Glucocorticoids nephrotic syndrome

The first point is that treatment with steroids is generally palliative rather than curative, and only in a very few diseases, such as leukemia and nephrotic syndrome, do corticosteroids alter prognosis. One must also consider which is worse, the disease to be treated or possible induced hypercortisolism. The patient s age can be an important factor, since such adverse effects as hypertension are more apt to occur in old and infirm individuals, especially in those with underlying cardiovascular disease. Glucocorticoids should be used with caution during pregnancy. If steroids are to be employed, prednisone or prednisolone should be used, since they cross the placenta poorly. 

It is a selective and very potent long acting glucocorticoid. It causes suppression of pituitary adrenal axis. Used in shock due to trauma, allergic emergencies, rheumatoid arthritis, asthma, nephrotic syndrome and suppression of inflammation in eye and skin disorders. 

A 6-year-old girl, who had taken prednisone for 2.5 years for nephrotic syndrome with seven relapses in 3 years, developed symptoms of benign intracranial hypertension after oral glucocorticoid dosage reduction over 10 months from 30 mg/day to 2.5 mg/every other day (46). Laboratory studies and head CT scan were normal, but there was bilateral papilledema and the cerebrospinal fluid pressure was increased. She was given prednisone 1 mg/kg/day initially, with acetazola-mide, and 25 ml of cerebrospinal fluid was removed. All her symptoms resolved and treatment was gradually withdrawn. She developed no further visual failure. 

Two patients developed hypopituitarism and empty sella syndrome during glucocorticoid pulse therapy for nephrotic syndrome (SEDA-22, 444 118). 

The author proposed that raised arterial pressure, which is an adverse effect of high dose glucocorticoid treatment, and low oncotic pressure due to a low protein plasma concentration in a patient with nephrotic syndrome, could have increased trans-synovial fluid flow at a lower arterial pressure than normal. 

Withdrawal symptoms disappear if the glucocorticoid is resumed, but as a rule they will in any case vanish spontaneously within a few days. More serious consequences can ensue, however, in certain types of cases and if adrenal cortical atrophy is severe. In patients treated with corticoids for the nephrotic syndrome and apparently cured, the syndrome is particularly likely to relapse on withdrawal of therapy if the adrenal cortex is atrophic (SEDA-3,305). In some cases, acute adrenocortical insufficiency after glucocorticoid treatment has actually proved fatal. It is advisable to withdraw long-term glucocorticoid therapy gradually so that the cortex has sufficient opportunity to recover. Table 5 lists methods of... 

In a patient with glucocorticoid-resistant nephrotic syndrome taking simvastatin and ciclosporin, there was an increase in lactic dehydrogenase activity, suggesting tissue injury, in the absence of an increase in creatine kinase (42). 

Cyclosporine is an important drug in preventing rejection after kidney, hver, heart and other organ transplantation (Haberal et al., 2004). Cyclosporine usually is combined with other immunosuppressives especially glucocorticoids and either azathioprine or mycophenolate mofedl and sirolimus (Krensky et al., 2005). In renal alio transplants it has improved graft acceptance in most clinics to 95 percent. In addition to its use in transplantation cyclosporine is used for the treatment of a number of autoimmune diseases. In autoimmune diseases, as might be anticipated, cyclosporine is most effective in those which are T cell mediated. These include several forms of psoriasis, rheumatoid arthritis refractive to all other therapy, uveitis, nephrotic syndrome and type I diabetes mellitus. 

Elrugs with primarily glucocorticoid effects, e.g. prednisolone, are chosen, so that dosage is not limited by the mineralocorticoid effects that are inevitable with hydrocortisone. But it remains essential to use only the minimum dose that will achieve the desired effect. Sometimes therapeutic effect must be partly sacrificed to avoid adverse effects, for it has not yet proved possible to separate the glucocorticoid effects from each other indeed it is not known if it is possible to eliminate catabolic effects and at the same time retain anti-inflammatory action. In any case, in some conditions, e.g. nephrotic syndrome, the clinician cannot specify exactly what action they want the drug developer to provide. 

A 57-year-old woman developed severe nephrotic syndrome after 3 months of interferon alfa re-treatment, and renal biopsy showed minimal change nephrotic syndrome with T cell-predominant interstitial nephritis (265). Proteinuria persisted despite interferon alfa withdrawal and resolved only after glucocorticoid treatment. 

In 11 children with nephrotic syndrome, of whom five were glucocorticoid-sensitive, six glucocorticoid-resistant, and all resistant to other immunosuppressive drugs, levamisole 2.5 mg/kg was given every 48 hours for up to 18 months (7). Two patients were also given ciclosporin. All the patients in the steroid-sensitive group but none in the steroid-resistant group reacted favorably to levamisole, with disappearance of protein from the urine. There... 

Levamisole 2 mg/kg on alternate days was given to 25 glucocorticoid-dependent children with frequent relapses of idiopathic nephrotic syndrome (8). The steroid was tapered, and continued for 3-14 months. During treatment with levamisole the relapse frequency was reduced by 40%. Two patients developed mild transient leukopenia, which disappeared 2 weeks after withdrawal. One had a slight rash that disappeared while treatment was continued and one complained of epigastric pain, which led to drug withdrawal. 

Leukocytoclastic vasculitis has been attributed to levamisole in a 7-year-old boy with glucocorticoid-dependent nephrotic syndrome (44). 

Low-dose methotrexate is usually not regarded as nephrotoxic, and one report of nephrotic syndrome with minimal change disease on renal biopsy should be regarded with caution, since there was recovery after glucocorticoid treatment and withdrawal of concomitant NSAIDs (SEDA-22, 416). 

Hypothyroidism Obstructive liver disease Nephrotic syndrome Anorexia nervosa Acute intermittent porphyria Drugs Progestins, thiazide diuretics, glucocorticoids, / -blockers, isotretinoin, protease inhibitors, cyclosporine, mirtazapine, sirolimus Obesity... 

Patients with nephrotic syndrome secondary to minimal change disease generally respond to steroid therapy, and glucocorticoids clearly are the first-line treatment in both adults and children. Initial daily doses of prednisone are 1-2 mg/kg for 6 weeks, followed by a gradual tapering of the dose over... 

Acute-phase reactant Glucocorticoids Hodgkin s lymphoma Bile duct obstruction Nephrotic syndrome (Hp 2-1 or 2-2) Ulcerative colitis... 

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