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Observations on very high‐dose steroid therapy in nephrotic syndrome

Sir, The standard dose of prednisolone in nephrotic syndrome (NS) is 60 mg/m2/day given in divided doses for four weeks. A low-dose (30 mg/m2/day or less than 1.5 mg/kg/day) has also been advocated ( 1 , 2). However, a regimen that can prevent subsequent relapse once treatment is discontinued has not been identified. We considered it worthwhile trying a high-dose regimen of prednisolone in our cases of NS, particularly in view of the frequent relapses of previous dosage regimens. Twenty-one children with NS were prospectively studied over a three-year period. The UMTH, which is a tertiary/referral centre, serves the North-East region of Nigeria, as well as contiguous countries, including Chad, Niger and Cameroun, all within the Sahel Savannah region of Africa. Seventeen new patients with NS and four other frequent relapsers, who had a relapse, with heavy proteinuria, were studied. Diagnostic criteria, as well as definitions of relapse, initial responders, etc., satisfied generally accepted criteria ( 1 , 3). Only steroid-responsive NS was studied. Informed consent concerning study objectives was obtained. Two of the four frequent relapsers commenced the trial on 120 mg/ 24 h/m2. The 17 “new” patients were initially given prednisolone 90 mg/24 h/m2 (maximum dosage 120 mg/ 24 him2) in three divided doses. Increments from 90 mg/ 24 h/m2 to a maximum of 120 mg/24 h/mL were made if after 14 days there was no remission. Daily prednisolone therapy was thereafter gradually tapered in 5to 10-mg decrements. All patients were regularly followed at the Outpatients Department. Full clinical examination was performed at induction of therapy and at each clinic visit, and patients were monitored for signs of steroid toxicity. Parents were instructed to return immediately to UMTH in the event of any adverse reactions or intercurrent illness. In all cases, the mean age at onset of NS was 5.7 years (range 15 months to 13 years) with a male/female ratio of 3.2: 1. The estimated duration of recognized illness before treatment ranged from I to 4 weeks, with a mean of 3 (0.17) weeks. The treatment groups and outcomes are shown in Table 1. The mean (SD) duration of overall steroid administration was 7.2 (1.7) weeks (range 4-1 1 weeks). The relapse patients had a longer duration of remission (20.5 (1 0.43) months, range 5-33 months) compared with the new cases (1 7.1 (1 I .7) months, range 4-27 months). No complications of steroid therapy were encountered during a period from 2 months to 3 years. Clinical assessments did not idenfify-cushingoid features. Linear growth was preserved. Full follow-up, particularly for growth, is ongoing. As a result of this study, it might be reasonable to consider the use of high-dose prednisolone in the management of NS. Although we accede to the small number of patients, we have found that a mean (SD) dose of prednisolone of 98.14 (8.43) mg/24 h/m2 (range 90-120 mg/24 him2) in divided doses is effective for the induction of remission. In all 21 cases, no further relapses have been seen to date, over a mean follow-up time of 2.9 years. Thus, it seems that a “cure” is feasible. The response times compared favourably to those previously reported for daily divided-dose prednisolone (“standard-dose”) regimens for fresh onset NS (9.6