Long-term cyclosporine A treatment of steroid-resistant and steroid-dependent nephrotic syndrome.

Eighteen patients with steroid-resistant nephrotic syndrome (SRNS) and steroid-dependent nephrotic syndrome (SDNS) were treated with cyclosporine A (CyA) (6 mg/kg/d) for 2 to 29 months. CyA levels were monitored monthly and plasma levels by Abbott TDX (Therapeutic Drug Analyzer System) fluorescence polarization immunoassay were maintained at 100 to 150 ng/mL. The corticosteroid dosage administered at the time CyA therapy was initiated was variable and was continued following CyA therapy. Six of these patients (all with SDNS and minimal change nephrotic syndrome [MCNS]) had been treated with one or more courses of cytotoxic drug therapy, and all had clinical evidence of corticosteroid toxicity after receiving corticosteroid therapy for 26 to 120 months. The corticosteroid dosage was reduced by slow tapering and was ultimately discontinued in six patients. These patients were maintained on CyA monotherapy for 7 to 21 months at a dose of 3.2 to 6.7 mg/kg/d. Following 11 to 29 months of CyA therapy, seven patients underwent an elective renal biopsy, which showed nephrotoxicity in all seven. This led to discontinuation of CyA in four patients. Following discontinuation of CyA monotherapy, all four patients relapsed within 2 to 4 months. CyA therapy did not achieve a remission in 10 patients with SRNS regardless of the presence of focal segmental glomerulosclerosis (FSGS) or MCNS on renal biopsy. In conclusion, CyA has limited effectiveness in patients with SDNS who manifest corticosteroid toxicity; however, CyA should be used cautiously because of the potential for CyA nephrotoxicity and the failure to obtain a sustained remission following discontinuation of CyA monotherapy. CyA dependence is substituted for corticosteroid dependence.