Advertisement

International Journal of Hematology

, Volume 83, Issue 5, pp 454–458 | Cite as

Treatment with Candesartan Combined with Angiotensin-Converting Enzyme Inhibitor for Immunosuppressive Treatment—Resistant Nephrotic Syndrome after Allogeneic Stem Cell Transplantation

  • Yuko Osugi
  • Hiroshi Yamada
  • Gaku Hosoi
  • Haruyoshi Noma
  • Misako Ikemiya
  • Takefumi Ishii
  • Masahiro Sako
Case Report

Abstract

Most cases of nephrotic syndrome following stem cell transplantation (SCT) occur 6 months after SCT. The patients are treated with immunosuppressive therapies; however, in some cases treatment is not effective. We used enalapril, an angiotensin-converting enzyme inhibitor (ACEI) and candesartan, an angiotensin II receptor blocker (ARB), for the control of proteinuria in a case of immunosuppressive treatment (IST)-resistant nephrotic syndrome. A 15-year-old boy with acute lymphoblastic leukemia underwent allogeneic peripheral blood SCT from a completely HLA-matched sibling after completion of a conditioning regimen composed of 12-Gy doses of total-body irradiation, 600 mg/m2 thiotepa, and 140 mg/m2 melphalan. Twenty-eight months after SCT, minimal-change nephrotic syndrome was diagnosed on the basis of biopsy findings. Although neither cyclosporine (trough level, 100–150 ng/mL) nor corticosteroid was effective, proteinuria disappeared 2 months after the beginning of treatment with tacrolimus (trough level, 13–20 ng/mL), and remission was maintained for 23 months. Nephrotic syndrome recurred, however, and was resistant to tacrolimus. Findings at the second renal biopsy revealed membranous nephropathy. An ARB (candesartan, 4 mg/day) in combination with an ACEI (enalapril, 5 mg/day) was started. Proteinuria improved within 2 weeks.We suggest that ARB combined with ACEI can be used to control proteinuria in patients with IST-resistant nephrotic syndrome after SCT.

Key words

Nephrotic syndrome Allogeneic stem cell transplantation Chronic GVHD Membranous nephropathy Angiotensin-converting enzyme inhibitor Candesartan Angiotensin II receptor blocker 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Akar H, Keven K, Celebi H, et al. Nephrotic syndrome after allogeneic peripheral blood stem cell transplantation. J Nephrol. 2002;15:79–82.PubMedGoogle Scholar
  2. 2.
    Lin J, Markowitz GS, Nicolaides M, et al. Membranous glomerulopathy associated with graft-versus-host disease following allogeneic stem cell transplantation. Am J Nephrol. 2001;21:351–356.CrossRefPubMedGoogle Scholar
  3. 3.
    Imai H, Oyama Y, Miura AB, Endoh M, Sakai H. Hematopoietic cell transplantation—related nephropathy in Japan. Am J Kidney Dis. 2000;36:474–480.CrossRefPubMedGoogle Scholar
  4. 4.
    Nergizoglu G, Keven K, Ates K, et al. Chronic graft-versus-host disease complicated by membranous glomerulonephritis. Nephrol Dial Transplant. 1999;14:2461–2463.CrossRefPubMedGoogle Scholar
  5. 5.
    Sato N, Kishi K, Yagisawa K, et al. Nephrotic syndrome in a bone marrow transplant recipient with chronic graft-versus-host disease. Bone Marrow Transplant. 1995;16:303–305.PubMedGoogle Scholar
  6. 6.
    Tsutsumi C, Miyazaki Y, Fukushima T, et al. Membranous nephropathy after allogeneic stem cell transplantation: report of 2 cases. Int J Hematol. 2004;79:193–197.CrossRefPubMedGoogle Scholar
  7. 7.
    Miyazaki Y, Mori Y, Kishimoto N, et al. Membranous nephropathy associated with donor lymphocyte infusion following allogeneic bone marrow transplantation. Int J Hematol. 2003;78:262–265.CrossRefPubMedGoogle Scholar
  8. 8.
    Clark AG, Barratt TM. Steroid-responsive nephrotic syndrome. In: Barratt TM, Avner ED, Harmon WE, eds. Pediatric Nephrology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:731–747.Google Scholar
  9. 9.
    Niaudet P. Steroid-resistant idiopathic nephrotic syndrome. In: Barratt TM, Avner ED, Harmon WE, eds. Pediatric Nephrology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:749–764.Google Scholar
  10. 10.
    Schweda F, Liebl R, Riegger GA, Kramer BK. Tacrolimus treatment for steroid- and cyclosporin-resistant minimal-change nephrotic syndrome. Nephrol Dial Transplant. 1997;12:2433–2435.CrossRefPubMedGoogle Scholar
  11. 11.
    Kurokawa K. Effects of candesartan on the proteinuria of chronic glomerulonephritis. J Hum Hypertens. 1999;13(suppl 1): S57-S60.CrossRefPubMedGoogle Scholar
  12. 12.
    Hilgers KF, Dotsch J, Rascher W, Mann JF. Treatment strategies in patients with chronic renal disease: ACE inhibitors, angiotensin receptor antagonists, or both? Pediatr Nephrol. 2004;19:956–961.CrossRefPubMedGoogle Scholar
  13. 13.
    Romagnani P, Lazzeri E, Mazzinghi B, et al. Nephrotic syndrome and renal failure after allogeneic stem cell transplantation: novel molecular diagnostic tools for a challenging differential diagnosis. Am J Kidney Dis. 2005,46:550–556.CrossRefPubMedGoogle Scholar
  14. 14.
    Makker SP. Membranous glomerulonephropathy. In: Barratt TM, Avner ED, Harmon WE, eds. Pediatric Nephrology. 4th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:719–730.Google Scholar
  15. 15.
    Rossing K, Jacobsen P, Pietraszek L, Parving HH. Renoprotective effects of adding angiotensin II receptor blocker to maximal recommended doses of ACE inhibitor in diabetic nephropathy: a randomized double-blind crossover trial. Diabetes Care. 2003;26:2268–2274.CrossRefPubMedGoogle Scholar

Copyright information

© The Japanese Society of Hematology 2006

Authors and Affiliations

  • Yuko Osugi
    • 1
  • Hiroshi Yamada
    • 2
  • Gaku Hosoi
    • 1
  • Haruyoshi Noma
    • 1
  • Misako Ikemiya
    • 1
  • Takefumi Ishii
    • 1
  • Masahiro Sako
    • 1
  1. 1.Department of Pediatric Hematology/OncologyOsaka City General HospitalOsakaJapan
  2. 2.Departments of PediatricsOsaka City General HospitalOsakaJapan

Personalised recommendations