Role of cyclosporine in glomerular diseases

BACKGROUND Clinical researchers are beginning to use the immunosuppressive agent cyclosporine to treat a variety of immunologically mediated diseases.

PURPOSE To review the clinical experience with cyclosporine in the nephrotic syndrome and in lupus nephritis.

SUMMARY Most studies to date have been small or uncontrolled, or both. Nevertheless, cyclosporine appears to produce remissions in adults and children with the nephrotic syndrome with minimal histologic changes ("minimal-change disease"). It also appears to produce remissions in children with focal and segmental glomerulosclerosis; it is less effective in adults and in individuals with focal and segmental glomerulosclerosis that is resistant to steroids. It appears to reduce proteinuria and to slow the progression of renal insufficiency in membranous glomerulonephritis but has little beneficial effect in IgA nephropathy. Anecdotal experience in patients with lupus nephritis suggests cyclosporine produces an improvement in symptoms, a decrease in protein excretion, and improvement in renal function when other treatments have failed. Cyclosporine's pharmacokinetic properties vary widely with the age of the patient and the presence of concomitant diseases and drugs. Relapses are common after the drug is stopped, and nephrotoxicity is a real risk with prolonged treatment.

CONCLUSIONS Cyclosporine shows promise in treating immunologically mediated glomerular diseases, but larger randomized studies will be needed to define its role in this setting. Physicians should become more familiar with this drug as its indications increase.