Levamisole and Mycophenolate Mofetil Significantly Reduce the Relapses Following Cyclosporine a Withdrawal in Steroid Dependent Nephrotic Syndrome

Author(s): Abeyagunawardena S, De Silva ESK, Abeyagunawardena AS

Introduction: Nephrotic syndrome (NS) is the commonest glomerular disorder in childhood. Cyclosporine-A (CsA) has been used widely for children around puberty with moderate to severe steroid dependency. As long term CsA is potentially nephrotoxic, continuing CsA beyond 5 years is not recommended. This retrospective study was conducted to evaluate the outcome of different strategies when withdrawing CsA in patients after 5 years of therapy.

Method: The study was carried out in a tertiary care facility which conducts 2 dedicated outpatient clinics for children with NS where CsA was used since 2003. Patients who have completed 5 years of therapy between 2007 to 2017 were considered for analysis. Patients who had a stable disease activity after commencing CsA, the drug was withdrawn and was kept under surveillance with no further treatment. The patients who had more severe disease were commenced on either levamisole (LV) or mycophenolatemofetil (MMF). The number of patients who relapsed within one year after withdrawal of CsA was compared.

Results: LV and MMF treated groups maintained a sustained remission rate of 80.6% and 82.6% respectively, following CsA withdrawal at one year compared to 51.9% with no treatment group. LV had lowered relapses by 2.49 times than the no treatment group (RR= 2.488, P= 0.020, CI 95%) and MMF had reduced relapses by 2.77 times than the no treatment group (RR=2.769, P= 0.022, CI 95%).

Conclusion: This retrospective study demonstrates a clear benefit of administering either LV or MMF when withdrawing long term CsA therapy in patients with NS.