Corticosteroids are often used in the treatment of NS despite an absence of supporting data. In recent years, corticosteroids and other immunosuppressive treatments have been investigated for use in NS ( Table 4 ) . 15 A Cochrane review showed that combining an alkylating agent with a corticosteroid has short- and long-term benefits for membranous nephropathy in adults with NS. 15 In general, immunosuppressive treatment has no proven benefit for most adults with idiopathic NS, and the potential risks may outweigh any benefits. The role of such treatment and specific treatment decisions, such as type and duration of therapy, depend on clinical factors and potentially on the histologic diagnosis identified on biopsy. If NS is steroid-resistant or does not improve, other immunosuppressive treatments should be considered in cooperation with a nephrologist. Immunosuppressive therapy for NS secondary to systemic lupus erythematosus is highly effective and supported by multiple studies, and may lead to partial or complete remission in patients with minimal change disease or primary focal segmental glomerulosclerosis.
Transplant centers should be notified before attempts to conceive; this allows for evaluation of graft function and adjustment of immunosuppressive regimens, if needed. Ideally, patients should not have experienced graft rejection within the past year; should have stable graft function, no acute infections, and controlled comorbidities; and should be on a stable immunosuppressive regimen before conceiving. 4 , 7 , 19 Certain immunosuppressive agents should be discontinued before pregnancy because of the increased risk of fetal compromise. Mycophenolic acid compounds have about a 25% risk of birth defects, and mammalian target of rapamycin inhibitors increase the risk of preterm delivery, decreased fetal weight, and delayed skeletal ossification. 7 , 19 , 23 Azathioprine, cyclosporine (Sandimmune), and tacrolimus (Prograf) have not been shown to increase the risk of birth defects. 19
Results Treatment with paricalcitol reduced parathyroid hormone levels within 4 weeks and maintained levels within the normal range throughout the study duration. At 48 weeks, the change in left ventricular mass index did not differ between treatment groups (paricalcitol group, g/m [95% CI, − to g/m ] vs placebo group, − g/m [95% CI, − to g/m ]). Doppler measures of diastolic function including peak early diastolic lateral mitral annular tissue velocity (paricalcitol group, − cm/s [95% CI, − to cm/s] vs placebo group, − cm/s [95% CI, − to cm/s]) also did not differ. Episodes of hypercalcemia were more frequent in the paricalcitol group compared with the placebo group.