Efficacy and safety of various immunosuppressive agents for pediatric Henoch-Schönlein purpura nephritis (IgA vasculitis nephritis) in Chinese children: a systematic review and network meta-analysis

Background Henoch-Schönlein purpura nephritis (HSPN) is a common secondary glomerular disease in children. Approximately 30% of children with Henoch-Schönlein purpura develop this renal complication, and among them, about 20% may progress to chronic kidney disease. Current treatment relies on glucocorticoids combined with immunosuppressive agents. However, direct comparisons between different immunosuppressive regimens are lacking, and the optimal clinical approach remains undefined. Given that the efficacy of certain agents, such as mycophenolate mofetil, may vary across ethnic populations, this network meta-analysis (NMA) was conducted to evaluate the comparative efficacy and safety of immunosuppressive regimens specifically within the Chinese pediatric population with HSPN. Methodology We systematically searched English and Chinese databases, including PubMed, Cochrane Library, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang Academic Journal Full Text Database, and China Biomedical Literature Database to identify randomized controlled trials (RCTs) that evaluated immunosuppressive therapies for pediatric Henoch-Schönlein purpura nephritis (IgA vasculitis nephritis). Network meta-analysis was performed using Stata 18.0, and the quality of the included studies along with the risk of bias was assessed using RevMan 5.4.1. Results Among the core efficacy outcomes, mycophenolate mofetil combined with conventional therapy (MMF+CT) ranked highest in reducing 24-hour urine protein (SUCRA = 80.4%) and elevating serum albumin (SUCRA = 86.0%). Tacrolimus combined with conventional therapy (TAC+CT) performed best in improving serum creatinine levels (SUCRA = 97.0%). Tripterygium wilfordii polyglycoside combined with conventional therapy (TWP+CT) was the most effective in shortening the time to resolution of hematuria (SUCRA = 98.7%) and proteinuria (SUCRA = 100.0%). In terms of safety, cyclosporine A combined with conventional therapy (CsA+CT) demonstrated the lowest risk of adverse events (SUCRA = 85.2%). Cluster analysis further indicated that mycophenolate mofetil combined with conventional therapy (MMF+CT) offered the most favorable balance between overall efficacy and safety. Conclusions Immunosuppressive agents have significantly improved treatment outcomes for Chinese children with HSPN. Mycophenolate mofetil combined with conventional therapy (MMF+CT) offers the best balance between efficacy and safety, particularly for controlling proteinuria and hypoalbuminemia. Tacrolimus combined with conventional therapy (TAC+CT) is more suitable for patients with impaired renal function, whereas Tripterygium wilfordii polyglycoside combined with conventional therapy (TWP+CT) is effective for rapid symptom control. These findings support a shift toward individualized, phenotype-driven treatment strategies for this population. However, the results are predominantly derived from Chinese RCTs and may not be generalizable to other ethnic groups. Future research should prioritize large-scale, multicenter, long-term RCTs in diverse populations to verify the long-term stability of these findings and standardize adverse event reporting criteria. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/ , identifier CRD420251234454.