CLINICAL RESEARCH www.jasn.

org

Tacrolimus Monotherapy after Intravenous

Methylprednisolone in Adults with Minimal Change
Nephrotic Syndrome
Xiayu Li,* Zhangsuo Liu,† Li Wang,‡ Rong Wang,§ Guohua Ding,| Wei Shi,¶ Ping Fu,**
Yani He,†† Genyang Cheng,† Shukun Wu,‡ Bing Chen,§ Juan Du,| Zhiming Ye,¶ Ye Tao,**
Bengang Huo,†† Heng Li,* and Jianghua Chen*
*Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China;
†
Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; ‡Department of
Nephrology, Sichuan Academy of Medical Sciences, Sichuan Provincial People’s Hospital, Chengdu, China; §Department of
Nephrology, Shandong Provincial Hospital Affiliated with Shandong University, Jinan, China; |Department of Nephrology,
Renmin Hospital of Wuhan University, Wuhan, China; ¶Nephrology Division, Guangdong General Hospital, Guangzhou,
China; **Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China; and ††Department of
Nephrology, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China

ABSTRACT
Glucocorticoid treatment is the first choice therapy for adults with minimal change nephrotic syndrome; how-
ever, this therapy associates with many adverse effects. Tacrolimus may be an alternative to conventional
glucocorticoid therapy. To investigate this possibility, we conducted a prospective, randomized, controlled trial
(WHO International Clinical Trials Registry Platform: ChiCTR-TRC-11001454) in eight renal units across China. We
randomized enrolled patients with adult–onset minimal change nephrotic syndrome (n=119) to receive gluco-
corticoid therapy or tacrolimus after intravenous methylprednisolone (0.8 mg/kg per day) for 10 days. Patients
received a conventional glucocorticoid regimen or tacrolimus monotherapy, starting with 0.05 mg/kg per day
(target trough whole–blood level of 4–8 ng/ml) for 16–20 weeks and subsequently tapering over approximately
18 weeks. Remission occurred in 51 of 53 (96.2%; all complete remission) glucocorticoid-treated patients and 55
of 56 (98.3%; 52 complete and three partial remission) tacrolimus-treated patients (P=0.61 for remission; P=0.68
for complete remission). The groups had similar mean time to remission (P=0.55). Relapse occurred in 49.0% and
45.5% of the glucocorticoid- and tacrolimus-treated patients, respectively (P=0.71), with similar time to relapse
(P=0.86). Seven (13.7%) glucocorticoid-treated and four (7.3%) tacrolimus-treated patients suffered frequent
relapse (P=0.28); five glucocorticoid-treated and two tacrolimus-treated patients became drug dependent
(P=0.26). Adverse events occurred more frequently in the glucocorticoid group (128 versus 81 in the tacrolimus
group). Seven adverse events in the glucocorticoid group and two adverse events in the tacrolimus group were
serious. Consequently, tacrolimus monotherapy after short–term intravenous methylprednisolone is noninferior
to conventional glucocorticoid treatment for adult–onset minimal change nephrotic syndrome in this cohort.

J Am Soc Nephrol 28: 1286–1295, 2017. doi: 10.1681/ASN.2016030342

Minimal change nephrotic syndrome (MCNS) ac-
counts for 10%–25% of all nephrotic syndromes
affecting adults.1,2 Glucocorticoids (GCs) are the
first-line therapy for adults with MCNS according
to the Kidney Disease Improving Global Outcomes
(KDIGO) clinical practice guidelines.3 Their use
has affected a remission in approximately 80% of
patients with MCNS.2–5 However, MCNS remains a
Received March 22, 2016. Accepted September 15, 2016.
Published online ahead of print. Publication date available at
www.jasn.org.
Correspondence: Dr. Jianghua Chen, Kidney Disease Center,
The First Affiliated Hospital, College of Medicine, Zhejiang Uni-
versity, 79 Qingchun Road, Hangzhou, 310003 Zhejiang Prov-
ince, China. Email: chenjianghua@zju.edu.cn
Copyright © 2017 by the American Society of Nephrology

1286 ISSN : 1046-6673/2804-1286 J Am Soc Nephrol 28: 1286–1295, 2017


therapeutic challenge for physicians, because 48%–76% of
initially steroid–responsive patients with MCNS experience
at least one relapse, whereas up to one third of patients fre-
quently relapse or become steroid dependent, necessitating
the use of a high cumulative dose of GCs.2–6 The adverse
effects of long–term GC treatment include osteoporosis, in-
fection, psychosis, cataract, hypertension, diabetes mellitus,
gastrointestinal bleeding, and obesity, many of which are se-
rious afflictions.6–9 Second– or third–line immunosuppres-
sive agents, such as cyclophosphamide, calcineurin inhibitors
(CNIs), mycophenolate mofetil, and rituximab, have been
used to reduce or alleviate the adverse effects of GCs in these
patients.2,3,8–11 Therefore, care must be taken to balance the
risks and benefits of GCs for the treatment of adult MCNS.
Ideal regimens in the treatment of adult MCNS should com-
prise rapid induction, longer–term sustained remission, and
fewer adverse effects.
The theory that T and/or B cell–mediated events result in
the production of a yet to be identified circulating factor that
harms glomerular cells, causing MCNS, is well documen-
ted.12,13 In addition, the roles of two podocyte proteins (i.e.,
CD80 and angiopoietin-like protein 4) have been explored in
MCNS.13–15 Tacrolimus (TAC) is a stronger suppressor of the
immune system, most notably of T cells, than cyclosporin and
differs in the nature of its cytokine suppression. This may
explain its differential effect on proteinuria in nephrotic syn-
dromes, particularly MCNS.16 Interestingly, recent findings
showed that the additional effect of TAC on proteinuria
was a result of the stabilization of the actin cytoskeleton or re-
duction of angiopoietin-like protein 4 levels in podocytes.17,18
These results suggest that the antiproteinuric effect of TAC is
independent of its immunosuppressive effect and instead,
results from a direct effect on podocytes, indicating its po-
tential application in the treatment of MCNS. Several previ-
ous studies have reported the use of TAC for the treatment of
refractory MCNS in adult and pediatric patients.10,19–22 A
controlled trial suggested that TAC might be a promising alterna-
tive to cyclosporin because of its lower risk of relapse and lack of
cosmetic adverse effects.21 We have previously published a case
series with TAC as the preferred CNI for the treatment of adults
with steroid-dependent and steroid-resistant MCNS, showing
that TAC was a more effective and safe treatment alternative for
such patients.19,20 In addition, our group recently found that TAC
might be a potential rescue therapy of adult patients with MCNS
irresponsive to a steroid (or a steroid combined with another
immunosuppressive drug) treatment or who developed reversible
acute renal failure.23,24
Despite these promising results, further research is warranted
to determine if TAC monotherapy has fewer adverse effects than
observed for steroid therapy to successfully replace steroids as the
primary course of therapy for patients with MCNS. This multi-
center, randomized trial tested this hypothesis by comparing a
new strategy of short–term intravenous methylprednisolone fol-
lowed by TAC monotherapy with conventional GC treatment in
adult patients with MCNS.
J Am Soc Nephrol 28: 1286–1295, 2017
www.jasn.org CLINICAL RESEARCH
RESULTS
Patients
One hundred nineteen adult patients admitted between
September 28, 2011 and May 10, 2013 at eight clinical cen-
ters were randomly enrolled into the trial (Figure 1). Fifty-
six and sixty-three patients were assigned to the GC group
and the TAC group, respectively. The baseline characteristics
of the two groups were similar (Table 1). One hundred nine
patients (53 in the GC group and 56 in the TAC group) com-
pleted at least 12 weeks of therapy and were included in the
subsequent evaluation of efficacy. One hundred patients (47
in the GC group and 53 in the TAC group) completed at least
24 weeks of therapy. One patient from each group discontin-
ued treatment due to serious adverse events (AEs)—severe
abdominal cavity infection in the GC group and reversible
acute nephrotoxicity in the TAC group.
A second renal biopsy was performed in some patients be-
cause of no remission, partial remission, or relapses (five and
four in the GC and TAC groups, respectively), resulting in a
modification of the initial histopathologic pattern in four pa-
tients (two each in the GC and TAC groups) from minimal
change nephropathy to FSGS.
The mean dose of TAC administered was 2.861.3 mg/d
(corresponding to 0.0560.02 mg/kg per day) during the first
20 weeks of treatment and 2.261.7 mg/d (corresponding
to 0.0460.03 mg/kg per day) during the following 16 weeks.
Primary Outcomes
Efficacy
The treatment efficacy was evaluated on the basis of the out-
come of patients who completed at least 12 weeks of therapy.
The study was designed as a noninferiority trial to determine
whether the difference in the remission (either complete or
partial remission) rates between the GC and TAC groups was
not .9.5%. The remission rates were 96.2% (51 of 53) and
98.3% (55 of 56) in the GC and TAC groups, respectively
(P=0.61), and could be evaluated with a 95% confidence in-
terval (95% CI) for difference (95% CI, 26% to 10%) in
noninferiority of the TAC group. Complete remission
was experienced by 51 of 53 patients (96.2%) in the GC
group and 52 of 56 patients (92.9%) in the TAC group
(P=0.68) (Figure 2). The mean time to remission was sim-
ilar in the GC (2.762.3; range =0.6–12.6 weeks) and TAC
(2.662.6; range =0.9–16.0 weeks) groups (P=0.55). Pa-
tients who showed no remission because of persistent severe
proteinuria (two in the GC group and one in the TAC
group) were recommended to receive the exchange proto-
col. One of these two patients in the GC group achieved
complete remission after switching to the TAC protocol;
the other patient exhibited resistance to both TAC and com-
bined TAC and GC therapy and was rediagnosed with FSGS
after repeat renal biopsy. The one patient with exhibiting
resistance to TAC showed no response after switching to the
GC protocol.
Tacrolimus in Adult Minimal Change Disease 1287
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Figure 1. Flow chart of study populations, including the number of patients who were assessed for eligibility, underwent randomization, and
completed the study treatment. Of 162 patients assessed for eligibility, 43 patients were withdrawn, 119 patients were randomly enrolled in GC
group (n=56) or TAC group (n=63). One hundred patients (47 in the GC and 53 in the TAC group) completed at least 24 weeks of therapy.

Changes in the Proteinuria and Serum Albumin Levels albumin levels between the two groups during the treatment
Figure 3 shows the proteinuria and serum albumin levels of period were not statistically significant (P.0.05).
the patients before the start and at the regular checkups after
the start of GC and TAC treatments. No significant differences Secondary Outcomes
were observed in mean proteinuria during therapy between Relapses
the two groups (P.0.05). The differences in the mean serum The incidence of relapse in both treatment groups is presented in
Table 2. Among those patients who experi-
Table 1. Baseline characteristics of participants enced remission, 26 of 51 (51.0%; GC) and
Characteristic Overall, n=119 GC Group, n=55 TAC Group, n=63 30 of 55 (54.5%; TAC) patients who under-
Women, n (%) 52 (43.7) 26 (46.4) 26 (41.3)
went remission sustained the remission suc-
Age at enrollment, yr 29.3610.9 28.6610.0 29.9612.0 cessfully (P=0.71). The mean time to relapse
Duration of disease, d 18.2617.3 16.1618.3 20.1616.3 was similar between the GC (24.2615.4;
Proteinuria, g/d 7.464.0 7.863.8 7.164.1 range =4.0–55.0 weeks) and the TAC
Serum albumin, g/L 17.565.0 17.364.7 17.765.3 (23.3616.9; range =1.5–54.0 weeks) groups
SCr, mmol/La 71.1619.4 72.7620.7 69.6618.2 (P=0.86). The Kaplan–Meier curves show
eGFR, ml/min per 1.73 m2b 121.6633.2 120.3634.7 122.8631.9 the probability of first relapse at different
BP, mmHg time points between the GC and TAC groups
Systolic 118.6613.5 119.2615.4 118.0611.8 (P=0.81; log rank test) (Figure 4). Frequent
Diastolic 75.6610.9 76.3612.4 75.069.6
relapses were observed in seven (13.7%; GC)
Hypertension, n (%) 12 (10.5) 6 (11.5) 6 (9.7)
and four (7.3%; TAC) patients (P=0.28),
Weight, kg 63.6610.7 64.4611.0 62.9610.4
Body mass index, kg/m2 23.363.3 23.462.9 23.263.6
whereas five and two patients in the GC and
Fasting blood sugar, mmol/L 4.760.6 4.760.7 4.760.5 TAC groups, respectively, became drug de-
Serum cholesterol, mmol/L 10.163.4 9.862.9 10.463.8 pendent (P=0.26). There were five late non-
Serum triglyceride, mmol/L 2.361.2 2.461.2 2.361.3 responders (three in the GC group and two in
Serum LDL, mmol/L 6.862.8 6.662.6 6.962.9 the TAC group).
Serum uric acid, mmol/L 359.16100.5 358.96101.4 359.26100.5
Values are expressed as the mean6SD or number (percentage).
a
To convert creatinine values to milligrams per deciliter, multiply by 0.0113.
Renal Function
b
The GFR was estimated using the four–variable Modification of Diet in Renal Disease Study equation: Four (7.1%) patients in the GC group and
GFR=1863SCr(21.154)3 age(20.203)31.212 (if black) 30.742 (if woman). three (4.8%) in the TAC group suffered

1288 Journal of the American Society of Nephrology J Am Soc Nephrol 28: 1286–1295, 2017
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(4.8%; TAC) patients who required statin

therapy. New-onset hyperuricemia was ob-
served in six (10.7%; GC) patients and 11
(17.5%; TAC) patients, of whom nine
showed reversal after cessation of TAC
therapy. New-onset hypertension occurred
in ten (17.9%; GC) patients versus four
(6.4%; TAC) patients who required antihy-
pertensive medication.
Eight dimensions of the 36-item short
form health survey (SF-36; physical func-
tioning, mental health, physical role, bodily
pain, general health, vitality, social func-
tioning, and emotional role) were similar
among the patients of the GC and TAC
groups at all time points.

AEs
Two hundred nine AEs (128 and 81 in pa-
tients in the GC and TAC groups, respec-
tively) were recorded in 92 patients (49,
Figure 2. Percentage of patients who achieved complete remission (CR) and partial
GC; 43, TAC) (Table 3); of these, nine
remission (PR) during the 36 weeks of therapy. The treatment efficacy was evaluated on
(seven and two in the GC and TAC groups,
the basis of the outcome of patients who completed at least 12 weeks of therapy. The
remission rate was 96.2% (51 out of 53 patients) and 98.3% (55 out of 56 patients) in the
respectively) were deemed as serious AEs
GC and TAC group, respectively (P=0.61). Complete remission was experienced by 51 that needed hospital treatment. The most
out of 53 patients (96.2%) in the GC group and 52 out of 56 patients (92.9%) in the TAC common AEs observed in the two groups
group (P=0.68). Three patients (2 in the GC group and 1 in the TAC group) showed no were infections, hepatotoxicity, gastroin-
remission. G, GC group; T, TAC group. testinal symptoms, and new-onset hyper-
tension. The patients in the GC group had
some additional AEs, including meta-
AKI. One patient in the TAC group developed exacerbated bolic disorders, osteoporosis, Cushing syndrome, purple
AKI, with an increase in serum creatinine (SCr) levels from 75 stripes, and acne; those in the TAC group also had reversible
mmol/L before TAC therapy to 156 mmol/L after 1 week of hyperuricemia.
therapy; the SCr decreased from 156 to 76 mmol/L after TAC
treatment was discontinued for 1 week. The other patients in
both groups suffered AKI because of a rapid decrease in the DISCUSSION
serum albumin levels during the relapse period. The changes
in the SCr and eGFR levels during the treatment period and This study suggests that TAC monotherapy after short–term
the final follow-up period are presented in Figure 5. The SCr intravenous methylprednisolone is noninferior to conven-
and eGFR levels did not differ significantly between the GC tional steroid therapy in inducing remission. A similar per-
and TAC groups (P.0.05). Repeat renal biopsies were per- centage of patients in the GC (96.2%) and TAC (98.3%)
formed in four patients after initiation of TAC. No evidence of groups showed remission (complete or partial), with 96.2%
TAC nephrotoxicity was observed in the sections obtained (GC) and 92.9% (TAC) of the patients experiencing complete
from patients. remission. Previous studies showed that GC therapy resulted
in remission in approximately 80% of adults with MCNS, with
Changes in Metabolic Indices and Quality of Life 50% of the patients responding by 4 weeks, and 10%–25% of
The changes in metabolic indices during therapy with GC or the patients requiring 12–16 weeks of therapy.2,4,5 However,
TAC are presented in Supplemental Table 1. New–onset over- the majority (over 90%) of the patients in this trial had at-
weight characteristics (body mass index of 25 to approxi- tained remission by 4 weeks, and the mean time to remission
mately 29.9 kg/m2) were observed in six (10.7%; GC) and was similar between the two groups. The optimal dose, trough
zero (TAC) patients (P=0.01). New–onset glucose intolerance level, and duration of TAC therapy remain unknown, because
was observed in six (10.7%; GC) and four (6.4%; TAC) pa- they are solely on the basis of case series reports.19–21 In this
tients, and new–onset diabetes mellitus was observed in three trial, we found that a mean TAC dose of 0.05 mg/kg per day,
patients of the GC group. Dyslipidemia after the 12-week ther- with trough levels ranging from 4 to 8 ng/ml, was sufficient to
apy was still observed in 11 (19.6%; GC) patients and three induce remission in the majority of the patients with MCNS.

J Am Soc Nephrol 28: 1286–1295, 2017 Tacrolimus in Adult Minimal Change Disease 1289
 CLINICAL RESEARCH www.jasn.org
Figure 3. Changes in proteinuria and serum albumin levels at baseline and during the with SCr levels .133 mmol/L and/or AKI
36 weeks of therapy. (A) Proteinuria and (B) serum albumin before therapy (week 0) and were excluded. Furthermore, long-term
during the 36 weeks of therapy. No significant differences between the two groups use of a CNI is associated with chronic
were observed in mean proteinuria and serum albumin levels before therapy and nephrotoxicity. 28,29 The SCr and eGFR
during the 36 weeks of therapy (P.0.05).
Relapse rates in adults with MCNS are high. Case series data
show that 48%–76% of the patients experience at least one
relapse after steroid-induced remission, which is often accom-
panied by frequent relapses or steroid dependence.4–6,25,26
Furthermore, in previous studies, the relapse group
showed a significantly higher frequency of steroid AEs, such
as cataract and osteoporosis, compared with the nonrelapse
group.6,7,26 Steroid-sparing agents, such as cyclophospha- such as dyslipidemia, glucose intolerance or diabetes mellitus,
mide, CNIs, and mycophenolate mofetil, are recommended
1290 Journal of the American Society of Nephrology
to avoid steroid dependence.3 A recent trial in-
dicated the efficacy of rituximab in childhood–
onset nephrotic syndrome, complicated
frequent relapses, and steroid depen-
dence.11 In our previous study, we showed
that steroid–dependent/steroid–resistant
adult patients with MCNS undergoing
TAC therapy experienced relapse rates of
approximately 40%–50%.20,21 This trial
showed the occurrence of relapse in
49.0% and 45.5% of the patients treated
with GC and TAC, respectively; frequent
relapses also occurred at similar rates in
both groups (13.7% versus 7.3%, respec-
tively). Because of the high relapse rate
observed using this particular treatment
regimen, future research is warranted to
evaluate whether extending the duration
of TAC therapy would result in fewer pa-
tients with relapse.
AKI in the presence of MCNS has been
well documented and typically occurs
in 25%–30% of the adult patients. 5,27
Waldman et al.5 retrospectively examined
95 adults with MCNS, 25.2% of who met
the criteria for AKI during initial presenta-
tion or relapse. In this trial, AKI was ob-
served in 7.1% (GC) and 4.8% (TAC) of the
patients, and the most common cause of
AKI was relapse with a rapid decrease in
serum albumin levels. Indeed, AKI in
MCNS could be consistent with a sudden
decreasing in serum albumin levels and
severe plasma volume depletion.5,24,27 Ad-
ditionally, acute nephrotoxicity is a con-
cern, because TAC is a CNI.28 To reduce
the risk of acute CNI nephrotoxicity in this
study, a short–term intravenous methyl-
prednisolone infusion before TAC treat-
ment was administered, and patients
levels remained stable in all patients of
this study after TAC or GC therapy. These
favorable results may be attributed to our use of a relatively
low TAC dosage and short treatment course. There is no ev-
idence of chronic CNI nephrotoxicity on the basis of repeat
renal biopsies of TAC-treated patients. However, the repeat
renal biopsies were acquired from only four patients who
underwent short–term follow-up periods.
In this trial, changes in metabolic indices and disorders,
hyperuricemia, and being overweight, during the treatment
J Am Soc Nephrol 28: 1286–1295, 2017

Table 2. The incidence of relapses in GC and TAC groups
n (%)
Relapse Event
GC Group, n=51 TAC Group, n=55
Maintained sustained remission 26 (51.0)
Relapses 25 (49.0)
Relapses during therapy with tapering dose 19 (37.3)
Relapses during therapy discontinuation 6 (11.8)
Frequent relapse 7 (13.7)
Drug dependencea 5 (9.8)
Late nonresponder 3 (5.9)
a
Drug dependence included steroid dependence and TAC dependence.
with GC and TAC were assessed. Interestingly, a greater num-
ber of patients in the GC group developed metabolic disorders
(characteristics of being overweight, dyslipidemia, and glucose
intolerance or new–onset diabetes mellitus). Previous studies
have reinforced the association between metabolic disorders
and all-cause mortality.30–33 TAC therapy has been reported to
cause new–onset diabetes mellitus and hyperuricemia more onset MCNS. This conclusion is on the basis of the similar
often in kidney transplant recipients.34,35 Here, the number of
patients with new-onset hyperuricemia was higher in the TAC
group; however, in the majority of the patients, this was re-
versed after TAC discontinuation.
The incidence of overall AEs tended to be more frequent in
the GC group compared with that in the TAC group. No sig-
nificant differences in the onset of infections, hepatotoxicity,
and gastrointestinal symptoms were observed between the two
Figure 4. The incidence of the first relapse in the GC and TAC groups. Kaplan-Meier
curves show the probability of the event (first relapse) at different time points be-
tween the GC and TAC groups (P=0.81 by long rank test). Point 0 represents onset
of remission.
J Am Soc Nephrol 28: 1286–1295, 2017
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groups. However, osteoporosis, new-onset
hypertension, and symptoms affecting the
P Value skin, muscles, and joints occurred more
frequently in patients who received GC
30 (54.5) 0.71
25 (45.5) 0.71
therapy.
18 (32.8.) 0.63 There are some limitations to our study.
7 (12.7) 0.88 First, the number of participants included
4 (7.3) 0.28 was relatively small. However, this limita-
2 (3.6) 0.26 tion does not diminish the importance of
2 (3.6) 0.67 our findings, because the data used for the
design of treatments for initial MCNS in
adults are limited to case reports and case
series. Second, the follow-up period was relatively short. We
plan to follow these patients for a longer period of time to assess
relapse occurrence, renal function, and AEs.
In conclusion, the results of our trial suggest that TAC
monotherapy after short–term intravenous methylpredniso-
lone is noninferior to conventional GC treatment for adult-
remission and relapse rates observed in both treatment groups.
Metabolic disorders occurred more frequently in the patients
of the GC group. In addition, patients in the GC group had a
higher number of AEs. Therefore, TAC monotherapy after
short–term intravenous methylprednisolone could be consid-
ered an alternative to conventional GC therapy for adult-onset
MCNS. In future studies, it would be worthwhile to investigate
if this novel treatment regimen could be used as the initial
therapeutic course for MCNS in adults
and children.
CONCISE METHODS
Study Design
In this prospective, open label, multicenter,
randomized, controlled trial, we compared a
TAC monotherapy regimen after short–term
intravenous methylprednisolone with conven-
tional GC treatment for adult-onset MCNS.
The study protocol was registered at the Chi-
nese Clinical Trial Registration of the World
Health Organization International Clinical
Trials Registry Platform (no. ChiCTR-TRC-
11001454). Detailed information is available
at http://www.chictr.org.cn/. The trial was
conducted in accordance with the Declaration
of Helsinki. Ethical approval was obtained
from the research ethics committees of all par-
ticipating hospitals. All patients provided in-
formed consent.
Participants
In this trial, patients were recruited from eight
nephrology centers across China. The inclusion
criteria were as follows: age 18–65 years old;
Tacrolimus in Adult Minimal Change Disease 1291
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Randomization and Treatment

Procedures
After the confirmation of eligibility, the patients
were randomly assigned (1:1) to one of two
groups (according to a random number label):
(1) GC group: short–term intravenous methyl-
prednisolone followed by a conventional taper-
ing oral prednisone regimen or (2) TAC group:
short–term intravenous methylprednisolone
followed by TAC monotherapy. The minimiza-
tion method was applied using a computer-
generated sequence.
All patients received an intravenous methyl-
prednisolone (0.8 mg/kg per day) infusion for 10
consecutive days at hospital admission. In the
GC group, patients subsequently received oral
prednisone at 1 mg/kg per day (maximum 80
mg/d) for 6–8 weeks according to the treatment
response. This dose was subsequently reduced
by 5 mg every week to 30 mg on alternate days
and maintained for 8 weeks followed by taper-
ing of the dose over approximately 12 weeks un-
til complete withdrawal. In the TAC group, TAC
therapy was initiated on the eighth day, with an
initial oral dose of 0.05 mg/kg per day (that was
divided into two doses administered over a 12-
hour interval). The TAC dosage was adjusted
to a target trough whole–blood level of 4–8 ng/ml
and maintained for 16–20 weeks according
to the treatment response. Subsequently, the
dose was tapered to achieve a target trough
level of 2–5 ng/ml over approximately 18
weeks until complete withdrawal. The treat-
ment course for both groups was 36 weeks.
The treatment was prolonged by 8 weeks for
patients who underwent partial remission af-
ter 12 weeks of therapy. Patients who showed
Figure 5. Changes in SCr and eGFR levels at baseline, during the periods of no remission after 12 weeks of therapy with
therapy and follow-up. SCr (A) and eGFR (B) before therapy (week 0), during the GC or TAC were recommended to withdraw
periods of therapy and follow-up. The SCr and eGFR levels before therapy, during from the trial and undertake the other treat-
the periods of therapy and follow-up did not differ significantly between the GC ment trial (TAC monotherapy or conventional
and TAC groups (P.0.05). GC therapy). Patients who relapsed during the
therapy were treated with a second cycle of GC
renal biopsy–verified diagnosis of minimal change nephropathy (ex- or TAC therapy. Patients who relapsed twice were recommended to
amined using light microscopy, immunofluorescence, and elec- withdraw from the study.
tron microscopy); new–onset nephrotic syndrome (proteinuria The dose of angiotensin–converting enzyme inhibitors or an-
.3.5 g/d and serum albumin ,30 g/L); initial SCr level of ,133 giotensin II receptor blockers used by the respective patients was
mmol/L; and urine volume of .600 ml/d (or .1000 ml/d after the maintained for the duration of therapy. If required, additional an-
use of diuretic drugs). Patients with the following conditions were tihypertensive drugs were administered to achieve adequate BP
excluded: secondary minimal change disease, AKI, hepatitis B control. Statins were administered to those patients who still had
or C infection, diabetes mellitus, a history of pancreatitis or gas- dyslipidemia after 12 weeks of therapy.
trointestinal ulcer, a history of congenital or acquired immuno-
deficiency, or previous treatment with corticosteroids or other Definitions and Outcome Measures
immunosuppressants (e.g., cyclophosphamide, CNIs, or myco- Complete remission was defined as a decrease in proteinuria to #0.3 g/d.
phenolate mofetil). Partial remission was defined as a decrease in proteinuria to ,3.5 g/d but

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Table 3. AEs and serious AEs for GC and TAC therapy SCr and eGFR levels, AKI, metabolic disorders
GC Group (128 Reports, TAC Group (81 Reports, (being overweight, glucose intolerance, diabetes
AEs mellitus, dyslipidemia, and hyperuricemia), AEs,
49 Patients), n=56 43 Patients), n=63
Infection and serious AEs.
Urinary tract infection 3 4
Female genital tract infection 1 1 Follow-Up
Upper respiratory infection 13 12 In this trial, the follow-up duration was 64 weeks
Lower respiratory tract infection 2 (1 SAE) 2 after therapy. Follow-ups were performed weekly
Abdominal cavity infection 1 (1 SAE) for the first 4 weeks, every 4 weeks for the sub-
Gastrointestinal symptoms 8 9 sequent 36 weeks, and every 8 weeks thereafter.
Hepatotoxicity 13 (1 SAE) 10 (1 SAE) During each visit, the patients underwent anthro-
AKI 4 (1 SAE) 3 (1 SAE)
pometric measurements (body weight and stand-
New-onset hypertension 10 4
ing height) and BP measurements. Complete
Metabolic disorder
New–onset glucose intolerance 6 4
blood count, proteinuria, blood glucose, SCr, se-
New–onset diabetes mellitus 3 (2 SAE) rum uric acid, lipid profile, albumin, alanine
New-onset hyperuricemia 6 11 aminotransferase, and aspartate aminotransfer-
Other 3 1 ase levels were determined. The trough TAC level
Osteoporosis 5 1 was measured every week until stable followed by
Electrolyte disorder 3 2 measurements every 4 weeks. The body mass
Arrhythmia 1 1 index (weight in kilograms divided by the square
Menstrual disorders 4 of the height in meters) was measured, and the
Psychiatry/neurology 4 (1 SAE) 3 questionnaire SF-36 and bone mineral density
Cushing syndrome 20
measurement (with dual energy x-ray absorpti-
Symptoms of skin, muscle, and joint
ometry) were performed at the baseline and every
Cramps 3 1
Arthralgia 2 2
12 weeks.
Hypertrichosis 1
Cutaneous ulcer 1 Sample Size
Erythra 4 2 TAC therapy was hypothesized to be noninferior
Alopecia 1 3 to GC therapy in achieving remission. On the basis
Purple stripes 5 of the results of previous studies and our obser-
Acne 6 vations that the remission rates of GC and TAC
SAE, serious adverse event. therapy in adult-onset MCNS were 80% and 90%,
respectively,2–5,19,20 a sample size of 54 patients in
.0.3 g/d. The persistence of nephrotic proteinuria after 12 weeks of each group (total of 108 patients) was required to determine that
treatment with prednisone (1.0 mg/kg per day) or oral TAC (with a TAC therapy was not .9.5% inferior to GC therapy with a type 1
trough whole–blood level of 4–8 ng/ml) was considered to be no remis- error probability of 2.5% and a power of 80% according to the for-
sion (treatment resistance). The time to remission was defined as the mulas by Gart and Nam.36 Allowing for an expected dropout rate of
time from the initiation of the therapy to the day when remission (com- 10%, we aimed at enrolling 120 patients.
plete or partial remission) was observed. Relapse was defined as an in-
crease in proteinuria to $3.5 g/d in patients who underwent partial or Statistical Analyses
complete remission. Time to relapse was defined as the time from ini- All efficacy analyses were on the basis of the intention-to-treat
tiation of remission to the day when the first relapse occurred. Frequent principle, comparing groups according to the randomly assigned
relapse was defined as two or more relapses within 6 months of the treatment. For the primary efficacy analysis for noninferiority, we
initial response or four or more relapses in any 12-month period, carried out a per-protocol analysis, which included patients who
and patients with two consecutive relapses during steroid (or TAC) received protocol treatments as scheduled. Noninferiority was as-
therapy or within 14 days of ceasing therapy were considered to be sessed by estimating the two–sided 95% CI for the difference in
drug (steroid or TAC) dependent. Late nonresponder was defined as remission rates between the GC and TAC groups using the method
no response to the second period of steroid or TAC therapy after by Gart and Nam36 and verifying that the lower limit of the 95% CI
relapsing during tapering or discontinuation of steroid or TAC ther- was not lower than 29.5%. The 9.5% margin was on the basis of
apy. AKI was defined as an increase in SCr to .50% above baseline clinical adjustment.
or .26.4 mmol/L during 48 hours according to KDIGO guidelines. All data were expressed as the mean6SD or median (interquartile
The primary outcome measures were the cumulative numbers of range) for continuous variables and percentage for categorical vari-
patients who experienced complete remission or partial remission. ables. The differences in normally distributed continuous variables
Secondary outcome measures were determined using the following between two groups were compared using the two–tailed indepen-
variables: relapse, time to remission, time to relapse, changes in the dent sample paired t test. A paired t test was performed to compare

J Am Soc Nephrol 28: 1286–1295, 2017 Tacrolimus in Adult Minimal Change Disease 1293
 CLINICAL RESEARCH www.jasn.org
two means obtained at different times during the therapy. Non-
parametric variables obtained at different times were compared
using the Wilcoxon signed rank test, and categorical variables
were compared by Fisher exact or chi-squared test. The probabil-
ity of the first relapse between two groups was estimated by the
Kaplan–Meier method, and survival curves were compared with
log rank tests. A P value ,0.05 was considered statistically signif-
icant. All statistical analyses were performed using the SAS soft-
ware, version 9.2.
ACKNOWLEDGMENTS
We thank Dr. Huiping Wang for reviewing the renal biopsies of the
patients and Dr. Xiuyang Li (College of Medicine, Zhejiang Univer-
sity) for reviewing the statistical analyses. Dr. Rong Lv, Fei Han, Qun
Li, Xuelin He, Rending Wang, and Wenhan Peng were in charge of
patient care and follow-up.
This trial was supported, in part, by National Nature Science
Foundation of China grants 2011BAI10B07, 2012CR517603, and
2012AA02A512.
The funding source had no role in the design of the study, data
collection, data analysis, data interpretation, or writing of the man-
uscript.
DISCLOSURES
None.
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Tacrolimus in Adult Minimal Change Disease 1295