What is the initial steroid therapy for the treatment of pediatric nephrotic syndrome?

Updated: Mar 04, 2020
  • Author: Jerome C Lane, MD; Chief Editor: Craig B Langman, MD  more...
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Exclude active infection or other contraindications before starting steroid therapy.

The original International Study of Kidney Disease in Children (ISKDC) protocol recommended induction therapy with oral prednisone or prednisolone at 60 mg/m2/day (2 mg/kg/day), with a maximum of 60 mg, daily for 4 weeks. Traditionally, the total daily dose was split into 2 doses. However, a single daily dose of steroids has efficacy equal to split dosing and fewer adverse effects. [67]

The KDIGO clinical practice guidelines recommend prednisone dosed at 60 mg/m2/day (2 mg/kg/day) given daily for 4-6 weeks, followed by 40 mg/m2 (1.5 mg/kg) given on alternate days for 2-5 months, with a minimum total duration of treatment of 12 weeks. [63]

Studies since the ISKDC have shown that a longer period of initial steroid treatment (6 weeks rather than 4 weeks) reduces the subsequent rate of relapse. Thus, the general consensus now is to prescribe the initial daily steroids for 6 weeks. [48, 59]

Earlier guidelines recommended that induction therapy be followed with maintenance therapy with oral prednisone or prednisolone at 40 mg/m2 (or 1.5 mg/kg), with a maximum of 40 mg, given as a single dose on alternate days for 4 weeks. Subsequent studies demonstrated that a longer alternate-day maintenance period of 6 weeks resulted in a lower rate of relapse. [48]

Thus, the general consensus is daily induction steroid treatment for 6 weeks, followed by alternate-day maintenance therapy for another 6 weeks. [59] After 6 weeks of alternate-day treatment, steroids may be stopped or slowly tapered over a variable length of time.

A Cochrane review suggested that after the initial daily steroid induction phase, continuation of alternate-day steroid therapy for 6 months could reduce the subsequent relapse rate by 33% compared with a shorter alternate-day regimen. [68] However, several randomized controlled trials failed to show a benefit of extended 6-month steroid therapy versus 2-3 months of treatment; therefore, the 6-month steroid regimen is no longer recommended. [56]

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