Effectiveness of a Low Dose Prednisolone Regimen for Treatment of Relapses in Children with Steroid Sensitive Nephrotic Syndrome

Dear Editor,

We read with interest the original article by Mantan et al.[1] titled “Effectiveness of a low dose prednisolone regimen for treatment of relapses in children with steroid sensitive nephrotic syndrome” and would like to compliment the authors for their elegant study on a very relevant issue in pediatricnephrology, which has been attempted by very few investigators earlier.[2] We, however, have a few observations which we would like to highlight through your journal.

The study was conducted on children who had infrequently relapsing course of nephrotic syndrome (IFRNS) with median relapse rate of one per year before enrollment in both intervention and control groups, with both groups requiring very low cumulative dose of steroids per kilogram body weight in previous 6 months, making its results extrapolatable to only children with very mild disease. It would have been more clinically relevant if the study could have included patients with frequently relapsing course and steroid dependence. Secondly, the authors have accepted short follow-up as a limitation but hypothesize that the enrolled children were likely to have similar course on prolongation of follow-up period, which is conjectural at best, and at least 6 months to 1-year of follow-up would be required to comment on noninferiority of reduced dose of steroids on the number of relapses in the patients.

Attention of the authors is drawn to a study by our group which we had to terminate prematurely in accordance with stoppage rules decided a priori, when 30% of the children showed treatment failure while on reduced dose therapy, which included children with infrequently relapsing course while on additional immunosuppression.[3] Finally, the primary outcome of the study was taken to be proportion of patients with remission in each group at the end of therapy, which appears to be confusing as all patients in the control group are expected to achieve remission by virtue of only children with steroid-sensitive nephrotic syndrome included in the study.