POS-218 Immunosuppressive Agents for Refractory Nephrotic Syndrome in adults: A Bayesian Network Analysis

Abstract

Nephrotic syndrome is a common and frequently occurring disease in chronic kidney diseases. However, some patients are often difficult to cure due to frequent recurrence, and can lead to unpredictable complications, side effects of steroids and immunosuppressants, and even life-threatening. Therefore, this study aimed to clarify the efficacy and acceptability of immunosuppressive therapy at inducing remission and adverse reaction in refractory nephrotic syndrome (RNS). Only parallel group randomized controlled trials (RCTs) were considered eligible for review and were performed in Medline, Embase and Cochrane database with the computerized searches. The primary outcome was complete, partial, and overall remission using an intention-to-treat analysis. The data were synthesized using bayesian network Meta-analysis. Seven studies with a total of 443 patients and 6 treatment strategies were enrolled in this study. The total remission rate of the combination of cyclosporine (CsA) with steroid was more effective than single steroid (OR18.94, 95% credible interval (CrI) 1.35-265.36), and cyclophosphamide (CTX) plus steroid was significantly superior to tacrolimus (TAC) plus steroid (OR11.21, 95%CrI 1.19-105.29). The risk of adverse events for steroids therapy was significantly lower than chlorambucil plus steroids with an OR of 0.01 (95%CrI 0.00, 0.63). Compared with chlorambucil plus steroids, TAC plus steroids were also associated with a lower risk of adverse events (OR 0.01, 95%CrI 0.00-0.43). CTX plus steroids had a lower rate of withdrawal than patients using TAC plus steroids (OR 0.33, 95%CrI 0.14-0.79). These results suggested that the combination of calcineurin inhibitors (CNIs) with steroids might be the best approach to improve the efficacy and acceptability among RNS patients. Although in this systematic review and network meta-analysis of studies of patients with RNS and at least 6 months of follow-up, there was uncertainty around the estimates of effect size for change in remission for all comparison with placebo. Larger RCTs are needed to resolve the uncertainty around efficacy of medications for adult RNS.