Cyclosporin and Prednisolone: Do They Prevent Recurrence of Focal Segmental Glomerulosclerosis ?

J. R. Burke, MD, Renal Unit, Princess Alexandra Hospital, Wooloongaba, Q 4102 Brisbane(Australia) Dear Sir, Patients with renal failure from focal segmental glom-erulosclerosis (FGS) have a high incidence of recurrence in transplant kidneys. The recurrence is estimated at approximately 30% in first renal allografts and 75% in second renal allografts [1]. We wish to report the possible prevention with cyclosporin of nephrotic syndrome from FGS in a child receiving a second cadaver allograft where the first renal transplant failed because of recurrent FGS. In addition, this case illustrates the interaction between cyclosporin and drugs which induce hepatic P450 enzymes – in this instance sodium valproate. A 5-year-old girl presented in 1977 with nephrotic syndrome. Total serum protein was 52 g/l, albumin 20 g/l, 24-hour urine protein 4.7 g and serum creatinine 0.07 mmol/l. There was no response to prednisolone 2 mg/kg/day for 6 weeks and cyclophosphamide 3 mg/ kg/day for 8 weeks; renal function deteriorated, and she commenced haemodialysis 15 months later. Bilateral nephrectomy because of severe hypertension was performed in 1979. In 1980, a renal cadaver transplant (HLA-A zero mismatch, HLA-B and HLA-DR 2 mismatches) was performed with prednisolone and azathioprine as immunosuppression. Recurrence of nephrotic syndrome was documented within 3 weeks (serum albumin 26 g/l, 24-hour urine protein 6.9 g/l, serum creatinine 0.06 mmol/l. A biopsy at 4 weeks after transplant showed 1 glomer-ulus with segmental hyalinosis and no evidence of rejection. Renal function deteriorated and she recommenced dialysis after 11 months. In January 1985, she received a second cadaver allograft (HLA-A 1 mismatch, HLA-B zero mismatch, HLA-DR 2 mismatches). Sodium valproate 25 mg/ kg/day was being administered for epilepsy. Pre-operatively, intravenous cyclosporin 25 mg/kg and methylprednisolone 15 mg/kg were given. In the postopera-