Small increases in prednisolone can prevent relapse during upper respiratory infections in patients with nephrotic syndrome
Article Outline
- Abeyagunawardena AS, Trompeter RS. Increasing the dose of prednisolone during viral infections reduces the risk of relapse in nephrotic syndrome: a randomised controlled trial. Arch Dis Child 2008;93:226-8
- References
- Copyright
Abeyagunawardena AS, Trompeter RS. Increasing the dose of prednisolone during viral infections reduces the risk of relapse in nephrotic syndrome: a randomised controlled trial. Arch Dis Child 2008;93:226-8
Question
In children with nephrotic syndrome, does a small short-term increase in the dose of prednisolone reduce the risk of relapse during viral upper respiratory tract infections (URTIs), compared with placebo?
Design
Randomized, double-blind, placebo-controlled crossover trial.
Setting
Nephrology clinic at a tertiary referral center in Sri Lanka.
Participants
48 children receiving low-dose (<0.6 mg/kg) prednisolone on alternate days as maintenance therapy were recruited, and 40 completed the trial (29 male, 11 female). Age at entry ranged from 1.5 to 13.2 years (median, 5.3 years).
Intervention
At the first sign of a URTI, patients were randomized to receive either placebo or prednisolone on the days when they were not regularly scheduled to get prednisolone. The intervention lasted 7 days (ie, 3 or 4 extra doses of prednisolone) and the prednisolone dose (or placebo dose) was identical to the patient's usual alternative day prednisolone dose. During a subsequent URTI, the patients crossed over interventions.
Outcomes
Relapse, defined as the presence of 3+ proteinuria for 3 consecutive days.
Results
The relapse rate after viral URTI was 19 of 40 (48%) in the placebo group and 7 of 40 (18%) in the prednisolone group (P = .014, number needed to treat [NNT] = 4). The mean dose of alternate day prednisolone was 0.36 mg/kg (range, 0.1-0.6 mg/kg). No significant adverse effects of the increased prednisolone were noted.
Conclusions
Additional doses of prednisolone during URTIs in patients with glucocorticoid-dependent nephrotic syndrome maintained on alternative day prednisone decreases the relapse rate without notable adverse effects.
Comment
The treatment of patients with frequently relapsing nephrotic syndrome, glucocorticoid-dependent nephrotic syndrome, or both poses many challenges for clinicians and families. In many patients, prolonged low-dose alternate-day glucocorticoid therapy provides adequate control without significant adverse effects. In this study, a URTI triggered relapse in >50% of the patients treated with placebo. This trial provides evidence that an additional 3 to 4 relatively low doses of prednisolone can reduce the relapse rate in these difficult-to-treat patients by >60% during URTIs. This confirms the earlier findings of Mattoo and Mahmoud.1 This study did not describe how long after a URTI a relapse would be ascribed to a treatment group or the number of relapses deemed not related to URTIs. In 1 older study, 70% of relapses were associated with URTIs.2 Thus, this relatively benign strategy could have a major impact on the overall incident of relapse in these patients. For those patients who continue to relapse on alternate-day glucocorticoid therapies, there are a variety of immunomodulating agents that can be used, often associated with significant costs and adverse effects. Definitive controlled trials are needed in this area, and this study strongly supports the inclusion of a daily glucocorticoid during URTIs in the intervention arm in such trials.
References
PII: S0022-3476(08)00292-8
doi:10.1016/j.jpeds.2008.04.007
© 2008 Mosby, Inc. All rights reserved.
