Comparative efficacy and safety of mycophenolate mofetil vs cyclophosphamide for induction therapy in childhood-onset lupus nephritis: Updated meta-analysis

BACKGROUNDChildhood-onset lupus nephritis (cLN) is a severe organ manifestation of systemic lupus erythematosus and is associated with substantial risks of chronic kidney disease and kidney failure.Comparative pediatric evidence for mycophenolate mofetil (MMF) and cyclophosphamide (CYC) as induction therapy remains limited and methodologically heterogeneous.This systematic review and meta-analysis evaluated the available comparative evidence without assuming equivalence or non-inferiority. AIMTo systematically compare the efficacy and safety of MMF vs CYC as induction therapy for cLN by synthesizing randomized and observational evidence. METHODSPubMed, EMBASE, Scopus, and Web of Science were searched from inception through April 30, 2026.The inclusion criteria consisted of randomized controlled trials and comparative observational studies comparing MMF with CYC for the induction treatment of cLN.The primary outcomes were complete remission, partial renal response, and total renal response.The secondary outcomes were complete response, mortality, infection, adverse events, and estimated glomerular filtration rate (eGFR).RoB 2 and ROBINS-I tools were used for risk of bias assessment, while the GRADE tool was used for certainty of evidence assessment.Meta-analyses were performed using a random-effects model.Randomized and observational studies were synthesized separately for primary inference; combined estimates across study designs were designated as exploratory and were not used as the principal basis for causal or comparative-effectiveness conclusions.