Pediatr Nephrol (2017) 32:1363–1367

DOI 10.1007/s00467-017-3616-5

ORIGINAL ARTICLE

Efficacy of higher-dose levamisole in maintaining remission

in steroid-dependant nephrotic syndrome
Asiri S. Abeyagunawardena 1 & Umeshi Karunadasa 1 & Heshan Jayaweera 1 &
Shenal Thalgahagoda 1 & Sampath Tennakoon 2 & Shamali Abeyagunawardena 3

Received: 12 October 2016 / Revised: 4 January 2017 / Accepted: 24 January 2017 / Published online: 15 March 2017
# IPNA 2017

Abstract to the Wilcoxon signed-rank test) was <0.001. No major ad-

Objective Levamisole (LEV) has been used successfully on verse events were noted.
an alternate-day regime of 2.5 mg/kg in steroid-dependant Conclusions The prescription of daily LEV is effective and
nephrotic syndrome (SDNS) to maintain remission. This pilot safe for maintaining SDNS remission.
study was carried out between 2010 and 2015 at a single
center in Sri Lanka to evaluate the efficacy of LEV prescribed Keywords Low-dose levamisole . Steroid-dependant
at 2.5 mg/kg daily, which is double the alternate-day dose. nephrotic syndrome . Relapse
Methods Sequential children with SDNS, relapsing more than
twice in the preceding 12 months and previously treated with
LEV and low-dose alternate-day prednisolone (0.1–0.6 mg/ Introduction
kg) were recruited to the study. This group received LEV
(2.5 mg/kg) daily with the same dose of alternate-day prednis- Nephrotic syndrome (NS), the most common manifestation of
olone for 1 year. Urine protein excretion was recorded by glomerular disease in children, classically refers to the tetrad
parents on a daily basis, and the presence of 3+ proteinuria of massive proteinuria, hypoalbuminemia, hyperlipidemia,
on 3 consecutive days was considered a relapse. Full blood and generalized edema [1]. Steroid-sensitive nephrotic syn-
counts and liver function tests were performed every 3 months drome (SSNS) is the predominant type of childhood NS, and
to monitor for adverse effects. 80–90% of children achieve remission with corticosteroid
Results Sixty-four children were enrolled into the study; six therapy. However, after 8 weeks of corticosteroid therapy oral-
were excluded due to prescription of other immunosuppres- ly, ∼80% of children will relapse, requiring further courses of
sive drugs. Median age was 7.9 years; 33 were boys. The steroids. Half of these children have steroid-dependent ne-
number of relapse episodes was 163 [mean per patient 2.8 ± phrotic syndrome (SDNS), in which relapses occur while be-
standard deviation (SD) 0.8] in patients on alternate-day LEV ing treated with reducing doses of steroids [2, 3].
and 77 (mean 1.3 ± SD 0.9) for those on daily LEV during the Complications such as sepsis, thrombosis, malnutrition, dys-
12-month period of observation. The P value 0.000 (according lipidemia, and hypovolemia are risks associated with relapses,
while high doses of prednisolone are associated with adverse
effects such as hypertension, diabetes, and behavioral disor-
* Asiri S. Abeyagunawardena ders [4–6].
asiriabey26@gmail.com Infections in NS arise as a result of reduced immunoglob-
ulin G (IgG), impaired cytokine and complement pathways,
1
Department of Paediatrics, Faculty of Medicine, University of depressed T-cell function, and immunosuppressed state
Peradeniya, Peradeniya, Sri Lanka caused by drugs. Steroids act by lowering polymorphonuclear
2
Department of Community Medicine, University of Peradeniya, activity and capillary permeability to decrease inflammation,
Peradeniya, Sri Lanka whereas cyclophosphamide (CYC), cyclosporine, mycophe-
3
Outpatient Department, Teaching Hospital Peradeniya, nolate mofetil (MMF), and levamisole (LEV) are given for
Peradeniya, Sri Lanka steroid sparing. CYC and MMF display long-term efficacy
1364 Pediatr Nephrol (2017) 32:1363–1367

in SDNS patients [7–10]. However, their potential side-ef- Table 1 Patient baseline characteristics at the beginning of the study
fects—such as opportunistic infections, sterility in men, and Characteristics Value
development of future malignancies are main concerns [11,
12]. Unlike in the developed world, increased risk of infec- Number of patients 58
tions and subsequent death of children with NS due to sepsis is Median age (years) 7.95
a major problem in developing countries like Sri Lanka. This Male 33 (56.9%)
may be attributed to overcrowding, inadequate sanitary facil- Female 25 (43.1%)
ities, lack of routine cleaning and basic infection control mea- Mean number of relapses prior to the study 2.81 (IQR = 2–3)
sures, and improper waste management commonly seen in Lowest steroid dose prior to study (mg/kg/year) 178.75
hospitals in such countries, all of which can give rise to op- Highest steroid dose prior to study (mg/kg/year) 364.75
portunistic infections in immune-compromised patients [13]. Mean steroid dose prior to study (mg/kg/year) 254.16
Levamisole, known as an immunomodulatory agent, is (IQR = 210.68–281.81)
used as a steroid-sparing agent mainly in patients with IQR interquartile range
SDNS and is normally administered at a dose of 2–2.5 mg/
kg on alternate days for 12–24 months [14]. Several studies
have suggested that LEV reduces relapse frequency and re- tablets used in quarters; hence, the amount administered was
duces steroid dose in SDNS patients, both as a first alternative between 2.32 mg and 2.86 mg/kg per dose. The highest pred-
to steroids and after failure of CYC or cyclosporine [15–17]. nisolone dose was 0.6 mg/kg and the lowest 0.3 mg/kg. Any
This single-center study was conducted to evaluate the ef- relapses were treated with the standard relapse regimen of
ficacy of LEV in maintaining remission in children with prednisolone 60 mg/m2 as a single daily dose until remission,
SDNS when administered daily, compared with alternate- followed by 40 mg/m2 on alternate days for 28 days. A
day administration. patient-held health record was maintained for each patient.
Parents were taught to test for and record urine protein daily.
The presence of 3+ proteinuria for 3 consecutive days was
Methods considered a relapse. Tests for full blood count, serum
glutamic–pyruvic transaminase (SGPT), serum creatinine,
This single-center pilot study was conducted at the Paediatric and blood pressure were reviewed every 3 months, as was
Nephrology Unit, Teaching Hospital Peradeniya, Sri Lanka. urine protein excretion to monitor for any adverse effects.
All procedures were in accordance with the ethical standards We analysed the difference in number of relapses, means
of the Scientific and Ethics Committee, Faculty of Medicine of neutrophil counts, and liver function tests prior to and after
of the University of Peradeniya, and with the 1964 daily LEV treatment initiation. Neutropenia was defined as an
Declaration of Helsinki and its later amendments or compara- absolute neutrophil count (ANC) <1.5 × 109/L [18]. Collected
ble ethical standards. Informed consent was obtained from all variables were entered into SPSS software version 19 and
participants. The study period was January 2010 to January analyzed using descriptive statistics, paired t test, and non-
2015. parametric tests.
Children with SDNS treated with LEV and low-dose alter-
nate-day prednisolone (0.1–0.6 mg/kg) and relapsing more
than twice in the preceding 12 months to the date of enrolment Mean relapses
4
were recruited. Steroid dependence was defined as two con-
secutive relapses during steroid therapy tapering or within 3.5

14 days of cessation of treatment. All patients underwent the 3 2.81

standard tapering regimen for prednisolone, in which it was
2.5
reduced by 2.5 mg every 3 months if the patient was stable on
a certain steroid dose and remained free of proteinuria for the 2
Series1
preceding 3 months. Previous treatment with any steroid- 1.5 1.33
sparing agents, biopsy histology revealing conditions other
than minimal-change nephropathy (MCN), and having sec- 1

ondary NS were criteria for exclusion from the study. Renal 0.5
biopsy was performed only for specific indications, such as
0
renal impairment, macroscopic hematuria, or other Relapses with alternate-day LEV Relapses with daily LEV
complications. Fig. 1 Mean number of relapses in patients on alternate-day and
This group of children received LEV (2.5 mg/kg) daily levamisole (LEV) [mean 2.81, interquartile range (IQR) = 2–3) and
with alternate-day prednisolone for 1 year, with 40 mg LEV daily LEV therapy (mean 1.3, IQR = 1–2)
Pediatr Nephrol (2017) 32:1363–1367 1365

Table 2 Comparison of
parameters with alternate-day With 1 year of With 1 year of daily LEV
doses of LEV (prior to the study) alternate-day LEV
and daily LEV
Lowest steroid dose per year (mg/kg/year) 178.75 54.75
Highest steroid dose per year (mg/kg/year) 364.75 259.00
Mean annual steroid dose (mg/kg/year) 254.16 (IQR = 210.68–281.81) 154.05 (IQR = 116.75–197.00)
Number of relapses 163 (IQR = 2–3) 77 (IQR = 1–2)

IQR interquartile range

Results Patient age had no observable impact on the number of re-

lapses prior to or during the study (P > 0.5).
Sixty-four participants were enrolled into the study, with the
oldest being 14.2 years and the youngest 4.5 years (median
7.95 years). Six children were excluded due to prescription of Discussion
other immunosuppressive drugs. Of the final study partici-
pants, 33 were boys (56.9%), and 25 were girls (43.1%). This study evaluated 2.5 mg/kg of LEV daily in comparison
The number of relapses during the 12-month period in those with 2.5 mg/kg on alternate days to assess its effect on relapses
on alternate-day LEV was 163 (mean 2.81 ± SD 0.78). in children with SDNS. Findings demonstrate significant reduc-
Baseline characteristics at the beginning of the study are tion of the number of relapses with this new dose which was
shown in Table 1. accompanied by a lower dose of alternate-day prednisolone of
The number of relapses with daily LEV was 77 (mean 1.33 0.1-0.6mg/kg. The 56.9% of patients who had improved
± SD 0.92) during the 12-month period of the study (Fig. 1). relapse rates and reduced dosages of steroids confirm the effi-
Of the 58 children enrolled, 12 (20.69%) were relapse free and cacy of this new strategy. The simultaneous reduction of the
21 had only one relapse with daily LEV. Hence, 56.9% of annual steroid dose is also highlighted as an added advantage.
children had better outcomes compared with their previous A vast majority of preadolescent children with idiopathic NS
alternate-day regimen. There was a significant reduction in have MCN on renal biopsy [19]. More than 90% of children
the number of relapses with daily LEV (P value = 0.000) than with MCN have steroid-sensitive nephrotic syndrome (SSNS),
with the alternate-day regimen (Wilcoxon signed-rank test) achieving remission with corticosteroids orally [20]. Most of
(Tables 2 and 3 and Fig. 1). these patients relapse, with various associated risk factors and
The total steroid dose given during the year of the study was complications. Recent research reports interesting findings
remarkably lower than that during the year prior to the study regarding steroid-sparing drugs for reducing NS relapse rates.
(P = 0.000). No serious infection was encountered in either In a notable review by Pravitsitthikul et al., the authors con-
group; minor episodes of infection were not counted. There clude that short-term courses of CYC or chlorambucil and
was no significant difference between mean neutrophil counts, prolonged courses of cyclosporine and LEV plus corticoste-
serum creatinine, and SGPT values between groups (P > 0.5). roids reduce relapse risk in children with SSNS compared with
Mean hemoglobin (Hb) level during daily LEV therapy was corticosteroids alone. MMF and rituximab are also promising
significantly higher than during the previous year (Table 4). [3]. However, higher relapse rates and more side effects were
seen with rituximab and CYC for patients on steroid therapy,
and no beneficial effect of MMF in maintaining steroid-free
Table 3 Comparison between the number of patients who relapsed remission was seen [21, 22]. The antihelminthic drug LEV is
with alternate-day and daily LEV
a synthetic, low-molecular-weight compound that modifies
No. relapses With alternate-day LEV With daily LEV P value components of host immune reaction [23]. Newer studies show
evidence for this immunomodulatory effect of LEV in NS.
No. % No. % MCN is associated with an immune response biased to-
0 0 0 12 20.69 0.000
ward type 2, with elevated serum IgE. Findings by Szeto
1 0 0 21 36.21 et al. show that LEV selectively induces interleukin 18 (IL-
2 23 39.66 19 32.76 18) gene expression, thereby resetting this imbalance toward
3 24 41.38 6 10.34 0.000 type 1. Rats treated with LEV also showed a dose-dependent
4 10 17.24 0 0 0.001 drop in serum IgE [24]. This restoration and maintenance of
5 1 1.72 0 0 0.322 immunity might lead to the reduced relapse rate seen in our
study. Levamisole also induces expression of glucocorticoid
1366 Pediatr Nephrol (2017) 32:1363–1367

Table 4 Comparison of
screening tests between alternate- Blood, kidney and liver Alternate-day LEV Daily LEV P value
day and daily LEV administration function test
Median Interquartile range Median Interquartile range

Neutrophil count (109/L) 6.2 5.15–6.70 5.95 5.5–6.6 0.704

Mean Hemoglobin level (g/dl) 11.80 10.87–12.62 12.20 11.17–12.80 0.013
Serum creatinine (μmol/L) 48.00 46.00–55.00 48.00 44.00–54.00 0.621
SGPT (IU/L) 28.00 26–32 28.00 26–32 0.708

SGPT serum glutamic–pyruvic transaminase

receptor (GCR) activities and signalling in order to directly act Several studies have shown side-effects such as vasculitis,
on human podocytes and protect them against injury [25]. neutropenia, and liver toxicity associated with LEV usage,
Infections are a main cause of relapses in NS children in although these issues subsided after the treatment ended [35,
developing countries, as explained previously [26, 27]. 36]. SGPT was monitored as a screening test, and based on the
Hence, a steroid-sparing drug that would help improve the results, no liver toxicity was observed. Neutropenia or anemia
patient’s comproised immunity would be a better choice than was not observed in this study. Although Hb level was signif-
cytotoxic drugs in such settings [1]. In the studies of Sumegi, icantly less during the year with daily LEV, no patient had Hb
Madani, and Al-Saran, LEV significantly reduced relapse below the normal range [37]. However, any possible relation
rates and cumulative annual steroid burden in children with between LEV doses and Hb is an interesting point and hence
frequently relapsing NS (FRNS) and SDNS, with the majority could be investigated in a future study. To conclude, a higher
remaining in total remission [28–30]. In a study by Boyer dose of daily LEV along with low alternate-day steroid thera-
et al., LEV had the similar beneficial effects over the long py has better efficacy and is safe in maintaining relapses in
term even after ceasing LEV therapy, with added advantages children with SDNS.
of normalized blood pressure in hypertensive children and
improved of height velocity [31]. Bagga et al., in 1997, Compliance with ethical standards All procedures performed in the
showed that a significant proportion of SDNS patients could study were in accordance with the ethical standards of the Scientific and
be kept in remission with LEV alone [16]. While all these Ethics committee, Faculty of Medicine of the University of Peradeniya
and with the 1964 Helsinki declaration and its later amendments or com-
studies have followed the alternate-day LEV dose, Fu et al.
parable ethical standards. Informed consent was obtained from all indi-
in 2004, reported that daily LEV usage is effective and can be vidual participants included in the study.
considered in children with FRNS or SDNS when response to
alternate-day treatment is unsatisfactory [32]. A retrospective Conflict of interest The authors declare that they have no conflict of
study by Ekambaram et al. also revealed that daily LEV was interest.
effective in a majority (77.3%) of FRNS and SDNS children,
reducing the cumulative steroid intake and relapse rates [33].
Our results are in concordance with these studies. References
The notable reduction in the number of relapses in this
study could be due to immune modulation by the higher dose 1. Park SJ, Shin JI (2011) Complications of nephrotic syndrome. Kor J
of LEV, with a significantly reduced steroid dose, thus Pediatr 54:322–328
2. Sinha M, MacLeod R, Rigby E, Clark A (2006) Treatment of severe
preventing infections and complications that would give rise
steroid-dependent nephrotic syndrome (SDNS) in children with
to relapses. On that account, side effects from higher steroid tacrolimus. Nephrol Dial Transplant 21:1848–1854
doses would also reduce as an added advantage. 3. Pravitsitthikul N, Willis NS, Hodson EM, Craig JC (2013) Non-
A number of immune cells, including B cells, monocytes, corticosteroid immunosuppressive medications for steroid-sensitive
T cells, and dendritic cells (DC), express nicotinic acetylcho- nephrotic syndrome in children. Cochrane Database Syst Rev. doi:
10.1002/14651858.CD002290.pub4
line receptors (nAChR). The influence of nicotine to alter the
4. Uwaezuoke SN (2015) Steroid-sensitive nephrotic syndrome in
action of these cells and thereby its anti-inflammatory effect in children: Triggers of relapse and evolving hypotheses on pathogen-
several diseases such as chronic obstructive pulmonary dis- esis. Ital J Pediatr 41:19
ease (COPD) and ulcerative colitis, is largely discussed in the 5. Niaudet P (2009) Long-Term Outcome of Children with Steroid-
literature [34]. Being a nicotinic receptor agonist, LEV might Sensitive Idiopathic Nephrotic Syndrome. Clin J Am Soc Nephrol
4:1547–1548
also play a role in the nicotinic pathway of the immune re- 6. Hall AS, Thorley G, Houtman PN (2003) The effects of corticoste-
sponse. Further exploring this aspect will create new therapeu- roids on behavior in children with nephrotic syndrome. Pediatr
tic modalities for NS. Nephrol 18:1220–1223
Pediatr Nephrol (2017) 32:1363–1367 1367

7. Bagga A, Hari P, Moudgil A, Jordan S (2003) Mycophenolate 23. Renoux G (1980) The General Immunopharmacology of LEV.
mofetil and prednisolone therapy in children with steroid- Drugs 20:89–99
dependent nephrotic syndrome. Am J Kidney Dis 42:1114–1120 24. Szeto C, Gillespie K, Mathieson P (2000) LEV induces interleukin-
8. Bircan Z, Kara B (2003) Intravenous cyclophosphamide is the drug 18 and shifts type 1/type 2 cytokine balance. Immunology 100:
of choice for steroid dependent nephrotic syndrome. Pediatr Int 45: 217–224
65–67 25. Jiang L, Dasgupta I, Hurcombe J, Colyer H, Mathieson P, Welsh G
9. Mendizábal S, Zamora I, Berbel O, Sanahuja M, Fuentes J, Simon J (2015) LEV in steroid-sensitive nephrotic syndrome: usefulness in
(2005) Mycophenolate mofetil in steroid/cyclosporine-dependent/ adult patients and laboratory insights into mechanisms of action via
resistant nephrotic syndrome. Pediatr Nephrol 20:914–919 direct action on the kidney podocyte. Clin Sci 128:883–893
10. Arbeitsgemeinschaft für Pädiatrische Nephrologie (1982) Effect of 26. Ali SH, Twfeek ZA, Ahmed Azat NF, Hasan AA (2016) Triggering
Cytotoxic Drugs in Frequently Relapsing Nephrotic Syndrome with Factors for Relapses in Steroid Sensitive Nephrotic Syndrome.
and without Steroid Dependence. New Engl J Med 306:451–454 IJCMAS 5:842–851
11. Jayaweera A, Abeyagunawardena A (2012) Effectiveness and safe- 27. Moorani K, Raj M (2012) Spectrum of Infections in Children with
ty of cyclosporin A therapy in steroid dependent nephrotic syn- Newly Diagnosed Primary Nephrotic Syndrome. Pak J Med Res
drome in childhood. Sri Lanka J Child Health 41:176–179 51:10–14
12. Latta K, von Schnakenburg C, Ehrich JH (2001) A meta-analysis of 28. Sumegi V, Haszon I, Ivanyi B, Bereczki C, Papp F, Turi S (2004)
cytotoxic treatment for frequently relapsing nephrotic syndrome in Long-term effects of levamisole treatment in childhood nephrotic
children. Pediatr Nephrol 16:271–282 syndrome. Pediatr Nephrol 19:1354–1360
13. Rimi N, Sultana R, Luby S, Islam M, Uddin M, Hossain M, Zaman 29. Madani A, Isfahani ST, Rahimzadeh N, Fereshtehnejad SM,
R, Nahar N, Gurley E (2014) Infrastructure and Contamination of Hoseini R, Moghtaderi M, Mohseni P, Ataiee N (2010) Effect of
the Physical Environment in Three Bangladeshi Hospitals: Putting Levamisole in steroid-dependent nephrotic syndrome. Iran J
Infection Control into Context. PLoS ONE 9(2):e89085 Kidney Dis 4:292–296
14. Bagga A (2008) Revised guidelines for management of steroid- 30. Al-Saran K, Mirza K, Al-Ghanam G, Abdelkarim M (2006)
sensitive nephrotic syndrome. Indian J Nephrol 18:31–39 Experience with levamisole in frequently relapsing, steroid-
15. Rashid HU, Ahmed S, Fatima N, Khanam A (1996) LEV in the dependent nephrotic syndrome. Pediatr Nephrol 21:201–205
treatment of steroid dependent or frequent relapsing nephritic syn- 31. Boyer O, Moulder J, Grandin L, Somers M (2008) Short- and long-
drome in children. Bangladesh Renal J 15:6–8 term efficacy of levamisole as adjunctive therapy in childhood ne-
16. Bagga A, Sharma A, Srivasta RN (1997) Levamisole therapy in phrotic syndrome. Pediatr Nephrol 23:575–580
corticosteroid-dependent nephrotic syndrome. Pediatr Nephrol 11: 32. Fu LS, Shien CY, Chi CS (2004) Levamisole in steroid-sensitive
415–417 nephrotic syndrome children with frequent relapses and/or steroid
17. Tenbrock K, Müller-Berghaus J, Fuchshuber A, Michalk D, dependency: Comparison of daily and every-otherday usage.
Querfeld U (1998) Levamisole treatment in steroid-sensitive and Nephron Clin Pract 97:c137–c141
steroid-resistant nephrotic syndrome. Pediatr Nephrol 12:459–462 33. Ekambaram S, Mahalingam V, Nageswaran P, Udani A,
18. Newburger P, Dale D (2013) Evaluation and Management of Geminiganesan S, Priyadarshini S (2014) Efficacy of levamisole
Patients With Isolated Neutropenia. Semin Hematol 50:198–206 in children with frequently relapsing and steroid-dependent ne-
19. International Study of Kidney Disease in Children Nephrotic syn- phrotic syndrome. Indian Pediatr 51(5):371–373
drome in children (1978) Prediction of histopathology from clinical 34. Jonge W, Ulloa L (2009) The alpha7 nicotinic acetylcholine recep-
and laboratory characteristics at time of diagnosis. Kidney Int 13: tor as a pharmacological target for inflammation. Br J Pharmacol
159–165 151:915–929
20. Trompeter RS, Lloyd BW, Hicks J, White RH, Cameron JS (1985) 35. Fu L, Chi C (2000) LEV in steroid-sensitive nephrotic syndrome
Long-term outcome for children with minimal-change nephrotic children with steroid-dependency and/or frequent relapses. Acta
syndrome. Lancet 1:368–370 Paediatr Taiwan 41:80–84
21. Webb H, Jaureguiberry G, Dufek S, Tullus K, Bockenhauer D 36. Bulugahapitiya D (1997) Liver toxicity in a nephrotic patient treat-
(2015) Cyclophosphamide and rituximab in frequently relapsing/ ed with LEV. Arch Dis Child 76:289
steroid-dependent nephrotic syndrome. Pediatr Nephrol 31:589– 37. Virgo P (n.d.) Children’s Reference Ranges for FBC. Normal Blood
594 Count Values in Childhood.https://www.nbt.nhs.uk/sites/default/
22. Deegens J, Wetzels J (2015) Therapy: Maintenance of steroid-free files/Childrens%20FBC%20Reference%20Ranges.pdf. Accessed
remission in nephrotic syndrome. Nat Rev Nephrol 11:569–570 December 20, 2016
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