0 mg/kg/day) [ 14 ]. In adults, short-term dosing is not as effective as it is in children with regard to the relapse rates, and it may be more effective to reduce the initial PSL dose, prolong treatment, and then taper the dosage down.…”

Infectious complications in adult patients with idiopathic minimal change nephrotic syndrome undergoing immunosuppressive therapy

“…A total of 213 accumulative cases of infectious complications of adult MCNS were reported among 1787 patients from four randomized controlled trials (RCTs), 7–10 12 observational studies 5,14–24 and patients of our hospital (Table 5). The published studies showed various incidences of infectious complications while none investigated the risk factor.…”