Interventions for focal segmental glomerulosclerosis in adults.

Area of Science:

• Nephrology
• Immunology
• Pharmacology

Background:

• Focal segmental glomerulosclerosis (FSGS) is a kidney disease with primary, genetic, or secondary causes, often leading to nephrotic syndrome or proteinuria.
• Remission rates for FSGS are low, with approximately half of patients progressing to kidney failure.
• This review updates a previous assessment from 2008, focusing on treatment efficacy in adults.

Purpose of the Study:

• To evaluate the benefits and harms of various immunosuppressive and non-immunosuppressive treatments for adult FSGS patients.
• To synthesize evidence from randomized controlled trials (RCTs) and quasi-RCTs on FSGS interventions.

Main Methods:

• Searched the Cochrane Kidney and Transplant Register up to June 2021, including CENTRAL, MEDLINE, and EMBASE.
• Included RCTs and quasi-RCTs comparing different immunosuppressive and non-immunosuppressive agents for FSGS in adults.
• Assessed study quality and extracted data, performing meta-analyses using random-effects models and the GRADE approach.

Main Results:

• Fifteen studies with 560 participants were included; no RCTs on corticosteroids versus placebo were found.
• Cyclosporin, with or without prednisone, showed potential for increasing complete or partial remission in steroid-resistant FSGS (low certainty evidence).
• Evidence for other interventions, including sparsentan, was of very low certainty, with uncertain effects on kidney function, hypertension, or infection.

Conclusions:

• No RCTs evaluating corticosteroids, a recommended first-line treatment, were identified.
• Cyclosporin may improve remission rates in steroid-resistant FSGS, but evidence is imprecise due to small study sizes.
• Future research must clearly define FSGS populations to guide treatment recommendations for primary, genetic, and secondary forms.