Efficacy of Mycophenolate Mofetil in Nephrotic Syndrome in Children: A Systematic Review and Network Metaanalysis

This Systematic review and meta-analysis compare efficacy of Mycophenolate mofetil (MMF) to other second line drugs levamisole, cyclosporine and Tacrolimus in Nephrotic syndrome in children and adolescents. Major databases Pubmed, Embase, Scopus, Web of Science, Cochrane and clinical trial registry platforms CENTRAL, WHO ICTRP etc. along with recent pediatric and nephrology journals with cross references from articles were searched. Protocol was registered at international registry platform PROSPERO as CRD42021236056. PRISMA guideline and PICO format was followed, GRADE analysis was done. Available studies in full text in English language were included in analysis. Population was Nephrotic syndrome in children and adolescents, Intervention as MMF, comparator as other second line drugs. KIDGO definitions were followed. Over all 10 studies were included and 3 groups meta-analyzed. MMF versus Levamisole 2 studies 191 subjects, MMF versus Cyclosporine 4 studies 256 subjects, MMF versus Tacrolimus 3 studies 196 subjects. Primary outcomes were frequency of relapse, achievement of complete remission and post treatment steroid dose. Efficacy of MMF, Levamisole, Cyclosporine, Tacrolimus, all 4 drugs was found to be almost similar, and the differences were not statistically significant. The overall effect size diamond either did not cross the central line or the effect was not persistent for all outcomes. Therefore, other factors like easy availability, cost, side effects and long-term safety should guide clinician as well as patients for an informed choice. Sample data is limited and follow up time is also limited to a median length of 12 months; therefore, generalizability of findings is also limited, considering the fact that it is meant for a disease like nephrotic syndrome where categorizing definition itself takes 12 months. More robust studies across the globe are still needed for gathering further evidence to either support or refute the findings