Focal segmental glomerulosclerosis--does treatment work?

This study also confirms that the mean time to remission in treated FSGS patients can be as long as 5 months and that treatment should continue beyond that time. It reports a relapse rate of 20% and a spontaneous remission rate of 30.7%. Recent studies have also demonstrated higher spontaneous remission rates than those previously [7] , particularly in comparison with American series. The higher spontaneous remission rate in Europe may reflect different disease aetiology, but this could also be due to better blood pressure control or increased use of ACE inhibitors or angiotensin receptor blockers (ARBs). There is evidence that ARBs can reduce proteinuria in patients with FSGS resistant to immunosuppressive treatment [9]. The presence of persistent nephrotic range proteinuria is a consistent indicator of a poor prognosis in FSGS, as it is in other glomerular diseases [10]. Achievement of remission has been shown to be an important prognostic marker [7, 11]. Studies report 94% 5-year renal survival rates in patients who achieve remission, compared with 53% 5-year survival rates in patients who do not achieve remission. The Toronto Registry Group also showed in their study that achieving and maintaining partial remission confers long-term benefit. However, there is a relative paucity of randomised control trial evidence in FSGS to guide treatment decisions and many nephrologists appear reluctant to recommend a prolonged course of imFocal segmental glomerulosclerosis (FSGS) is a common cause of adult nephrotic syndrome, accounting for between 10 and 35% of adult cases [1, 2]. Historically, the prognosis of untreated nephrotic patients is poor, with 50% developing end-stage renal failure within 8 years [3, 4]. Treatment with prednisolone for 4–8 weeks had a marginal effect on outcomes. Recent studies have shown that high dose prednisolone for longer periods of 4–5 months improved response rates from 15 to 67% [5–7]. However, in current clinical practice, 40–50% of patients with FSGS and nephrotic range proteinuria are not treated with immunosuppression [7]. The report by Goumenos et al. [8] in this edition of Nephron Clinical Practice adds to the evidence that treatment with immunosuppression can lead to remission of nephrotic range proteinuria in patients with FSGS. Despite its limitations as a retrospective study with a small patient population, it has 5-year follow-up data and reports remission rates of 75%. It also demonstrates that treatment using a combination of lower dose prednisolone and azathioprine or cyclosporine may be an effective alternative to high dose prednisolone alone, particularly in patients in whom avoidance of high dose prednisolone is preferable (those with diabetes, obesity or osteoporosis). Their remission rates are amongst the best recorded in the literature, although we must bear in mind that the numbers in this study are small. Published online: June 19, 2006