Treatment of nephrotic syndrome drugs

Treatment of nephrotic syndrome drugs

First, glucocorticoids (referred to as hormones)

Hormone therapy may play a role in diuresis and eliminate urinary protein by suppressing inflammatory reaction, suppressing immune reaction, inhibiting aldosterone and antidiuretic hormone secretion, affecting glomerular basement membrane permeability and so on. The use of principles are: ① start enough; ② slow drug; ③ long-term maintenance. Commonly used programs are prednisone 1mg / (kg · d), oral 8 weeks, if necessary, may be extended to 12 weeks; sufficient amount of 1 to 2 weeks after treatment by 10% of the original amount, when reduced to 20mg / d When the symptoms easy to repeat, should be more slowly reduction; finally to the minimum effective dose (10mg / d) as the maintenance dose, and then served six months to a year or longer. The use of hormones can be taken a day a Dayton service, or in the maintenance of medication during the next two days the amount of one-time Dayton clothing to reduce the adverse effects of hormones. Severe edema, liver dysfunction or poor efficacy of prednisone, can be replaced by prednisolone (equal dose) oral or intravenous infusion.
According to the clinical response of patients to glucocorticoids, divided into "hormone-sensitive" (medication within 8 weeks of nephrotic syndrome), "hormone-dependent" (hormone to a certain extent, that relapse) and "hormones Resistant "(steroid therapy ineffective) three categories, their respective further treatment measures are different. The use of high-dose hormone therapy, can quickly and completely inhibit the activity of some enzymes, and hormone-specific receptors to saturation in a short time to play the greatest effect of anti-inflammatory hormone; the other hand, high-dose hormone immunosuppression and Diuretic effect was also more obvious than the conventional dose. So it can be used to treat refractory nephrotic syndrome ineffective of conventional hormones, can alleviate some patients.
Long-term use of hormone patients prone to infection, drug-induced diabetes, osteoporosis and other adverse reactions, a few cases may also occur aseptic avascular necrosis of the femoral head, to strengthen monitoring and timely treatment.

Second, cytotoxic drugs
These drugs can be used in "hormone-dependent" or "hormone-resistant" patients, synergistic hormone therapy. If no hormonal contraindications, generally not as the first choice or a separate treatment.
① cyclophosphamide (CTX): is the most commonly used cytotoxic drugs in vivo by the liver cell microsomal hydroxylation, resulting in alkylation of metabolites and has a strong immunosuppressive effect. Application dose of 2mg per kilogram body weight per day, divided into 1 or 2 times orally; or 200mg by adding normal saline injection 20ml, the next day intravenous injection. Cumulative amount of 6 ~ 8g after withdrawal. The main adverse reactions for bone marrow suppression and toxic liver damage, and there may be gonadal suppression (especially men), hair loss, gastrointestinal reactions and hemorrhagic cystitis. Recently, cyclophosphamide (CTX) 0.5 ~ 0.75g / (m2 · times) intravenous treatment of relapsing nephrotic syndrome, similar to the role of oral, but the side effects are relatively small.
② nitrogen mustard: for the first for the treatment of nephrotic syndrome drugs, treatment is better. But because of strong local tissue stimulation, severe gastrointestinal reactions and strong bone marrow suppression, the clinical application of less. In other cytotoxic drugs ineffective, should still be recommended. This drug at bedtime from the intravenous infusion of the three through the first injection, before administration can be used sedative antiemetic, such as promethazine; Note continued to drop 5% glucose solution 100 ~ 200ml rinse blood vessels to prevent vein inflammation. Usually 1mg from the beginning, the next day injection of 1mg, each additional amount of 1mg, to 5mg 2 times a week after injection, the cumulative amount of 1.5 to 2.0mg per kilogram of body weight (80 ~ 100mg) after withdrawal.
③ Other: Chlorambucil 2mg, 3 times / d orally, taking a total of 3 months, less toxic than nitrogen mustard, the effect is also poor. In addition, azathioprine, vincristine and thiotepa has also been reported, but the effect is weak.
Third, cyclosporine
Can selectively inhibit T helper cells and T cytotoxic effector cells, has been used as a second-line drugs for the treatment of hormone and cytotoxic drugs refractory nephrotic syndrome. Commonly used amount of 5mg / (kg · d), two oral, medication and monitoring to maintain the blood concentration during the valley of 100 ~ 200ng / ml. Medication 2 to 3 months after the slow reduction, were served for six months or so. The main adverse reactions for liver and kidney toxicity, and can cause high blood pressure, hyperuricemia, hirsutism and gingival hyperplasia. The drug is expensive, more adverse reactions and easy to relapse after drug withdrawal, its application is limited.

Four, mycophenolate mofetil
Mycophenolate mofetil (MMF) pharmacological effects and azathioprine similar, but a high degree of selectivity, and bone marrow suppression and liver cell injury and other adverse reactions, early for anti-transplant rejection, the effect is good; clinical trials of the drug treatment Special types of lupus nephritis and systemic vasculitis, but also achieved significant results. However, mycophenolate mofetil (MMF) is expensive, with its treatment of refractory nephrotic syndrome, only a few uncontrolled clinical reports, the application of the future remains to be further studied. Mycophenolate mofetil (MMF) induced dose of 1 ~ 2g / d, continued treatment for 3 months after the reduction to 0.5g / d after maintenance treatment for 6 to 12 months.

Five, tacrolimus
FK506 treatment with cyclosporine (CsA) similar, but the role of renal toxicity than cyclosporine (CsA) of a new type of immunosuppressive drugs. The initial therapeutic dose was 0.1 mg / (kg · d) in adults and the blood concentration was maintained at 5 ~ 15ng / ml for 12 weeks. If the patient nephrotic syndrome remission, urine protein negative, the dose can be reduced to 0.08mg / (kg · d), and then continued treatment for 12 weeks. 6 months later reduced to 0.05mg / (kg · d) maintenance treatment.
The use of hormones, cytotoxic drugs and other new immunosuppressive drugs in the treatment of nephrotic syndrome can have a variety of programs, the principle is to enhance the efficacy at the same time, to minimize side effects. Recently, foreign scholars based on previous clinical studies concluded that the application of hormone therapy or not, the application of time and course of treatment should be combined with the patient's age, glomerular pathology, proteinuria and renal dysfunction and other conditions are different, And has introduced some new recommendations for treatment. China must be combined with their own experience to further practice and summarize.