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Cicek N, Yıldız N, Guven S, Kaya M, Gokce I, Alpay H. Clinical Predictors of Steroid Resistance in Childhood Nephrotic Syndrome. Clin Pediatr (Phila) 2024; 63:1300-1307. [PMID: 38142361 DOI: 10.1177/00099228231219109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
We aimed to evaluate the clinical parameters, histopathological findings of nephrotic syndrome (NS) patients, and independent factors predicting steroid resistance in a single tertiary center. One hundred and sixty-two children (57 girls and 105 boys) with NS who were followed between 1998 and 2018 were analyzed in this retrospective cohort. The median (interquartile range; range) age and follow-up time were 4.9 (5.7; 0.1-16.8) and 5.5 (5.4; 0.1-20.3) years. A total of 82.7% of the patients were steroid-sensitive nephrotic syndrome (SSNS) and 17.3% were steroid-resistant nephrotic syndrome (SRNS). The median age at first presentation was lower in the SSNS group (P = .002). The most common histopathological findings were focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD). Hypertension and macroscopic and microscopic hematuria were higher in the SRNS group (P < .001). The age and microscopic hematuria were independent risk factors for steroid resistance (P = .019 and P = .002, respectively). Complement 3 (C3) was evaluated in 148 patients and found low in 7 patients who were subsequently diagnosed as membranoproliferative glomerulonephritis. There is still no better clinical predictor for steroid response than late age of onset and microscopic hematuria. Hypertension may also give a hint for potential steroid resistance.
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Affiliation(s)
- Neslihan Cicek
- Department of Pediatric Nephrology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Nurdan Yıldız
- Department of Pediatric Nephrology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Sercin Guven
- Department of Pediatric Nephrology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Mehtap Kaya
- Department of Pediatric Nephrology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Ibrahim Gokce
- Department of Pediatric Nephrology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Harika Alpay
- Department of Pediatric Nephrology, School of Medicine, Marmara University, Istanbul, Turkey
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The Role of Cytokines in Nephrotic Syndrome. Mediators Inflamm 2022; 2022:6499668. [PMID: 35185384 PMCID: PMC8849808 DOI: 10.1155/2022/6499668] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 01/16/2022] [Accepted: 01/27/2022] [Indexed: 12/22/2022] Open
Abstract
Idiopathic nephrotic syndrome (INS) is an important primary glomerular disease characterized by severe proteinuria. Evidence supports a role for T cell dysfunction in the pathogenesis of INS. Glucocorticoids are the primary therapy for INS; however, steroid-resistant NS (SRNS) patients are at a higher risk of drug-induced side effects and harbor poor prognosis. Although the exact mechanism of the resistance is unknown, the imbalances of T helper subtype 1 (Th1), Th2, and regulatory T cells (Tregs) and their cytokines may be involved in the pathogenesis of glucocorticoid responsiveness. Up to now, no confirmed biomarkers have been able to predict SRNS; however, a panel of cytokines may predict responsiveness and identify SRNS patients. Thus, the introduction of distinctive cytokines as novel biomarkers of SRNS enables both preventions of drug-related toxicity and earlier switch to more effective therapies. This review highlights the impacts of T cell population imbalances and their downstream cytokines on response to glucocorticoid responsiveness state in INS.
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Christian MT, Maxted AP. Optimizing the corticosteroid dose in steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:37-47. [PMID: 33611671 PMCID: PMC7896825 DOI: 10.1007/s00467-021-04985-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
The use of corticosteroids in the treatment of steroid-sensitive nephrotic (SSNS) syndrome in children has evolved surprisingly slowly since the ISKDC consensus over 50 years ago. From a move towards longer courses of corticosteroid to treat the first episode in the 1990s and 2000s, more recent large, well-designed randomized controlled trials (RCTs) have unequivocally shown no benefit from an extended course, although doubt remains whether this applies across all age groups. With regard to prevention of relapses, daily ultra-low-dose prednisolone has recently been shown to be more effective than low-dose alternate-day prednisolone. Daily low-dose prednisolone for a week at the time of acute viral infection seems to be effective in the prevention of relapses but the results of a larger RCT are awaited. Recently, corticosteroid dosing to treat relapses has been questioned, with data suggesting lower doses may be as effective. The need for large RCTs to address the question of whether corticosteroid doses can be reduced was the conclusion of the authors of the recent corticosteroid therapy for nephrotic syndrome in children Cochrane update. This review summarizes development in thinking on corticosteroid use in SSNS and makes suggestions for areas that merit further scrutiny.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK.
| | - Andrew P Maxted
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK
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Pasini A, Bertulli C, Casadio L, Corrado C, Edefonti A, Ghiggeri G, Ghio L, Giordano M, La Scola C, Malaventura C, Maringhini S, Mastrangelo AP, Materassi M, Mencarelli F, Messina G, Monti E, Morello W, Puccio G, Romagnani P, Montini G. Childhood Idiopathic Nephrotic Syndrome: Does the Initial Steroid Treatment Modify the Outcome? A Multicentre, Prospective Cohort Study. Front Pediatr 2021; 9:627636. [PMID: 34307246 PMCID: PMC8295604 DOI: 10.3389/fped.2021.627636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/12/2021] [Indexed: 12/02/2022] Open
Abstract
Background: A great majority of children with idiopathic nephrotic syndrome will relapse after successful treatment of the initial episode. The possibility that different steroid dosing regimens at onset, adjusted for risk factors, can reduce the rate of relapse represents an interesting option to investigate. Objectives: To evaluate the effect of the initial steroid regimen, adjusted for time to remission (TTR), on the frequency of relapses and steroid dependence, and to verify the influence of prognostic factors on disease course. Methods: A multicentre, prospective, cohort study. Children with nephrotic syndrome, with TTR ≤ 10 days (Group A), were given a 20-week prednisone regimen (2,828 mg/m2) and those with a TTR >10 days, a 22-week regimen (3,668 mg/m2) (Group B). Previously published retrospective data from the same centers were also evaluated. Main outcomes were: relapse rate, number of frequent relapsers + steroid dependent children and total prednisone dose after induction. Results: 143 children were enrolled. Rate of relapsed subjects (77 vs. 79%) and frequent relapsers + steroid dependent subjects (40 vs. 53%) did not differ between Groups A and B, or between the retrospective and prospective cohorts. The cumulative prednisone dose taken after the induction treatment was similar in both groups and in the retrospective and prospective cohorts. TTR was not associated with relapse risk. Age at onset and total serum protein were significantly lower in relapsing patients. At ROC analysis, the best cut-off was 5.3 years for age at onset and 4.2 g/dL for total serum protein. According to these cut-offs, older children with higher total serum protein had a higher relapse free survival rate (58%) than younger children with lower total serum protein (17%). Conclusions: TTR was not found to be a prognostic factor of relapse; because of this, different steroid regimens, adjusted for TTR, did not modify the relapse rate in any relevant measure. Conversely, younger age and low total serum protein were independent predictors of relapse risk, however this outcome was not modified by higher prednisone regimens. Clinical Trial Registration:https://www.ClinicalTrials.gov/, identifier: NCT01386957 (www.nefrokid.it).
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Affiliation(s)
- Andrea Pasini
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Bertulli
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Casadio
- Unità Operativa Complessa of Paediatrics and Neonatology, Local Health Authority of Romagna, Ravenna, Italy
| | - Ciro Corrado
- Pediatric Nephrology Unit, Children's Hospital “G. Di Cristina”, A.R.N.A.S. “Civico”, Palermo, Italy
| | - Alberto Edefonti
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - GianMarco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, Laboratory on Pathophysiology of Uremia, Istituto G. Gaslini, Genoa, Italy
| | - Luciana Ghio
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Giordano
- Nephrology Unit, Giovanni XXIII Children's Hospital, Bari, Italy
| | - Claudio La Scola
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Malaventura
- Section of Pediatrics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Silvio Maringhini
- Pediatric Nephrology Unit, Children's Hospital “G. Di Cristina”, A.R.N.A.S. “Civico”, Palermo, Italy
| | - Antonio P. Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Materassi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Francesca Mencarelli
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Messina
- Nephrology Unit, Giovanni XXIII Children's Hospital, Bari, Italy
| | - Elena Monti
- Specialty School of Paediatrics - Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Paola Romagnani
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
- Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
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Hahn D, Samuel SM, Willis NS, Craig JC, Hobson EM. Corticosteroid therapy for nephrotic syndrome in children. Cochrane Database Syst Rev 2020; 2020:CD001533. [PMID: 35659203 PMCID: PMC8094227 DOI: 10.1002/14651858.cd001533.pub6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND In nephrotic syndrome protein leaks from blood into the urine through the glomeruli resulting in hypoproteinaemia and generalised oedema. While most children with nephrotic syndrome respond to corticosteroids, 80% experience a relapsing course. Corticosteroids have reduced the death rate to around 3%. However, corticosteroids have well recognised potentially serious adverse effects such as obesity, poor growth, hypertension, diabetes mellitus, osteoporosis, and behavioural disturbances. This is an update of a review first published in 2000 and updated in 2002, 2005, 2007, and 2015. OBJECTIVES The aim of this review was to assess the benefits and harms of different corticosteroid regimens in children with steroid-sensitive nephrotic syndrome (SSNS). The benefits and harms of therapy were studied in two groups of children 1) children in their initial episode of SSNS, and 2) children who experience a relapsing course of SSNS. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 30 May 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) performed in children (one to 18 years) in their initial or subsequent episode of SSNS, comparing different durations, total doses or other dose strategies using any corticosteroid agent. DATA COLLECTION AND ANALYSIS Two authors independently assessed risk of bias and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS In this 2020 review update 16 new included studies were identified providing a total of 48 included studies with 3941 randomised participants. Risk of bias methodology was often poorly performed with only 25 studies and 22 studies respectively assessed to be at low risk for random sequence generation and allocation concealment. Only nine studies (19%) were at low risk of bias for performance (blinding of participants and personnel) and 11 studies were at low risk of detection bias (blinding of outcome assessment); nine of these studies were placebo-controlled RCTs. Twenty-two studies (fewer than 50%) were at low risk for attrition bias and 23 studies were at low risk for reporting bias (selective outcome reporting). In seven studies, which evaluated children in their initial episode of SSNS and were at low risk of bias for selection bias, there is little or no difference in the number of children with frequent relapses when comparing two months of prednisone with three months or more (RR 0.99, 95% CI 0.82 to 1.19; 585 participants, 4 studies; I2 = 0%) or when comparing three months with five to seven months of therapy (RR 0.99, 95% CI 0.74 to 1.33; 376 participants, 3 studies; I2 = 35%; high certainty evidence). In analyses of eight studies at low risk of selection bias, there is little or no difference in the number of children with any relapse by 12 to 24 months when comparing two months of prednisone with three months or more (RR 0.91, 95% CI 0.78 to 1.06; 637 participants; 5 studies; I2 = 47%) or when comparing three months with five to seven months of therapy (RR 0.88, 95% CI 0.70 to 1.11; 377 participants, 3 studies; I2 = 53%). Little or no difference was noted in adverse effects between the different treatment durations. Among children with relapsing SSNS, two small studies showed that time to remission did not differ between prednisone doses of 1 mg/kg compared with the conventional dose of 2 mg/kg (MD 0.71 days, 95% CI -0.43 to 1.86; 79 participants) and that the total prednisone dose administered was lower (MD -20.60 mg/kg, 95% CI -25.65 to -15.55; 20 participants). Two studies found little or no difference in the number with relapse at six months when comparing dosing by weight with dosing by surface area (RR 1.03, 95% CI 0.71 to 1.49; 146 participants). One study found a reduced risk of relapse with low daily dosing compared with alternate daily dosing (MD -0.90 number of relapses/year, 95% CI -1.33 to -0.47). Four studies found that in children with frequently relapsing disease, daily prednisone during viral infections compared with alternate-day prednisone or no treatment reduced the risk of relapse. AUTHORS' CONCLUSIONS There are now four well designed studies randomising 823 children which have clearly demonstrated that there is no benefit of prolonging prednisone therapy beyond two to three months in the first episode of SSNS. Small studies in children with relapsing disease have identified no differences in the times to remission using half the conventional induction dose of 2 mg/kg or 60 mg/m2. It is imperative that a much larger study be carried out to confirm these findings. Lower dose prednisone therapy administered daily during an upper respiratory infection or other infection reduces the risk of relapse compared with continuing alternate-day prednisone or no prednisone based on four small studies. The results of a much larger RCT enrolling more than 300 children are awaited to determine the relative efficacies and adverse effects of using alternate-day compared with daily prednisone to prevent relapse in children with intercurrent infections.
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Affiliation(s)
- Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Susan M Samuel
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Narelle S Willis
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elisabeth M Hobson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Rituximab for very low dose steroid-dependent nephrotic syndrome in children: a randomized controlled study. Pediatr Nephrol 2020; 35:1437-1444. [PMID: 32232637 DOI: 10.1007/s00467-020-04540-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Steroid-dependent nephrotic syndrome (SDNS) carries a high risk of toxicity from steroids or steroid-sparing agents. This open-label, randomized controlled trial was designed to test whether the monoclonal antibody rituximab is non-inferior to steroids in maintaining remission in juvenile forms of SDNS and how long remission may last (EudraCT:2008-004486-26). METHODS We enrolled 30 children 4-15 years who had developed SDNS 6-12 months before and were maintained in remission with low prednisone doses (0.1-0.4 mg/Kg/day). Participants were randomized following a non-inferiority design to continue prednisone alone (n 15, controls) or to add a single intravenous infusion of rituximab (375 mg/m2, n 15 intervention). Prednisone was tapered in both arms after 1 month. Children assigned to the control arm were allowed to receive rituximab to treat disease relapse. RESULTS Proteinuria increased at 3 months in the prednisone group (from 0.14 to 1.5 g/day) (p < 0.001) and remained unchanged in the rituximab group (0.14 g/day). Fourteen children in the control arm relapsed within 6 months. Thirteen children assigned to rituximab (87%) were still in remission at 1 year and 8 (53%) at 4 years. Responses were similar in children of the control group who received rituximab to treat disease relapse. We did not record significant adverse events. CONCLUSIONS Rituximab was non-inferior to steroids for the treatment of juvenile SDNS. One in two children remains in remission at 4 years following a single infusion of rituximab, without significant adverse events. Further studies are needed to clarify the superiority of rituximab over low-dose corticosteroid as a treatment of SDNS.
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Wands D, Reynolds BC. Extended initial course of prednisolone did not improve clinical outcomes in steroid-sensitive nephrotic syndrome. Arch Dis Child Educ Pract Ed 2020; 105:189. [PMID: 31619452 DOI: 10.1136/archdischild-2019-318060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- David Wands
- Gastroenterology, Hepatology and Clinical Nutrition, Royal Hospital for Children, Glasgow, UK
| | - Ben C Reynolds
- Paediatric Renal Unit, Royal Hospital for Children, Glasgow, UK
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Webb NJA, Woolley RL, Lambe T, Frew E, Brettell EA, Barsoum EN, Trompeter RS, Cummins C, Deeks JJ, Wheatley K, Ives NJ. Long term tapering versus standard prednisolone treatment for first episode of childhood nephrotic syndrome: phase III randomised controlled trial and economic evaluation. BMJ 2019; 365:l1800. [PMID: 31335316 PMCID: PMC6531851 DOI: 10.1136/bmj.l1800] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine whether extending initial prednisolone treatment from eight to 16 weeks in children with idiopathic steroid sensitive nephrotic syndrome improves the pattern of disease relapse. DESIGN Double blind, parallel group, phase III randomised placebo controlled trial, including a cost effectiveness analysis. SETTING 125 UK National Health Service district general hospitals and tertiary paediatric nephrology centres. PARTICIPANTS 237 children aged 1-14 years with a first episode of steroid sensitive nephrotic syndrome. INTERVENTIONS Children were randomised to receive an extended 16 week course of prednisolone (total dose 3150 mg/m2) or a standard eight week course of prednisolone (total dose 2240 mg/m2). The drug was supplied as 5 mg tablets alongside matching placebo so that participants in both groups received the same number of tablets at any time point in the study. A minimisation algorithm ensured balanced treatment allocation by ethnicity (South Asian, white, or other) and age (5 years or less, 6 years or more). MAIN OUTCOME MEASURES The primary outcome measure was time to first relapse over a minimum follow-up of 24 months. Secondary outcome measures were relapse rate, incidence of frequently relapsing nephrotic syndrome and steroid dependent nephrotic syndrome, use of alternative immunosuppressive treatment, rates of adverse events, behavioural change using the Achenbach child behaviour checklist, quality adjusted life years, and cost effectiveness from a healthcare perspective. Analysis was by intention to treat. RESULTS No significant difference was found in time to first relapse (hazard ratio 0.87, 95% confidence interval 0.65 to 1.17, log rank P=0.28) or in the incidence of frequently relapsing nephrotic syndrome (extended course 60/114 (53%) v standard course 55/109 (50%), P=0.75), steroid dependent nephrotic syndrome (48/114 (42%) v 48/109 (44%), P=0.77), or requirement for alternative immunosuppressive treatment (62/114 (54%) v 61/109 (56%), P=0.81). Total prednisolone dose after completion of the trial drug was 6674 mg for the extended course versus 5475 mg for the standard course (P=0.07). There were no statistically significant differences in serious adverse event rates (extended course 19/114 (17%) v standard course 27/109 (25%), P=0.13) or adverse event rates, with the exception of behaviour, which was poorer in the standard course group. Scores on the Achenbach child behaviour checklist did not, however, differ. Extended course treatment was associated with a mean increase in generic quality of life (0.0162 additional quality adjusted life years, 95% confidence interval -0.005 to 0.037) and cost savings (difference -£1673 ($2160; €1930), 95% confidence interval -£3455 to £109). CONCLUSIONS Clinical outcomes did not improve when the initial course of prednisolone treatment was extended from eight to 16 weeks in UK children with steroid sensitive nephrotic syndrome. However, evidence was found of a short term health economic benefit through reduced resource use and increased quality of life. TRIAL REGISTRATION ISRCTN16645249; EudraCT 2010-022489-29.
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Affiliation(s)
- Nicholas J A Webb
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9PL, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tosin Lambe
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Elizabeth A Brettell
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Emma N Barsoum
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan J Deeks
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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Schijvens AM, Dorresteijn EM, Roeleveld N, Ter Heine R, van Wijk JAE, Bouts AHM, Keijzer-Veen MG, van de Kar NCAJ, van den Heuvel LPWJ, Schreuder MF. REducing STEroids in Relapsing Nephrotic syndrome: the RESTERN study- protocol of a national, double-blind, randomised, placebo-controlled, non-inferiority intervention study. BMJ Open 2017; 7:e018148. [PMID: 28963315 PMCID: PMC5623563 DOI: 10.1136/bmjopen-2017-018148] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Oral corticosteroids are the first-line treatment for idiopathic childhood nephrotic syndrome. Most children experience several relapses, needing repeated courses of corticosteroid therapy. This exposes them to side effects and long-term complications. For most patients, long-term prognosis is for complete resolution of the disease over time and maintenance of normal kidney function. Therefore, it is vital to focus on minimising adverse events of the disease and its therapy. Unfortunately, no randomised controlled trials are available to determine the optimal corticosteroid treatment of an infrequent relapse of nephrotic syndrome. Recent studies show that treatment schedules for the first episode can safely be shortened to 2 months. The hypothesis of the REducing STEroids in Relapsing Nephrotic syndrome (RESTERN) study is that a 4-week reduction of alternate-day steroids after inducing remission is effective and safe, reduces steroid exposure by 35% on average and is therefore preferable. METHODS AND ANALYSIS The RESTERN study is a nationwide, double-blind, randomised, placebo-controlled, non-inferiority intervention study. Children aged 1-18 years with a relapse of steroid-sensitive nephrotic syndrome are eligible for this study. Study subjects (n=144) will be randomly assigned to either current standard therapy in the Netherlands or a reduced prednisolone schedule. The primary outcome of the RESTERN study is the time to first relapse after the final prednisolone dose. The secondary outcomes are the number or relapses, progression to frequent relapsing or steroid dependent nephrotic syndrome and the cumulative dosage of prednisolone during the study period. ETHICS AND DISSEMINATION This non-inferiority trial will be performed in accordance with the Declaration of Helsinki and has been approved by the medical ethical committee of Arnhem-Nijmegen and the Dutch Competent Authority (Central Committee on Research Involving Human Subjects, CCMO). After completion of this study, results will be published in national and international peer-reviewed scientific journals. Papers will be published according to CCMO guidelines. The final report will be made available to trial participants. TRIAL REGISTRATION NUMBER NTR5670, EudraCT no 2016-002430-76.
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Affiliation(s)
- A M Schijvens
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - E M Dorresteijn
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - N Roeleveld
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - R Ter Heine
- Department of Pharmacy, Radboudumc, Nijmegen, The Netherlands
| | - J A E van Wijk
- Department of Pediatric Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - A H M Bouts
- Department of Pediatric Nephrology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - M G Keijzer-Veen
- Department of Pediatric Nephrology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N C A J van de Kar
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - L P W J van den Heuvel
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
- Department of Growth and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - M F Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
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Wang J, Mao J, Chen J, Fu H, Shen H, Zhu X, Liu A, Shu Q, Du L. Evaluation of mycophenolate mofetil or tacrolimus in children with steroid sensitive but frequently relapsing or steroid-dependent nephrotic syndrome. Nephrology (Carlton) 2016; 21:21-7. [PMID: 26697959 DOI: 10.1111/nep.12537] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 11/28/2022]
Abstract
AIM Approximately 30-40% of children with steroid sensitive nephrotic syndrome have frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS). Mycophenolate mofetil (MMF) and tacrolimus (TAC) are often alternative treatment choices for these patients. METHODS A single-center prospective study was conducted to compare the efficacy of MMF or TAC in reducing relapses and maintaining remission in children with FRNS or SDNS. Of the 72 recruited patients, either MMF (20∼30 mg/kg/d, n = 34) or TAC (0.05∼0.15 mg/kg/d, n = 38) was administered for 12 months. RESULTS The mean 6-month relapse rates decreased from 2.56 episodes before therapy to 0.76 episodes in the first 6 months after therapy (c(2) = 44.362, p < 0.001) and 0.67 in the next 6 months (c(2) = 37.817, p < 0.001) in the MMF group. In the TAC group, the mean 6-month relapse rates decreased from 2.39 episodes before therapy to 0.41 episodes in the first 6 months after therapy (c(2) = 62.242, p < 0.001) and 0.42 in next 6 months (c(2) = 67.482, p < 0.001). No significant difference in the relapse rate was found between the groups (before therapy, c(2) = 0.902, p = 0.637; first 6 months, c(2) = 5.358, p = 0.147; second 6 months, c(2) = 4.089, p = 0.252). And there was also no significant difference in cumulative sustained remission and the incidence of adverse events between two groups. CONCLUSIONS In combination with low-dose steroids, MMF or TAC presented similar efficacy in maintaining remission in children with FRNS/SDNS in the present study. Therapy with MMF or TAC is a promising strategy with a moderate risk of side effects in children who are steroid sensitive but have FRNS/SDNS.
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Affiliation(s)
- Jingjing Wang
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Jianhua Mao
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Junyi Chen
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Haidong Fu
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Huijun Shen
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiujuan Zhu
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Aimin Liu
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Qiang Shu
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lizhong Du
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
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Hevia P, Nazal V, Rosati MP, Quiroz L, Alarcón C, Márquez S, Cuevas K. [Idiopathic Nephrotic Syndrome: recommendations of the Nephrology Branch of the Chilean Society of Pediatrics. Part One]. ACTA ACUST UNITED AC 2015; 86:291-8. [PMID: 26362970 DOI: 10.1016/j.rchipe.2015.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 04/29/2015] [Accepted: 05/13/2015] [Indexed: 01/04/2023]
Abstract
Idiopathic nephrotic syndrome is the most common glomerular disease in childhood, affecting 1 to 3 per 100,000 children under the age of 16. It most commonly occurs in ages between 2 and 10. Its cause is unknown and its histology corresponds to minimal change disease in 90% of cases, or focal segmental glomerulosclerosis. 80 to 90% of cases respond to steroids (steroid-sensitive nephrotic syndrome) with good prognosis and long-term preservation of renal function over time. 70% of patients with SSNS have one or more relapses in their evolution, and of these, 50% behave as frequent relapsing or steroid-dependent, a group that concentrate the risk of steroid toxicity. Patients with steroid-resistant nephrotic syndrome have a poor prognosis and 50% of them evolve to end-stage renal disease. The goal of therapy is to induce and maintain remission of the disease, reducing the risk secondary to proteinuria while minimizing the adverse effects of treatments, especially with prolonged use of corticosteroids. This paper is the result of the collaborative effort of the Nephrology Branch of the Chilean Society of Pediatrics with aims at helping pediatricians and pediatric nephrologists to treat pediatric SNI. In this first part, recommendations of steroid-sensitive nephrotic syndrome are discussed.
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Affiliation(s)
- Pilar Hevia
- Unidad de Nefrología, Hospital San Juan de Dios, Santiago, Chile.
| | - Vilma Nazal
- Unidad de Nefrología, Hospital Metropolitano La Florida, Santiago, Chile
| | - María Pía Rosati
- Unidad de Nefrología, Hospital San Juan de Dios, Santiago, Chile
| | - Lily Quiroz
- Unidad de Nefrología, Hospital de Carabineros, Santiago, Chile
| | - Claudia Alarcón
- Unidad de Nefrología, Hospital Felix Bulnes, Santiago, Chile
| | - Sonia Márquez
- Unidad de Nefrología, Complejo Asistencial Dr. Sótero del Río, Santiago, Chile
| | - Karen Cuevas
- Unidad de Nefrología, Hospital San Juan de Dios, Santiago, Chile
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Abstract
BACKGROUND In nephrotic syndrome protein leaks from the blood to the urine through the glomeruli resulting in hypoproteinaemia and generalised oedema. While most children with nephrotic syndrome respond to corticosteroids, 80% experience a relapsing course. Corticosteroids have reduced the mortality rate to around 3%. However corticosteroids have well recognised potentially serious adverse effects such as obesity, poor growth, hypertension, diabetes mellitus, osteoporosis and behavioural disturbances. This is an update of a review first published in 2000 and updated in 2003, 2005 and 2007. OBJECTIVES The aim of this review was to assess the benefits and harms of different corticosteroid regimens in children with steroid-sensitive nephrotic syndrome (SSNS). The benefits and harms of therapy were studied in two groups of children 1) children in their initial episode of SSNS, and 2) children who experience a relapsing course of SSNS. SEARCH METHODS We searched the Cochrane Renal Group's Specialised Register to 26 February 2015 through contact with the Trials Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) performed in children (three months to 18 years) in their initial or subsequent episode of SSNS, comparing different durations, total doses or other dose strategies using any corticosteroid agent. DATA COLLECTION AND ANALYSIS Two authors independently assessed risk of bias and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS Ten new studies were identified so a total of 34 studies (3033 total participants) were included in the 2015 review update. The risk of bias attributes were frequently poorly performed. Low risk of bias was reported in 18 studies for sequence generation, 16 studies for allocation concealment, seven for performance and detection bias, 15 for incomplete reporting and 16 for selective reporting. Three months or more of prednisone significantly reduced the risk of frequently relapsing nephrotic syndrome (FRNS) (6 studies, 582 children: RR 0.68, 95% CI 0.47 to 1.00) and of relapse by 12 to 24 months (8 studies, 741 children: RR 0.80, 95% CI 0.64 to 1.00) compared with two months. Five or six months of prednisone significantly reduced the risk of relapse (7 studies, 763 children: RR 0.62, 95% CI 0.45 to 0.85) but not FRNS (5 studies, 591 children: RR 0.78, 95% CI 0.50 to 1.22) compared with three months. However there was significant heterogeneity in the analyses. Subgroup analysis stratified by risk of bias for allocation concealment showed that the risk for FRNS did not differ significantly between two or three months of prednisone and three to six months among studies at low risk of bias but was significantly reduced in extended duration studies compared with two or three months in studies at high risk or unclear risk of bias. There were no significant differences in the risk of adverse effects between extended duration and two or three months of prednisone. Four studies found that in children with FRNS, daily prednisone during viral infections compared with alternate-day prednisone or no treatment significantly reduced the rate of relapse. AUTHORS' CONCLUSIONS In this 2015 update the addition of three well-designed studies has changed the conclusion of this review. Studies of long versus shorter duration of corticosteroids have heterogeneous treatment effects, with the older high risk of bias studies tending to over-estimate the effect of longer course therapy, compared with more recently published low risk of bias studies. Among studies at low risk of bias, there was no significant difference in the risk for FRNS between prednisone given for two or three months and longer durations or total dose of therapy indicating that there is no benefit of increasing the duration of prednisone beyond two or three months in the initial episode of SSNS.The risk of relapse in children with FRNS is reduced by the administration of daily prednisone at onset of an upper respiratory tract or viral infection. Three additional studies have increased the evidence supporting this conclusion. This management strategy may be considered for children with FRNS. A paucity of data on prednisone use in relapsing nephrotic syndrome remains. In particular there are no data from RCTs evaluating the efficacy and safety of prolonged courses of low dose alternate-day prednisone although this management strategy is recommended in current guidelines.
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Affiliation(s)
- Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145
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Ravani P, Rossi R, Bonanni A, Quinn RR, Sica F, Bodria M, Pasini A, Montini G, Edefonti A, Belingheri M, De Giovanni D, Barbano G, Degl'Innocenti L, Scolari F, Murer L, Reiser J, Fornoni A, Ghiggeri GM. Rituximab in Children with Steroid-Dependent Nephrotic Syndrome: A Multicenter, Open-Label, Noninferiority, Randomized Controlled Trial. J Am Soc Nephrol 2015; 26:2259-66. [PMID: 25592855 DOI: 10.1681/asn.2014080799] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 11/18/2014] [Indexed: 01/03/2023] Open
Abstract
Steroid-dependent nephrotic syndrome (SDNS) carries a high risk of toxicity from steroids or steroid-sparing agents. This open-label, noninferiority, randomized controlled trial at four sites in Italy tested whether rituximab is noninferior to steroids in maintaining remission in juvenile SDNS. We enrolled children age 1-16 years who had developed SDNS in the previous 6-12 months and were maintained in remission with high prednisone doses (≥0.7 mg/kg per day). We randomly assigned participants to continue prednisone alone for 1 month (control) or to add a single intravenous infusion of rituximab (375 mg/m(2); intervention). Prednisone was tapered in both groups after 1 month. For noninferiority, rituximab had to permit steroid withdrawal and maintain 3-month proteinuria (mg/m(2) per day) within a prespecified noninferiority margin of three times the levels among controls (primary outcome). We followed participants for ≥1 year to compare risk of relapse (secondary outcome). Fifteen children per group (21 boys; mean age, 7 years [range, 2.6-13.5 years]) were enrolled and followed for ≤60 months (median, 22 months). Three-month proteinuria was 42% lower in the rituximab group (geometric mean ratio, 0.58; 95% confidence interval, 0.18 to 1.95 [i.e., within the noninferiority margin of three times the levels in controls]). All but one child in the control group relapsed within 6 months; median time to relapse in the rituximab group was 18 months (95% confidence interval, 9 to 32 months). In the rituximab group, nausea and skin rash during infusion were common; transient acute arthritis occurred in one child. In conclusion, rituximab was noninferior to steroids for the treatment of juvenile SDNS.
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Affiliation(s)
- Pietro Ravani
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada;
| | - Roberta Rossi
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Alice Bonanni
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Robert R Quinn
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Felice Sica
- Division of Pediatrics, Hospital of Foggia, Foggia, Italy
| | - Monica Bodria
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Andrea Pasini
- Nephrology and Pediatric Dialysis, Department of Pediatrics, Azienda Ospedaliera Universitaria Sant'Orsola, Bologna, Italy
| | - Giovanni Montini
- Nephrology and Pediatric Dialysis, Department of Pediatrics, Azienda Ospedaliera Universitaria Sant'Orsola, Bologna, Italy
| | - Alberto Edefonti
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mirco Belingheri
- Pediatric Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Giancarlo Barbano
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Ludovica Degl'Innocenti
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Francesco Scolari
- Division of Nephrology and Dialysis, Ospedale di Montichiari Azienda Ospedaliera Spedali Civili di Brescia, Brescia, Italy
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Pediatrics, University Hospital of Padua, Padua, Italy
| | - Jochen Reiser
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois; and
| | - Alessia Fornoni
- Miller School of Medicine, University of Miami, Miami, Florida
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, Giannina Gaslini Children's Hospital, Genoa, Italy
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Absar A, Diamond M, Sonia Y, Arshalooz R, Safia A, Waqar K, Shahid P. Ten year experience of pediatric kidney biopsies from a single center in Pakistan. Indian J Nephrol 2011; 20:190-2. [PMID: 21206680 PMCID: PMC3008947 DOI: 10.4103/0971-4065.73446] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
There are many established registries of kidney biopsies around the world. In addition, there are several reports available in literature from many countries on pediatric kidney biopsy. This study was done to determine the indications and pathological patterns of kidney biopsies of children referred to our hospital, and compare our data with the data available from other countries. This is a cross-sectional study of pediatric kidney biopsies over a 10-year period, from January 1997 to December 2006. All biopsies were done in Aga Khan University Hospital, Karachi, Pakistan. Age range was from 1 to 14 years. Data were analyzed for indications and histopathological diagnosis. A total of 54 kidney biopsies were included in the initial analysis. Here 13 samples were excluded and final analysis was done on the remaining 41 samples. The most common indication of kidney biopsy was nephrotic syndrome in 25 samples (61%). The most common histopathology was minimal change disease in 15 (37%), followed by focal segmental glomerulosclerosis in 5 (12%) of the biopsies.
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Affiliation(s)
- A Absar
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi - 74800, Pakistan
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C1q nephropathy in the pediatric population: pathology and pathogenesis. Pediatr Nephrol 2010; 25:1385-96. [PMID: 20180137 DOI: 10.1007/s00467-009-1429-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 12/11/2009] [Accepted: 12/15/2009] [Indexed: 10/19/2022]
Abstract
C1q nephropathy was originally described nearly 25 years ago by Jennette and Hipp. Since that time there have been a limited number of publications on C1q nephropathy, most of them in the pediatric literature. Despite reported incidences as high as 16% in some pediatric biopsy series, a consensus definition on the diagnosis of C1q nephropathy is lacking and its existence as a distinct clinical disease entity remains controversial. The purpose of this review is to discuss the biology of C1q in the context of mechanisms of C1q deposition, and to provide a detailed analysis of the published pediatric case series with a focus on the pathological criteria used to establish the diagnosis of C1q nephropathy as well as long-term outcomes in children.
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Early age at debut is a predictor of steroid-dependent and frequent relapsing nephrotic syndrome. Pediatr Nephrol 2010; 25:1299-304. [PMID: 20446093 DOI: 10.1007/s00467-010-1537-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/13/2010] [Accepted: 03/31/2010] [Indexed: 10/19/2022]
Abstract
The purpose of this study was to identify characteristics of patients with steroid-sensitive nephrotic syndrome (SSNS) that point to a high risk of frequent relapsing (FR) or steroid-dependent (SD) SSNS. A retrospective analysis of 54 consecutive patients with SSNS was performed. In this cohort, the incidence of idiopathic NS was 1.9/100,000, age at debut was 5.5 years, and the mean follow-up was 4.0 years. A total of 56% (30/54) of our patients were classified with FR/SD SSNS. FR/SD patients were significantly younger at debut than non-FR/SD patients (3.5 vs. 8.5 years, respectively; p < 0.002). Males were overrepresented in the FR/SD group (69 vs. 38%; p = 0.03). No differences were found in terms of haematuria, hypoalbuminaemia, or days to achieve remission. In total, 31 and 23 patients were on a 6 + 6-week (pred-long) and 4 + 4-week (pred-short) steroid treatment regimen, respectively. There was a reduction in the number of FR/SD patients in the pred-long group relative to the pred-short group (38 vs. 80%, respectively). In the pred-long group, the 12 FR/SD patients were younger than the 19 non-FR/SD patients (4.4 +/- 3.1 vs. 8.4 +/- 4.1 years; p<0.005). Low age at debut and male gender was associated with a high risk of SD/FR in this unselected series of SSNS patients despite the prolongation of the steroid course at debut of SSNS.
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Gipson DS, Massengill SF, Yao L, Nagaraj S, Smoyer WE, Mahan JD, Wigfall D, Miles P, Powell L, Lin JJ, Trachtman H, Greenbaum LA. Management of childhood onset nephrotic syndrome. Pediatrics 2009; 124:747-57. [PMID: 19651590 DOI: 10.1542/peds.2008-1559] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The therapeutic approach to childhood nephrotic syndrome is based on a series of studies that began with an international collaborative effort sponsored by the International Study of Kidney Disease in Children in 1967. The characteristics of children presenting with nephrotic syndrome have changed over recent decades with greater frequency of the challenging condition focal segmental glomerulosclerosis and a greater prevalence of obesity and diabetes mellitus, which may be resistant to glucocorticoids in the former and exacerbated by long-term glucocorticoid therapy in the latter 2 conditions. The Children's Nephrotic Syndrome Consensus Conference was formed to systematically review the published literature and generate a children's primary nephrotic syndrome guideline for use in educational, therapeutic, and research venues.
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Affiliation(s)
- Debbie S Gipson
- Division of Nephrology and Hypertension, Department ofMedicine and Pediatrics, University of North Carolina, ChapelHill, North Carolina 27599-7155, USA.
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Yokote Y, Kimura E, Kimura M, Kozono Y. Biomechanical analysis of combined treatment of high calcium and bisphosphonate in tibia of steroid-treated growing-phase rats. Dent Mater J 2009; 27:647-53. [PMID: 18972779 DOI: 10.4012/dmj.27.647] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Childhood systemic diseases are commonly treated with steroids. Consequently, steroid-induced osteoporosis is often observed as a side effect of steroid therapy. However, osteoporosis of tibia resulting from steroid therapy has not been reported yet. Herein we constructed a steroid-induced osteoporosis in tibia of the growing phase rats to examine internal structural changes of the bone and tried to find out the effect of bisphosphonates as a new and early treatment method. Biomechanical analysis was performed using two-dimensional microdensitometry and three-dimensional pQCT method. In addition, the following evaluations were carried out: noninvasive bone strength measurements in steroid-induced osteoporotic rat tibiae; comparing the effectiveness of single high-calcium diet versus combined treatment of high calcium and bisphosphonate for osteoporosis; and quantitative measurement of four elements (Ca, P, Mg, Zn) in bone matrix. Our data suggested that a combined treatment of high calcium and bisphosphonate was an effective new method to improve and treat steroid-induced osteoporosis in childhood.
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Affiliation(s)
- Yusuke Yokote
- Yokote Dental Clinic, 107-1 Koro, Koderacho, Himeji, Hyogo, 679-2151, Japan
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Bacchetta J, Harambat J, Cochat P. Corticothérapie prolongée chez l’enfant : quelle place pour un traitement adjuvant dans le syndrome néphrotique ? Arch Pediatr 2008; 15:1685-92. [DOI: 10.1016/j.arcped.2008.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 07/02/2008] [Accepted: 08/08/2008] [Indexed: 10/21/2022]
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Mrkobrada M, Thiessen-Philbrook H, Haynes RB, Iansavichus AV, Rehman F, Garg AX. Need for quality improvement in renal systematic reviews. Clin J Am Soc Nephrol 2008; 3:1102-14. [PMID: 18400967 PMCID: PMC2440265 DOI: 10.2215/cjn.04401007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 02/11/2008] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Systematic reviews of clinical studies aim to compile best available evidence for various diagnosis and treatment options. This study assessed the methodologic quality of all systematic reviews relevant to the practice of nephrology published in 2005. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We searched electronic databases (Medline, Embase, American College of Physicians Journal Club, Cochrane) and hand searched Cochrane renal group records. Clinical practice guidelines, case reports, narrative reviews, and pooled individual patient data meta-analyses were excluded. Methodologic quality was measured using a validated questionnaire (Overview Quality Assessment Questionnaire). For reviews of randomized trials, we also evaluated adherence to recommended reporting guidelines (Quality of Reporting of Meta-Analyses). RESULTS Ninety renal systematic reviews were published in year 2005, 60 of which focused on therapy. Many systematic reviews (54%) had major methodologic flaws. The most common review flaws were failure to assess the methodologic quality of included primary studies and failure to minimize bias in study inclusion. Only 2% of reviews of randomized trials fully adhered to reporting guidelines. A minority of journals (four of 48) endorsed adherence to consensus guidelines for review reporting, and these journals published systematic reviews of higher methodologic quality (P < 0.001). CONCLUSIONS The majority of systematic reviews had major methodologic flaws. The majority of journals do not endorse consensus guidelines for review reporting in their instructions to authors; however, journals that recommended such adherence published systemic reviews of higher methodologic quality.
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Affiliation(s)
- Marko Mrkobrada
- Division of Nephrology, University of Western Ontario, London, Ontario, Canada
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Abstract
BACKGROUND In nephrotic syndrome (NS) protein leaks from the blood to the urine through the glomeruli resulting in hypoproteinaemia and generalised oedema. While the majority of children with NS respond to corticosteroids, 70% experience a relapsing course. Corticosteroids have reduced the mortality rate to around 3%. However corticosteroids have well recognised potentially serious adverse effects such as obesity, poor growth, hypertension, diabetes mellitus and osteoporosis. OBJECTIVES To determine the benefits and harms of corticosteroid regimens in preventing relapse in children with steroid sensitive NS (SSNS). SEARCH STRATEGY We searched CENTRAL, Cochrane Renal Group Specialised Register, MEDLINE and EMBASE without language restriction, reference lists of articles and contact with known investigators. Date of last search: December 2006 SELECTION CRITERIA Randomised controlled trials performed in children (three months to 18 years) in their initial or subsequent episode of SSNS, comparing different durations, total doses or other dose strategies using any corticosteroid agent, with outcome data at six months or more. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. Results were expressed as relative risk (RR) with 95% confidence intervals (CI) or mean difference (WMD). Meta-regression was used to explore potential between-study differences due to baseline risk of relapse, study quality and interventions. MAIN RESULTS Twenty four trials were identified. Six trials comparing two months of prednisone or prednisolone with three months or more in the first episode showed longer duration significantly reduced the risk of relapse at 12 to 24 months (RR 0.70, 95% CI 0.58 to 0.84). There was an inverse linear relationship between treatment duration and risk of relapse (RR = 1.26 - 0.112 duration; P = 0.03). Four trials showed that six months of prednisone was more effective than three months in reducing the risk for relapse (RR 0.57; 95% CI 0.45 to 0.71). Deflazacort was significantly more effective in maintaining remission than prednisone in children who frequently relapsed in a single study (RR 0.44, 95% CI 0.25 to 0.78). There were no increases in adverse events. AUTHORS' CONCLUSIONS Children in their first episode of SSNS should be treated for at least three months with an increase in benefit for up to seven months of treatment. For a baseline risk for relapse following the first episode of 60% with two months of therapy, daily prednisone or prednisolone given for four weeks followed by alternate-day therapy for six months would reduce the number of children relapsing by 33%.
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Affiliation(s)
- E M Hodson
- Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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Deflazacort: a glucocorticoid with few metabolic adverse effects but important immunosuppressive activity. Adv Ther 2007; 24:1052-60. [PMID: 18029332 DOI: 10.1007/bf02877711] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Deflazacort (DFZ) is a synthetic glucocorticoid that has few adverse effects on glucose and calcium metabolism and fewer deleterious effects on the neuronal population. Therefore, it may have a crucial role in the treatment of patients with autoimmune disorders associated with central nervous system or metabolic affectations. To date, the pharmacologic safety profile of DFZ is considered similar to that of other glucocorticoids. Nevertheless, cumulative clinical and laboratory evidence suggests that DFZ has, in fact, greater immunosuppressive activity than was previously thought. Therefore, it is possible that DFZ increases the risk of acquiring opportunistic infection compared with other synthetic glucocorticoids. Additional pharmacologic studies are needed to fully establish the immunosuppressive potency of DFZ and, consequently, to determine the appropriate ratio of bioequivalence in humans.
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Gbadegesin R, Hinkes B, Vlangos C, Mucha B, Liu J, Hopcian J, Hildebrandt F. Mutational analysis of NPHS2 and WT1 in frequently relapsing and steroid-dependent nephrotic syndrome. Pediatr Nephrol 2007; 22:509-13. [PMID: 17216259 DOI: 10.1007/s00467-006-0377-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Revised: 09/25/2006] [Accepted: 10/16/2006] [Indexed: 10/23/2022]
Abstract
Idiopathic nephrotic syndrome is a common pediatric kidney disease, 80% of all cases are steroid sensitive (SSNS). A significant proportion of children with SSNS will have a frequently relapsing or steroid-dependent course (FRNS/SDNS) that is associated with significant treatment-related morbidity. Mutations in NPHS2 account for more than 28% of all cases of steroid-resistant nephrotic syndrome (SRNS) and dominant mutations in WT1 for 5%; while mutations are absent from children with uncomplicated SSNS. Since FRNS/SDNS is phenotypically positioned within a spectrum between SSNS and SRNS, we hypothesized that heterozygous mutations of NPHS2 may be causing FRNS/SDNS. Mutational analysis of NPHS2 and WT1 was carried out in a single-center cohort of 20 children with FRNS/SDNS, ten children with uncomplicated SSNS (control), and 22 children with SRNS (control). Renal biopsy findings were available in 15/20 children with FRNS/SDNS and revealed IgM nephropathy, MCNS, and FSGS in six, five, and four children, respectively. Children with FRNS/SDNS were significantly younger at first presentation than those with SSNS and SRNS (median age: 3.0 years in FRNS/SDNS patients, 7.0 years in SSNS patients, and 5.0 in SRNS patients; p < 0.001). No NPHS2 or WT1 mutations were found in patients with FRNS/SDNS and uncomplicated SSNS. The hypothesis that FRNS/SDNS may be associated with heterozygous mutations in NPHS2 or WT1 was not confirmed.
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Affiliation(s)
- Rasheed Gbadegesin
- Department of Pediatrics, Division of Nephrology, Ann Arbor, MI 48109, USA
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Abstract
Clinical practice in paediatric nephrology is continuously evolving to mirror the research output of the 21st century. The management of antenatally diagnosed renal anomalies, urinary tract infections, nephrotic syndrome and hypertension is becoming more evidence based. Obesity and related hypertension is being targeted at primary and secondary care. The evolving field of molecular and cytogenetics is discovering genes that are facilitating clinicians and families with prenatal diagnoses and understanding of disease processes. The progression of chronic kidney disease in childhood to end-stage renal failure (ESRF) can be delayed using medical treatment to reduce proteinuria and treat hypertension. Pre-emptive living-related renal transplantation has become the treatment of choice for children with ESRF, thereby reducing the morbidity and mortality associated with peritoneal and haemodialysis. Although peritoneal dialysis, which is performed in the patient's home, is the preferred modality for children for whom there is no living or deceased donor for transplantation, home nocturnal haemodialysis is becoming a feasible option. Imaging modalities with the use of magnetic resonance and computerised tomography are continuously improving. As mortality for renal and vasculitic diseases improves, the gauntlet is now thrown down to reduce morbidity with secondary prevention of longer-term complications such as atherosclerosis and hyperlipidaemia. Clinical and drug trials in the fields of hypertension, nephrotic syndrome, systemic lupus erythematosus, vasculitis and transplantation are producing more effective treatments, thereby reducing the morbidity resulting from the disease processes and the side effects of drugs.
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Affiliation(s)
- Stephen D Marks
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK.
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Woroniecki RP, Orlova TN, Mendelev N, Shatat IF, Hailpern SM, Kaskel FJ, Goligorsky MS, O'Riordan E. Urinary proteome of steroid-sensitive and steroid-resistant idiopathic nephrotic syndrome of childhood. Am J Nephrol 2006; 26:258-67. [PMID: 16763371 DOI: 10.1159/000093814] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2006] [Accepted: 05/03/2006] [Indexed: 11/19/2022]
Abstract
The response to steroid therapy is used to characterize the idiopathic nephrotic syndrome (INS) of childhood as either steroid-sensitive (SSNS) or steroid-resistant (SRNS), a classification with a better prognostic capability than renal biopsy. The majority (approximately 80%) of INS is due to minimal change disease but the percentage of focal and segmental glomerulosclerosis is increasing. We applied a new technological platform to examine the urine proteome to determine if different urinary protein excretion profiles could differentiate patients with SSNS from those with SRNS. Twenty-five patients with INS and 17 control patients were studied. Mid-stream urines were analyzed using surface enhanced laser desorption and ionization mass spectrometry(SELDI-MS). Data were analyzed using multiple bioinformatic techniques. Patient classification was performed using Biomarker Pattern Software and a generalized form of Adaboost and predictive models were generated using a supervised algorithm with cross-validation. Urinary proteomic data distinguished INS patients from control patients, irrespective of steroid response, with a sensitivity of 92.3%, specificity of 93.7%, positive predictive value of 96% and a negative predictive value of 88.2%. Classification of patients as SSNS or SRNS was 100%. A protein of mass 4,144 daltons was identified as the single most important classifier in distinguishing SSNS from SRNS. SELDI-MS combined with bioinformatics can identify different proteomic patterns in INS. Characterization of the proteins of interest identified by this proteomic approach with prospective clinical validation may yield a valuable clinical tool for the non-invasive prediction of treatment response and prognosis.
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Affiliation(s)
- Robert P Woroniecki
- Section of Pediatric Nephrology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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Hoyer PF, Brodeh J. Initial treatment of idiopathic nephrotic syndrome in children: prednisone versus prednisone plus cyclosporine A: a prospective, randomized trial. J Am Soc Nephrol 2006; 17:1151-7. [PMID: 16540560 DOI: 10.1681/asn.2005090922] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Previous studies of the Arbeitsgemeinschaft für Pädiatrische Nephrologie in children with steroid-sensitive nephrotic syndrome have shown that the length of initial prednisone therapy has an impact on the subsequent relapse rate. The aim of this randomized, prospective, multicenter study was to reduce the number of relapses further by increasing the initial immunosuppression: Patients with an initial attack of nephrotic syndrome were randomly allocated to treatment with 6 wk of 60 mg/m(2) per d prednisone followed by 6 wk of 40 mg/m(2) per 48 h (Pred group) or to the same prednisone treatment plus 8 wk of cyclosporine (Pred+CsA group). The primary end point was first relapse; follow-up was truncated at 2 yr. In the Pred+CsA group (n = 49 patients), the first relapse occurred later compared with the Pred group (n = 55 patients) (median 22.8 versus 12.5 mo). After 6 mo, 10.4% of patients in the Pred+CsA group experienced a first relapse versus 31.5% in the Pred group (P = 0.01); after 1 yr, 36.5 versus 51% (P = 0.15); and after 2 yr, 51 versus 50%. The mean relapse rate per patient was 0.12 versus 0.57 after 6 mo (P = 0.01), 0.63 versus 1.03 after 1 yr (P = 0.02), and 1.03 versus 2.06 after 2 yr (not significant). The significant benefit for adding CsA was lost after 9 to 12 mo. GFR remained unchanged. The subsequent treatment rate with cyclophosphamide was lower in the CsA group (five versus 12 patients) after 2 yr. With the use of logistic regression statistics, children who were younger than 7 yr show a significantly better sustained remission rate with initial CsA treatment for the 2-yr observation time (P = 0.03). It remains questionable, however, whether the intensified initial treatment with CsA could be recommended generally.
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Affiliation(s)
- Peter F Hoyer
- Department of Pediatric Nephrology, University Clinic Essen, Hufelandstrasse 55, D-45122 Essen, Germany.
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Hodson EM, Craig JC, Willis NS. Evidence-based management of steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2005; 20:1523-30. [PMID: 15968558 DOI: 10.1007/s00467-005-1968-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2005] [Accepted: 03/15/2005] [Indexed: 01/05/2023]
Abstract
Using data from systematic reviews and randomised controlled trials, the evidence for managing steroid sensitive nephrotic syndrome (SSNS) is reviewed. In the initial episode, increased duration (3-7 months) of prednisone compared with 2 months significantly reduced the risk for relapse at 12-24 months [relative risk (RR) 0.70; 95% confidence intervals (CI) 0.58-0.84] without increase in adverse effects. Six months of prednisone was significantly more effective than 3 months (RR 0.57; 95% CI 0.45-0.71). Higher prednisone doses given for the same duration reduced the risk of relapse (RR 0.59; 95% CI 0.42-0.84) suggesting that both dose and duration of prednisone therapy lead to prolonged remission. In relapsing SSNS prolonged prednisone treatment, daily prednisone during infections, oral or intravenous cyclophosphamide, chlorambucil, levamisole and cyclosporin significantly reduced the risk of relapse. Comparative effects of these options remain uncertain because of the absence of head-to-head trials, but existing trial evidence is strongest for cyclophosphamide and cyclosporin. Further adequately powered multinational trials are required to determine the optimum induction dose and duration of prednisone in the initial episode of SSNS and to determine the relative efficacies of immunosuppressive agents and the efficacy of newer agents, including mycophenolate and tacrolimus, in relapsing SSNS.
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Affiliation(s)
- Elisabeth M Hodson
- Cochrane Renal Group, NHMRC Centre for Clinical Research Excellence in Renal Medicine, Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, NSW 2145 Westmead, Australia.
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