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  Table of Contents  
Year : 2013  |  Volume : 23  |  Issue : 1  |  Page : 41-46

Calcineurin inhibitor induced nephrotoxicity in steroid resistant nephrotic syndrome

1 Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pathology, Division of Nephrology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication16-Feb-2013

Correspondence Address:
A Bagga
Division of Nephrology, Department of Pediatrics, 3053, Teaching Block, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-4065.107197

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Prolonged therapy with calcineurin inhibitors (CNI) is effective in patients with difficult nephrotic syndrome. However, information on prevalence and risk factors for nephrotoxicity in children with steroid-resistant nephrotic syndrome is limited. This retrospective observational study was conducted on 40 patients with steroid-resistant nephrotic syndrome treated with cyclosporine (CyA) (n = 28) or tacrolimus ( n = 12) for more than 2 years. Nephrotoxicity was defined by the presence of striped fibrosis involving ≥10% of the interstitium or nodular hyalinosis in more than one arteriole. Ten additional parameters were graded semi-quantitatively. Continuous data are presented as median and interquartile range (IQR). The median (IQR) age at onset of nephrotic syndrome and CNI therapy were 30 (21-45) and 49.5 (40-102.5) months. A second renal biopsy, following 30 (26-35) months of CNI therapy, showed histological toxicity in 10 (25%) patients. Toxicity was seen in 7 and 3 patients receiving CyA and tacrolimus, respectively, and 5 patients each with minimal change and focal segmental glomerulosclerosis. Therapy with CNI was associated with significant increases in scores for global glomerulosclerosis, tubular atrophy, interstitial fibrosis, nonnodular arteriolar hyalinosis ( P < –0.001 for all), arteriolar smooth-muscle vacuolization ( P = –0.02), juxtaglomerular hyperplasia ( P = –0.002), and tubular microcalcinosis ( P = –0.06). Risk factors for nephrotoxicity were initial resistance (OR 9; 95% CI 1.0-80.1; P = –0.049); dose of CyA (OR 9.2; 95% CI 1.1-74.6; P = –0.037); duration of heavy proteinuria (OR 1.2; 95% CI 1.0-1.4; P = –0.023); and hypertension during therapy (OR 6; 95% CI 1.3-28.3; P = –0.023). Following prolonged CNI therapy, one in four biopsies show features of toxicity. Prolonged duration of heavy proteinuria, hypertension, initial steroid resistance and high CyA dose predict the occurrence of nephrotoxicity.

Keywords: Cyclosporine, focal segmental glomerulosclerosis, tacrolimus

How to cite this article:
Sinha A, Sharma A, Mehta A, Gupta R, Gulati A, Hari P, Dinda A K, Bagga A. Calcineurin inhibitor induced nephrotoxicity in steroid resistant nephrotic syndrome. Indian J Nephrol 2013;23:41-6

How to cite this URL:
Sinha A, Sharma A, Mehta A, Gupta R, Gulati A, Hari P, Dinda A K, Bagga A. Calcineurin inhibitor induced nephrotoxicity in steroid resistant nephrotic syndrome. Indian J Nephrol [serial online] 2013 [cited 2022 Sep 29];23:41-6. Available from:

  Introduction Top

The management of patients with steroid resistance, constituting 10-20% children with idiopathic nephrotic syndrome, is difficult. [1],[2] Disease complications are common and patients with persistent proteinuria show progressive decline in renal function. The outcomes have improved following the use of calcineurin inhibitors (CNI), cyclosporine (CyA), or tacrolimus, which induce remission in 50-80% patients. [3],[4] Prolonged treatment with CNI results in several adverse effects, the most significant being nephrotoxicity, characterized histologically by striped pattern of interstitial fibrosis, and peripheral nodular arteriolar hyalinosis. [5],[6] Risk factors for nephrotoxicity include younger age, [7],[8] prolonged duration of therapy, [8],[9] high trough levels of medications, [7] persistent nephrotic range proteinuria [9] and hyperuricemia. [10] Most information pertains to CyA and there is limited information on tacrolimus or on comparative toxicities.

We reviewed the case notes of patients with steroid resistant nephrotic syndrome treated with tacrolimus or CyA for at least 2 years in order to determine renal histological changes associated with their use and for prevalence and risk factors for nephrotoxicity.

  Materials and Methods Top

Medical records of all patients, 1- to 18-year-old, with idiopathic steroid resistant nephrotic syndrome secondary to minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS) who began treatment with either CyA or tacrolimus between January 2005 and December 2008, were reviewed. A repeat kidney biopsy to determine CNI nephrotoxicity was performed in all patients who had received therapy for 2 or more years. Standard definitions were used for nephrotic syndrome, remission, and relapse. [2] Initial steroid resistance was defined as the absence of remission despite treatment with prednisolone at a dose of 2 mg/kg/day for 4 weeks at the onset of disease; patients with initial remission but steroid resistance in a subsequent relapse were classified as late resistance.


Therapy with CyA or tacrolimus was given at a dose of 4-5 and 0.1-0.15 mg/kg/day, respectively, in two divided doses. The trough levels were measured using radioimmunoassay for CyA and microparticle enzyme immunoassay for tacrolimus, targeted to 80-150 and 4-7 ng/ml, respectively; lower levels were accepted for patients in remission. All the patients received treatment with prednisolone (0.4-0.5 mg/kg on alternate days), enalapril (0.2-0.4 mg/kg/day), and calcium supplements. At 6 months, response to therapy with CNI was categorized as complete remission (urine protein to creatinine, Up/Uc ratio <0.2 mg/mg); partial remission (Up/Uc 0.2-2.0, normal serum albumin level and no edema); and non-response (Up/Uc ratio >2, edema or hypoalbuminemia). [2] Therapy with these agents was discontinued in patients with nonresponse at 6 months or persistently elevated serum creatinine ≥50% above baseline, hyperglycemia (glucose >180 mg/dl on two or more occasions), seizures, or recurrent and severe headaches. [2]

Relapses were treated with prednisolone at 2 mg/kg/day until remission, followed by 1.5 mg/kg on alternate days for 4 weeks with subsequent tapering. Duration of heavy proteinuria was the number of days of nephrotic range (3-4+) proteinuria, including the time to partial or complete remission and during disease relapses.

Renal histology

Renal biopsy was performed at initiation of therapy, and after 2 years of therapy. Specimens with seven or more glomeruli in at least one core were considered adequate, and examined by light microscopy (hematoxylin-eosin, periodic acid Schiff and silver methenamine stains) and immunofluorescence staining for immunoglobulins and complement. All biopsies were reviewed by two nephropathologists who were blinded to clinical details. Histology was classified as MCD or FSGS. [11]

Based on the second biopsy, nephrotoxicity was defined as the presence of either striped pattern of interstitial fibrosis and tubular atrophy involving at least 10% of the tubulointerstitium, or arteriolopathy characterized by nodular hyalinosis in more than one arteriole. [8],[9],[10],[12] Additional parameters on both the biopsies were graded from 0 to 3, based on percent histological involvement, as proposed by Kambham et al.[13] Global glomerulosclerosis, mesangial matrix expansion, mesangial hypercellularity, isometric tubular vacuolization and tubular atrophy were scored as 0 (none), 1 (1-25%), 2 (26-50%), and 3 (>50% involved). Non-striped interstitial fibrosis was graded as 0 (0-5%), 1 (6-25%), 2 (26-50%), and 3 (>50% involved); and juxtaglomerular hyperplasia and tubular calcinosis as 0 (none), 1 (<10%), 2 (11-25%), and 3 (>25% involved). Non-nodular arteriolar hyalinosis and arteriolar smooth muscle vacuolization were scored as 1 (involving single arteriole), 2 (two arterioles involved), and 3 (many arterioles involved). A score of ≥2 was considered significant involvement for the purpose of analysis.


Data were analyzed using Stata, version 11.1 (StataCorp, College Station, TX, USA). Continuous data are presented as median and interquartile range (IQR). Clinical and histological features among patients receiving CyA and tacrolimus, and those with presence or absence of CNI nephrotoxicity, were compared using the rank sum test. Within group comparisons were made using the sign rank test. Risk factors associated with CNI toxicity were examined by univariate logistic analysis and results are expressed as odds ratio (OR) with 95% confidence interval (CI).

  Results Top

Of 40 patients, 28 had received therapy with CyA for 31 (26-35.5) months and 12 had received tacrolimus for 29 (27-30.5) months until the time of the second biopsy. The clinical and laboratory features at initiation of therapy were similar for the two groups [Table 1]. Initial and late steroid resistance was present in 24 and 16 patients, respectively. The renal histology at the onset of CNI therapy showed MCD and FSGS in 24 and 16 patients, respectively. FSGS showed tip and perihilar lesions in 1 patient each, and not otherwise specified histology in 14. The median (IQR) dose of CyA was 4.6 (4.1-5.1) mg/kg/day and tacrolimus was 0.11 (0.09-0.14) mg/kg/day. The respective trough levels at second biopsy were 145.8 (80.7-178.7) ng/ml and 6.08 (3.2-7.5) ng/ml.

At second biopsy, 9 patients treated with CyA had complete remission, 13 had steroid-sensitive relapses, and 6 had partial remission. Of the patients receiving tacrolimus, four had sustained remission, six had steroid sensitive relapses and two had partial remission.
Table 1: Features at initiation of therapy with calcineurin inhibitors

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Histopathology before and following therapy

Scores for histological variables on initial biopsies were comparable in patients receiving CyA and tacrolimus. At baseline, patients with FSGS showed slightly higher scores for mesangial matrix expansion (rank sum P = –0.079) and arteriolar smooth muscle vacuolization (P = –0.091).

Comparison of findings between biopsies performed before and following 30 (26-35) months of therapy showed increase in scores for global glomerulosclerosis (mean difference 0.52; 95% CI 0.25-0.79; P = 0.001), tubular atrophy (0.48; 95% CI 0.24-0.72; P < –0.001), interstitial fibrosis (0.6, 95% CI 0.31-0.89; P < –0.001), non-nodular arteriolar hyalinosis (0.92, 95% CI 0.51-1.33; P < –0.001), arteriolar smooth muscle vacuolization (0.48; 95% CI 0.08-0.88; P = –0.02), juxtaglomerular hyperplasia (0.72, 95% CI 0.28-1.16; P = –0.002), and tubular microcalcinosis (0.36, 95% CI -0.01-0.73; P = –0.06). Progression in these findings was similar for biopsies with MCD and FSGS, and for those receiving CyA or tacrolimus (data not shown).

Histological evidence of CNI toxicity was present in 10 (25%) biopsies. Striped interstitial fibrosis was present in nine patients and nodular arteriolar hyalinosis in three. A significant proportion of biopsies with nephrotoxicity also showed high (≥2) scores for nonstriped interstitial fibrosis and nonnodular arteriolar hyalinosis [Table 2].
Table 2: Number of biopsies (percentage) with semi-quantitative scores≥2 for various histological variables in patients with or without calcineurin inhibitor nephrotoxicity

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Risk factors for nephrotoxicity

Upon comparison of baseline features at the initiation of therapy, patients with nephrotoxicity showed higher frequency of initial resistance (9 of 10 vs. 15 of 30; P = 0.032) and hypertension (6 of 10 vs. 6 of 30; P = –0.04) than in those without nephrotoxicity. The duration of heavy proteinuria was significantly longer at 8.5 (4.9-28.1) weeks in patients with nephrotoxicity compared with 3.2 (0.9-8.0) weeks in those without toxicity ( P = –0.007). The former patients had also received higher doses of cyclosporine [5.0 (4.8-5.1) mg/kg/day vs. 4.3 (3.9-4.8) mg/kg/day; P = –0.037]. On univariate analysis, factors associated with nephrotoxicity were initial resistance (OR 9; 95% CI 1.0-80.1; P = –0.049); dose of CyA (OR 9.2; 95% CI 1.1-74.6; P = –0.037); duration of heavy proteinuria (OR 1.2; 95% CI 1.0-1.4; P = –0.023) and hypertension during therapy (OR 6; 95% CI 1.3-28.3; P = –0.023).

Change in estimated glomerular filtration rate

Serum creatinine and estimated glomerular filtration rate at the initiation of therapy were 0.50 (0.30-0.65) mg/dl and 90.8 (77.4-126.1) ml/min/1.73 m 2 , respectively [Table 1]. The GFR was similar for patients receiving CyA and tacrolimus ( P = –0.77), and for those with MCD and FSGS (85.1 vs. 112.7 ml/min/1.73 m 2 ; P = –0.15). At repeat biopsy, serum creatinine was 0.53 (0.30-0.91) mg/dl and GFR 81.0 (64.0-109.2) ml/min/1.73 m 2 . The decline in GFR in patients with nephrotoxicity was 22.7 (−7.0 to 28.2) ml/min/1.73 m 2 compared with −1.8 (−22.4 to 39.8) ml/min/1.73 m 2 in those without toxicity ( P = –0.76). The reduction in GFR was similar for patients receiving CyA and tacrolimus (7.4 vs. −3.2 ml/min/1.73 m 2 ; P = –0.73) and for MCD and FSGS (−1.8 vs. 22.7 ml/min/1.73 m 2 ; P = –0.17).

Other adverse effects

Patients treated with CyA showed gum hyperplasia ( n = –7) and hirsutism ( n = –8). Seizures, raised transaminases and hyperlipidemia were observed with tacrolimus and CyA in one patient each. Hyperglycemia ( n = –2) resolved upon discontinuation of tacrolimus. There was no correlation between renal and extra renal toxicities.

  Discussion Top

Our results show that 25% patients of steroid resistant nephrotic syndrome treated with CyA or tacrolimus for 2-3 years have histological evidence of nephrotoxicity. The prevalence was similar for both agents and for patients with MCD and FSGS. Risk factors for toxicity were initial resistance to corticosteroids, higher dosage of CyA, presence of hypertension during therapy and prolonged duration of nephrotic range proteinuria.

Nephrotoxicity associated with use of CNI is defined variably based on a spectrum of histological abnormalities. [7],[12],[14],[15],[16] On the basis of current criteria, the prevalence of nephrotoxicity in children treated with CyA for nephrotic syndrome varies, and relates to the duration of therapy. Histological features of toxicity were noted in 3.8% of the patients following 12-month therapy, and 15.4-16.7% after treatment for 12-41 months. [14],[15],[17] The high prevalence (25%) in the present study may reflect a sampling error or referral bias at a tertiary center. Iijima et al. and Fujinaga et al. proposed that treatment with CyA for more than 2 and 3 years, respectively, was an independent risk factor for nephrotoxicity. [8],[9] Others suggest that nephrotoxicity is related to high doses of CyA, or to high blood levels of tacrolimus.[7],[14] These findings confirm the experience in transplant recipients relating nephrotoxicity to the dose and duration of CyA therapy. [18],[19] Although experimental evidence suggests that angiotensin-converting enzyme inhibitors might have a role in preventing interstitial fibrosis, [20] further studies are necessary to examine their role in preventing CNI-associated nephrotoxicity.

The presence of nephrotic range proteinuria has been associated with CyA-induced nephrotoxicity. Nephrotoxicity was related to the frequency of disease relapses in 30 patients with difficult nephrotic syndromes. [8] Similar to our findings, Iijima et al. showed that heavy proteinuria lasting for over 30 days was an independent predictor of CyA-associated nephrotoxicity. [9] Other risk factors for nephrotoxicity in the present patients were hypertension during therapy and initial corticosteroid resistance. A previous report on 53 patients with nephrotic syndrome showed that treatment for hypertension was associated with CyA-associated nephrotoxicity. [10] Although initial steroid resistance is associated with severe disease and adverse outcomes, [21],[22] its relationship with CNI toxicity is not reported previously.

Tacrolimus is proposed to have lower potential for nephrotoxicity. [23],[24] Although early reports in transplant recipients supported these findings, [25],[26] a recent meta-analysis showed that the risk of nephrotoxicity in transplant allografts was similar for CyA and tacrolimus. [27] Although there are no comparative reports, the present retrospective review did not show differences in histological changes and proportion of patients with nephrotoxicity following therapy with either agent.

Although it might be difficult to distinguish histological changes of CNI toxicity from those caused by disease progression, the two features used to define nephrotoxicity in the present study are fairly specific. [8],[9],[10] Using criteria similar to those proposed by Kambham et al.[13] on serial biopsies, we found that therapy was associated with increased scores for global glomerulosclerosis, tubular atrophy, non-striped interstitial fibrosis, non-nodular arteriolar hyalinosis, and arteriolar smooth muscle vacuolization. It is possible that some of these changes may relate to injury induced by hypertension or persistent proteinuria and/or progression of lesions in FSGS. Furthermore, scores for non-striped interstitial fibrosis and non-nodular arteriolar hyalinosis were higher among biopsies with nephrotoxicity. These observations confirm previous findings in patients with nephrotic syndrome treated with tacrolimus. [7],[16] Serial allograft biopsies suggest that arteriolar smooth muscle vacuolization and juxtaglomerular hyperplasia were considered useful indicators of CNI toxicity. [28],[29]

In the present patients, there was no demonstrable change in GFR during therapy. A similar lack of correlation between GFR and nephrotoxicity was reported in children with steroid resistant nephrotic syndrome treated with CyA [30] or tacrolimus. [31] Others showed that prolonged therapy with CyA for up to 10 years in patients with nephrotic syndrome resulted in relatively modest (12%) decline in renal function. [32] A clinical trial on 72 patients with FSGS treated with CyA showed that the median ratio of estimated GFR at 6 months to baseline was 0.73. [33] A recent prospective study at this center in 52 patients treated with tacrolimus for 12 months demonstrated a 10% reduction in GFR. [34]

Findings from the study suggest that one-fourth of the children with steroid resistant nephrotic syndrome show histological evidence of nephrotoxicity following prolonged therapy with CNI. The risk of toxicity was similar in patients receiving CyA and tacrolimus and was increased for patients with initial resistance, persistent hypertension and nephrotic range proteinuria. Our findings emphasize the utility of protocol biopsies and potential for alternative strategies, including the use of mycophenolate mofetil or rituximab, to maintain disease remission.

  References Top

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3.Singh A, Tejani C, Tejani A. One-center experience with cyclosporine in refractory nephrotic syndrome in children. Pediatr Nephrol 1999;13:26-32.  Back to cited text no. 3
4.Choudhry S, Bagga A, Hari P, Sharma S, Kalaivani M, Dinda A. Efficacy and safety of tacrolimus versus cyclosporine in children with steroid-resistant nephrotic syndrome: A randomized controlled trial. Am J Kidney Dis 2009;53:760-9.  Back to cited text no. 4
5.Hulton SA, Jadresic L, Shah V, Trompeter RS, Dillon MJ, Barratt TM. Effect of cyclosporine A on glomerular filtration rate in children with minimal change nephrotic syndrome. Pediatr Nephrol 1994;8:404-7.  Back to cited text no. 5
6.El-Husseini A, El-Basuony F, Mahmoud I, Sheashaa H, Sabry A, Hassan R, et al. Long-term effects of cyclosporine in children with idiopathic nephrotic syndrome: A single-centre experience. Nephrol Dial Transplant 2005;20:2433-8.  Back to cited text no. 6
7.Butani L, Ramsamooj R. Experience with tacrolimus in children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2009;24:1517-23.  Back to cited text no. 7
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10.Kengne-Wafo S, Massella L, Diomedi-Camassei F, Gianviti A, Vivarelli M, Greco M, et al. Risk factors for cyclosporin A nephrotoxicity in children with steroid-dependant nephrotic syndrome. Clin J Am Soc Nephrol 2009;4:1409-16.  Back to cited text no. 10
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14.Gregory MJ, Smoyer WE, Sedman A, Kershaw DB, Valentini RP, Johnson K, et al. Long-term cyclosporine therapy for pediatric nephrotic syndrome: A clinical and histologic analysis. J Am Soc Nephrol 1996;7:543-9.  Back to cited text no. 14
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17.Hino S, Takemura T, Okada M, Murakami K, Yagi K, Fukushima K, et al. Follow-up study of children with nephrotic syndrome treated with a long-term moderate dose of cyclosporine. Am J Kidney Dis 1998;31:932-9.  Back to cited text no. 17
18.Falkenhain ME, Cosio FG, Sedmak DD. Progressive histologic injury in kidneys from heart and liver transplant recipients receiving CyA. Transplantation 1996;62:364-70.  Back to cited text no. 18
19.Ruiz P, Kolbeck PC, Scroggs MW, Sanfilippo F. Associations between cyclosporine therapy and interstitial fibrosis in renal allograft biopsies. Transplantation 1988;45:91-5.  Back to cited text no. 19
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22.Rennert WP, Kala UK, Jacobs D, Goetsch S, Verhaart S. Pulse cyclophosphamide for steroid-resistant focal segmental glomerulosclerosis. Pediatr Nephrol 1999;13:113-6.  Back to cited text no. 22
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24.Jain S, Bicknell GR, Nicholson ML. Tacrolimus has less fibrogenic potential than cyclosporin A in a model of renal ischaemia-reperfusion injury. Br J Surg 2000;87:1563-8.  Back to cited text no. 24
25.Solez K, Vincenti F, Filo RS. Histopathologic findings from 2-year protocol biopsies from a U.S. multicenter kidney transplant trial comparing tarolimus versus cyclosporine: A report of the FK506 Kidney Transplant Study Group. Transplantation 1998;66:1736-40.  Back to cited text no. 25
26.Martins L, Ventura A, Branco A, Carvalho MJ, Henriques AC, Dias L, et al. Cyclosporine versus tacrolimus in kidney transplantation: Are there differences in nephrotoxicity? Transplant Proc 2004;36:877-9.  Back to cited text no. 26
27.Coates PT. Nephrotoxicity and calcineurin inhibitors. Nephrology 2007;12:S85-7.  Back to cited text no. 27
28.Horike K, Takeda A, Yamaguchi Y, Ogiyama Y, Yamauchi Y, Murata M, et al. Is arteriolar vacuolization a predictor of calcineurin inhibitor nephrotoxicity? Clin Transplant 2011;25:23-7.  Back to cited text no. 28
29.Sharma A, Jain S, Gupta R, Guleria S, Agarwal S, Dinda A. Calcineurin inhibitor toxicity in renal allografts: Morphologic clues from protocol biopsies. Indian J Pathol Microbiol 2010;53:651-7.  Back to cited text no. 29
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30.Seikaly MG, Prashner H, Nolde-Hurlbert B, Browne R. Long-term clinical and pathological effects of cyclosporin in children with nephrosis. Pediatr Nephrol 2000;14:214-7.  Back to cited text no. 30
31.Sinha MD, MacLeod R, Rigby E, Clark AG. Treatment of severe steroid-dependent nephrotic syndrome (SDNS) in children with tacrolimus. Nephrol Dial Transplant 2006;21:1848-54.  Back to cited text no. 31
32.Kranz B, Vester U, Büscher R, Wingen AM, Hoyer PF. Cyclosporine-A-induced nephrotoxicity in children with minimal-change nephrotic syndrome: Long-term treatment up to 10 years. Pediatr Nephrol 2008;23:581-6.  Back to cited text no. 32
33.Gipson DS, Trachtman H, Kaskel FJ, Greene TH, Radeva MK, Gassman JJ, et al. Clinical trial of focal segmental glomerulosclerosis in children and young adults. Kidney Int 2011;80:868-78.  Back to cited text no. 33
34.Gulati A, Sinha A, Gupta A, Kanitkar M, Sreenivas V, Sharma J, et al. Treatment with tacrolimus and prednisolone is preferable to intravenous cyclophosphamide as the initial therapy for children with steroid-resistant nephrotic syndrome. Kidney Int 0; 82:1130-5.  Back to cited text no. 34


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