Cyclophosphamide Pulse Therapy in Relapsing Nephrotic Syndrome

Cyclophosphamide Pulse Therapy in Relapsing Nephrotic Syndrome E.N. Wardle Dr. E.N. Wardle, MD, 20 Oxford Road, Littlemore, Oxford OX4 4PE (UK) Dear Sirs, Having just read the letter by Gandhi and Thomas [1], I would like to comment on my experience in treating some 16 children with minimal-change nephrotic syndrome in Abha, Saudi Arabia, over a 3-year period. Since the work of Lagrue [2] and Laurenet et al. [3], is persuasive that allergy is a feature of many cases of minimal-change nephrotic syndrome, and the one careful study of milk exclusion was impressive [4], we adopted a policy of asking all parents to ensure that such children did not consume cow’s milk, goat’s milk, camel’s milk, or products containing them, or eggs. Unfortunately, the follow-up of some children was erratic, but by the end of the period, all but 1 child was in remission, and some 50% were apparently cured. In fact, my particular approach to steroid therapy was probably equally important. Assuming that there is an allergic/environmental basis, it is irrational to give high-dose steroids for 6–8 weeks and then to stop them in anticipation of a cure. Once remission was obtained, I gave a maintenance dose of 15–10–7.5 mg prednisolone daily or on alternate days over a period of 1–2 years. In that time, any dietary indiscretion associated with recrudescence was carefully documented. Drinking milk was the obvious mistake in some cases. I am emphasizing this policy in order to show that cyclophosphamide may never be necessary and that its use could be a travesty of justice. The 1 problem child in our series was given ciclosporin. Patients generally do not relapse on maintenance steroid therapy, and the small dose required does not curtail growth or have any serious side-effects. References Gandhi R, Thomas C: Cyclophosphamide Pulse Therapy in Frequently Relapsing Nephrotic Syndrome. Nephron 1990; 55:444. Lagrue G: Idiopathic nephrotic syndrome: The prognosis is not linked to total serum IgE level. Nephron 1989;52:283–284. Laurenet J, Rostoker G, Robera R: Is adult idiopathic nephrotic syndrome food allergy? Value of oligo-antigenic diets. Nephron 1987;47:7–11. Sandberg DH, Mclntosh RM, Bernstein CW, Carr R, Strauss J: Severe steroid-responsive nephrosis associated with hypersensi-tivity. Lancet 1977;i:388–390.