Efficacy and Safety of Tacrolimus Versus Cyclosporine in Children With Steroid-Resistant Nephrotic Syndrome: A Randomized Controlled Trial

Background: To examine whether tacrolimus is more effective and safe than cyclosporine (CsA) in inducing remission in patients with steroid-resistant nephrotic syndrome (SRNS). Study Design: Randomized controlled trial, nonblind, parallel group. Settings & Participants: Tertiary-care hospital; 41 consecutive patients with idiopathic SPINS, estimated glomerular filtration rate greater than 60 mL/min/1.73 m(2), and histological characteristics showing minimal change disease, focal segmental glomerulosclerosis, or mesangio-proliferative glomerulonephritis were randomly assigned to treatment with tacrolimus (n = 21) or CsA (n = 20). Intervention: Tacrolimus (0.1 to 0.2 mg/kg/d) or CsA (5 to 6 mg/kg/d) for 1 year; cotreatment with alternate-day prednisolone and enalapril. Outcomes: Patients achieving complete remission (urinary protein-creatinine ratio < 0.2 g/g and serum albumin >= 2.5 g/dL) or partial remission (urinary protein-creatinine ratio, 0.2 to 2 g/g, and serum albumin :2.5 g/dL) at 6 and 12 months; time to remission; proportion with relapses; side effects. Results: No patient was lost to follow-up. After 6 months of therapy, remission occurred in 18 (85.7%) and 16 patients (80%) treated with tacrolimus and CsA, respectively (relative risk [RR], 1.07; 95% confidence interval [CI], 0.81 to 1.41). Rates of remission at 12 months were also similar (RR, 1.14; 95% CI, 0.84 to 1.55). The proportion of patients who experienced relapse was significantly greater in those receiving CsA compared with tacrolimus (FIR, 4.5; 95% CI, 1.1 to 18.2; P = 0.01). The decrease in blood cholesterol levels was greater with tacrolimus compared with CsA (difference in mean values, 45.1 mg/dL; 95% CI, 19.1 to 71.2). Persistent nephrotoxicity necessitating stoppage of medicine was seen in 4.7% and 10% patients, respectively. Cosmetic side effects (hypertrichosis and gum hypertrophy) were significantly more frequent in CsA-treated patients (P < 0.001). Limitations: Single-center study, small sample size, and short duration of follow-up. Conclusions: Tacrolimus or CsA in combination with low-dose steroids show similar efficacy in inducing remission in patients with SRNS. Therapy with tacrolimus is a promising alternative to CsA in view of the lower risk of relapses and lack of cosmetic side effects. Am J Kidney Dis 53:760-769. (C) 2009 by the National Kidney Foundation, Inc.