Letter to the Editor NEPHRON Nephron 1996:72:332 Yunus Erdem Ahmet Ugur Yalçm Ciclosporin A in Lupus Nephritis Oktay Oymak Ünal Yasavul Çetin Turgan §ali Çaglar Nephrology Department, Hacettepe University School of Medicine. Ankara. T urkey Dear Sir. Renal involvement is the major cause of morbidity and mortality in patients with sys temic lupus erythematosus (SLE) despite im- munosupressive therapy since up to 60-70% of patients with lupus nephritis progress to end-stage renal disease [1], The most widely used therapeutic regimens include steroid plus azathioprine or cyclophosphamide [2]. The activation of disease under immunosup pressive therapy poses a great problem. Cer tain clinical approaches had been proposed to improve the survival. Plasmapheresis seems to be ineffective and did not improve the prognosis of patients under standard im munosuppressive treatment [3]. Ciclosporin A (CSA; Sandimmun®, Sandoz), by inhib iting interleukin-2 production, suppresses the helper T cells and has been shown to reduce anti-DNA production in an experi mental animal model of SLE [4], Ten patients (3 male, 7 female, mean age 29.5 ± 10.01 years, range 19-50) showing serologic or clinical activation of SLE under the immunosuppressive treatment with prednisolone and azathioprine were enrolled in the study. Patients with uncontrolled hy pertension and a serum creatinine level above 2 mg/dl were excluded. All patients fulfilled 4 or more of the American Rheuma tism Association revised criteria. In 2 pa tients, renal biopsy was performed showing diffuse proliferative nephritis. Daily protein excretion was above 0.5 g in all patients. CSA (3-5 mg/kg/day) divided into 2 doses, was added to treatment of patients and dos age was then adjusted according to serum CSA levels. The mean follow-up duration before and after CSA was 49 and 29 months, respectively. Each patient was followed regu larly and at each visit blood pressure, serum creatinine. AST, ALT. 24-hour urinary pro tein excretion along with ANA and anti- DNA were recorded. An informed consent was obtained from all patients. In 5 patients, marked clinical and sero logic improvements were seen and contin ued to the end of the study. One patient died because of CNS involvement, and another was initiated to a chronic hemodialysis pro gram. In the remaining 3 patients clinical or serologic activation persisted. Hypertension was observed in 3 of 10 patients and con trolled with antihypertensive therapy. Mean anti-DNA titers of patients were significant ly decreased at the end of study (from 87.2 ± 9.8 to 49.6 ± 16.7 lU/ml. p < 0.05). There were no significant changes in proteinuria and serum creatinine levels. Although there were some encouraging results, there was no controlled trial with CSA as a treatment of lupus nephritis. Ef fects of CSA in SLE were evaluated in some uncontrolled trials and anecdotal reports [5- 7]. Favre et al. [8] showed decrement in pro teinuria and clinical improvement in 26 pa tients. No change in anti-DNA production was reported. We observed decrement in the anti-DNA titers and clinical improvement in 5 of 10 patients showing clinical or serologic activation of disease. Controlled trials are needed to clarify the role of CSA in the treat ment of lupus nephritis. References 1 ("heigh .IS. Stcnzel KH: End-stage renal disease in systemic lupus erythematosus. Am J Kidney Dis 1993;21:2-8. 2 Dor.adio JV, Glassock RJ: Immunosuppres sive drag therapy in lupus nephritis. Am.I Kid ney Dis 1993:21:239-250. 3 Lewis EJ. Hunsicker LG. Lan SP. Rohde RD. Lachin JM: A controlled trial of plasmaphere sis therapy in severe lupus nephritis. N Engl J M 1992:326:1373-1379. 4 Israel-Biet D. Noël LH, Bach MA. Dardenne M. Bach JF: Marked reduction of DNA anti body production and glomerulopathy in thy- mulin (FTS-Zn) or ciclosporine A treated (NZB x NZWjFi mice. Clin Exp Immunol 1983:54: 359-365. 5 Feuiren G, Querin S, Noël LH. Chatenoud L. Beaurain G, Tron F. Lesavre P. Bach JF: Ef fects of cyclosporine A in severe systemic lupus erythematosus. J Pediatr 1987:111:1063— 1068. 6 Enriquez R, Tovar JV. Amoros F, Cabezuelo JB. Gonzalez C: Can ciclosporin A be used without steroids in systemic lupus erythemato- sus?Ncphron 1991:57:367-368. 7 Hussein MM, Mooij JMV, Roujouleh H: Cy closporine in the treatment of lupus nephritis including two patients treated during pregnan cy. Clin Nephrol 1993:40:160-163. 8 Favre H. Miescher PA, Huang YP, Chatelanat F. Mihatsch MJ: Ciclosporin in the treatment of lupus nephritis. Am J Nephrol 1989:9(suppl 1 ):57—60. KARGER. E-Mail karger@karger.ch Fax +41 61 306 12 34 c 1996 S. Karger AG, Basel 0028-2766/96/0722-0332S8.00/0 Dr. Yunus Erdem Hacettepe Tip Fakiiltesi Nefroloji Bölümü Hacettepe TR-06100 Ankara ( Turkey)