Adrenocortical suppression increases the risk of relapse in nephrotic syndrome.
OBJECTIVE
Children with nephrotic syndrome (NS) are usually treated with long-term low dose alternate day prednisolone with or without glucocorticoid sparing therapy, such as levamisole or ciclosporin, to maintain remission. The degree of hypothalamic-pituitary-adrenal axis (HPA) suppression with such therapeutic strategies has not been studied systematically. HPA suppression could cause a relapse or adrenal crisis.


METHODS
To study the risks of HPA suppression, a modified low dose synacthen test (0.5 mug) was administered to 32 patients (22 male,10 female) with a mean age of 9.7 years (range 3.8-17.6 years) with NS receiving long-term alternate day prednisolone for over 12 months. Twelve patients received alternate day prednisolone, 11 alternate prednisolone+levamisole and nine alternate prednisolone+ciclosporin. All patients were followed up for 3 years and the relapse rate noted.


RESULTS
20/32 (62.5%) patients had a peak serum cortisol concentration of <500 nmol/l, which suggested suboptimal cortisol secretion and possible HPA suppression. 10/12 children in the prednisolone group and 8/11 in the levamisole group had a suboptimal cortisol response compared with 2/9 in the ciclosporin group. During follow-up, the 20 children who had a suboptimal cortisol response had significantly more relapses (95 relapses) compared to the 12 children with a normal cortisol response who had 24 relapses (p = 0.01).


CONCLUSIONS
Children with NS receiving long-term alternate day prednisolone therapy are at risk of developing HPA suppression and should be evaluated using the modified synacthen test. Children with evidence of HPA suppression are at a greater risk of relapse.
Abeyagunawardena
Asiri S
AS
Department of Paediatrics, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka. asiri26@hotmail.com
Hindmarsh
Peter
P
Trompeter
Richard S
RS
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D003366:Cosyntropin; D016572:Cyclosporine / Q000627:therapeutic use; D004334:Drug Administration Schedule; D004359:Drug Therapy, Combination; D005260:Female; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D006801:Humans; D006854:Hydrocortisone / Q000097:blood; D007030:Hypothalamo-Hypophyseal System / Q000187:drug effects* / Q000503:physiopathology; D007978:Levamisole / Q000627:therapeutic use; D008297:Male; D009404:Nephrotic Syndrome / Q000188:drug therapy / Q000503:physiopathology*; D010913:Pituitary-Adrenal System / Q000187:drug effects* / Q000503:physiopathology; D011239:Prednisolone / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use; D012008:Recurrence
D005938:Glucocorticoids; D003366:Cosyntropin; D007978:Levamisole; C006418:adrenocorticotropin zinc; D016572:Cyclosporine; D011239:Prednisolone; D006854:Hydrocortisone