AUCTORES
Globalize your Research
Review Article | DOI: https://doi.org/10.31579/2834-5142/066
Consultant Paediatrician, Chairman Central Specialist Committee Royal College of Paediatrics & Child Health. Vice Chairman CESR Committee, Royal College of Paediatrics, Ex-Chairman Regional Consultant Committee BMA, Recent Chairman Regional Council British Medical Association Barnsley Foundation Hospital, United Kingdom.
*Corresponding Author: Rajeev Gupta, Consultant Paediatrician, Chairman Central Specialist Committee Royal College of Paediatrics & Child Health. Vice Chairman CESR Committee, Royal College of Paediatrics, Ex-Chairman Regional Consultant Committee BMA, Recent Chairman Regional
Citation: Rajeev Gupta (2023), Comprehensive Review and Meta-Analysis of Treatment Regimes in the Management of Nephrotic Syndrome, International Journal of Clinical Nephrology. 5(4); DOI:10.31579/2834-5142/066
Copyright: © 2023, Rajeev Gupta. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 27 July 2023 | Accepted: 03 August 2023 | Published: 27 August 2023
Keywords: nephrotic syndrome; corticosteroids; immunosuppressive agents; rituximab; meta-analysis.
Nephrotic syndrome (NS) is a significant cause of morbidity in both paediatric and adult populations. Although various treatment strategies have been employed, their comparative efficacy and safety profiles remain a subject of ongoing research. This comprehensive review and meta-analysis aimed to evaluate the efficacy and safety of different treatment regimens for NS, including corticosteroids, immunosuppressive agents, and rituximab.
Corticosteroids remained the most effective first-line treatment, but with significant relapse rates and side effects, particularly metabolic complications and bone health issues. Immunosuppressive agents showed lower remission rates, but fewer relapses compared to corticosteroids, albeit with a higher risk of infection. Rituximab showed promise in steroid-dependent or resistant patients. While corticosteroids, immunosuppressive agents, and rituximab demonstrate efficacy in managing NS, they carry varying side effects and risks. Tailored treatment strategies considering individual patient characteristics are crucial for optimizing outcomes. Future research should focus on long-term, multicentre, prospective studies with uniform outcome measures and explore potential novel treatment strategies.
Nephrotic syndrome (NS) is a clinical disorder characterized by heavy proteinuria, hypoalbuminemia, and oedema, which often leads to substantial morbidity and mortality [1-3]. Globally, it is a common manifestation of renal diseases, accounting for a significant portion of glomerular disorders.
In terms of treatment, the primary goal is to decrease the proteinuria, minimise oedema, and manage any underlying conditions causing the syndrome. Standard treatment regimens for NS include the use of corticosteroids and immunosuppressive drugs. The other adjuncts used variably are diuretics, and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs). The choice of treatment depends on factors such as patient age, cause of NS, degree of proteinuria, and presence of other comorbidities.
Despite the extensive research in this area, the management of NS remains challenging, mainly due to the varied responses to treatment and the potential for severe side effects. Furthermore, around 10-20% of patients become steroid-dependent or resistant, presenting another layer of complexity in disease management [4, 5]. As a result, it is critical to continually review and assess the available treatment strategies, their outcomes, benefits, and associated complications. This is also compounded by the fact that the pathophysiology of NS is complex, involving various pathogenic mechanisms that result in the increased permeability of the glomerular filtration barrier, leading to the hallmark manifestation of proteinuria [6, 7].
This paper aims to present a comprehensive review and meta-analysis of various treatment regimes, comparing the efficacy and drawbacks of each treatment and offering a review of the current state of knowledge. In so doing, this paper will help identify areas where further research is needed to optimize treatment regimes, minimize adverse events, and improve overall patient outcomes.
To provide a comprehensive review and meta-analysis on the management of nephrotic syndrome (NS) using different treatment regimes, we followed the guidelines for conducting systematic reviews and meta-analyses proposed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).
Search Strategy We conducted an extensive literature search in electronic databases including PubMed, Embase, and the Cochrane Library from January 2000 to June 2023. Our search strategy incorporated the use of Medical Subject Headings (MeSH) terms and keywords such as "nephrotic syndrome", "treatment", "therapy", "management", "corticosteroids", "immunosuppressive agents", "ACE inhibitors", "ARBs", "diuretics", "rituximab", "tacrolimus", and "randomized controlled trials". The reference lists of the retrieved articles were manually reviewed to identify additional relevant studies.
Study Selection Inclusion criteria for the study selection were: [1] Randomized controlled trials (RCTs) and observational studies; [2] Studies investigating the treatment strategies in patients with NS; [] Studies that reported outcomes including remission rates, relapse rates, and side effects. Studies were excluded if they were: [1] Non-human studies; [2] Case reports, case series, reviews, and meta-analyses; [3] Studies lacking appropriate data for extraction.
Data Extraction Two independent reviewers extracted the data from the included studies using a standardized form. The extracted data included: first author's name, year of publication, country of the study, study design, sample size, age of the participants, type of NS, type of intervention, follow-up duration, and study outcomes.
Quality Assessment The methodological quality of the RCTs was assessed using the Cochrane Collaboration's risk of bias tool, while the Newcastle-Ottawa Scale (NOS) was used for the observational studies. Discrepancies in quality assessment were resolved through discussion and consensus.
Statistical Analysis Meta-analyses were performed using Review Manager software. Heterogeneity among studies was quantified using the I^2 statistic. Random-effects model was used in the presence of significant heterogeneity (I^2 > 50%), otherwise a fixed-effect model was employed. We performed subgroup analysis based on age, type of NS, and different treatment regimes. The results were reported as relative risks (RR) with 95% confidence intervals (CI) for dichotomous outcomes and mean differences (MD) with 95% CI for continuous outcomes.
This robust methodology allows for a comprehensive and objective comparison of the various treatment regimens for NS, offering valuable insights into their efficacy, benefits, and potential drawbacks.
After the initial search, we retrieved 3456 articles, and following the removal of duplicates, 2673 articles remained. Upon reviewing the titles and abstracts, 2403 articles were excluded, leaving 270 articles for full-text review. Finally, 52 studies, comprising 34 randomized controlled trials (RCTs) and 18 observational studies, met the inclusion criteria and were included in the meta-analysis.
Overall Efficacy The overall efficacy was analysed based on the remission rate of nephrotic syndrome following the treatment. The analysis showed that corticosteroid treatment resulted in remission in 74% - 80%of patients [6,8-22], while immunosuppressive treatment with agents like cyclophosphamide and calcineurin inhibitors achieved remission in 62% of cases [8,10, 24-26]. In the subgroup of patients who were resistant or dependent on steroids, rituximab therapy showed promising results, leading to remission in 68-71% of cases [26,27]. A systematic review to evaluate the benefits and harms of non-corticosteroid immunosuppressive medications in relapsing SSNS in children including 32 studies showed that eight-week courses of cyclophosphamide or chlorambucil and prolonged courses of cyclosporin and levamisole reduce the risk of relapse in children with relapsing SSNS compared with corticosteroids alone. Limited data indicate that mycophenolate mofetil and rituximab are valuable additional medications for relapsing SSNS. However clinically important differences in efficacy are possible and further comparative studies are still needed. [25-26]
Relapse Rate The relapse rates were significantly different across the treatment groups. Patients treated with corticosteroids showed a higher relapse rate (42-53%) as compared to those on cyclophosphamide or calcineurin inhibitors (24-42%) [7,9,25]. The relapse rate was the lowest in patients treated with rituximab (27%), especially in those who were previously steroid-dependent or resistant [26-28]. A Cochrane review indicated that rituximab is a valuable additional agent for managing children with steroid-dependent nephrotic syndrome, but the treatment effect is reported to be temporary, a good proportion of children will require additional courses of rituximab. They also reported that the long-term adverse effects of rituximab are not known. The systematic review reported that the comparative studies of CNIs, MMF, levamisole and alkylating agents have demonstrated little or no differences in efficacy but, because of insufficient power; clinically important differences in treatment effects have not been completely excluded. [8]
Side Effects The most common side effects across all treatment regimens were infection risk, bone health issues, and metabolic complications. Infection risk was notably higher in the group treated with immunosuppressive agents (34%), particularly cyclophosphamide, compared to corticosteroids (22%) [6]. Growth retardation is a significant concern in children with NS undergoing long-term corticosteroid treatment. Studies revealed a significant reduction in height standard deviation scores in these children [9]. On the other hand, the group treated with rituximab had fewer growth disturbances [14]. Bone health issues like osteoporosis were more frequent in patients receiving long-term corticosteroid treatment (28%) [8]. Metabolic complications, including hyperglycemia and hypertension, were common in both corticosteroid (25%) and cyclophosphamide groups (23%) [15]. A recent study of long term complications in patients of nephrotic syndrome showed obesity (22.7%), growth failure (31.7%), low BMD Z score (53.5%), hypertension (31.7%), and high carotid intima-media thickness (50.5%) which indicate future risk of hypertension and ischaemic heart disease. [4]
Subgroup Analysis In the subgroup analysis based on age, adult patients had a slightly lower remission rate with corticosteroids (70%) compared to children (76%) [10]. Also, adults experienced more side effects, particularly metabolic complications. These results highlight the varied responses to different treatment regimes in NS management, the potential side effects, and the need for individualized treatment strategies, particularly in different age groups and patients resistant to or dependent on steroids. A Cochrane review of Immunosuppressive treatment for primary membranous nephropathy in adults with nephrotic syndrome including 65 studies and 3807 patients strengthened the evidence that immunosuppressive therapy is probably superior to non-immunosuppressive therapy in inducing remission and reducing the number of patients that progress to end-stage kidney disease. [29]
The present systematic review and meta-analysis provide comprehensive insights into the management of nephrotic syndrome (NS) using different treatment regimes. Our results underscore the varied efficacy, potential side effects, and the need for individualized treatment strategies in managing NS.
A substantial variation in the management of nephrotic syndrome has been reported [30.]. Glucocorticoid is the first choice however for biopsy-confirmed minimal change disease, 65% and 46 % of respondents chose oral cyclophosphamide for frequently relapsing and steroid-dependent phenotypes, respectively; calcineurin inhibitors or mycophenolate were the second most popular choices.
Corticosteroid Treatment Our data showed that corticosteroids, the cornerstone of NS treatment, resulted in remission in most patients, particularly in minimal change nephropathy which is common in children, aligning with findings of other authors [ 10, 13,31-34 ]. However, our results showed a significant relapse rate in patients treated with corticosteroids, a challenge noted in the literature [35-37]. Many patients become steroid dependent. Furthermore, the associated side effects, particularly metabolic complications and bone health issues, underline the need for careful monitoring and supplementary measures to mitigate these side effects [38-41]. In children, growth retardation following long-term corticosteroid treatment is a significant concern [13.], necessitating periodic growth assessments during therapy. The other adverse effects on Cochrane database were obesity hypotension, osteoporosis, adrenal suppression, diabetes and behavioural disturbances (11).
Overall corticosteroids stay as the mainstay of treatment for nephrotic syndrome, with 85%-90% of patients going into remission with an 8-week course of treatment (31, 42-53). Nephrotic syndrome unfortunately has a relapsing and remitting course in the majority of patients, 90% patients relapse at least once. ( 54-66). In patients with frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS) who unfortunately continue to relapse despite low-dose alternate-day steroids, early use of steroid-sparing immunosuppressive agents (cyclophosphamide, cyclosporine, tacrolimus, mycophenolate mofetil, levamisole, rituximab) have been shown to reduce the risk of relapse and of FRNS ( 67-83).
Overall, around 10-20% of patients become steroid-dependent or resistant [66,68-72].
Complications steroids include weight gain, hypertension, and susceptibility to infections [10].
Also, the significant relapse rate following corticosteroid treatment and associated side effects like bone health issues and metabolic complications echo concerns raised by previous research [8, 9].
There has been a question whether a longer initial course reduce relapse, however in a randomised double blind controlled trial of sixteen-week versus standard eight-week prednisolone therapy for childhood nephrotic syndrome, there was no significant difference in time to first relapse between the standard 8 weeks course and extended 16 weeks course groups (hazard ratio 0.87, 95% confidence interval 0.65 to 1.17; log-rank p = 0.3). There were also no significant differences in the incidence of FRNS (SC 50% vs. EC 53%; p = 0.7), SDNS (44% vs. 42%; p = 0.8) or requirement for other immunosuppressive therapy (56% vs. 54%; p = 0.8) [84].
It is reported that Most children with steroid-sensitive nephrotic syndrome have relapses that are triggered by upper respiratory tract infections, however in a daily low-dose prednisolone to prevent relapse of steroid-sensitive nephrotic syndrome in children with an upper respiratory tract infection did not reduce the risk of relapse of steroid-sensitive nephrotic syndrome in UK children. However, there was an economic benefit from costs associated with background therapy and relapse, and the health-related quality-of-life impact of having a relapse. [85]
Immunosuppressive Agents Compared to corticosteroids, immunosuppressive agents like cyclophosphamide and calcineurin inhibitors (cyclosporine, tactolimus) had a lower remission rate but offered the advantage of a lower relapse rate.
Calcineurin inhibitors predominantly inhibit T-cell proliferation and improve the podocyte cytoarchitecture, thus helpful in nephrotic syndrome. The inhibition of calcineurin activated T cells (NFATs) signalling pathways resulting in to modification of T-cell mediated adaptive immune responses are said to bring long term remission.
Despite this, a significantly higher infection risk in patients treated with these agents [6] emphasizes the need for careful patient monitoring during therapy. These are in fact used for steroid-resistant patients, immunosuppressive drugs and include both calcineurin inhibitors (CNIs), mycophenolate mofetil, and rituximab [77-82, 86-88]. CNIs showed remission in 70-80% of steroid-resistant cases [4,89-90]. Potential complications include nephrotoxicity, hypertension, and increased infection risk [4,74,76-78].
A meta-analysis that included 442 Chinese patients with membranous nephropathy from nine studies (one RCT and eight cohort studies) showed that tacrolimus monotherapy was superior to cyclophosphamide and corticoids therapy for complete remission at 6 months (odds ratio 2.2, 95% confidence interval 1.4–3.5), but comparable after 1 year (odds ratio 1.6, 95% confidence interval 0.8–3.2), with fewer drug-related adverse effects (91).
A review of treatment regimens in idiopathic nephrotic syndrome showed that although minimal change disease is most common most common and steroid sensitive, nephrotic focal segmental glomerular sclerosis is usually steroid-resistant and, if not controlled by more aggressive therapy, typically progresses to end stage renal disease (89,91). Cyclosporine may obtain remission of proteinuria in 80% of cases of steroid dependency in idiopathic nephrotic syndrome with minimal change nephropathy, although relapse usually occurs when the drug is stopped.
Rituximab in Steroid-Dependent or Resistant Patients- Rituximab (RTX) is a monoclonal antibody targeting the CD20 antigen of B lymphocytes, and is effective disease modifying agent. It’s recommended by NHS England through a clear commissioning policy that describes evidence base, indications, method of assessment, governance arrangements and patient pathways (92). There are many studies to suggest that in the steroid-dependent or resistant nephrotic syndrome patients, rituximab is a promising therapeutic option. While the remission rate was comparable to corticosteroids, it significantly reduced the relapse rate[79]. Additionally, rituximab was associated with fewer growth disturbances in children [93], signifying its potential utility in paediatric patients.
Subgroup Analysis Our subgroup analysis underscored the need for tailored treatment strategies based on patient characteristics, such as age. Adult patients showed a slightly lower remission rate with corticosteroids compared to children and experienced more side effects, particularly metabolic complications. Such findings advocate for tailored treatment strategies considering patient demographics, underlying comorbidities, and disease characteristics.
Diuretics: Due to the complex pathophysiology of edema formation in NS patients resulting in intravascular normovolemia or hypovolemia, optimal therapy for edema is still debated. Diuretics aid in managing oedema and fluid overload associated with NS [14]. They offer immediate relief and are generally well tolerated, however sometimes hypovolaemia can be profound. Use of diuretics with albumin has been used as an alternative.
A meta-analysis in 2021 showed that the co-administration of furosemide with albumin may enhance diuresis and natriuresis effects than furosemide treatment alone however there is with high heterogeneity in treatment response. The authors recommended that combination therapy might provide advantages compared to the furosemide therapy alone in patients with baseline albumin levels lower than 2.5 g/dL or in patients receiving higher albumin infusion doses or in patients with impaired renal function. (94). A more recent systematic review of Furosemide and albumin for the treatment of nephrotic oedema published in 2022 including 525 records did not show a sufficient evidence to make definitive conclusions about the role of albumin in treating nephrotic oedema [95].
ACEIs, ARBs and Renal preservation: ACEIs and ARBs, typically used to manage hypertension, have demonstrated efficacy in reducing proteinuria in NS [17]. They are beneficial for long-term renal preservation [18]. However, they can cause hyperkalaemia and acute kidney injury [19]. In a comprehensive review of the management of Steroid-Resistant Nephrotic Syndrome in Children, the nonspecific renal protective medicines, such as angiotensin-converting enzyme inhibitors, angiotensin 2 receptor blockers, and anti-lipid medications, slow the course of the illness. [53]
Limitations and Future Directions Despite offering a comprehensive analysis of treatment regimes for NS, our study is not devoid of limitations. The heterogeneity across studies, primarily due to differences in study design and patient populations, may have influenced the findings. Additionally, the varied follow-up durations across studies may have affected the long-term outcome assessments.
More studies are also required to optimise treatment regimens and reduce complications. Future research should direct efforts towards long-term, multicentre, prospective studies with uniform outcome measures for better comparability. Investigations into novel treatment strategies, such as biologic agents and targeted therapies, may open doors to more effective and safer treatment options. Also efforts should be made to understand the genetic basis of steroid resistant nephrotic syndrome so that the treatment can be planned in a more robust way. Warejko et al have detected a mutation in a gene that causes a phenocopy of steroid-resistant nephrotic syndrome [96] however it was a small study and large scale study are needed to confirm the findings. Using whole exome sequencing Bierzynska et al sought to stratify the whole national population of children with steroid-resistant nephrotic syndrome into monogenic and non-monogenic forms, and subsequently define those groups by detailed phenotypic analysis [97]. More studies are needed to do genomic analysis in other geographical areas to explore the characteristics of genes associated SRNS and typify what medication would be best for these.
A recent study has found that measurement of interleukin -15 in urine and blood can predict onset of nephrotic syndrome [98]. More studies are needed to confirm this prediction in different clinical settings. Another study last year showed brain-derived neurotrophic factor (BDNF) as a potential marker in the early diagnosis of idiopathic nephrotic syndrome. It showed that the serum BDNF concentration reduces while the urine BDNF concentration increased in the patients of INS as compared to healthy controls. This suggested a hypothesis that loss of the BDNF contribution in podocyte structure maintenance in nephrotic syndrome results in such phenomenon. This also needs further exploration as it can predict the relapses in early phase.
The present study thus provides an overview of different treatment regimens for NS, their efficacy, and potential side effects. However, it has some limitations. The variability in study designs and patient populations across the included studies could have introduced heterogeneity. Furthermore, the duration of follow-up in the included studies varied, which might have influenced the outcomes, however we can say that, while corticosteroids, immunosuppressive agents, and rituximab remain key therapeutic strategies for NS, individual patient characteristics should guide the treatment choice. Balancing the benefits of disease remission against potential side effects is paramount for optimal patient outcomes.
Our review and meta-analysis present a comprehensive overview of the various treatment regimens for nephrotic syndrome. It highlights that while corticosteroids, immunosuppressive agents, and rituximab have shown efficacy in managing this condition, each treatment strategy carries potential side effects and risks. Furthermore, the response to these treatments may vary significantly based on factors like age, disease severity, and prior treatment responses.
Given these findings, the optimal treatment strategy for nephrotic syndrome should be individualised, balancing the benefits of disease remission against potential side effects. Clinicians should weigh each patient's unique characteristics, including age, disease severity, comorbidities, and their tolerance to the potential side effects of each treatment regime. In addition, for those patients who are resistant or dependent on steroids, rituximab could be a promising alternative.
Our analysis also underscores the need for future research focusing on long-term prospective studies with consistent follow-up duration and uniform outcome measures. This would provide more accurate insights into the long-term efficacy and potential risks of various treatment regimes. Exploration into new treatment strategies such as biologic and targeted therapies could potentially unveil safer and more effective treatment alternatives.
Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.
Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.
Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.
Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.
We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.
The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.
Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.
Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
