Over 11 years of stable renal function after remission of nephrotic-range proteinuria in type I diabetics treated with an ACE inhibitor

It has previously been considered inevitable that a progressive deterioration in renal function would occur in type I diabetics who have proteinuria in the nephrotic range. We have reviewed all type I diabetic patients presenting with nephrotic-range albuminuria to this department over a 13-year period. Of 16 patients identified, 4 have demonstrated a prolonged stability of renal function, with 2 losing their albuminuria. The latter 2 patients, who have been treated with an angiotensin-converting enzyme inhibitor for over 11 years, are presented in detail. The possible factors contributing to progression and the role of angiotensin-converting enzyme inhibitors in the treatment of advanced diabetic nephropathy are discussed.

Effect of sairei-to on prostaglandin E2-induced phosphatidylinositol breakdown in aminonucleoside nephrotic rat

We describe the effects of Sairei-to, a Chinese herbal medicine, on aminonucleoside-induced nephrotic rats (ANNR), and analyze the urinary excretion of protein and phosphatidylinositol (PI) turnover via prostaglandin E2 (PGE2) receptors in isolated glomeruli. Sairei-to suppressed urinary excretion of protein and PGE2 in ANNR, and inhibited acceleration of PI turnover in isolated nephrotic glomeruli. The affected responsiveness of the PI turnover system to PGE2 in a nephrotic state was presumed to be normalized by Sairei-to. These findings suggest that Sairei-to restores abnormal changes in the PI turnover system in ANNR kidneys, and thereby inhibit excretion of protein into the urine.

Treatment of idiopathic nephrotic syndrome with cyclosporine A

Cyclosporine A has been empirically used for more than 12 years in the treatment of idiopathic nephrotic syndrome, in both children and adults. There is consistent evidence, from both experimental and human studies, that the highly lipophilic cyclosporine molecule diminishes or abolishes proteinuria by two differing mechanisms. The first is its immunosuppressive action, which is presumably directed toward secretion of a glomerular permeability factor. The second appears to be a non-immunologic effect on glomerular permselectivity, explaining reduced proteinuria in various etiologies of nephrotic syndrome with no immunologic background. The success rate for inducing remission of idiopathic nephrotic syndrome is highest in steroid-dependent forms, essentially observed in minimal change disease where complete remission is achieved in 75% of cases. It is lowest in steroid-resistant idiopathic nephrotic syndrome, especially when accompanied with lesions of focal segmental glomerulosclerosis, with a success rate in the order of 20% complete remission and 25% partial remission. The initial dosage in adults should not exceed 5.5 mg/kg/day which was shown to be the cut-off level of toxicity in renal biopsy-based studies. It is slightly higher in children, and some studies suggest that high serum cholesterol levels should allow higher dosages for increased remission rates without additional toxicity. Long-term treatment of INS requires serial monitoring of renal function with drug dosage reduction when serum creatinine rises by 30% over baseline, and it is recommended to carry out renal biopsy after 1 to 2 years of treatment to verify the absence of interstitial fibrosis even though renal function tests are apparently stable. Renal insufficiency and/or severe hypertension complicate treatment in approximately 10% of cases, essentially in FSG, in which the development of the primary renal disease, which is not controlled by CsA, is additive to the nephrotoxic potential of the drug. Cyclosporine dependency is the rule during the first year of treatment. However, in a meaningful number of cases, tapering CsA dosage to a stop or to a low maintenance dosage is compatible with stable remission without risk of nephrotoxicity. Therefore, cyclosporine, the main advantage of which is its corticosteroid-sparing effect, appears to be a significant advance in the treatment of idiopathic nephrotic syndrome.

Hemostatic profile in nephrotic syndrome

OBJECTIVE

To evaluate the coagulation profile and its relation to steroid therapy, and the frequency of thromboembolic complications and its correlation with coagulation parameters in nephrotic syndrome (NS).

SETTING

Hospital based.

SUBJECTS AND METHODS

Forty children with NS were subdivided into four groups, namely, fresh cases, steroid dependent, remission after therapy and steroid resistant. An equal number of age and sex matched children served as controls. In all the study and control subjects, detailed clinical examination, liver function tests, renal function tests and detailed coagulation profile were done. Evaluation of renal veins and inferior vena cava for the presence of thrombosis was also done by abdominal ultrasonography.

RESULTS

Thrombocytosis was detected in 57.5% and the degree of thrombocytosis was directly related to the amount of proteinuria. The mean prothrombin and thrombin times were within normal range in the study children. The activated partial thromboplastine time (APTT) was prolonged in six cases (15%) and three out of these six children had thromboembolic complications. Antithrombin-III level was significantly lower (p < 0.001) whereas protein C and S were significantly elevated (p < 0.001) as compared to controls. The levels became normal with remission of the disease. Steroid therapy significantly increased the levels of proteins C, protein S. AT-III and fibrinogen as compared to controls. Thromboembolic complications were seen in 3 cases (7.6%) and were associated with very low levels of AT-III and protein C and all three had serum albumin below 2 g/dl.

CONCLUSIONS

The importance of coagulation profile in nephrotic syndrome is highlighted and a high index of suspicion for thromboembolic complications is warranted in patients with thrombocytosis, hyper fibrinogenemia, prolonged APTT and in children with low levels of AT-III, protein C and protein S.

Risk factors for relapse in childhood nephrotic syndrome

We investigated the risk factors for relapse in 48 children with steroid-sensitive nephrotic syndrome using univariate and multivariate proportional hazard analysis. All patients were treated with the same corticosteroid regimen. A low serum level of total protein and young age at onset increased the relapse rate. Recurrence risk was not associated with the patient's sex, the percentage body weight gain, blood urea nitrogen level, serum level of creatinine, the hematocrit, or the administration of human albumin. We conclude that young age and a low serum level of total protein at onset were independent risk factors for relapse of childhood nephrotic syndrome.

[Nephrotic syndrome related to chronic graft versus host disease after allogeneic bone marrow transplantation in a patient with malignant lymphoma]

A 13-yr-old boy was diagnosed as T cell lymphoma. After the second remission, he underwent BMT from an HLA-identical, MLC negative sibling donor. After BMT, he developed grade II acute GVHD. GVHD was improved by pulsed steroid therapy using prednisolone. About 12 months after BMT, he developed bronchiolitis obliterans, sicca syndrome, and leukoderma, which were related to chronic GVHD. Pulsed steroid therapy was carried out twice, and his condition improved. Twenty-seven months after BMT, he developed nephrotic syndrome. A renal biopsy was performed, and the diagnosis was histologically membranous nephropathy and focal glomerular sclerosis. The response to steroids was not satisfactory. After 5 weeks, dipyridamole was added, but proteinuria persisted. Proteinuria disappeared 8 weeks after the addition of cyclosporine. The second biopsy after 5 months of treatment revealed an improvement in the renal lesions. The patient showed a low T4 to T8 ratio of T-lymphocytes at the onset of nephrotic syndrome. However after treatment with cyclosporine, the ratio gradually increased. These findings suggested the nephrotic syndrome in this patient was related to renal involvement in the course of chronic GVHD.

[Therapeutic use of heparan sulfate in nephrotic syndrome: rational use]

We report the beneficial effects of heparan sulfate administration in nephrotic syndrome (NS) in reducing the degree of proteinuria, in ameliorating the chylomicron removal defect and the hypercoagulable state and, consequently, in slowing down the progression to uraemia.

Clinical and morphological predictors of renal outcome in adult patients with focal and segmental glomerulosclerosis (FSGS)

In this retrospective study, we examined 35 adult patients with biopsy-proven, primary focal and segmental glomerulosclerosis (FSGS) and nephrotic syndrome to determine whether any of the clinical and morphological features of FSGS were associated with a higher risk of a poor renal outcome. Clinical factors assessed were the age, sex, amount of urinary protein, and presence of microscopic hematuria, hypertension and renal dysfunction at onset in each patient. Morphological parameters included the number of segmental sclerosis and global sclerosis, sclerosis score, location of segmental sclerosis, mean glomerular diameter, grade of tubulo-interstitial changes, and presence of vascular lesions. Twenty-three patients (66%) were in complete or incomplete (partial) remission, and 12 (34%) were non-responders at the end of follow-up. On univariate analysis, the age at onset, sclerosis score, mean glomerular diameter, and grade of tubulo-interstitial changes in no response were significantly greater than those parameters in remission. Multivariate logistic regression analysis revealed that the degree of tubulo-interstitial changes and mean glomerular diameter were independent risk factors for a poor renal outcome. These findings suggest that the estimation of these latter two parameters allows the nephrologist to predict the probable course and prognosis of an adult with FSGS. Intensive and prolonged therapy is recommended for patients without these two morphological features.

Inhibition of progression of chronic puromycin aminonucleoside nephrosis by probucol, an antioxidant

Oxidants have been shown to be involved in the initiation of chronic puromycin aminonucleoside nephrosis in rats, but it is uncertain whether they have a role in the progression of this disease. Rats given a single internal jugular venous bolus of puromycin aminonucleoside (PA) develop early nephrotic syndrome that subsides after about 28 days followed by a 4-wk period of minimal proteinuria and then the development of focal glomerulosclerosis and increasing proteinuria. Fifty-two rats on a high-cholesterol diet were divided into four groups. Two groups of 16 animals each received a single internal jugular venous bolus of PA. One of these groups was started on the dietary antioxidant, probucol (1% wt/wt), 4 days after the PA injection and continued on it until termination. The remaining rats were given an internal jugular venous injection of an equivolume of normal saline. Five of these animals were also started on dietary probucol 4 days after the saline injection. At 11 days postinjection all animals given PA, whether on probucol or not, developed marked proteinuria with histologically minimal glomerular change and significant increases in intraglomerular monocyte and proliferating cell nuclear antigen counts. Forty-two days after PA injection all PA-injected rats had minimal urinary protein injection and no glomerular changes. At 98 days postinjection rats given PA without probucol developed focal glomerulosclerosis and significant proteinuria compared with PA-injected rats on probucol and those injected with saline (P < 0.05). The probucol-fed PA-injected rats showed no glomerular disease and their urinary protein excretion rates were very similar to those of the saline controls. The results indicate that probucol inhibits the progression of chronic puromycin aminonucleoside nephrosis and are consistent with the suggestion that oxidants are involved in the progression of this entity.

Steroid-resistant nephrotic syndrome associated with malignant thymoma

Two patients with malignant thymoma of lymphoepithelial cell type developed nephrotic syndrome and irreversible acute renal failure 18 months after the radiation therapy. Repeated renal biopsies revealed focal segmental glomerulosclerosis (FSGS) in both cases (a 66-year-old female and a 82-year-old female). Several immunological disorders were found, being a presence of autoantibodies such as antinuclear antibody, anti-acetylcholine receptor antibody, antistriatal antibody and an elevation of serum IgM. In both cases the nephrotic syndrome was resistant to corticosteroid as well as cyclophosphamide. Renal dysfunction eventually progressed to end-stage renal failure requiring regular hemodialysis treatment. A sustained immunological impairment related to the residual malignant thymoma was considered to be of pathogenic importance for the delayed occurrence of nephrotic syndrome. Fifteen thymoma cases with nephrotic syndrome from the previous reports are also reviewed.

[Favorable effects of epsilon-aminocaproic acid on the children with nephrotic syndrome and Schonlein-Henoch syndrome treated with corticosteroids]

An effect of EACA given in the daily dose of 85-230 mg/kg for 1-1-days on the activity of certain plasma protease inhibitors in 7 children with steroid-sensitive and steroid-dependent nephrotic syndrome (age between 3.5 and 18 years), and in 6 children with Schönlein-Henoch syndrome (aged between 3.5 and 6 years). Additionally, an effect of EACA on clinical status, dynamics of improvement, proteinuria and/or erythrocyturia, and incidence of adverse reactions was studied. It was found that EACA significantly increased antithrombin III activity by approximately 68.8% proteinase alpha 1-inhibitor by 41.8% alpha 2-antiplasmin by 55% in patients with nephrotic syndrome, and increased an activity of protease alpha 1-inhibitor by 75% in patients with Schönlein-Henoch syndrome. EACA given together with corticosteroids enhanced their efficiency manifested--especially in children with Schönlein-Henoch syndrome--by a rapid diminishment of skin changes, proteinuria and erythrocyturia. A drop in blood pressure, loose stools, upper respiratory inflammation, and fever were most frequent adverse reactions. EACA given alone produced rapidly increasing edema in patients with hephrotic syndrome. It seems that EACA may be used as an adjuvant therapy in some cases of nephrotic and Schönlein-Henoch syndromse.

[Henoch-Schönlein nephritis with nephrotic syndrome during pregnancy]

We report a 33-year-old female with nephrotic syndrome associated with Henoch-Schönlein nephritis (HSN) during pregnancy. She presented purpura in the legs at 20 weeks in her third pregnancy. A biopsy of her purpuric skin lesion showed leukocytoclastic vasculitis. After a month she was admitted to Sapporo City General Hospital because of development of a nephrotic syndrome. She was treated with heparin as anticoagulants therapy and delivered of a healthy girl by Cesarean section at 34 weeks. Renal biopsy, carried out beyond a month after delivery, revealed diffuse proliferative glomerulonephritis with prominent IgA deposits, which made the diagnosis of HSN (grade III of classification of the renal histopathology of HSN from the International Study of Kidney Disease in Childhood). Prednisolone 40 mg, dipyridamole 300 mg per day and pulse doses of steroid were administrated. Two months later proteinuria was not detected. A sister of the patient had also Henoch-Schönlein Purpura in her childhood. They shared HLA DR 4, DQ 4 which are known to be associated with IgA nephropathy. Fifty percent of pregnant women with chronic glomerulonephritis shows increased proteinuria. Pregnancy may have influence on the increased proteinuria in this case.

Immunosuppressive treatment of the nephrotic syndrome due to mesangial lesions

To assess the effectiveness of an intensive immunosuppressive regimen on the nephrotic syndrome due to mixed membranous and mesangial lesions, we studied 18 patients with nephrotic syndrome and miscellaneous histologic features characterized by mesangial proliferation and sclerosis, non-specific basement membrane changes such as thickening, fraying and scalloping, in the absence of extensive immune complex deposition by immunofluorescence. The patients were treated with an immunosuppressive regimen that combined prednisone and cyclophosphamide for at least 6 months with the following schedule: 1) induction with prednisone daily 250 to 750 mg i.v. for 3 to 8 days, plus cyclophosphamide 100 to 200 mg p.o. daily; 2) maintenance with prednisone 100 to 200 mg p.o. in alternate days for 30 to 75 days, and cyclophosphamide as before; 3) tapering, with prednisone in alternate day regimen, reduced on average by 25 mg every month, plus cyclophosphamide as before; 4) discontinuation of cyclophosphamide and slow withdrawal of prednisone. Treatment lasted on average 9 months, with an average cumulative dose of prednisone of 9.2 g and of cyclophosphamide of 26.7 g. At the end of treatment, 14 patients had a complete remission and 4 remained stable. On longer follow-up, one out of these 4 patients, who had renal failure before treatment, subsequently progressed to end-stage renal disease. Nine patients relapsed after an average remission of 6 years. Eight of them remitted completely on a repeat cycle. One patient refused the retreatment and progressed to end-stage renal disease within one year. After an average follow-up of 7.3 +/- 1.1 years, plasma creatinine for the whole group had fallen from 138 +/- 26 to 103 +/- 20 mumol/l and proteinuria from 6.7 +/- 0.7 to 0.4 +/- 0.2 g/d (p < 0.001). In conclusion, in patients with these forms of nephrotic syndrome this immunosuppressive regimen is highly effective in inducing remission, in preventing progression to end-stage renal disease and in treating relapses.

Dose-intensive melphalan with blood stem cell support for the treatment of AL amyloidosis: one-year follow-up in five patients

The morbidity and lethality of AL amyloidosis is caused by the deposition of lg light chains as fibrillar amyloid protein in vital organs, disrupting their function, and not by the generally low burden of clonal plasma cells that produce the paraproteins. Survival of patients with AL amyloidosis is no more than 1 to 2 years from the time of diagnosis with current management approaches. Clearly, more effective therapies are needed for this rapidly lethal disease. Five patients were treated with dose-intensive melphalan and blood stem cell support and followed for a period of 1 year. Patients were diagnosed with AL amyloidosis by tissue biopsy and categorized by performance status and organ involvement. Their plasma cell dyscrasias were evaluated with immunofixation electrophoresis of serum and urine specimens, quantitative serum lgs, and immunohistochemical staining of bone marrow biopsy specimens. After treatment with dose-intensive intravenous melphalan followed by infusion of autologous growth-factor-mobilized blood stem cells, clinical evaluations and plasma cell studies were repeated at 3 and 12 months. Three men and 2 women aged 38 to 53 years were treated. Median performance status (SWOG) was 2 (1 to 3), and clinical presentations included nephrotic syndrome (n = 1), symptomatic cardiomyopathy (n = 1), gastrointestinal involvement with polyneuropathy (n = 2), and hepatomegaly (n = 1). With a median follow-up of 13 months (12 to 17 months), all five patients are well and have shown stable or improved performance status and clinical remission of organ-related dysfunction, including a 50% reduction in daily proteinuria with no change in creatinine, reversal of symptoms of cardiomyopathy and reductions of posterior wall and septal thickening, reversal of polyneuropathy and gastric atony, and resolution of hepatomegaly by computed tomographic scan. In 3 of the 5 patients (60%) at 12 months after treatment, plasma cell dyscrasias could not be detected. Dose-intensive chemotherapy with intravenous melphalan and growth-factor-mobilized blood stem cell support is feasible therapy for patients with AL amyloidosis, even when there is clinical evidence of cardiac involvement. At least some patients with AL amyloidosis achieve complete remission of their plasma cell dyscrasia, improvement in performance status, and clinical remission of organ-specific disease after this form of treatment.

Nephrotic syndrome in Trinidadian children

57 children with idiopathic nephrotic syndrome who were seen at two hospitals in Trinidad between 1989 and 1995 (median follow-up period, 38 months) were classified according to their response to glucocorticoids. 27 (47%) were two to six years old at presentation; 37 (65%) were of East Indian descent, 7 (12%) were of African descent, and 12 (21%) were of mixed race. 55 (96%) responded to glucocorticoids. Renal biopsies in 15 patients revealed membranoproliferative glomerulonephritis and membranous nephropathy in the two patients who had not responded to glucocorticoids. Ten patients showed mesangial hypercellularity, associated with immunoglobulin deposits in 7 cases. Age, presentation with nephrotic features, mesangial hypercellularity and immunoglobulin deposits did not predict for unresponsiveness to glucocorticoids. These findings may be explained by the predominance of East Indians in the study group.

[Prolonged gold therapy for nephrotic syndrome in a patient with undiagnosed polyarthritis]

A 36-years old female patient with undiagnosed arthritis developed nephrotic syndrome following chronic gold therapy. After prolongated and active treatment with pulses and oral steroids complete recovery was achieved. The likely nephrotoxic mechanism involved and clinical implications are discussed.

Infantile nephrotic syndrome and atopy

Nephrotic syndrome presenting in the 1st year of life is often associated with a very poor prognosis for normal renal function. A small proportion of patients, particularly boys, presenting after the first 3 months of life with idiopathic-type, steroid-sensitive nephrosis, have a much better prognosis and may achieve sustained remission. We describe three boys with infantile idiopathic nephrotic syndrome of the mesangial proliferative glomerulonephritis type who went into complete remission. The patients, their first-degree relatives or both suffered from atopy (eczema, asthma or hayfever). This is the first report linking infantile nephrotic syndrome and atopy. The literature linking idiopathic nephrotic syndrome and atopy is reviewed, and the implications of our findings discussed.

Treatment of anemia of nephrotic syndrome with recombinant erythropoietin

Nephrotic syndrome has been recently shown to cause erythropoietin (EPO) deficiency in humans and experimental models. However, efficacy and safety of recombinant EPO (rEPO) in the treatment of the associated anemia has not been previously investigated. We report a patient with nephrotic syndrome and only moderately impaired renal function. This patient showed severe disabling EPO-deficiency anemia that was treated with subcutaneous rEPO. This treatment led to a marked amelioration of the anemia and a dramatic improvement in the patient's sense of well-being and quality of life. The patient's glomerular filtration rate remained stable and the pre-existing hypertension remained under control with appropriate therapy throughout the 30-week course of rEPO therapy. Thus, rEPO therapy appears to be effective in the treatment of EPO-deficiency anemia caused by the nephrotic syndrome. Controlled studies are required to further substantiate the efficacy and safety of rEPO in the nephrotic syndrome.

Nutritional management of the child with mild to moderate chronic renal failure

1. The best way to prevent early growth failure in children with renal disease is by the use of specified nutrition and appropriate buffer, activated vitamin D, and calcium-containing phosphate binders as needed. With prenatal diagnosis of anatomically abnormal kidneys available, this type of early intervention may be much more feasible in the 1990s. 2. Supplemental sodium and water in children with polyuria and intravascular volume depletion may prevent growth failure. Cow milk is detrimental in this group of individuals because of high solute and protein load, often causing intravascular volume depletion, hyperphosphatemia, and acidosis. 3. Children with acquired glomerular disease may need sodium restriction and, if treated with steroids, a diet low in saturated fat. 4. Children with nephrotic syndrome and severe edema should be evaluated for malabsorption and subsequent malnutrition. Protein intake should be supplemented only at the RDA and to replace ongoing losses. Long-term sodium restriction is appropriate. Hyperlipidemia should be monitored: if nephrosis is chronic, a low saturated fat diet should be instituted. Angiotensin-converting enzyme inhibitors can decrease urinary protein loss and may ameliorate hyperlipidemia. Children resistant to therapy can have very high morbidity. 5. Children with <50 % of normal creatinine clearance should have PTH measured and activated vitamin D therapy should be started if PTH is elevated more than two to three times normal. Thereafter careful monitoring of calcium, phosphorus, and PTH is crucial to prevent renal osteodystrophy, low turnover bone disease, and hypercalcemia with hypercalciuria and nephrocalcinosis. 6. Children with tubular defects with severe polyuria also may benefit from low-solute, high-volume feedings. 7. All physicians caring for children with renal disease should have pediatric nephrology consultation available. Prevention of growth failure is much more cost effective than pharmacologic therapy. Before initiating growth hormone treatment for growth retardation, assiduous treatment of co-existing renal osteodystrophy and provision of optimal nutritional intake should be accomplished.

[Verification of indications for kidney biopsy in children with steroid-dependent nephrotic syndrome]

The aim of this study was to assess if cytostatic treatment of steroidodependent nephrotic syndrome in children should be preceded by renal biopsy. The result of treatment of 75 children with steroidodependent nephrotic syndrome were analysed. They were randomized for treatment with chlorambucil and cyclophosphamide and divided into two groups. Group I includes 32 children without preceding biopsy, group II, 43 children with established histopatologic diagnosis. Remission was achieved by 25 (78%) children in group I (15 (79%) of 19 treated with chlorambucil and 10(77%) of 13 treated with cyclophosphamide) and 38 (88.4%) in group II (25 (96%) of 26 treated with chlorambucil and 13 (76%) of 17 treated with cyclophosphamide). The results of therapy in children of two groups are comparable. This would indicate that a trial of cytostatic treatment can be started without previous renal biopsy.