Prednisone for Steroid-Sensitive Nephrotic Syndrome: Can We Use Lower Doses for the First Presentation in Children?

Since the 1970s, the accepted standard of care for children presenting with their first episode of nephrotic syndrome has been a course of oral prednisone comprising 60 mg/m2 (2 mg/kg) daily for 4 weeks followed by 40 mg/m2 (1.5 mg/kg) on alternate days for 4 weeks with or without a tapering dose. A meta-analysis of randomized controlled trials (RCTs) in 2007 concluded that prednisone treatment for ≥3 months compared with 2 months reduced the risk of relapse at 12-24 months. However some included studies were at high risk of bias, which, on average, leads to an overestimation of the treatment effect observed. Subsequently 4 RCTs (3 of which were placebo-controlled) published between 2013 and 2019 that were at low risk of bias and involving 775 children demonstrated no benefit of extended-duration treatment beyond 8-12 weeks (with daily administration followed by alternate-day prednisone) for the outcome of first relapse or frequent relapses...