title: Treatment with candesartan combined with angiotensin-converting enzyme inhibitor for immunosuppressive treatment-resistant nephrotic syndrome after allogeneic stem cell transplantation.
abstract: Most cases of nephrotic syndrome following stem cell transplantation (SCT) occur 6 months after SCT. The patients are treated with immunosuppressive therapies; however, in some cases treatment is not effective. We used enalapril, an angiotensin-converting enzyme inhibitor (ACEI) and candesartan, an angiotensin II receptor blocker (ARB), for the control of proteinuria in a case of immunosuppressive treatment (IST)-resistant nephrotic syndrome. A 15-year-old boy with acute lymphoblastic leukemia underwent allogeneic peripheral blood SCT from a completely HLA-matched sibling after completion of a conditioning regimen composed of 12-Gy doses of total-body irradiation, 600 mg/m2 thiotepa, and 140 mg/m2 melphalan. Twenty-eight months after SCT, minimal-change nephrotic syndrome was diagnosed on the basis of biopsy findings. Although neither cyclosporine (trough level, 100-150 ng/mL) nor corticosteroid was effective, proteinuria disappeared 2 months after the beginning of treatment with tacrolimus (trough level, 13-20 ng/mL), and remission was maintained for 23 months. Nephrotic syndrome recurred, however, and was resistant to tacrolimus. Findings at the second renal biopsy revealed membranous nephropathy. An ARB (candesartan, 4 mg/ day) in combination with an ACEI (enalapril, 5 mg/day) was started. Proteinuria improved within 2 weeks. We suggest that ARB combined with ACEI can be used to control proteinuria in patients with IST-resistant nephrotic syndrome after SCT.
authors.affiliation: Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan. YOsugi@aol.com
authors.forename: Yuko
authors.initials: Y
authors.lastname: Osugi
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Yamada
authors.forename: Gaku
authors.initials: G
authors.lastname: Hosoi
authors.forename: Haruyoshi
authors.initials: H
authors.lastname: Noma
authors.forename: Misako
authors.initials: M
authors.lastname: Ikemiya
authors.forename: Takefumi
authors.initials: T
authors.lastname: Ishii
authors.forename: Masahiro
authors.initials: M
authors.lastname: Sako
mesh_terms: D000293:Adolescent; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D000959:Antihypertensive Agents / Q000008:administration & dosage*; D001562:Benzimidazoles / Q000008:administration & dosage*; D001713:Biphenyl Compounds; D004351:Drug Resistance / Q000187:drug effects; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage; D008297:Male; D009404:Nephrotic Syndrome / Q000188:drug therapy* / Q000209:etiology / Q000473:pathology; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000150:complications / Q000473:pathology / Q000628:therapy; D011507:Proteinuria / Q000188:drug therapy / Q000209:etiology / Q000473:pathology; D033581:Stem Cell Transplantation / Q000009:adverse effects; D013777:Tetrazoles / Q000008:administration & dosage*; D013997:Time Factors; D014184:Transplantation, Homologous
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D000959:Antihypertensive Agents; D001562:Benzimidazoles; D001713:Biphenyl Compounds; D007166:Immunosuppressive Agents; D013777:Tetrazoles; C081643:candesartan