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The treatment of steroid sensitive nephrotic syndrome U D Mahamithawa1 Sri Lanka Journal of Child Health, 2002; 31: 60-2 (Key words: steroid sensitive nephrotic syndrome, SSNS, treatment)
Due to an oversight, a part of the above article was
omitted from the last issue of the journal. We are now
Children with frequent relapses usually remain
Frequently relapsing and steroid dependent MCNS
There are no randomized controlled trials
These children are difficult to treat and develop steroid
comparing repeated courses of standard relapse
toxicity. The first step in management is to identify
therapy with long term low dose alternate day
frequent relapsers and steroid dependence accurately, using the definitions given. This requires the
prednisolone therapy for frequent relapses.
paediatrician to spend time evaluating the course of the
disease and the treatment given throughout. The
definitions are applicable only if standard relapse
treatment has been used in the preceding relapses.
cyclosporin or levamisole substantially reduce
Cyclosporin and levamisole effectively induce
The relative efficacy of levamisole is not known. In the
remission, but are unable to sustain this effect
University Paediatric unit, at the Lady Ridgeway
Hospital for Children, we have been using this drug
since 1993. A 10 year review of 110 children with
There is insufficient data at present to show that
SSNS followed up by us showed that levamisole was
alkylating agents are more effective than
able to induce remissions lasting 2 years or longer and
cyclosporin or levamisole in reducing the
there was no statistically significant difference in
efficacy when compared with cyclophosphamide14.
However, it appears as though levamisole is more effective in the milder forms of the disease. We have not
encountered any serious side effects with this drug to
Treatment protocol for children with SSNS
This protocol is a modified version of the guidelines
set out by the British Association for Paediatric
This drug is nephrotoxic and therefore can be used only
if facilities are available to monitor drug levels very
regularly. The Medical Research Institute has recently
commenced assessing blood levels of cyclosporin, but
this is done only on 2 specified days of the week. The
very high cost of the drug and the problems of assessing
blood levels regularly makes it difficult for us, in Sri
1Senior Lecturer in Paediatrics, Faculty of Medicine,
Maintenance Prednisolone 0.1-0.5mg/kg/EOD for 6 months Slow withdrawal over another 6 months
prednisolone therapy for initial treatment of
minimal change nephrotic syndrome. Paediatr
idiopathic nephrotic syndrome in children.
2. Shaloup R J. Pathogenesis of lipoid nephrosis:
11. Hodson E M, Knight J F, Willis N S, Craig J
a disorder of T-cell function. Lancet 1975; II:
controlled trials. Arch Dis Child 2000; 83: 45-
12. International study of Kidney Diseases in
Children. Nephrotic syndrome in children.
Nephrology, Alternate day versus intermittent
Randomized trial comparing 2 prednisolone
prednisolone in frequently relapsing nephrotic
regimes in steroid responsive patients who
relapse early, J. Pediatri 1979; 95: 239 -43.
5. Ueda N, Chihara M, Kamaguchi S, Niinomi Y,
13. Durkan A M, Hodson E M, Willis N S, Craig J
Nonoda T, et al. Intermittent versus long term
C. Immunosuppressive agents in childhood
tapering prednisolone for initial therapy in
children with idopathic nephrotic syndrome. J.
randomized controlled trials. Kidney Int. 2001;
6. Ksiazek J, WyszyNska T. Short versus long
initial prednisolone treatment in steroid
14. Mahamithawa U D, Hubert H D N, Bahirathan
sensitive nephrotic syndrome in children. Acta
S. Use of alternative treatment in SSNS - A ten
International Congress of Tropical Pediatrics
7. Ehrich J H H, Brodehl J. Arbeitsge meinschaft
far Paeuaa-trusche Nephrologie, Long versus
standard pred nisolone therapy for initial
treatment of idiopathic nephrotic syndrome in
Association for Paediatric Nephrology and
children. Eur J. Pediatr. 1993; 152: 357-61.
Research Unit, Royal College of Physicians.
Consensus statement on management and audit
8. Ekka B K, Bagga A, Srivastava R N, Single
potential for steroid reponsive nephrotic
versus divided dose prednisolone therapy for
syndrome. Arch Dis.Child 1994; 70: 151-7.
relapses of nephrotic syndrome. Paediatr.
9. International Study of Kidney Diseases in
Children, Early identification of frequent relapsers among children with MCNS. J. Paediatr. 1982; 101: 514-8.
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O Conselho do Governo, reunido no dia 26 de março de 2013, na Calheta, no âmbito da visita estatutária à ilha de São Jorge, tomou as seguintes deliberações: 1. Aprovar a atribuição de um apoio financeiro à Câmara Municipal da Calheta correspondente à componente não comparticipada por fundos comunitários das obras de reabilitação da rede viária municipal do concelho afetada pelas