Intravenous cyclophosphamide therapy in adults with henoch-schönlein purpura

LETTER TO THE EDITOR

Intravenous cyclophosphamide therapy in adults with henoch-schönlein purpura

Jae Il Shin; Jae Seung Lee

The Institute of Kidney Disease, Department of Pediatrics, Yonsei University College of Medicine, Severance Children's Hospital, Seoul, Korea. Email: [e-mail]

We read with interest the article "Henoch-Schönlein Purpura in adults" by López Meiller et al.¹ They reported 3 adult patients with Henoch-Schönlein nephritis (HSN)(one with hematuria and two with heavy proteinuria) who were treated with IV cyclophosphamide (1g/m²/month for six months).¹

Although the treatments of severe Henoch-Schönlein nephritis still remains controversial, oral cyclophosphamide has been used in children with severe Henoch-Schönlein nephritis with conflicting results.^2-4 Tanaka et al. reported that prompt initiation of oral prednisolone (1.5 mg/kg/day) combined with an 8-week course of oral cyclophosphamide (2 mg/kg/day) therapy could be effective not only in regressing the renal histologic findings but also in decreasing proteinuria in children with severe Henoch-Schönlein nephritis.² Kawasaki et al. also showed that methylprednisolone and urokinase pulse therapy combined with oral cyclophosphamide was more useful for children with severe Henoch-Schönlein nephritis than methylprednisolone and urokinase pulse therapy alone.³ However, when Tarshish et al. performed a randomized controlled study (supportive therapy with or without oral cyclophosphamide 90 mg/m²/day for 42 days), there were no differences in outcome between the two groups.⁴

Nevertheless, there has been no study on the therapeutic effect of intravenous cyclophosphamide therapy on children or adults with severe Henoch-Schönlein nephritis. On this point, López Meiller et al.'s study¹ is novel and has important clinical implications for the treatment of severe Henoch-Schönlein nephritis. However, the indications and duration of intravenous cyclophosphamide therapy should also be considered, because this protocol (intravenous cyclophosphamide, 1g/m²/month for six months) which has been previously used in severe diffuse proliferative lupus nephritis can cause various side effects.⁵ Therefore, at least heavy proteinuria or severe histologic findings should be the indications for intravenous cyclophosphamide therapy in severe Henoch-Schönlein nephritis. However it should be noted that one patient in the López Meiller et al.'s study¹ who showed hematuria without proteinuria was treated with intravenous cyclophosphamide. Also, one or two pulses of IV cyclophosphamide might be enough to control renal inflammations in Henoch-Schönlein nephritis, because two Henoch-Schönlein purpura patients with heavy proteinuria treated with 6 pulses of IV cyclophosphamide had shown a favorable clinical response after only one pulse.¹

Therefore, further studies should be performed to evaluate the therapeutic effect of IV or oral cyclophosphamide in a large number of adults with severe Henoch-Schönlein nephritis, and the dose and duration of therapy should also be elucidated in the future.

Comment on: Henoch-Schönlein Purpura in adults. Clinics. 2008;63(2):273-6.

• 1. López Meiller MJ, Cavallasca JA, Maliandi Mdel R, Nasswetter GG. Henoch-Schönlein Purpura in adults. Clinics. 2008;63:273-76.
• 2. Tanaka H, Suzuki K, Nakahata T, Ito E, Waga S. Early treatment with oral immunosuppressants in severe proteinuric purpura nephritis. Pediatr Nephrol. 2003;18:347-50.
• 3. Kawasaki Y, Suzuki J, Suzuki H. Efficacy of methylprednisolone and urokinase pulse therapy combined with or without cyclophosphamide in severe Henoch-Schoenlein nephritis: a clinical and histopathological study. Nephrol Dial Transplant. 2004;19:858-64.
• 4. Tarshish P, Bernstein J, Edelmann CM Jr. Henoch-Schönlein purpura nephritis: course of disease and efficacy of cyclophosphamide. Pediatr Nephrol. 2004;19:51-6.
• 5. Omdal R, Husby G, Koldingsnes W. Intravenous and oral cyclophosphamide pulse therapy in rheumatic diseases: side effects and complications. Clin Exp Rheumatol. 1993;11:283-88.

Publication Dates

• Publication in this collection
  12 Aug 2008
• Date of issue
  2008