The Newcastle upon Tyne Hospitals NHS Foundation Trust

Renal unit treatment protocol for

Treatment of minimal change GN
OR steroid sensitive nephrotic syndrome

Remember:
-All immunosuppressive protocols must be discussed with a consultant
nephrologist before starting
-Ask all patients if they have had chickenpox or TB before starting
immunosuppression. If they cannot remember having had chickenpox, send
blood to microbiology/virology for ZIG.
-You must check that female patients are not pregnant and are using effective
contraception before starting any immunosuppression or ACEI/ARB.

If renal biopsy report confirms minimal change GN:
Steroid therapy leads to complete remission in 80 to 95 percent of adults with
minimal change;
50 percent respond by four weeks
10 to 25 percent require more than three to four months of therapy.
50 to 75 percent of steroid -responsive adults will have a relapse
frequent relapses occur in 10 to 25 percent
Steroid-dependence is seen in 25 to 30 percent.
Most relapses occur within one year after steroid therapy has been tapered or
discontinued, although occasional patients have a much later relapse.
Relapses may be triggered by allergies or infection.

1. Commence steroid treatment:
Prescribe oral prednisolone, starting at 60 mg orally per day. Continue 60 mg
od until in remission with protein leak has reduced to trace or negative on
dipstix , plus improving serum albumin levels (maximum duration of 60mg od
is 8 weeks).
Once in remission - reduce prednisolone to 40 mg od for 2 weeks
then 30 mg od for 2 weeks
then 20 mg od.
then reduce more slowly, by 5 mg every month, to zero over 3 to 4
months.
2. Give PPI as - lansoprazole 30mg to all patients
3. Add bisphosphonate, Alendronate 70 mg weekly, for all patients except
women planning a future pregnancy.
4. Anticoagulate with warfarin if albumin is less than 20 g/l.
5. Add aspirin 75 mg od if albumin >20 g/l
5. Treatment of hypercholesterolaemia is not necessary initially, as this will
usually resolve once proteinuria resolves; review cholesterol level once in
remission.

2. If steroid avoidance is necessary (e.g. for obese or diabetic patients)
discuss risks and benefits with patient;
prescribe oral cyclophosphamide for a total course of 12 weeks.
Start with cyclophosphamide dose of 1 mg/kg, plus cotrimoxazole 480 mg od.
August 2008 Page 1 of 2 Review Date: August 2011
August 2008 Page 2 of 2 Review Date: August 2011
If tolerated (check WCC >4) increase cyclophosphamide to 1.5 mg/kg then 2
mg/kg.
Check WCC weekly for the first month, then every 2 weeks thereafter.

3. If steroids do not give a complete remission after 16 weeks of adequate
dose treatment (steroid-insensitive nephrotic syndrome)
OR if nephrotic syndrome relapses when steroid dose is reduced (steroid-
dependent nephrotic syndrome):

Increase prednisolone dose again to 60 mg od and add a second
immunosuppressive agent which must be discussed with a consultant
nephrologist who will decide which agent to add, in the following order:
1. Neoral (ciclosporin A) 5 mg/kg in two daily divided doses targeting a
trough level of 50-100. If no response after 4 months, discontinue.
If remission is obtained, continue for 18m before trying to withdraw,
OR tacrolimus 0.1 mg/kg in two divided doses targeting a trough level of
4-8,
OR MMF starting at 500 mg BD and increasing to 1 g bd,
OR cyclophosphamide 1 to 2 mg/kg for 12 weeks.

2. Consider continuing long term low dose steroids - prednisolone 15mg
alt days - for steroid-dependent patients.
3. Consider neoral (or tacro) PLUS MMF PLUS low dose steroids for
frequent relapsers.
4. Consider rituximab (2 xIV doses of 1g 14 days apart, see separate
protocol) for frequent relapsers who do not respond to any of the
above.

Once back in remission, try again to reduce steroids to 5mg od or 10 mg alt
days, and try to reduce second immunosuppressive agent to a minimum after
6 months in remission. Continue CyA or tacrolimus for 18m before trying to
withdraw.


A.L.Brown
August 2008