Article

Randomized, Controlled Trial of Tacrolimus and Monotherapy for Adults with De Novo A Multicenter, Randomized, Controlled Trial

1 2 3 3 2 Nicholas Rhys Medjeral-Thomas, Christopher Lawrence, Marie Condon, Bhrigu Sood, Paul Warwicker, 1 4 4 5 6 7 1,8 1 Renal and Transplant Heather Brown, James Pattison, Sunil Bhandari, Jonathan Barratt, Neil Turner, H. Terence Cook, Jeremy B. Levy, Centre, Imperial 1,8 1,8 1 1 1 Liz Lightstone, Charles Pusey, Jack Galliford, Thomas D. Cairns, and Megan Griffith College Healthcare NHS Trust, London, Abstract United Kingdom; 2The Lister Hospital, Background and objectives Minimal change disease is an important cause of nephrotic syndrome in adults. East and North are first-line therapy for minimal change disease, but a prolonged course of treatment is often Hertfordshire NHS required and relapse rates are high. Patients with minimal change disease are therefore often exposed to high Trust, Stevenage, United Kingdom; cumulative doses and are at risk of associated adverse effects. This study investigated whether 3 de novo South West Thames tacrolimus monotherapy without corticosteroids would be effective for the treatment of minimal change Renal and disease. Transplantation Unit, Epsom and St Helier Design, setting, participants, & measurements This was a multicenter, prospective, open-label, randomized, University Hospitals controlledtrial involving six units acrossthe United Kingdom.Adult patients with first presentationof NHS Trust, Epsom, United Kingdom; minimal change disease and nephrotic syndrome were randomized to treatment with either oral tacrolimus at 4Guy’s and St Thomas’ 0.05 mg/kg twice daily, or prednisolone at 1 mg/kg daily up to 60 mg daily. The primary outcome was complete NHS Foundation Trust, remission of nephrotic syndrome after 8 weeks of therapy. Secondary outcomes included remission of nephrotic London, United 5 syndrome at 16 and 26 weeks, rates of relapse of nephrotic syndrome, and changes from baseline function. Kingdom; Hull University Teaching fi Hospitals NHS Trust, Results There were no signi cant differences between the tacrolimus and prednisolone treatment cohorts in the Hull, United Kingdom; proportion of patients in complete remission at 8 weeks (21 out of 25 [84%] for prednisolone and 17 out of 25 [68%] 6Department of for tacrolimus cohorts; P50.32; difference in remission rates was 16%; 95% confidence interval [95% CI], 211% to , Immunity 40%),16 weeks (23 out of 25 [92%] for prednisolone and19 out of 25 [76%] for tacrolimus cohorts;P50.25;difference and Inflammation, 2 University of Leicester, in remission rates was 16%; 95% CI, 8% to 38%), or 26 weeks (23 out of 25 [92%] for prednisolone and 22 out of Leicester, United 25 [88%] for tacrolimus cohorts; P50.99; difference in remission rates was 4%; 95% CI, 217% to 25%). There was no Kingdom; 7Centre for significant difference in relapse rates (17 out of 23 [74%] for prednisolone and 16 out of 22 [73%] for tacrolimus Inflammation cohorts) for patients in each group who achieved complete remission (P50.99) or in the time from complete Research, University remission to relapse. of Edinburgh, Edinburgh, United Kingdom; and 8Centre Conclusions Tacrolimus monotherapy can be effective alternative treatment for patients wishing to avoid for Inflammatory therapy for minimal change disease. Disease, Imperial CJASN – College London, 15: 209 218, 2020. doi: https://doi.org/10.2215/CJN.06180519 London, United Kingdom

Introduction require a prolonged initial course of corticosteroids Correspondence: Minimal change disease causes up to 25% of ne- to enter remission (9,13–15). Additionally, the relapse Dr. Megan Griffith, phrotic syndrome in adults (1–3). Nephrotic syn- rate in adults is high at 48%–76%, and worse in adults Renal Unit, 4th Floor fi Ham House, drome is associated with signi cant comorbidities, younger than 45 years of age (9,13). This necessitates Hammersmith including (4,5), thromboembolic events (6,7), the use of repeated courses of . The resultant Hospital, Du Cane and hyperlipidemia (8). Furthermore, AKI accom- high-dose corticosteroid exposure is associated with Road, London W12 panies the presentation of minimal change disease in adverse effects, including weight gain, mel- OHS, UK. Email: m.e. griffi[email protected] up to 25% of cases (9). Consequently, most clinicians litus, infection, osteoporosis, cosmetic changes, and recommend treatment for minimal change disease gastrointestinal bleeding (14,16). patients with high doses of corticosteroids. How- Steroid-sparing therapeutic agents have been used ever, this is a rare disease and there is a paucity of to treat patients with frequently relapsing or steroid- data from randomized, controlled trials in adults on dependent minimal change disease (17). These in- the efficacy of therapy (10–12). Many adult patients clude , , tacrolimus, www.cjasn.org Vol 15 February, 2020 Copyright © 2020 by the American Society of Nephrology 209 210 CJASN

mycophenolate, and, more recently, (18–29). hypoalbuminemia. Only one patient in each cohort had Tacrolimus is widely available and generally well toler- UPCR,300 mg/mmol, and these patients had UPCR of ated and therefore a relatively attractive alternative to 249 and 261 mg/mmol, respectively. Biopsy specimens corticosteroids for treatment of minimal change disease. were examined and reported locally and reviewed by a Minimal change disease pathogenesis is thought to be single histopathologist (H.T.C.) if there was diagnostic dependent on systemic T changes and subsequent uncertainty. Patients were excluded if they had any of the cytokine production that impairs glomerular function following: hepatitis B, C, or HIV infection; other untreated (17). Tacrolimus is a inhibitor that suppresses infections; women who were pregnant, breast feeding, or IL-2 transcription and inhibits activation. Tacroli- at risk of ; patients who had immunosuppres- mus may also reduce proteinuria by directly stabilizing sion for nephrotic syndrome in the past 18 months or podocyte structure (30). Additionally, tacrolimus may be that may affect the outcome of their associated with a more favorable side-effect profile than current episode of nephrotic syndrome; or any condition alternative calcineurin inhibitors such as ciclosporin, as that would cause the study to be detrimental to the patient. well as having fewer side effects than corticosteroids (28). Local responsible clinicians directed the management Retrospectivecaseseriesreport successful tacrolimus of with angiotensin receptor blockers or treatment of frequently relapsing, steroid-dependent, and angiotensin-converting enzyme inhibitors and hypercho- steroid-resistant minimal change disease (19,26). Likewise, lesterolemia with statins. Primary venous thromboembo- ciclosporin has been used as monotherapy in prospective lism prophylaxis was subcutaneous low-molecular-weight trials of steroid-dependent and steroid-resistant minimal heparin while serum albumin was ,2.0 g/dl, or aspirin change disease treatment (22,31). As significant corticosteroid 75 mg daily if the serum albumin was $2.0 g/dl but toxicity can occur from the first, often prolonged, therapeutic ,3.0 g/dl (37). Patients considered to be at high risk of course for minimal change disease, as well as from sub- latent tuberculosis were also prescribed isoniazid 150 mg sequent courses given for relapses, steroid-sparing agents daily and pyridoxine 50 mg weekly during immunosup- such as calcineurin inhibitors and cyclophosphamide are pression treatment. sometimes also used for a first presentation of minimal We randomized patients at a 1:1 ratio to receive either change disease. However, there are few data on the effec- oral tacrolimus or prednisolone. Participants were enrolled tiveness of steroid-free regimens for de novo disease. by the local principal investigators at each site. Consec- In , steroid avoidance or early utively enrolled patients were allocated a trial number withdrawal results in improved BP and lower rates of new- by the lead site. Before the trial commenced, each trial onset diabetes, dyslipidemia, weight gain, and infections number was randomized to a treatment arm by computer- (32–35). These associations appear to be dose-dependent generated random permuted blocks (with concealment of (36). Steroid-free regimens may likewise be beneficial in block size from the clinical team). Allocation and masking minimal change disease. was through computer-generated sheets in opaque, tamper- This prospective, multicenter, randomized, open-label evident envelopes (one for each trial number) that were trial compared tacrolimus and prednisolone monother- stored securely at the lead site and opened by the trial apy for the treatment of adult patients with minimal team after each patient enrolment. The intervention as- change disease, and investigated the hypothesis that signment was communicated to the local principal inves- tacrolimus monotherapy is noninferior to corticosteroids tigator. Randomization sequence was not known by the for inducing remission and has comparable relapse rates, trial investigators. The treatment was nonblinded after but is associated with fewer adverse events. This is the intervention assignment. The trial was monitored through- first prospective, multicenter trial of steroid-free treat- out by the data monitoring committee. Trial recruitment ment for de novo minimal change disease in adults. finished after the target study population had been reached and was closed when all patients had completed follow-up. Materials and Methods Patients allocated to tacrolimus received an initial dose This was a multicenter, randomized, controlled trial that of 0.05 mg/kg twice daily, with target blood trough levels recruited patients from six out of the seven units enrolled of 6–8 ng/ml. In the event of inadequate clinical response in the study. The study protocol was registered at the at 8 weeks of treatment, the target blood trough level was European Clinical Trials Database (EudraCT, number increased to 9–12 ng/ml. Twelve weeks after achieving 2009–014292–52) and ClinicalTrials.gov (identifier: complete remission, the tacrolimus doses were gradually NCT00982072). The trial was conducted in accordance reduced over 8 weeks and stopped. Patients allocated to with the Declaration of Helsinki. Ethics approval was prednisolone received initial doses of 1 mg/kg per day with obtained from the United Kingdom (UK) National Research a maximum dose of 60 mg/d. One week after achieving Ethics Service Committee (reference 09/H0711/68). complete remission, the steroid dose was halved for The inclusion criteria were age .18 years, nephrotic 4–6 weeks then gradually reduced and stopped over a syndrome, and a kidney biopsy showing minimal change further 6 weeks, ensuring patients received a minimum of disease. We defined nephrotic syndrome as the combination 16 weeks of prednisolone. Patients receiving predniso- of urine protein-to-creatinine ratio (UPCR) .100 mg/mmol lone were also prescribed 20 mg and calcium and a serum albumin of ,3.0 g/dl. We adopted this carbonate/colecalciferol (1000 mg/800 IU) two tablets daily. level of proteinuria to avoid excluding patients with The primary outcome was the proportion of patients hypoalbuminemia and significant but non-nephrotic range achieving complete remission at 8 weeks. We defined proteinuria, which may have been subsequent to severe complete remission apriorias UPCR,50 mg/mmol. CJASN 15: 209–218, February, 2020 Tacrolimus Monotherapy for De Novo Minimal Change Disease, Medjeral-Thomas et al. 211

Partial remission was defined as UPCR reduction of at least compared using unpaired t test. Continuous variables with 50% from enrolment and a value between 50 mg/mmol skewed distribution were compared using Mann–Whitney and 300 mg/mmol. The secondary outcomes were the U test and confidence intervals were calculated using the proportion of patients achieving complete remission at 16 Hodges–Lehmann method. We compared the proportion and 26 weeks, the proportion who relapsed after complete of patients in remission and relapse with Fisher exact test remission, change in serum creatinine from baseline, and andusedtheBaptista–Pike method to calculate odds ratio the number of adverse events. Relapse was defined as (OR) confidence intervals and the Newcombe–Wilson UPCR.300 mg/mmol in patients who had achieved method with continuity correction for confidence intervals complete remission. Patients who achieved complete re- of differences in proportions. We adjusted P values for mission were followed up for 7862weeksfromcom- differences in remission rates for multiple analyses with the plete remission or until relapse. We reviewed patients two-stage linear step-up procedure of Benjamini et al. (40). weekly for 4 weeks, then monthly for 6 months, then every 3 months, or more frequently at the investigators’ discre- tion if clinically indicated. At each review we measured Results proteinuria (UPCR), and tested blood for full blood count, Patients biochemical profile, nonfasting glucose, and trough tacroli- We enrolled 55 patients from six hospitals across the mus levels. The per-protocol analysis evaluated patients who UK. All patients had de novo disease. Three patients were completed at least 8 weeks of therapy. We also compared excluded after review of their biopsy specimen by outcomes on an intention-to-treat basis. electron microscopy determined they had an alternative Statistical advice on sample size calculations was diagnosis (features of membranous nephropathy in two provided by the Department of Statistics, Imperial Col- patients and nephritis in one patient). Randomi- lege London (London, UK). Noninferiority was assessed zation allocated 27 patients to tacrolimus and 25 patients by estimating the two-sided 95% confidence interval to prednisolone treatment (Figure 1). Two patients in the (95% CI) for the difference in remission rates between tacrolimus group did not complete 8 weeks of treatment; the two groups using the Koopman asymptomatic score one patient developed an allergic rash and diarrhea 2 days (38).We aimed to verify that the lower limit of the 95% CI after starting tacrolimus; one patient developed lower was not lower than 10% (D value of 20.1). The expected respiratory tract infection 8 days into treatment and were complete remission rate for patients treated with corti- withdrawn on the request of the local clinician. Ten costeroids at 8 weeks was estimated at 60% (23), and patients in each cohort received treatment for hyperten- tacrolimus at 84% (39). Allowing for a 10% drop-out rate, sion with angiotensin receptor blockers or angiotensin- we calculated we needed to enroll 52 patients. We used converting enzyme inhibitors (Table 1). The median total GraphPad Prism Version 6.00 for Windows for statistical treatment time until relapse of nephrotic syndrome, or analyses. Normally distributed continuous variables were completion of withdrawal was 36 weeks (interquartile

Enrolled 55 Excluded after biopsy review = 3

Randomized Prednisolone Tacrolimus 52

25 27

25Treatment 27

Withdrawn Allergic reaction (day 2) = 1 Analysis for remission at Respiratory tract infection (day 8) = 1 25 25 8, 16 and 26 weeks

Monitor for relapse or 25 25 lack of efficacy

Figure 1. | Study design and study cohort flowchart. Of 55 patients enrolled, 52 were randomized to treatment, and 25 patients in each cohort completed treatment. Two patients in the tacrolimus group did not complete treatment; one patient developed diarrhea and rash 2 days after starting tacrolimus; one patient developed lower respiratory tract infection 8 days into treatment; both were withdrawn from the study to receive nonprotocol treatment. These patients are included in the intention-to-treat analysis and excluded from the per-protocol analysis. 212 CJASN

Table 1. Patient characteristics at enrollment

Characteristic Overall (n550) Prednisolone (n525) Tacrolimus (n525)

Male n (%) 27 (54%) 15 (60%) 12 (48%) Age Median (range) 43 (18–74) 39 (18–73) 43 (18–74) White n (%) 33 (66%) 17 (68%) 16 (64%) Serum creatinine, mg/dl Median (range) 0.82 (0.53–2.96) 0.81 (0.59–2.33) 0.82 (0.53–2.96) eGFR, ml/min per 1.73 m2 Median (range) 98 (27–120) 94 (29–120) 99 (27–120) Urine protein-to-creatinine ratio, mg/g Median (range) 7310 (2204–15,708) 6504 (2310–15,708) 7717 (2204–15,619) Urine protein-to-creatinine ratio, mg/mmol Median (range) 826 (249–1775) 735 (261–1775) 872 (249–1765) Serum albumin, g/dl Median (range) 1.6 (0.7–2.9) 1.7 (0.7–2.9) 1.5 (0.7–2.4) Systolic BP, mm Hg Median (range) 127 (101–145) 128 (101–145) 126 (108–140) Diastolic BP, mm Hg Median (range) 80 (50–90) 80 (67–89) 73 (50–90) Antihypertensive treatment n (%) 20 (40%) 10 (40%) 10 (40%)

range [IQR], 26–52 weeks) for the tacrolimus cohort com- Relapse Rates pared with 23 weeks (IQR, 14–29 weeks) for the corticoste- There was no significant difference between the tacroli- roid cohort. The median follow-up across the study was mus and prednisolone cohorts in the proportion of patients 44 weeks (IQR, 22–82 weeks). who relapsed after achieving complete remission (Table 2). Relapse after complete remission was recorded in 17 out of 23 in the prednisolone cohort, and 16 out of 22 in the Primary Outcome tacrolimus cohort (P50.99; difference in relapse rates, 11%; fi There were no signi cant differences between the treatment 95% CI, 222% to 26%). The timings of relapses were similar arms in the proportion of patients in complete remission at 8 between the two treatment groups (Figure 3). At 26 weeks apriori fi weeks, although the results did not meet the de nition from complete remission, 13 out of 23 (57%) in the prednis- of noninferiority. olone cohort and 15 out of 22 (68%) in the tacrolimus cohort Intention-to-Treat Analysis. A total of 21 out of 25 (84%) were relapse free (P50.54; difference in relapse rates, 11%; patients in the prednisolone cohort and 17 out of 27 (63%) 95% CI, 216% to 42%). Two of the patients in remission in the patients in the tacrolimus cohort were in remission at 8 weeks prednisolone group subsequently left the United Kingdom (P50.12). The difference in remission rates was 21% (95% and were lost to follow-up; one at 36 weeks and one at 40 CI, 26% to 44%). weeks. At 52 weeks, seven out of 21 (33%) in the prednisolone Per-Protocol Analysis. Of patients who completed cohort and nine out of 22 (41%) in the tacrolimus cohort were relapse free (P50.75; difference in relapse rates, 8%; 95% CI, 8 weeks of treatment, 21 out of 25 (84%) in the prednisolone 2 cohort and 17 out of 25 (68%) in the tacrolimus cohort were 21% to 38%). At 78 weeks, four out of 21 (19%) in the P5 prednisolone cohort and six out of 22 (27%) in the tacrolimus in remission at 8 weeks ( 0.32). The differences in remission P5 rates were 16% (95% CI, 211% to 40%) (Figure 2, Table 2). cohort were relapse free ( 0.72; difference in relapse rates, 8%; 95% CI, 218% to 37%). Most relapses occurred after immunosuppression treatment had been stopped (nine out Secondary Outcomes of 17 [53%] relapses in the prednisolone cohort and nine out of 16 [56%] in the tacrolimus cohort). The duration of Remission Rates. There were no significant differences remission was not statistically different between the pred- between the treatment arms in the proportion of patients in nisolone and tacrolimus cohorts (median time complete complete remission at 16 or 26 weeks. remission to relapse 22.0 weeks in the prednisolone cohort Intention-to-Treat Analysis. At 16 weeks, 23 out of 25 and 32.7 weeks in tacrolimus cohort; P50.72). (92%) patients in the prednisolone cohort and 19 out of 27 There were no significant differences in mean serum (70%) patients in the tacrolimus cohort were in complete creatinine between the treatment groups during the 12- P5 remission ( 0.08; difference in remission rates, 22%; 95% month follow-up period (Figure 4). CI, 23% to 43%). At 26 weeks, the proportions were 23 out of 25 (92%) in the prednisolone cohort and 22 out of 27 (81%) in the tacrolimus cohort (P50.71; difference in rates 2 Other Outcomes 11%; 95% CI, 12% to 32%). Post hoc analysis demonstrated that a significantly greater Per-Protocol Analysis. Analysis of patients completing proportion of patients treated with prednisolone were in 8 weeks of treatment showed 23 out of 25 (92%) patients in complete remission at 4 weeks. By intention-to-treat anal- the prednisolone cohort and 19outof25(76%)patients ysis, complete remission rates were 16 out of 25 (64%) in the in the tacrolimus cohort were in complete remission at prednisolone cohort and six out of 27 (22%) in the tacro- 16 weeks (P50.25; difference in remission rates, 16%; limus cohort (P50.005; difference in remission rates, 42%; 95% CI, 28% to 38%). At 26 weeks, the proportions 95% CI, 12% to 63%). The per-protocol analysis showed 16 were 23 out of 25 (92%) for the prednisolone cohort and out of 25 (64%) patients in the prednisolone cohort and six 22 out of 25 (88%) for the tacrolimus cohort (P50.99; out of 25 (24%) in the tacrolimus cohort were in complete difference in remission rates, 4%; 95% CI, 217% to remission at 4 weeks (P50.01; difference in remission rates, 25%) (Figure 2, Table 2). 40%; 95% CI, 13% to 60%). However, post hoc analysis of CJASN 15: 209–218, February, 2020 Tacrolimus Monotherapy for De Novo Minimal Change Disease, Medjeral-Thomas et al. 213

A 100%

90%

80%

70%

60%

50% Prednisolone (n=25) 40% Tacrolimus (n=25) 30%

Achieved complete remission 20%

10%

0% 02468101214161820222426 Weeks from starting treatment

Weeks 0 4 8 12 16 20 24 26

Prednisolone 0162122 23 23 23 23 Tacrolimus 0 6 17 18 19 20 21 22

B 100% 90% 80% 70% 60% 50% Prednisolone (n=25) Tacrolimus (n=25) 40% 30% 20% 10% Achieved partial or complete remission partial or complete Achieved 0% 0 2 4 6 8 10 12 14 16 18 20 22 24 26 Weeks from starting treatment

Weeks 0 4 8 12 16 20 24 26

Prednisolone 0 20 23 23 23 23 24 24 Tacrolimus 0 19222223242424

Figure 2. | The proportion of patients achieving complete remission. (A) Complete remission and (B) all remission (complete or partial remission) against weeks from the start of treatment in the prednisolone (gray, solid line) and tacrolimus (black, dashed line) cohorts. The number of patients achieving remission is shown in the table below each graph. total remission rates (complete or partial remission) at (3.24 g/dl in the prednisolone and 2.75 g/dl in the tacrolimus 4 weeks showed no significant difference between treatment cohorts; P50.03; difference in means, 0.49 g/dl; 95% CI, arms (Figure 2B). By intention-to-treat analysis, 20 out of 25 0.05 to 0.93 g/dl). No significant difference in albumin was patients (80%) in the prednisolone cohort and 19 out of 27 detected at the other time points. Differences in UPCR did patients (70%) in the tacrolimus cohort achieved complete or not reach statistical significance at 4-week follow-up partial remission at 4 weeks (P50.53; difference in remission (median prednisolone cohort UPCR, 11 mg/g [IQR, rates, 10%; 95% CI, 217% to 34%). The per-protocol analysis 6–109 mg/g]; median tacrolimus cohort UPCR, 58 mg/g showed 20 out of 25 patients (80%) in the prednisolone cohort [IQR, 6–216 mg/g]; P50.36) or at subsequent time points. and 19 out of 25 patients (76%) in the tacrolimus cohort achieved complete or partial remission at 4 weeks (P50.99; difference in remission rates, 4%; 95% CI, 222% to 29%). Adverse Events Post hoc analysis of the per-protocol cohorts showed the Adverse events were recorded from the intention-to-treat mean serum albumin was significantly higher in the pred- cohorts. Eighteen adverse events were recorded from 25 nisolone than the tacrolimus cohort at 4 weeks follow-up patients in the prednisolone cohort (0.72 events per patient), 214 CJASN

Table 2. Primary, secondary, and exploratory outcomes

Overall Prednisolone Tacrolimus Outcome P Value n Cohort Percentage n Cohort Percentage n Cohort Percentage

Primary outcome Complete remission 38 50 76 21 25 84 17 25 68 0.32 (0.54) by 8 wk Secondary outcomes Complete remission 42 50 84 23 25 92 19 25 76 0.25 (0.54) by 16 wk Complete remission 45 50 90 23 25 92 22 25 88 0.99 (1.00) by 26 wk Any relapse after 33 45 73 17 23 74 16 22 73 0.99 complete remission Change in serum 50 Median 5 0.02 25 Median 5 0.01 25 Median 5 0.02 0.16 creatinine Range 521.25 Range 521.25 Range 520.47 at 12 mo, mg/dl to 0.64 to 0.20 to 0.64 Exploratory outcomes Complete remission 22 50 44 16 25 64 6 25 24 0.01 (0.05) by 4 wk Complete or partial 39 50 78 20 25 80 19 25 76 0.99 (1.00) remission by 4 wk Failed to achieve 5 50 10 2 25 8 3 25 12 0.99 complete remission

Adjusted P values for multiple analyses are shown in parentheses. and 20 adverse events were recorded in the 27 patients in (P50.99 for difference in serious adverse event rates the tacrolimus cohort (0.74 events per patient; P50.99 between the treatment cohorts). Specifically, there were compared with the prednisolone cohort) (Table 3). There admissions for perforated diverticular disease, severe were four serious adverse events that required admission headache, traumatic fractured radius, and lower respi- in the prednisolone and three in the tacrolimus cohorts ratory tract infection in the prednisolone cohort (Table 3).

100.00%

90.00% Prednisolone Tacrolimus 80.00%

70.00%

60.00%

50.00%

Relapse free 40.00%

30.00%

20.00%

10.00%

0.00% 0 132639526578 Weeks from complete remission

Weeks from complete remission 0 12265278 Prednisolone (number followed-up) 22 (23) 18 (23) 13 (23) 7 (21) 4 (21) Tacrolimus (number followed-up) 22 (22) 19 (22) 15 (22) 9 (22) 6 (22)

Figure 3. | The proportion of patients who suffered a relapse after complete remission in the prednisolone (gray, solid line) and tacrolimus (black, dashed line) cohorts. The number of patients with relapse after complete remission at 26-week intervals is shown. Two of the patients in remission in the prednisolone group were lost to follow-up at 36 weeks and 40 weeks. CJASN 15: 209–218, February, 2020 Tacrolimus Monotherapy for De Novo Minimal Change Disease, Medjeral-Thomas et al. 215

Mean serum creatinine from treatment 1.2 Table 3. Adverse events recorded in the prednisolone and 1 tacrolimus cohorts 0.8 Prednisolone Tacrolimus Adverse Events 0.6 (n525) (n527) 0.4 Prednisolone Tacrolimus Total 18 (4 SAEa)20(3SAEb) 0.2 Infections requiring 65

Serum creatinine (mg/dl) 0 antibiotics 0 1 2 3 4 5 6 7 8 9 10 11 12 URTI requiring 23 Months from treatment antibiotics LRTI requiring 3 (1 SAE) 1 SAE Median urine protein creatinine ratio from treatment antibiotics 1000 Urinary tract infections 1 900 Infective diarrhea 1 800 Vaginal candidiasis 1 700 Musculoskeletal pain 4 600 Gastrointestinal 1 SAE 5 (1 SAE) 500 symptoms 400 Headache 2 (1 SAE) 1 (mg/mmol) 300 Prednisolone Tacrolimus Gum pain 2 200 Weight gain 1 100 Low mood 2 Urine protein creatinine ratio 0 Acneiform rash 2 0 1 2 3 4 5 6 7 8 9 10 11 12 1 1 Months from treatment Uncontrolled 1SAE hypertension Mean serum albumin from treatment Deranged LFTs 1 4.5 Traumatic limb fracture 2 (1 SAE) 4 3.5 SAE, serious adverse event; URTI, upper respiratory tract in- 3 fection; LRTI, lower respiratory tract infection; LFT, function test. 2.5 a 2 SAEs recorded in the prednisolone cohort were one admission with perforated diverticular ulcer, one episode of severe 1.5 fi 1 Prednisolone Tacrolimus headache requiring investigation (no organic cause identi ed),

Serum albumin (g/dl) one patient with traumatic fractured radius, and one patient 0.5 with lower respiratory tract infection requiring intravenous 0 0 1 2 3 4 5 6 7 8 9 10 11 12 antibiotics and supplemental oxygen. bThe SAE recorded in the tacrolimus cohort were one admission Months from treatment with uncontrolled hypertension, one admission with diarrhea and rash 2 days into treatment, and one admission with lower respiratory tract infection. Figure 4. | Changes in mean serum creatinine, median urine protein- to-creatinine ratio, and mean serum albumin from the start of treatment and during follow-up in the prednisolone and tacrolimus treated cohorts. The urine protein-to-creatinine ratio data were to inform clinicians and allow appropriate counseling of nonparametrically distributed. patients on the likely success of alternative regimens. This is the first prospective, multicenter, randomized trial of a corticosteroid-free treatment regimen for de novo minimal In the tacrolimus cohort, there were admissions for severe change disease in adults. Although the results did not hypertension, diarrhea and rash 2 days into treatment meet our aprioridefinition of noninferiority, the lack of with subsequent withdrawal from the study, and lower significant differences in primary and secondary outcomes respiratory tract infection 8 days into treatment with sub- between the treatment cohorts demonstrate tacrolimus sequent withdrawal from the study. There were no deaths monotherapy is an effective alternative to corticosteroids during follow-up in either cohort. We recorded a similar for the treatment of minimal change disease. To counter number of infective episodes in each cohort (Table 3). We any ambiguity, we have provided intention-to-treat anal- recorded one episode of hyperglycemia in each cohort, ysis as well as the per-protocol analysis of patient who but both were treated with diet alone; we recorded no new completed at least 8 weeks of therapy. Post hoc analysis cases of diabetes mellitus in either cohort (Table 3). demonstrated more patients treated with prednisolone achieved complete remission at 4 weeks than in the tacrolimus arm. However, the clinical significance of this Discussion is not clear, as most patientsinbothgroupshadachieved Minimal change disease is a rare disease in adults, and significant reductions in proteinuria (UPCR,300 mg/mmol) there is a paucity of clinical trials. Corticosteroids are by 4 weeks, and analysis of total remission rates (complete effective in minimal change disease, but the side effects or partial remission) at 4 weeks showed no significant are significant, hence many patients and their physicians difference between treatment arms. This warrants further would prefer to consider alternative treatments. How- study, as it may be relevant in some patients, especially ever, there are few data in the literature on the effective- perhaps those presenting with severe complications of ne- ness of steroid-free regimens in minimal change disease phrotic syndrome. For patients treated with steroids 216 CJASN

initially, concomitant tacrolimus treatment, may allow striae and “moon facies,” which can be especially debili- early steroid withdrawal and limitation of steroid- tating for this group of patients, particularly the young associated toxicity, as in the study by Li et al. (39). adults, and also have an effect on adherence with treatment. Rates of complete remission in this trial are comparable Although our study was not powered to demonstrate dif- with those documented in previous minimal change disease ferences in side effects, it was reasoned that noninferiority in patient series for both steroids and calcineurin inhibitors. terms of remission from nephrotic syndrome in patients with Retrospective studies of prednisolone treatment regimens minimal change disease would be likely to portend side- (1 mg/kg daily for 4–16 weeks, and with 24 weeks total effect benefits for patients treated with tacrolimus compared treatment) similar to our study, documented remission rates with corticosteroids. We recorded equal and relatively few of 70%–90% by 16 weeks of treatment (8,9). In general, adverse events in both treatment regimens. The study by calcineurin inhibitor use has predominantly been report- Li et al. recorded a higher rate of total adverse events (209 ed in steroid-resistant, steroid-dependent, and frequently adverse events in 119 study patients), and did show an relapsing minimal change disease cases and involved increased adverse event frequency in the prednisolone 9–12 months of treatment, making direct comparison diffi- cohort, particularly osteoporosis and new-onset hyperten- cult. However, remission rates from these studies were sion (39). After intravenous for similar at between 60% and 80% with an average time to 10 days, the prednisolone treatment regimen used by Li remission of about 5 weeks (8). With regards to de novo et al. provided 1 mg/kg oral prednisolone (up to a maximum minimal change disease, a single case series of 12 minimal of 80 mg/d) and 22–24 weeks total prednisolone treatment. change disease patients with relative contraindications In comparison our regimen involved no intravenous to corticosteroids treated with cyclosporine alone for methylprednisolone, prednisolone doses up to a maximum 12 months documented response rates of 75% and minimal of 60 mg/d, and a minimum of 16 weeks of treatment. The adverse effects (24). Data from patients with minimal duration and target plasma levels of tacrolimus were similar change disease treated with tacrolimus without prednis- in the two studies. The lower prednisolone doses and the olone are limited. However, a number of studies suggest steroid-free study arm in our study may explain the differ- tacrolimus is effective in combination with prednisolone ences in adverse event burden between the studies. Addi- (16) and is better tolerated than cyclosporine as a steroid- tional adverse events may be recorded with longer duration sparing agent (19,26,28). The most comprehensive clinical of follow-up, especially in patients with relapsing minimal trial of de novo minimal change disease in adults comes change disease who require repeated courses of treatment to from China. In this, Li et al. compared the use of tacrolimus achieve and maintain remission. and prednisolone monotherapy in adults with minimal Our study is relatively small but is none the less change disease (39) after treatment of all patients with important, as most other published data in adults with high-dose daily intravenous methylprednisolone (0.8 mg/kg) de novo minimal change disease relates to retrospective for 10 days (39). Notably high remission rates were achieved studies and case series, particularly in Western popula- in both cohorts, more than 90% of both treatment cohorts tions, reflecting the difficulty of conducting studies in this were in remission by 4 weeks (39). This may be because of group of patient with a rare disease. the initial use of high-dose intravenous corticosteroids in all Corticosteroids are standard therapy for de novo min- their patients, but there may also be a difference in response imal change disease. This study is the first multicenter, rates between Chinese and UK patients (13,23). randomized, controlled trial of a steroid-free regimen in Relapse rates were similar in our tacrolimus and pred- adults. On the basis of remission, relapse and adverse nisolone treatment groups and comparable to the 48%–76% event rates, it provides evidence that tacrolimus mono- relapse rates reported in other case series (9,13,14,42). Our therapy is an effective alternative to corticosteroids for de relapse rate is higher than either of the cohorts in the Li et al. novo minimal change disease. This is highly significant for study (39). This may also be explained by the use of intrave- the treatment of patients with this disease. nous methylprednisolone in the Li et al. study or to racial differences in relapse rates. Other studies have documen- Data Sharing Statement ted relapse rates of 73%–76% in predominantly white We are happy to share deidentified, collected cohort data and cohorts compared with 48% in a large cohort from China results for comparative and replication research. Additional related (9,13,23). The relapse rates may also reflect treatment documents, such as the study protocol, will be available on request. regimen durations and doses. At trial design, the sparsity The planned data use must not breach the ethical approval obtained of available data on tacrolimus treatment for minimal change for our study. There is no prespecified time limit to data availability. diseaseledustoadoptaregimenofmodesttreatment Please contact the corresponding author to request access. exposure. We also aimed to use a corticosteroid regimen of similar duration for comparison. This resulted in regimens Acknowledgments of relatively modest duration and dosing. Regimens of We thank clinical research nurse Tom Walters for his support and longer duration and higher dosing may improve relapse assistance, Bernard North (Department of Statistics, Imperial Col- rates and should be investigated in future trials. legeLondon)foradviceon calculation of samplessize,andDr.Adam fi This study was motivated by the signi cant adverse Mclean for generating the random allocation sequence. effect burden associated with the use of corticosteroids in patients with minimal change disease (11,41). Obesity and Disclosures metabolic syndromes consistently associate with increased Dr. Barratt reports receiving consultant fees from Aduro Bio- all-cause mortality (43). There are also significant unpleas- tech, Alnylam, Calliditas, EMD Serono, Novartis, Omeros, Ret- ant cosmetic side effects associated with steroids such as rophin, andVisterraoutsidethesubmittedwork.Dr.Cookreports CJASN 15: 209–218, February, 2020 Tacrolimus Monotherapy for De Novo Minimal Change Disease, Medjeral-Thomas et al. 217

receiving consultant fees from Achillion Pharmaceuticals and 14. Shinzawa M, Yamamoto R, Nagasawa Y,Oseto S, Mori D, Tomida PsiOxus Therapeutics outside the submitted work. Dr. Galliford K, Hayashi T, Izumi M, Fukunaga M, Yamauchi A, Tsubakihara Y, Isaka Y: Comparison of methylprednisolone plus prednisolone reports receiving consultant fees as a scientificadvisoryboard with prednisolone alone as initial treatment in adult-onset min- member from Alexion Pharmaceuticals and - imal change disease: A retrospective cohort study. Clin J Am Soc ceuticals outside of the submitted work. Dr. Griffith reports re- Nephrol 9: 1040–1048, 2014 ceivingconsultantfeesasascientificadvisory boardmemberfrom 15. Mak SK, Short CD, Mallick NP: Long-term outcome of adult-onset Vifor Pharma UK outside the submitted work. Dr. Levy re- minimal-change nephropathy. Nephrol Dial Transplant 11: 2192–2201, 1996 ports receiving consultant fees as an educational advisor from 16. Eguchi A, Takei T, Yoshida T, Tsuchiya K, Nitta K: Combined Gilead Sciences outside the submitted work. Dr. Lightstone re- cyclosporine and prednisolone therapy in adult patients with the ports receiving consultant fees from Achillion, AstraZeneca, first relapse of minimal-change nephrotic syndrome. Nephrol Aurinia, Genentech, GSK, Medimmune, Pfizer, Roche, and UCB, Dial Transplant 25: 124–129, 2010 and research support from Roche outside the submitted work. 17. Hogan J, Radhakrishnan J: The treatment of minimal change disease in adults. J Am Soc Nephrol 24: 702–711, 2013 Dr. Sood reports receiving travel support from Alexion Phar- 18. Al-Khader AA, Lien JW, Aber GM: Cyclophosphamide alone in maceuticals to attend a sponsored educational event, and from the treatment of adult patients with minimal change glomerulo- Vifor Pharma UK outside the submitted work. Dr. Turner reports nephritis. Clin Nephrol 11: 26–30, 1979 receiving consultant fees as an advisory board member from 19. Li H, Shi X, Shen H, Li X, Wang H, Li H, Xu G, Chen J: Tacrolimus Otsuka, Sanofi Genzyme, and Shire (Takeda). Dr. Warwicker re- versus intravenous pulse cyclophosphamide therapy in Chinese adults with steroid-resistant idiopathic minimal change ne- ports receiving lecture fees from Alexion Pharmaceuticals outside phropathy: A multicenter, open-label, nonrandomized cohort of the submitted work. All other authors have nothing to disclose. trial. Clin Ther 34: 1112–1120, 2012 20. Mak SK, Lo KY, Wong CY, Tong GM, Wong PN, Wong AK: Funding Treatment with cyclophosphamide in elderly-onset nephrotic We acknowledge the National Institute for Health Research Im- syndrome. Nephron Clin Pract 101: c25–c32, 2005 21. Uldall PR, Feest TG, Morley AR, Tomlinson BE, Kerr DN: Cy- perial Biomedical Research Centre for support of this study. clophosphamide therapy in adults with minimal-change ne- phrotic syndrome. Lancet 1: 1250–1253, 1972 22. 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Correction There was no significant difference between the Nicholas Rhys Medjeral-Thomas, Christopher tacrolimus and prednisolone cohorts in the proportion Lawrence,MarieCondon,BhriguSood,Paul of patients who relapsed after achieving complete re- Warwicker, Heather Brown, James Pattison, Sunil mission (Table 2). Relapse after complete remission was Bhandari, Jonathan Barratt, Neil Turner, H. Terence recorded in 17 out of 23 in the prednisolone cohort, and 16 Cook, Jeremy B. Levy, Liz Lightstone, Charles Pusey, outof22inthetacrolimuscohort(P50.99; difference in Jack Galliford, Thomas D. Cairns, and Megan Griffith: relapse rates, 1%;95%CI,222% to 26%). Randomized, Controlled Trial of Tacrolimus and Pred- In the final paragraph of the methods section, the text nisolone Monotherapy for Adults with De Novo Mini- below incorrectly cited reference 39 instead of a citation mal Change Disease: A Multicenter, Randomized, that was erroneously missing: “The expected complete Controlled Trial. Clin J Am Soc Nephrol 15: 209–218, remission rate for patients treated with corticosteroids at 8 2020; DOI: https://doi.org/10.2215/CJN.06180519. weeks was estimated at 60% (23), and tacrolimus at 84% Because of author error, on page 212 of the above- (39).” This text should have instead cited the following referenced article, the percentage in boldfaced font article: Gulati, S, Prasad, N, Sharma, RK, Kumar, A, was inadvertently written as 11% instead of 1%. In the Gupta, A, Baburaj, VP: Tacrolimus: a new therapy for following, the correct percentage is indicated in situ in steroid-resistant nephrotic syndrome in children. the section from the article. Nephrol Dial Transplant, 23: 910–913, 2008.

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