Cyclosporine in the treatment of steroid-dependent and steroid-resistant idiopathic nephrotic syndrome in children

Steroid-resistant nephrotic syndrome: long-term evolution after sequential therapy

We present a retrospective study of 30 children of mean age 3.02 +/- 1.81 years with steroid-resistant nephrotic syndrome (SRNS) treated with intravenous injection of methylprednisolone plus orally administered prednisone; 24 children also received cyclophosphamide (CP). Sixteen were resistant to steroids from the beginning, and 14 after a mean of 11.26 +/- 16.61 months. The initial histological diagnosis was: 18 minimal change disease (MCD), 11 focal segmental glomerulosclerosis (FSGS) and one diffuse mesangial proliferative glomerulonephritis (DMPG). Total remission was achieved in 22 patients (73.3%), partial response in three (10%) and no response in five (16.6%), two of whom were brothers carrying an NPHS2 gene double mutation. There was no difference in response between the MCD and FSGS patients; the only patient with DMPG did not respond. Only initial resistance was a sign of bad prognosis. At follow-up (6.4 +/- 3.6 years from last pulse), 21/22 were still in remission, 14/21 were without treatment. Six patients required cyclosporine or mycophenolate mofetil because of steroid dependence. Two non-responders developed end-stage renal failure (ESRF); the remaining patients maintained normal glomerular filtration. The treatment was well tolerated. In conclusion, most of the patients treated with sequential therapy consisting of methylprednisolone (MP) (100%) and CP (80%) showed remission and preserved renal function, but 20% developed steroid dependence.

Effect of intrauterine growth retardation on the progression of nephrotic syndrome

BACKGROUND/AIM

Neonates with intrauterine growth retardation (IUGR) experience higher morbidity and mortality rates than appropriate-for-gestational-age (AGA) neonates. The purpose of our study was to clarify whether IUGR has any influences on the progression of nephrotic syndrome in children.

METHODS

We performed a retrospective review of 56 children with nephrotic syndrome. IUGR was defined as a birth weight less than the tenth percentile for gestational age. Among 56 patients having nephrotic syndrome, 8 had IUGR, and 48 were AGA.

RESULTS

The 24-hour urinary protein level in children with IUGR was significantly higher than that in children who were AGA (7.61 +/- 6.75 vs. 3.92 +/- 3.70 g/day, p < 0.05). There was a statistically significant difference in the incidence of steroid resistance (62.5 vs. 10.4%, p < 0.05) and in the time to remission (median 60 vs. 13 days, p < 0.05) between the children with IUGR and those being AGA. Also, there was a significant difference in the incidences of treatment with cytotoxic agents (75 vs. 29.2%, p < 0.05) and complications such as hypertension.

CONCLUSIONS

Our report indicates that IUGR predicts an unfavorable progression of nephrotic syndrome. So, it is important for nephrologists to pay attention to the clinical course of nephrotic syndrome in neonates with IUGR.

Use of cyclosporin in the treatment of steroid resistant post-keratoplasty atopic sclerokeratitis

AIMS

To demonstrate that oral cyclosporin is successful in the management of steroid refractory post-keratoplasty atopic sclerokeratitis (PKAS).

METHODS

Series of three patients.

RESULTS

The patients developed PKAS between 2 and 11 days after surgery. All cases failed to respond to oral prednisolone 60-80 mg daily for 10-30 days but resolved with the addition of systemic cyclosporin 5.0-7.5 mg/kg/day. There have been no relapses following withdrawal of therapy after 3-18 months.

CONCLUSIONS

PKAS is an uncommon, but severe, complication of corneal graft surgery and often responds to oral prednisolone treatment. Oral cyclosporin results in rapid resolution of PKAS in steroid unresponsive cases.

Cyclosporin treatment of glomerular diseases

Cyclosporin is a potent immunosuppressive agent that has become the first line therapy in organ transplantation. Its efficacy has led to its use in a variety of immune-mediated glomerular diseases. A selection of controlled and uncontrolled trials has studied the effects of cyclosporin in patients with minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), IgA nephropathy, membranoproliferative glomerulonephritis (MPGN) and lupus nephritis. We review the recent literature and suggest recommendations for using cyclosporin in these diseases, based on this evidence and our experience.