Adrenocortical Insufficiency and Relapsing in the Idiopathic Nephrotic Syndrome of Childhood

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Abstract
Twenty-five children with minimal change idiopathic nephrotic syndrome (INS) were given ACTH tests before, during and after prednisone medication (total of 55 medication episodes). Most had insulin tests, too. Continuous medication caused a significant decrease in the responses of all children. A significant recovery was universally evident already at the end of intermittent medication. No further consistent change was observed during remission 6 mo. later. Both before and at the end of the medication, 1/3 of the children had subnormal responses. The children were grouped according to the length of the ensuing remission: group I, < 0.5 yr; group II, 0.5 to 1.0 yr; group III, > 1.0 yr. Both before and after medication the basal plasma cortisol concentration and the responses to ACTH and insulin were significantly higher in group III than in group I. At the end of the medication the responses were also significantly higher in group II than in group I. A normal response predicted a > 0.5 yr remission and a subnormal response a < 0.5 yr remission. This was true for 20 of 27 responses to ACTH before medication and for 23 of 27 responses at the end of the medication. For the insulin test, only the response at the end of the medication was significantly predictive (16 of 18). An analysis with the ACTH test of 2 to 6 consecutive relapses in 14 children confirmed the value of the adrenocortical state in predicting the length of remission. The postmedication tests were superior to the premedication tests in predictive value. Children with postmedication adrenocortical suppression should be detected and given an appropriate cortisol substitution until their adrenocortical function has normalized. Other schedules of glucocorticoid medication of INS should be evaluated for lesser adrenocortical suppression.