Hypertrophic lupus vulgaris of 67 years' duration

In two patients (nos 1 and 3), recovery appears to be complete, and virtually so in patient 4, However, in patients 2 and 5, there is still significant impairment of renal function, compared with pretreatment values of creatinine and CFR. although improvement has taken place since discontinuing CyA. There was good correlation between GFR and serum creatinine as measurements of renal function, apart from patients 2 and 5 (who had the poorest recovery of renal function). Both had normal baseline serum creatinine levels, but relatively low baseline GFR measurements for their ages. although in patient 2 this was after 2-5 years of treatmenl. The GFR is a more sensitive test than serum creatinine for detecting impaired renal function, and it is therefore possible that patients 2 and 5 may have had some pre-existing renal abnormality which predisposed them to the nephrotoxic sideeffects of CyA. Therefore, a pretreatment GFR would appear to be an additional safeguard in detecting mild renal disease which may be aggravated by CyA. If this is not available, it is probably advisable to use the mean of three baseline serum creatinine levels. There was no correlation between the length of time the serum creatinine was persistently elevated and subsequent impairment of renal function. Patients 1 and 4 had the longest periods of elevation of creatinine (20 months and 3 years, respectively), but both showed good recovery to within 10% of baseline measurements. Patients 2 and 5. who had the least recovery, both had elevated creatinine levels for periods of 15 months. This study (although it is acknowledged that the numbers involved are small) shows that renal function does improve when CyA is discontinued after relatively long treatment periods, and that there is no progression ofthe nephrotoxicity. There are little available data on reversibility of impaired renai function after CyA. A study by Korstanje ct fl/.' reported eight patients who had received low-dose CyA for an average period of 12 months (range 4 -16 months), and who showed sustained renal impairment 4 months after withdrawal of CyA. This may have been related to the initial CyA dose (5 mg/kg), and renal function may still improve after this period. However, in two of our five patients there is still some degree of impaired renal function, and it will therefore be important to follow these individuals, to document their subsequent course.