MON-034 A case of frequent relapse minimal change nephrotic syndrome with steroid-induced psychiatric syndromes treated by a low-dose and short-term steroid therapy in combination with cyclosporine

Abstract

Oral prednisolone (PSL) alone in an initial dosage of 1.0 mg/kg/day is generally administered for a minimum of 4 weeks in adult patients with minimal change nephrotic syndrome (MCNS), and 80% of patients with MCNS achieve clinical remission. However, relapses frequently occur in manyMCNS patients,rendering repeathigh-dosePSLtreatment necessary. Long-term treatment with high-dose steroids increasesthe risk of steroid toxicity, such as diabetes mellitus, gastric complications, infections, osteoporosis, and steroid-induced psychiatric syndrome, which may compromise the patient’s quality of life. Therefore, useful strategies are necessary to reduce the dosage and duration of steroid therapy for frequent relapse MCNS (FRNS) troubled by steroid toxicity.Here we suggest a new combination therapy of low-dose and short-term steroid with cyclosporine (CyA). A 51-year-old man with FRNS with a history of recurrent steroid-induced psychiatric syndrome was admitted to our department in April 2018. Immunosuppressive therapy with both PSL and CyA (initial dose0.3 mg/kg/day and 1.5 mg/kg/day, respectively)was started. Complete remission was obtained just 2 weeks later;the dose of PSL was promptly reduced and tapered. Clinical course and Results A 51-year-old man was admitted to our hospital for biopsy-proven recurrence of FRNS. MCNS initially occurred at the age of 15, and he was basically treated withPSL(initial dosage 1.0 mg/kg/day at onset and at relapses). The steroid therapy had finished at the age of 42, after which complete remission was maintained. At the age of 16 he had developed steroid-induced depression ;hispsychiatric symptoms were maintained in stable condition with psychiatrist visits andfluvoxamine maleate acid (300 mg/day). After admission we started an immunosuppressive therapy with PSL in combination with CyA (initial dosage of 0.3 mg/kg/day and 1.5 mg/kg/day, respectively), based on his history of depression and in attempt to reduce the dosage and duration of steroid therapy. Complete remission was obtained after 2 weeks of treatment, but steroid-induced psychiatric syndrome recurred the day after remission. Thus, we promptly reduced the dosage of PSL (weekly by 2.5-5 mg/day), which rapidly improvedpsychiatric syndrome. The dosage of PSL was 5 mg/day at 5 weeks after the start of treatment, and complete remission wasmaintained without relapse of MCNS. We successfully treated a recurrent case of FRNS with steroid-induced psychiatric syndrome by alow-dose,short-term steroid therapy andCyA, which induced early complete remission,allowed promptPSL dose reductionwithout relapse,and quickly resolved psychiatric symptoms. This treatment protocol is very useful and can be a future treatment strategy for FRNS with steroid-induced psychiatric syndrome.