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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Focal segmental glomerulosclerosis &#40;FSGS&#41; is defined as an increase in the mesangial matrix in some glomeruli with obliteration of capillary lumens&#44; sclerosis&#44; hyalinosis&#44; foam cells&#44; and adhesions to the Bowman&#8217;s capsule&#46; The damage is non-specific&#44; and several different causes have been described&#46; As such&#44; it is essential to distinguish between idiopathic and secondary forms of the disease &#40;Table 1&#41;&#44; since their pathogenesis&#44; prognosis&#44; and treatment are very different&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Fortunately&#44; FSGS is an uncommon disease that is found only in 9&#37; of all kidney biopsies in our country&#44; with stable rates in recent years&#46; However&#44; it is the third-leading cause of nephrotic syndrome&#44; preceded only by membranous nephropathy and minimal change nephropathy&#46;<span class="elsevierStyleSup">2</span> Here&#44; we will only be referring to idiopathic FSGS that presents with nephrotic syndrome&#44; since this is a major challenge for the attending physician given the knowledge gaps regarding its pathogenesis&#46; As with other glomerular diseases&#44; its treatment must be based on the best evidence available through controlled clinical trials&#46; However&#44; few studies have been performed to resolve the current problems with treatment&#44; and many of them are of poor quality&#44; as reported by Quereda and Ballar&#237;n in an excellent systematic review published in <span class="elsevierStyleItalic">Nefrolog&#237;a</span> in 2007&#46;<span class="elsevierStyleSup">3</span> Their conclusions have not lost their relevance and coincide with the recommendations soon to be published in the KDIGO guidelines for the treatment of glomerulonephritis&#46; FSGS is no exception to this rule of low number and quality of clinical trials studying glomerular diseases&#44; with even lower representation than lupus nephritis and membranous nephropathy&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">INITIAL TREATMENT</span></p><p class="elsevierStylePara">Patients with idiopathic FSGS that do not develop a nephrotic syndrome&#44; as well as those with secondary FSGS&#44; do not receive immunosuppressive treatment &#40;recommendation 1C&#44; GRADE system&#41;&#46; In these cases&#44; the standard treatment consists of&#58; <span class="elsevierStyleItalic">1&#41;</span> maintain blood pressure below 130&#47;80mm Hg&#59; <span class="elsevierStyleItalic">2&#41;</span> administer angiotensin-converting enzyme &#40;ACE&#41; inhibitors&#44; angiotensin II receptor antagonists&#44; or both&#59; <span class="elsevierStyleItalic">3&#41;</span> administer statins&#59; <span class="elsevierStyleItalic">4&#41;</span> administer antiplatelet or anticoagulation therapy&#59; and <span class="elsevierStyleItalic">5&#41;</span> diet for renal protection&#46;<span class="elsevierStyleSup">5</span> The initial treatment is based on a prednisone cycle &#40;1mg&#47;kg&#47;day&#44; maximum of 80mg&#47;day or 2mg&#47;kg&#47;day on alternate days&#44; maximum of 120 mg&#41;&#44; which should be maintained for 16 weeks before the condition is declared corticosteroid-resistant&#46;<span class="elsevierStyleSup">6</span> Treatment with prednisone can cause remission of the disease in 60&#37;-70&#37; of patients&#44; according to the studies&#46; These responses depend on the intensity of the initial proteinuria&#44; the tubular&#47;interstitial lesions&#44; and the baseline creatinine level&#44; although it is not possible <span class="elsevierStyleItalic">a priori </span>to separate the patients that will respond to corticosteroid treatment from those that will not&#46; As a rule&#44; this should not be combined with treatment using other immunosuppressive drugs&#44; unless there is a risk of toxicity or intolerance to steroids &#40;obesity&#44; osteoporosis&#44; diabetes&#44; advanced age&#44; or psychiatric imbalances&#41;&#46; If they were to be used&#44; calcineurin inhibitors are recommended &#40;suggestion 2D&#41;&#44; as will be indicated later when discussing corticosteroid-resistant forms of the disease&#46;<span class="elsevierStyleSup">3 </span>Partial or complete remission of proteinuria has been associated with a good prognosis&#44; and it is the most indicative marker of patient evolution&#44; even more than clinical and histological results&#46;<span class="elsevierStyleSup">7</span> Approximately 30&#37;-40&#37; of patients are corticosteroid-resistant&#44; presenting problems for developing a treatment plan&#44; since resistance to corticosteroids is the strongest predictor for the development of chronic kidney disease&#58; 35&#37; at 5 years and 70&#37; at 10 years&#46; As such&#44; the current conundrum is&#58; how can we treat idiopathic FSGS that has not responded to steroids or is corticosteroid-dependent&#63; Can we modify the patient evolution towards kidney failure&#63; Here&#44; we will go through the different treatments recommended in corticosteroid-resistant FSGS according to the evidence published on the subject &#40;Table 2&#41;&#46; Obviously&#44; each case should be analysed individually&#44; and treated according to the personal opinion and experience of the physicians that directly attend to each patient&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CALCINEURIN INHIBITORS</span></p><p class="elsevierStylePara">Cyclosporin A &#40;CsA&#41; is the best documented method of treatment in controlled trials and observational studies&#46;<span class="elsevierStyleSup">3&#44;8</span> The recommended dose is 2-5mg&#47;kg&#47;day administered in two doses &#40;with levels of 125-175ng&#47;ml&#41; during a minimum of 6 months&#46; If at the end of this time there is no response&#44; treatment must be suspended and the patient should be considered resistant to CsA&#46; In the case of a partial or complete response&#44; which appears in 60&#37;-70&#37; of cases&#44;<span class="elsevierStyleSup">9&#44;10</span> treatment should be maintained for at least 12 months&#44; and can then be progressively reduced by 25&#37; every 2 months&#46; Approximately half of all patients that initially respond to CsA develop resistance eventually&#46; Fewer studies exist regarding the use of tacrolimus in the treatment of corticosteroid-resistant FSGS&#44; but Segarra et al<span class="elsevierStyleSup">11</span> obtained positive results from using tacrolimus &#40;0&#46;15mg&#47;kg&#47;day&#59; levels of 5-10ng&#47;l&#41; and low-dose steroids &#40;0&#46;15mg&#47;kg&#47;day&#41; in 25 patients with previous resistance to steroids and CsA&#46; Therefore&#44; its use in patients that have not responded to CsA is an attractive treatment option that deserves a try before moving on to other alternatives&#46; Even so&#44; treatment with calcineurin inhibitors creates other problems&#58; nephrotoxicity and recurrence after treatment suspension&#46; The first condition can be avoided by using the minimum possible dose&#44; monitoring patient levels&#44; and by performing a kidney biopsy in order to evaluate vascular and interstitial damage&#46; Recurrence is very common after reducing the dosage or suspending treatment with this drug&#44; reaching even 70&#37; in some studies&#46; A study&#44; sponsored by the GLOSEN &#40;glomerulonephritis study group of the Spanish Society of Nephrology&#41;&#44; has been recently performed on 5 patients&#44; who were administered calcineurin inhibitors as an induction therapy&#44; followed by rituximab once remission was established&#44; with no positive results in avoiding recurrence after treatment suspension&#46;<span class="elsevierStyleSup">12</span> Recurrence is still an unresolved problem that requires more in-depth<span class="elsevierStyleBold"> </span>studies&#46; On the other hand&#44; given that approximately 30&#37; of cases do not respond to calcineurin inhibitors&#44; other treatments have also been tested&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MYCOPHENOLATE MOFETIL</span></p><p class="elsevierStylePara">Experience with this drug is scarce&#44;<span class="elsevierStyleSup">6</span> with an approximately 44&#37; of cases showing a partial response&#44; but half of these patients suffer a recurrence when medication is suspended&#46;<span class="elsevierStyleSup">7</span> This is an option when other immunosuppressive drugs cannot be administered&#44; or when steroid dosage must be decreased &#40;suggestion 2C&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RITUXIMAB</span></p><p class="elsevierStylePara">In a recent study that was also sponsored by GLOSEN&#44;<span class="elsevierStyleSup">13</span> involving 8 patients with FSGS resistant to other drug treatments&#44; rituximab had a positive effect in only 3 cases&#44; making it an unattractive alternative&#44; at least as a monotherapy&#46; Therefore&#44; controlled studies are needed&#44;<span class="elsevierStyleSup">8</span> but it still can provide an alternative when nephrotoxicity develops due to the administration of calcineurin inhibitors&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ALKYLATING AGENTS</span></p><p class="elsevierStylePara">Some experience has been gained in the administration of cyclophosphamide and chlorambucil&#44; as they were used before the advent of calcineurin inhibitors&#46; However&#44; they only produce a complete response in 20&#37; of cases&#44; and a partial response in 45&#37;&#46; These results&#44; along with the adverse effects &#40;infections&#44; tumours&#44; leukopenia&#44; infertility&#41;&#44; have severely reduced the role of these drugs&#44;<span class="elsevierStyleSup">9</span> with insufficient evidence to support their use&#46;<span class="elsevierStyleSup">6&#44;15&#44;16</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">COMBINED TREATMENTS</span></p><p class="elsevierStylePara">Given the limitations presented by the previous drug treatments&#44; some authors have incorporated the concept of synergistic effects of immunosuppressive drugs &#40;taken from the experience gained in transplantations&#41; into the treatment of glomerular diseases&#46; In this issue of <span class="elsevierStyleItalic">Nefrolog&#237;a</span>&#44; Segarra et al<span class="elsevierStyleSup">17</span> have published on their experience in treating primary FSGS in 27 adult patients with previously failed treatment plans using steroids and CsA&#44; combining CsA &#40;4mg&#47;kg&#47;day&#41; with mycophenolate mofetil &#40;2000mg&#47;day&#41; for 12 months&#46; This was an observational study with no controls&#44; and it produced disappointing results&#46; None of the patients in this study reached complete remission of the disease&#44; and only one fourth partial remission&#46; Additionally&#44; the glomerular filtration rate was significantly reduced in all patients&#44; and 59&#37; of cases developed uraemia at the end of the 5-year follow-up period&#44; which is a similar result to that achieved by treating patients symptomatically&#46; Lastly&#44; the authors used a multivariate analysis to show that initial glomerular filtration rates and mean proteinuria during the follow-up period were correlated with renal impairment&#46; El-Reshaid et al<span class="elsevierStyleSup">18</span> had already tested a similar combined treatment&#44; with somewhat better results&#44; but in patients without previous failure of CsA treatment&#46; The role that this three-part association may play in the treatment of idiopathic FSGS resistant to steroids and CsA is still unclear&#46; Although the authors did not perform a genetic analysis&#44; it is quite probable that the hereditary forms of the disease were not present in the study&#44; since the necessary genetic mutations &#40;NPHS1&#44; NPHS2&#44; alpha-actinin-4&#44; CD2P&#44; TRPC-6 and others&#41; are very rare in adults&#46;<span class="elsevierStyleSup">19</span> With these results&#44; the triple therapy using steroids&#44; CsA&#44; and mycophenolate mofetil appears not to decrease proteinuria or slow the development of kidney disease&#46;</p><p class="elsevierStylePara">Although the treatment of corticosteroid-resistant idiopathic FSGS is still an unresolved issue&#44; we must not be pessimistic&#46; Several different clinical trials have been initiated<span class="elsevierStyleSup">20&#44;21</span> that may help to improve the current results&#46; As the KDIGO guidelines will state&#44; more controlled clinical trials are needed to compare the efficacy of calcineurin inhibitors&#44; mycophenolate mofetil&#44; rituximab&#44; and alkylating agents in treating corticosteroid-resistant FSGS&#46; Lastly&#44; we must re-evaluate the use of our current arsenal of immunosuppressive drugs&#44; whose mechanisms of action are still unknown and are mostly empirical&#46;<span class="elsevierStyleSup">22</span> According to a recent review by Meyrier&#44;<span class="elsevierStyleSup">23</span> the factor or factors that lead to an increase in capillary permeability must be identified in order to treat these patients accordingly&#46;</p><p class="elsevierStylePara">In conclusion&#44; the treatment of idiopathic FSGS patients with nephrotic syndrome is still unresolved&#44; and clinicians are faced with a challenge in producing some type of response in the patient and slowing or halting the evolution towards kidney failure&#46; In spite of the negative results obtained by the excellent study by Segarra et al&#44;<span class="elsevierStyleSup">17</span> which inspired this &#8220;Editorial Comment&#44;&#8221; we must continue to research ways to improve the current unsatisfactory results&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara">1&#46; FSGS is a non-specific glomerular lesion that is classified as idiopathic &#40;primary&#41; or secondary&#46;</p><p class="elsevierStylePara">2&#46; Patients with idiopathic FSGS that do not develop nephrotic syndrome and cases of secondary FSGS should not be treated using steroids or immunosuppressive drugs&#46;</p><p class="elsevierStylePara">3&#46; Idiopathic FSGS patients with nephrotic syndrome should be initially treated with a cycle of steroids &#40;or steroids and CsA in the case of intolerance to high levels of steroids&#41; for a minimum of 4 weeks and a maximum of 16 weeks&#46;</p><p class="elsevierStylePara">4&#46; Patients with corticosteroid-resistant FSGS should be treated using CsA and low doses of steroids for at least 6 months&#44; monitoring blood levels and nephrotoxicity&#46; Patients that do not respond to treatment can benefit from the administration of tacrolimus&#46;</p><p class="elsevierStylePara">5&#46; Mycophenolate mofetil and rituximab can be effective alternatives in the case of resistance to CsA&#44; although little evidence exists&#46;</p><p class="elsevierStylePara">6&#46; Alkylating agents &#40;cyclophosphamide and chlorambucil&#41; are only barely indicated and their use is not recommended&#44; except for in very severe cases of dependence on corticosteroids&#46;</p><p class="elsevierStylePara">7&#46; Until now&#44; combined treatments have not produced any positive results&#46;</p><p class="elsevierStylePara">8&#46; New treatments are needed based on controlled clinical trials that can induce a response in proteinuria and avoid the evolution of the disease towards kidney failure&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10940&#95;108&#95;17294&#95;en&#95;t110940&#46;jpg" class="elsevierStyleCrossRefs"><img src="10940_108_17294_en_t110940.jpg" alt="Causes of focal segmental glomerulosclerosis"></img></a></p><p class="elsevierStylePara">Table 1&#46; Causes of focal segmental glomerulosclerosis</p><p class="elsevierStylePara"><a href="grande&#47;10940&#95;108&#95;17295&#95;en&#95;t210940&#46;jpg" class="elsevierStyleCrossRefs"><img src="10940_108_17295_en_t210940.jpg" alt="Treatments for idiopathic focal segmental glomerulosclerosis patients with nephrotic syndrome"></img></a></p><p class="elsevierStylePara">Table 2&#46; Treatments for idiopathic focal segmental glomerulosclerosis patients with nephrotic syndrome</p>"
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How to Treat Corticosteroid-Resistant Idiopathic Focal Segmental Glomerulosclerosis?
¿Cómo tratar la glomeruloesclerosis focal y segmentaria idiopática corticorresistente?
F.. Rivera Hernándeza
a Sección de Nefrología, Hospital General de Ciudad Real,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Focal segmental glomerulosclerosis &#40;FSGS&#41; is defined as an increase in the mesangial matrix in some glomeruli with obliteration of capillary lumens&#44; sclerosis&#44; hyalinosis&#44; foam cells&#44; and adhesions to the Bowman&#8217;s capsule&#46; The damage is non-specific&#44; and several different causes have been described&#46; As such&#44; it is essential to distinguish between idiopathic and secondary forms of the disease &#40;Table 1&#41;&#44; since their pathogenesis&#44; prognosis&#44; and treatment are very different&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Fortunately&#44; FSGS is an uncommon disease that is found only in 9&#37; of all kidney biopsies in our country&#44; with stable rates in recent years&#46; However&#44; it is the third-leading cause of nephrotic syndrome&#44; preceded only by membranous nephropathy and minimal change nephropathy&#46;<span class="elsevierStyleSup">2</span> Here&#44; we will only be referring to idiopathic FSGS that presents with nephrotic syndrome&#44; since this is a major challenge for the attending physician given the knowledge gaps regarding its pathogenesis&#46; As with other glomerular diseases&#44; its treatment must be based on the best evidence available through controlled clinical trials&#46; However&#44; few studies have been performed to resolve the current problems with treatment&#44; and many of them are of poor quality&#44; as reported by Quereda and Ballar&#237;n in an excellent systematic review published in <span class="elsevierStyleItalic">Nefrolog&#237;a</span> in 2007&#46;<span class="elsevierStyleSup">3</span> Their conclusions have not lost their relevance and coincide with the recommendations soon to be published in the KDIGO guidelines for the treatment of glomerulonephritis&#46; FSGS is no exception to this rule of low number and quality of clinical trials studying glomerular diseases&#44; with even lower representation than lupus nephritis and membranous nephropathy&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">INITIAL TREATMENT</span></p><p class="elsevierStylePara">Patients with idiopathic FSGS that do not develop a nephrotic syndrome&#44; as well as those with secondary FSGS&#44; do not receive immunosuppressive treatment &#40;recommendation 1C&#44; GRADE system&#41;&#46; In these cases&#44; the standard treatment consists of&#58; <span class="elsevierStyleItalic">1&#41;</span> maintain blood pressure below 130&#47;80mm Hg&#59; <span class="elsevierStyleItalic">2&#41;</span> administer angiotensin-converting enzyme &#40;ACE&#41; inhibitors&#44; angiotensin II receptor antagonists&#44; or both&#59; <span class="elsevierStyleItalic">3&#41;</span> administer statins&#59; <span class="elsevierStyleItalic">4&#41;</span> administer antiplatelet or anticoagulation therapy&#59; and <span class="elsevierStyleItalic">5&#41;</span> diet for renal protection&#46;<span class="elsevierStyleSup">5</span> The initial treatment is based on a prednisone cycle &#40;1mg&#47;kg&#47;day&#44; maximum of 80mg&#47;day or 2mg&#47;kg&#47;day on alternate days&#44; maximum of 120 mg&#41;&#44; which should be maintained for 16 weeks before the condition is declared corticosteroid-resistant&#46;<span class="elsevierStyleSup">6</span> Treatment with prednisone can cause remission of the disease in 60&#37;-70&#37; of patients&#44; according to the studies&#46; These responses depend on the intensity of the initial proteinuria&#44; the tubular&#47;interstitial lesions&#44; and the baseline creatinine level&#44; although it is not possible <span class="elsevierStyleItalic">a priori </span>to separate the patients that will respond to corticosteroid treatment from those that will not&#46; As a rule&#44; this should not be combined with treatment using other immunosuppressive drugs&#44; unless there is a risk of toxicity or intolerance to steroids &#40;obesity&#44; osteoporosis&#44; diabetes&#44; advanced age&#44; or psychiatric imbalances&#41;&#46; If they were to be used&#44; calcineurin inhibitors are recommended &#40;suggestion 2D&#41;&#44; as will be indicated later when discussing corticosteroid-resistant forms of the disease&#46;<span class="elsevierStyleSup">3 </span>Partial or complete remission of proteinuria has been associated with a good prognosis&#44; and it is the most indicative marker of patient evolution&#44; even more than clinical and histological results&#46;<span class="elsevierStyleSup">7</span> Approximately 30&#37;-40&#37; of patients are corticosteroid-resistant&#44; presenting problems for developing a treatment plan&#44; since resistance to corticosteroids is the strongest predictor for the development of chronic kidney disease&#58; 35&#37; at 5 years and 70&#37; at 10 years&#46; As such&#44; the current conundrum is&#58; how can we treat idiopathic FSGS that has not responded to steroids or is corticosteroid-dependent&#63; Can we modify the patient evolution towards kidney failure&#63; Here&#44; we will go through the different treatments recommended in corticosteroid-resistant FSGS according to the evidence published on the subject &#40;Table 2&#41;&#46; Obviously&#44; each case should be analysed individually&#44; and treated according to the personal opinion and experience of the physicians that directly attend to each patient&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CALCINEURIN INHIBITORS</span></p><p class="elsevierStylePara">Cyclosporin A &#40;CsA&#41; is the best documented method of treatment in controlled trials and observational studies&#46;<span class="elsevierStyleSup">3&#44;8</span> The recommended dose is 2-5mg&#47;kg&#47;day administered in two doses &#40;with levels of 125-175ng&#47;ml&#41; during a minimum of 6 months&#46; If at the end of this time there is no response&#44; treatment must be suspended and the patient should be considered resistant to CsA&#46; In the case of a partial or complete response&#44; which appears in 60&#37;-70&#37; of cases&#44;<span class="elsevierStyleSup">9&#44;10</span> treatment should be maintained for at least 12 months&#44; and can then be progressively reduced by 25&#37; every 2 months&#46; Approximately half of all patients that initially respond to CsA develop resistance eventually&#46; Fewer studies exist regarding the use of tacrolimus in the treatment of corticosteroid-resistant FSGS&#44; but Segarra et al<span class="elsevierStyleSup">11</span> obtained positive results from using tacrolimus &#40;0&#46;15mg&#47;kg&#47;day&#59; levels of 5-10ng&#47;l&#41; and low-dose steroids &#40;0&#46;15mg&#47;kg&#47;day&#41; in 25 patients with previous resistance to steroids and CsA&#46; Therefore&#44; its use in patients that have not responded to CsA is an attractive treatment option that deserves a try before moving on to other alternatives&#46; Even so&#44; treatment with calcineurin inhibitors creates other problems&#58; nephrotoxicity and recurrence after treatment suspension&#46; The first condition can be avoided by using the minimum possible dose&#44; monitoring patient levels&#44; and by performing a kidney biopsy in order to evaluate vascular and interstitial damage&#46; Recurrence is very common after reducing the dosage or suspending treatment with this drug&#44; reaching even 70&#37; in some studies&#46; A study&#44; sponsored by the GLOSEN &#40;glomerulonephritis study group of the Spanish Society of Nephrology&#41;&#44; has been recently performed on 5 patients&#44; who were administered calcineurin inhibitors as an induction therapy&#44; followed by rituximab once remission was established&#44; with no positive results in avoiding recurrence after treatment suspension&#46;<span class="elsevierStyleSup">12</span> Recurrence is still an unresolved problem that requires more in-depth<span class="elsevierStyleBold"> </span>studies&#46; On the other hand&#44; given that approximately 30&#37; of cases do not respond to calcineurin inhibitors&#44; other treatments have also been tested&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MYCOPHENOLATE MOFETIL</span></p><p class="elsevierStylePara">Experience with this drug is scarce&#44;<span class="elsevierStyleSup">6</span> with an approximately 44&#37; of cases showing a partial response&#44; but half of these patients suffer a recurrence when medication is suspended&#46;<span class="elsevierStyleSup">7</span> This is an option when other immunosuppressive drugs cannot be administered&#44; or when steroid dosage must be decreased &#40;suggestion 2C&#41;&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RITUXIMAB</span></p><p class="elsevierStylePara">In a recent study that was also sponsored by GLOSEN&#44;<span class="elsevierStyleSup">13</span> involving 8 patients with FSGS resistant to other drug treatments&#44; rituximab had a positive effect in only 3 cases&#44; making it an unattractive alternative&#44; at least as a monotherapy&#46; Therefore&#44; controlled studies are needed&#44;<span class="elsevierStyleSup">8</span> but it still can provide an alternative when nephrotoxicity develops due to the administration of calcineurin inhibitors&#46;<span class="elsevierStyleSup">14</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ALKYLATING AGENTS</span></p><p class="elsevierStylePara">Some experience has been gained in the administration of cyclophosphamide and chlorambucil&#44; as they were used before the advent of calcineurin inhibitors&#46; However&#44; they only produce a complete response in 20&#37; of cases&#44; and a partial response in 45&#37;&#46; These results&#44; along with the adverse effects &#40;infections&#44; tumours&#44; leukopenia&#44; infertility&#41;&#44; have severely reduced the role of these drugs&#44;<span class="elsevierStyleSup">9</span> with insufficient evidence to support their use&#46;<span class="elsevierStyleSup">6&#44;15&#44;16</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">COMBINED TREATMENTS</span></p><p class="elsevierStylePara">Given the limitations presented by the previous drug treatments&#44; some authors have incorporated the concept of synergistic effects of immunosuppressive drugs &#40;taken from the experience gained in transplantations&#41; into the treatment of glomerular diseases&#46; In this issue of <span class="elsevierStyleItalic">Nefrolog&#237;a</span>&#44; Segarra et al<span class="elsevierStyleSup">17</span> have published on their experience in treating primary FSGS in 27 adult patients with previously failed treatment plans using steroids and CsA&#44; combining CsA &#40;4mg&#47;kg&#47;day&#41; with mycophenolate mofetil &#40;2000mg&#47;day&#41; for 12 months&#46; This was an observational study with no controls&#44; and it produced disappointing results&#46; None of the patients in this study reached complete remission of the disease&#44; and only one fourth partial remission&#46; Additionally&#44; the glomerular filtration rate was significantly reduced in all patients&#44; and 59&#37; of cases developed uraemia at the end of the 5-year follow-up period&#44; which is a similar result to that achieved by treating patients symptomatically&#46; Lastly&#44; the authors used a multivariate analysis to show that initial glomerular filtration rates and mean proteinuria during the follow-up period were correlated with renal impairment&#46; El-Reshaid et al<span class="elsevierStyleSup">18</span> had already tested a similar combined treatment&#44; with somewhat better results&#44; but in patients without previous failure of CsA treatment&#46; The role that this three-part association may play in the treatment of idiopathic FSGS resistant to steroids and CsA is still unclear&#46; Although the authors did not perform a genetic analysis&#44; it is quite probable that the hereditary forms of the disease were not present in the study&#44; since the necessary genetic mutations &#40;NPHS1&#44; NPHS2&#44; alpha-actinin-4&#44; CD2P&#44; TRPC-6 and others&#41; are very rare in adults&#46;<span class="elsevierStyleSup">19</span> With these results&#44; the triple therapy using steroids&#44; CsA&#44; and mycophenolate mofetil appears not to decrease proteinuria or slow the development of kidney disease&#46;</p><p class="elsevierStylePara">Although the treatment of corticosteroid-resistant idiopathic FSGS is still an unresolved issue&#44; we must not be pessimistic&#46; Several different clinical trials have been initiated<span class="elsevierStyleSup">20&#44;21</span> that may help to improve the current results&#46; As the KDIGO guidelines will state&#44; more controlled clinical trials are needed to compare the efficacy of calcineurin inhibitors&#44; mycophenolate mofetil&#44; rituximab&#44; and alkylating agents in treating corticosteroid-resistant FSGS&#46; Lastly&#44; we must re-evaluate the use of our current arsenal of immunosuppressive drugs&#44; whose mechanisms of action are still unknown and are mostly empirical&#46;<span class="elsevierStyleSup">22</span> According to a recent review by Meyrier&#44;<span class="elsevierStyleSup">23</span> the factor or factors that lead to an increase in capillary permeability must be identified in order to treat these patients accordingly&#46;</p><p class="elsevierStylePara">In conclusion&#44; the treatment of idiopathic FSGS patients with nephrotic syndrome is still unresolved&#44; and clinicians are faced with a challenge in producing some type of response in the patient and slowing or halting the evolution towards kidney failure&#46; In spite of the negative results obtained by the excellent study by Segarra et al&#44;<span class="elsevierStyleSup">17</span> which inspired this &#8220;Editorial Comment&#44;&#8221; we must continue to research ways to improve the current unsatisfactory results&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara">1&#46; FSGS is a non-specific glomerular lesion that is classified as idiopathic &#40;primary&#41; or secondary&#46;</p><p class="elsevierStylePara">2&#46; Patients with idiopathic FSGS that do not develop nephrotic syndrome and cases of secondary FSGS should not be treated using steroids or immunosuppressive drugs&#46;</p><p class="elsevierStylePara">3&#46; Idiopathic FSGS patients with nephrotic syndrome should be initially treated with a cycle of steroids &#40;or steroids and CsA in the case of intolerance to high levels of steroids&#41; for a minimum of 4 weeks and a maximum of 16 weeks&#46;</p><p class="elsevierStylePara">4&#46; Patients with corticosteroid-resistant FSGS should be treated using CsA and low doses of steroids for at least 6 months&#44; monitoring blood levels and nephrotoxicity&#46; Patients that do not respond to treatment can benefit from the administration of tacrolimus&#46;</p><p class="elsevierStylePara">5&#46; Mycophenolate mofetil and rituximab can be effective alternatives in the case of resistance to CsA&#44; although little evidence exists&#46;</p><p class="elsevierStylePara">6&#46; Alkylating agents &#40;cyclophosphamide and chlorambucil&#41; are only barely indicated and their use is not recommended&#44; except for in very severe cases of dependence on corticosteroids&#46;</p><p class="elsevierStylePara">7&#46; Until now&#44; combined treatments have not produced any positive results&#46;</p><p class="elsevierStylePara">8&#46; New treatments are needed based on controlled clinical trials that can induce a response in proteinuria and avoid the evolution of the disease towards kidney failure&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10940&#95;108&#95;17294&#95;en&#95;t110940&#46;jpg" class="elsevierStyleCrossRefs"><img src="10940_108_17294_en_t110940.jpg" alt="Causes of focal segmental glomerulosclerosis"></img></a></p><p class="elsevierStylePara">Table 1&#46; Causes of focal segmental glomerulosclerosis</p><p class="elsevierStylePara"><a href="grande&#47;10940&#95;108&#95;17295&#95;en&#95;t210940&#46;jpg" class="elsevierStyleCrossRefs"><img src="10940_108_17295_en_t210940.jpg" alt="Treatments for idiopathic focal segmental glomerulosclerosis patients with nephrotic syndrome"></img></a></p><p class="elsevierStylePara">Table 2&#46; Treatments for idiopathic focal segmental glomerulosclerosis patients with nephrotic syndrome</p>"
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