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Tseng MH, Lin SH, Fan WL, Wu TW, Lin SP, Ding JJ, Tsai IJ, Tsai JD. Phenotype, genotype, and clinical outcome of Taiwanese with congenital nephrotic syndrome. J Formos Med Assoc 2024; 123:647-654. [PMID: 37845138 DOI: 10.1016/j.jfma.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/15/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND/PURPOSE Congenital nephrotic syndrome (CNS) is one of the important causes of end-stage kidney disease in children. Studies on the genotype, phenotype, and clinical outcome in infants with CNS caused by genetic mutations are scarce. METHODS We analyzed the genetic background, clinical manifestations, treatment response, and prognosis of pediatric patients with CNS in Taiwan. RESULTS Fifteen infants with CNS were enrolled, and 11 patients of median age 21 (interquartile range 3∼44) days caused by genetic mutations from 10 unrelated families were included in the study. Of the eleven patients, 9 had extra-renal manifestations including microcephaly, facial dysmorphism, and skeletal anomalies. More than two-thirds of the patients had disease onset before 1 month of age. Diffuse meningeal sclerosis was the most common histological characteristic. Whole exome sequencing followed by direct Sanger sequence revealed mutations in OSGEP (R247Q), WT1 (R366H and R467Q), LAMB2 (Q1209∗ and c. 5432-5451 19 bp deletion), NUP93 (D302V), and LAGE3 (c.188+1G > A). Three of the variants were novel. Corticosteroids and/or immunosuppressants were administered in 2 patients, but both were refractory to treatment. During the mean 3.5 years of follow-up, all but two died of uremia and sepsis. The two survivors reached end-stage kidney disease and required peritoneal dialysis, and one of them underwent uneventful renal transplantation. CONCLUSION The majority of patients with CNS in Taiwan were caused by OSGEP followed by WT1 mutation. R247Q is the hotspot mutation of OSGEP in Taiwan. CNS patients in Taiwan suffer from significant morbidity and mortality.
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Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Lang Fan
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Ta-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, CA, USA; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Shuan-Pei Lin
- Division of Pediatric Genetics, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
| | - Jhao-Jhuang Ding
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - I-Jung Tsai
- Division of Nephrology, Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.
| | - Jeng-Daw Tsai
- Division of Nephrology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan; Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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Suihko A, Tainio J, Tuokkola J, Ylinen E, Hölttä T, Jahnukainen T. Late nephrectomy in infants with congenital nephrotic syndrome of the Finnish type. Acta Paediatr 2024. [PMID: 38785367 DOI: 10.1111/apa.17294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 05/08/2024] [Accepted: 05/14/2024] [Indexed: 05/25/2024]
Abstract
AIM Bilateral nephrectomy is commonly performed in patients with congenital nephrotic syndrome of the Finnish type. The optimal timing of nephrectomy is unclear. METHODS Growth, thromboembolic events, infections, transplant-related complications and ability to eat were compared between infants with early (Group 1, n = 13) and late (Group 2, n = 10) nephrectomy. 'Early' was defined as nephrectomy at 7-kg body weight followed by peritoneal dialysis and 'late' as nephrectomy at ≥10 kg followed by 3-4 weeks of haemodialysis and kidney transplantation. Patients were followed until the end of the first post-transplant year. RESULTS Dialysis time was significantly longer in group 1 than in group 2. Late nephrectomy did not increase the risk for thromboembolic events or septicaemia but decreased tube feeding dependency (group 1 69% vs. group 2 20%, p = 0.019). Motor development at transplantation was considered normal in 80% of the infants with late nephrectomy compared to 31% in the early nephrectomy group (p = 0.019); however, the difference between the groups disappeared by the end of the follow-up. CONCLUSION Infants with late nephrectomy have comparative outcome but less feeding tube dependency and better motor development during the first post-transplant months compared to infants with early nephrectomy.
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Affiliation(s)
- Aino Suihko
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juuso Tainio
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jetta Tuokkola
- Clinical Nutrition Unit, Internal Medicine and Rehabilitation, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
- Department of Medicine, Endocrinology and Clinical Nutrition, Kuopio University Hospital, Kuopio, Finland
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tuula Hölttä
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Krall P, Rojo A, Plaza A, Canals S, Ceballos ML, Cano F, Guerrero JL. Case report: Unveiling a less severe congenital nephrotic syndrome in a Rapa Nui patient with a NPHS1 Maori founder variant. FRONTIERS IN NEPHROLOGY 2024; 4:1379061. [PMID: 38808020 PMCID: PMC11130413 DOI: 10.3389/fneph.2024.1379061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/19/2024] [Indexed: 05/30/2024]
Abstract
Background Congenital nephrotic syndrome (CNS) is a severe kidney disorder characterized by edema, massive proteinuria, and hypoalbuminemia that manifests in utero or within three months after birth. CNS affects 1-3 per 100,000 children, primarily associated with genetic variants and occasionally with infections. Genetic analysis is the first-line method for diagnosis. The most common founder variants have been identified in European populations, often resulting in end-stage kidney disease by 1-2 years of age. Case-diagnosis/treatment A female full-term neonate, without prenatal signs of kidney disease, was admitted to Rapa Nui (Eastern Island) Hospital at the age of 2 months due to bronchial obstruction. She presented fever, oliguria, edema, urine protein-to-creatinine ratio (UPCR) 433.33, and hypoalbuminemia (0.9 g/dL). She was transferred to a mainland Chilean hospital following CNS diagnosis. Viral screening detected cytomegalovirus (CMV) positivity in both blood and urine. A kidney biopsy revealed interstitial nephritis and diffuse podocyte damage and the tissue PCR resulted negative for CMV. Interviews with the parents revealed consanguinity, suggestive of hereditary CNS. Genetic analysis identified the Maori founder variant, NPHS1 c.2131C>A (p.R711S), in homozygosis. The patient received albumin infusions and antiviral therapy, being discharged when she was 5 months old, with improved laboratory parameters evidenced by UPCR 28.55, albumin 2.5 g/dL, and cholesterol 190 mg/dL. Subsequent clinical monitoring was conducted through virtual and in-person consultations. At her last follow-up at 4 years 2 months old, she presented UPCR 16.1, albumin 3.3 g/dl and cholesterol 220 mg/dL, maintaining normal kidney function and adequate growth. Conclusions To our knowledge, this represents the first case of CNS in Chile carrying a NPHS1 variant associated with prolonged kidney survival. As described in the Maori population, the patient exhibited a less severe clinical course compared to classical NPHS1 patients. Genetic testing for the Maori founder variant in CNS patients related to the New Zealand population, could impact management decisions and potentially prevent the need for nephrectomies.
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Affiliation(s)
- Paola Krall
- Instituto de Medicina, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
| | - Angélica Rojo
- Unidad de Nefrología, Diálisis y Trasplante Renal, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Anita Plaza
- Instituto de Medicina, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile
| | - Sofia Canals
- Unidad de Lactantes, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - María Luisa Ceballos
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
- Unidad de Nefrología, Diálisis y Trasplante Renal, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - Francisco Cano
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
- Unidad de Nefrología, Diálisis y Trasplante Renal, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
| | - José Luis Guerrero
- Departamento de Pediatría y Cirugía Infantil Oriente, Facultad de Medicina, Universidad de Chile, Santiago de Chile, Chile
- Unidad de Nefrología, Diálisis y Trasplante Renal, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
- Programa de Telesalud, Hospital Luis Calvo Mackenna, Santiago de Chile, Chile
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Savonius O, Kaskinen A, Hölttä T, Ylinen E, Tainio J, Nieminen T, Jahnukainen T. Serological responses to immunization during nephrosis in infants with congenital nephrotic syndrome of the Finnish type. Front Pediatr 2024; 12:1392873. [PMID: 38756974 PMCID: PMC11097774 DOI: 10.3389/fped.2024.1392873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/22/2024] [Indexed: 05/18/2024] Open
Abstract
Background Pretransplant vaccination is generally recommended to solid organ transplant recipients. In infants with congenital nephrotic syndrome (CNS), the immune response is hypothetically inferior to other patients due to young age and urinary loss of immunoglobulins, but data on the immunization response in severely nephrotic children remain scarce. If effective, however, early immunization of infants with CNS would clinically be advantageous. Methods We investigated serological vaccine responses in seven children with CNS who were immunized during nephrosis. Antibody responses to measles-mumps-rubella -vaccine (MMR), a pentavalent DTaP-IPV-Hib -vaccine (diphtheria, tetanus, acellular pertussis, inactivated poliovirus, Haemophilus influenzae type b), varicella vaccine, combined hepatitis A and B vaccine, and pneumococcal conjugate vaccine (PCV) were measured after nephrectomy either before or after kidney transplantation. Results Immunizations were started at a median age of 7 months [interquartile range (IQR) 7-8], with a concurrent median proteinuria of 36,500 mg/L (IQR 30,900-64,250). Bilateral nephrectomy was performed at a median age of 20 months (IQR 14-25), and kidney transplantation 10-88 days after the nephrectomy. Antibody levels were measured at median 18 months (IQR 6-23) after immunization. Protective antibody levels were detected in all examined children for hepatitis B (5/5), Clostridium tetani (7/7), rubella virus (2/2), and mumps virus (1/1); in 5/6 children for varicella; in 4/6 for poliovirus and vaccine-type pneumococcal serotypes; in 4/7 for Haemophilus influenzae type B and Corynebacterium diphtheriae; in 1/2 for measles virus; and in 2/5 for hepatitis A. None of the seven children had protective IgG levels against Bordetella pertussis. Conclusion Immunization during severe congenital proteinuria resulted in variable serological responses, with both vaccine- and patient-related differences. Nephrosis appears not to be a barrier to successful immunization.
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Affiliation(s)
- Okko Savonius
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anu Kaskinen
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tuula Hölttä
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juuso Tainio
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tea Nieminen
- Department of Pediatric Infectious Diseases, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Crawford B, Kizilbash S, Bhatia VP, Kulsum-Mecci N, Cannon S, Bartosh SM. Native nephrectomy in advanced pediatric kidney disease: indications, timing, and surgical approaches. Pediatr Nephrol 2024; 39:1041-1052. [PMID: 37632524 DOI: 10.1007/s00467-023-06117-3] [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] [Received: 05/20/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/28/2023]
Abstract
In pediatric kidney failure, native kidneys may pose a risk to successful transplant outcomes. The indications and timing of native nephrectomy represent a controversial management decision. A lack of high-quality, outcomes-based data has prevented development of evidence-based guidelines for intervention. In this article, we review the published literature on medical indications for native nephrectomy and current knowledge gaps. In addition, we provide a surgical perspective regarding timing and approach.
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Affiliation(s)
- Brendan Crawford
- Department of Pediatrics, Division of Nephrology, University of Arkansas Medical Sciences, Little Rock, AR, USA.
| | - Sarah Kizilbash
- Department of Pediatrics, Division of Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - Vinaya P Bhatia
- Department of Urology, Division of Pediatric Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nazia Kulsum-Mecci
- Department of Pediatrics, Division of Nephrology, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Shannon Cannon
- Department of Urology, Division of Pediatric Urology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Sharon M Bartosh
- Department of Pediatrics, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Goodman KN, Puapatanakul P, Barton KT, He M, Miner JH, Gaut JP. A Case of Congenital Nephrotic Syndrome with Crescents Caused by a Novel Compound Heterozygous Pairing of NPHS1 Genetic Variants. Case Rep Nephrol 2024; 2024:5121375. [PMID: 38444459 PMCID: PMC10914425 DOI: 10.1155/2024/5121375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/07/2024] [Accepted: 02/17/2024] [Indexed: 03/07/2024] Open
Abstract
Congenital nephrotic syndrome is an autosomal recessive inherited disorder that manifests as steroid-resistant massive proteinuria in the first three months of life. Defects in the glomerular filtration mechanism are the primary etiology. We present a child who developed severe nephrotic syndrome at two weeks of age and eventually required a bilateral nephrectomy. Genetic testing revealed compound heterozygous variants in NPHS1 including a known pathogenic variant and a missense variant of uncertain significance. Light microscopy revealed crescent formation-an atypical finding in congenital nephrotic syndrome caused by nephrin variants-in addition to focal segmental and global glomerulosclerosis. Electron microscopy showed diffuse podocyte foot process effacement. Confocal and Airyscan immunofluorescence microcopy showed aggregation of nephrin in the podocyte cell body that is not a result of diffuse podocyte foot process effacement as seen in minimal change disease. These findings confirm the novel variant as pathogenic.
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Affiliation(s)
- Kyle N. Goodman
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Pongpratch Puapatanakul
- Division of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kevin T. Barton
- Division of Nephrology, Hypertension and Apheresis, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mai He
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Jeffrey H. Miner
- Division of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Joseph P. Gaut
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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Toya Y, Ishikawa K, Yoshida T, Matsumoto A, Akasaka M, Nozu K. Usefulness of Early Genetic Diagnosis for Twins With a Family History of Congenital Nephrotic Syndrome. Cureus 2023; 15:e36667. [PMID: 37101999 PMCID: PMC10124580 DOI: 10.7759/cureus.36667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2023] [Indexed: 03/29/2023] Open
Abstract
We reported a dichorionic diamniotic placental twin (DD twin) with a family history of a congenital nephrotic syndrome of the Finnish type (CNF), of which the parent had heterozygous for the NPHS1 gene mutation. The DD twin was born at 36 weeks gestation, and their fused placenta weighed 1,340 g. Although the first-born child had heavy proteinuria and hypoalbuminemia and needed daily albumin replacement to manage severe edema, the second had only mild proteinuria after birth. Genetic testing performed 28 days after birth detected homozygous for the NPHS1 gene mutation in only the first-born child but not in the second, which resulted in performing invasive left nephrectomy and peritoneal dialysis (PD) to manage edema in the first. For DD twins with a family history of CNF, prenatal diagnosis of CNF may be difficult. Therefore, close postnatal clinical observation and early genetic testing are essential for the diagnosis of CNF.
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Kidney disease and thyroid dysfunction: the chicken or egg problem. Pediatr Nephrol 2022; 37:3031-3042. [PMID: 35737115 DOI: 10.1007/s00467-022-05640-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/04/2022] [Accepted: 05/19/2022] [Indexed: 01/10/2023]
Abstract
Patients with non-dialysis-dependant chronic kidney disease (NDD-CKD) and dialysis-dependant chronic kidney disease (DD-CKD) frequently also suffer from thyroid disorders, especially hypothyroidism which is found two to five times more often among them compared to the general population. Emerging research has illustrated the potential prognostic implications of this association as NDD-CKD and DD-CKD patients with hypothyroidism have been shown to have higher mortality rates, and treatment of subclinical hypothyroidism in NDD-CKD patients has been reported to attenuate the decline of glomerular filtration rate over time. This review illustrates the bidirectional, multi-layered interplay between the kidneys and the thyroid gland explaining how pathologies in one organ will affect the other and vice versa. Additionally, it outlines the impact of thyroid disorders on routine parameters of kidney function (especially serum creatinine and serum cystatin C) that nephrologists should be aware of in their clinical practice. Lastly, it summarizes the emerging evidence from clinical studies on how treatment of subclinical hypothyroidism in NDD-CKD and DD-CKD patients may potentially have beneficial effects on kidney function as well as mortality. While most of the research in this area has been performed on adult patients, we specifically discuss what is currently known about thyroid dysfunctions in paediatric CKD patients as well and provide management suggestions. The evidence accumulated so far clearly indicates that further, prospective studies with meticulous methodology are warranted to refine our understanding of thyroid disorders in paediatric and adult CKD patients and establish optimal treatment pathways.
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Childhood nephrotic syndrome and the clinical profile of thromboembolism: a systematic review and meta-analysis. Pediatr Res 2022; 93:1463-1469. [PMID: 36127405 DOI: 10.1038/s41390-022-02302-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/26/2022] [Accepted: 08/25/2022] [Indexed: 11/08/2022]
Abstract
Nephrotic syndrome (NS) is a common kidney disease of childhood, affecting 2-7 children per 100,000. A potentially life-threatening complication affecting children with NS is thromboembolism (TE). However, there remains a paucity of information regarding the burden of TE and its associated risk factors in this population. A systematic review was performed on observational studies examining TE events in children with NS, published in Medline, Embase, CINAHL, and CENTRAL, until May 2021. Meta-analyses were separately conducted on the prevalence of TE within articles exclusively studying children with congenital NS and among articles including all forms of NS. Out of 13,626 articles, 22 were included (14,290 children). The pooled prevalence of symptomatic TE among articles including patients with all forms of NS was 3.60% (95% CI 1.95-5.63), which increased to 8.70% (95% CI 5.11-12.96) in articles with exclusively congenital NS patients. Children with steroid-resistant NS were at a higher risk of TE compared to steroid-sensitive children (OR 4.40, 95% CI 1.34-15.59, p = 0.013). Focal segmental glomerulosclerosis was the most common histology present in patients with TE (51.2%). Children diagnosed with NS have a significant risk of TE, particularly in patients with congenital NS and steroid resistance. IMPACT: The prevalence of symptomatic thromboembolic (TE) events in children with nephrotic syndrome (NS) was 3.60% (95% CI 1.95-5.63), which increased more than two-fold in children with congenital NS to 8.70% (95% CI 5.11-12.96). Potential risk factors for TE events in this population include congenital forms of NS and steroid resistance. This review provides a better estimate of the prevalence of TE in children with NS, while identifying potentially higher-risk populations who may benefit from TE screening and thromboprophylaxis.
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Constantinescu AR, Mattoo TK, Smoyer WE, Greenbaum LA, Niu J, Howard N, Muff-Luett M, Benoit EB, Traum A, Annaim AA, Wenderfer SE, Plautz E, Rheault MN, Myette RL, Twombley KE, Kamigaki Y, Wandique-Rapalo B, Kallash M, Vasylyeva TL. Clinical presentation and management of nephrotic syndrome in the first year of life: A report from the Pediatric Nephrology Research Consortium. Front Pediatr 2022; 10:988945. [PMID: 36210940 PMCID: PMC9534228 DOI: 10.3389/fped.2022.988945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/19/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Nephrotic syndrome (NS) in the first year of life is called congenital (CNS) if diagnosed between 0-3 months, or infantile (INS) if diagnosed between 3-12 months of age. The aim of this study was to determine if there were clinically meaningful differences between CNS and INS patients, regarding clinical presentation, management and outcomes. DESIGN SETTING PARTICIPANTS AND MEASUREMENTS Eleven Pediatric Nephrology Research Consortium sites participated in the study, using IRB-approved retrospective chart reviews of CNS and INS patients born between 1998 and 2019. Data were collected on patient characteristics, pertinent laboratory tests, provided therapy, timing of unilateral/bilateral nephrectomy and initiation of renal replacement therapy (RRT). RESULTS The study included 69 patients, 49 with CNS and 20 with INS, with a median age at diagnosis of 1 and 6 months, respectively. Management for the two groups was similar regarding nutrition, thyroxin supplementation, immunoglobulin administration, and thrombosis prophylaxis. Within the first 2 months after diagnosis, daily albumin infusions were used more often in CNS vs. INS patients (79 vs. 30%; p = 0.006), while weekly infusions were more common in INS patients (INS vs. CNS: 50 vs. 3%; p = 0.001). During the 6 months preceding RRT, albumin infusions were more frequently prescribed in CNS vs. INS (51 vs. 15%; p = 0.007). Nephrectomy was performed more often in CNS (78%) than in INS (50%; p = 0.02). End-stage kidney disease tended to be more common in children with CNS (80%) vs. INS (60%; p = 0.09). CONCLUSION Compared to INS, patients with CNS had a more severe disease course, requiring more frequent albumin infusions, and earlier nephrectomy and RRT. Despite center-specific variations in patient care, 20-40% of these patients did not require nephrectomy or RRT.
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Affiliation(s)
- Alexandru R Constantinescu
- Integrated Medical Sciences, Charles E Schmidt College of Medicine at Florida Atlantic University, Boca Raton, FL, United States.,Pediatric Nephrology, Joe DiMaggio Children's Hospital, Hollywood, FL, United States
| | - Tej K Mattoo
- Pediatrics and Urology, Wayne State University School of Medicine, Detroit, MI, United States
| | - William E Smoyer
- Center for Clinical and Translational Research, The Ohio State University, Columbus, OH, United States
| | | | - Jianli Niu
- Department of Research and Scholarly Activity at Memorial Healthcare System, Hollywood, FL, United States
| | - Noel Howard
- Health Sciences Center School of Medicine, Texas Tech University, Amarillo, TX, United States
| | - Melissa Muff-Luett
- Pediatric Nephrology, Children's Hospital and Medical Center, Omaha, NE, United States
| | | | - Avram Traum
- Pediatric Nephrology, Boston Children's Hospital, Boston, MA, United States
| | - Ali A Annaim
- Pediatric Nephrology, Children's Hospital of Atlanta, Atlanta, GA, United States
| | - Scott E Wenderfer
- Pediatric Nephrology, Texas Children's Hospital, Houston, TX, United States
| | - Emilee Plautz
- University of Minnesota, Minneapolis, MN, United States
| | - Michelle N Rheault
- Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, United States
| | - Robert L Myette
- Pediatric Nephrology, Children's Hospital of Eastern Ontario and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Katherine E Twombley
- Pediatric Nephrology, Medical University of South Carolina College of Medicine, Charleston, SC, United States
| | - Yu Kamigaki
- Center for Clinical and Translational Research, The Ohio State University, Columbus, OH, United States
| | | | - Mohammad Kallash
- Pediatric Nephrology, Nationwide Children's Hospital, Columbus, OH, United States
| | - Tetyana L Vasylyeva
- Pediatric Nephrology, Health Sciences Center School of Medicine, Texas Tech University, Amarillo, TX, United States
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11
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AbuMaziad AS, Abusaleh R, Bhati S. Congenital nephrotic syndrome. J Perinatol 2021; 41:2704-2712. [PMID: 34983935 DOI: 10.1038/s41372-021-01279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 06/24/2021] [Accepted: 11/15/2021] [Indexed: 11/09/2022]
Abstract
Congenital nephrotic syndrome (CNS), a challenging form of nephrotic syndrome, is characterized by massive proteinuria, hypoalbuminemia, and edema. Extensive leakage of plasma proteins is the main feature of CNS. Patients can be diagnosed in utero or during the first few weeks of life, usually before three months. The etiology of CNS can be related to either genetic or nongenetic etiologies. Pathogenic variants in NPHS1, NPHS2, LAMB2, WT1, and PLCE1 genes have been implicated in this disease. The clinical course is complicated by significant edema, infections, thrombosis, hypothyroidism, failure to thrive, and others. Obtaining vascular access, frequent intravenous albumin infusions, diuretic use, infection prevention, and nutritional support are the mainstay management during their first month of life. The best therapy for these patients is kidney transplantation. CNS diagnosis and treatment continue to be a challenge for clinicians. This review increases the awareness about the pathogenesis, diagnosis, and management of CNS patients.
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Affiliation(s)
- Asmaa S AbuMaziad
- Department of Pediatrics, Division of Nephrology, University of Arizona, Tucson, AZ, USA.
| | - Rami Abusaleh
- Department of Pediatrics, Division of Nephrology, University of Arizona, Tucson, AZ, USA
| | - Shanti Bhati
- Department of Pediatrics, Division of Nephrology, University of Arizona, Tucson, AZ, USA
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12
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Nishi K, Kamei K, Ogura M, Sato M, Ishiwa S, Shioda Y, Kiyotani C, Matsumoto K, Nozu K, Ishikura K, Ito S. Risk factors for post-nephrectomy hypotension in pediatric patients. Pediatr Nephrol 2021; 36:3699-3709. [PMID: 33988732 DOI: 10.1007/s00467-021-05115-7] [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] [Received: 12/14/2020] [Revised: 03/12/2021] [Accepted: 04/30/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although hypotension is a life-threatening complication of nephrectomy in children, risk factors for its development remain unknown. We evaluated the incidence, clinical course, and associated risk factors of pediatric post-nephrectomy hypotension in an observational study. METHODS This retrospective observational study included the clinical data of children who underwent nephrectomy in our center between 2002 and 2020. Patients undergoing nephrectomy at kidney transplantation and those who developed hypotension before nephrectomy were excluded. RESULTS The study included 55 nephrectomies in 51 patients, including 42 unilateral, 4 two-stage bilateral, and 5 simultaneous bilateral nephrectomies. The diagnoses were isolated Wilms tumor, neuroblastoma, congenital nephrotic syndrome, Denys-Drash syndrome, WAGR (Wilms tumor, aniridia, genitourinary malformations, and mental retardation) syndrome, and autosomal recessive polycystic kidney disease in 24, 10, 9, 6, 1, and 1 patient, respectively. Post-nephrectomy hypotension developed in 11 (20%) patients. Two patients (3.6%) had persistent hypotension; both had their kidneys resected, and one patient (1.8%) died. Male sex, kidney disease, resection of both kidneys, low estimated glomerular filtration rate, increased left ventricular posterior wall thickness in diastole, hypertension before nephrectomy, antihypertensive use, hyperreninemia, and hyperaldosteronism were significantly associated with post-nephrectomy hypotension. Multivariate logistic regression analysis revealed that hypertension before nephrectomy was the only significant risk factor for post-nephrectomy hypotension (P = 0.04). CONCLUSIONS Hypertension before nephrectomy is a significant risk factor for pediatric post-nephrectomy hypotension. Life-threatening hypotension, which might occur after bilateral nephrectomy in infants, should be considered, especially in children with higher risks.
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Affiliation(s)
- Kentaro Nishi
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Sho Ishiwa
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Pediatric Nephrology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoko Shioda
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Chikako Kiyotani
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kimikazu Matsumoto
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shuichi Ito
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 157-8535, Japan
- Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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13
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Unilateral nephrectomy for young infants with congenital nephrotic syndrome of the Finnish type. Clin Exp Nephrol 2021; 26:162-169. [PMID: 34581898 DOI: 10.1007/s10157-021-02141-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/22/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The management of congenital nephrotic syndrome of the Finnish type (CNF) is challenging. It is difficult to withdraw intravenous albumin infusions, resulting in long-term hospitalization. In addition, fatal hypotension after bilateral nephrectomy has been reported. In our center, we have performed unilateral nephrectomy during early infancy. METHODS Infants diagnosed with CNF between 2011 and 2020 in our institution were enrolled. We examined the clinical course before and after unilateral nephrectomy and evaluated the effectiveness of this strategy. RESULTS Seven patients (all showing NPHS1 mutations) were enrolled. All required daily intravenous albumin infusion via central venous catheter (CVC). Unilateral nephrectomy was performed at a median of 76 days of age (59-208 days). Surgical complications did not occur in any of patients. The mean albumin dose was decreased after unilateral nephrectomy (2.0 vs 0.4 g/kg/day; p = 0.02). Intravenous albumin infusion could be withdrawn at a median of 17 days, the CVC removed at a median of 21 days, and they discharged at a median of 82 days after unilateral nephrectomy. Although bacterial infections were noted seven times before unilateral nephrectomy, only one episode occurred after surgery. Four patients initiated peritoneal dialysis at two to three years of age and all of them underwent kidney transplantation thereafter. CONCLUSIONS Unilateral nephrectomy during early infancy may be an effective treatment allowing for withdrawal from albumin infusion, prevention of complications, withdrawal from CVCs and shortening hospital stay for patients with CNF.
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14
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Yoshida S, Wei X, Zhang G, O'Connor CL, Torres M, Zhou Z, Lin L, Menon R, Xu X, Zheng W, Xiong Y, Otto E, Tang CHA, Hua R, Verma R, Mori H, Zhang Y, Hu CCA, Liu M, Garg P, Hodgin JB, Sun S, Bitzer M, Qi L. Endoplasmic reticulum-associated degradation is required for nephrin maturation and kidney glomerular filtration function. J Clin Invest 2021; 131:143988. [PMID: 33591954 DOI: 10.1172/jci143988] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/11/2021] [Indexed: 02/06/2023] Open
Abstract
Podocytes are key to the glomerular filtration barrier by forming a slit diaphragm between interdigitating foot processes; however, the molecular details and functional importance of protein folding and degradation in the ER remain unknown. Here, we show that the SEL1L-HRD1 protein complex of ER-associated degradation (ERAD) is required for slit diaphragm formation and glomerular filtration function. SEL1L-HRD1 ERAD is highly expressed in podocytes of both mouse and human kidneys. Mice with podocyte-specific Sel1L deficiency develop podocytopathy and severe congenital nephrotic syndrome with an impaired slit diaphragm shortly after weaning and die prematurely, with a median lifespan of approximately 3 months. We show mechanistically that nephrin, a type 1 membrane protein causally linked to congenital nephrotic syndrome, is an endogenous ERAD substrate. ERAD deficiency attenuated the maturation of nascent nephrin, leading to its retention in the ER. We also show that various autosomal-recessive nephrin disease mutants were highly unstable and broken down by SEL1L-HRD1 ERAD, which attenuated the pathogenicity of the mutants toward the WT allele. This study uncovers a critical role of SEL1L-HRD1 ERAD in glomerular filtration barrier function and provides insights into the pathogenesis associated with autosomal-recessive disease mutants.
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Affiliation(s)
- Sei Yoshida
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,State Key Laboratory of Medical Chemical Biology, College of Life Sciences, Frontiers Science Center for Cell Responses, Nankai University, Tianjin, China
| | - Xiaoqiong Wei
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Gensheng Zhang
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Christopher L O'Connor
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Mauricio Torres
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Zhangsen Zhou
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Liangguang Lin
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Rajasree Menon
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Xiaoxi Xu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Wenyue Zheng
- State Key Laboratory of Medical Chemical Biology, College of Life Sciences, Frontiers Science Center for Cell Responses, Nankai University, Tianjin, China
| | - Yi Xiong
- Center for Molecular Medicine and Genetics, Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Edgar Otto
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chih-Hang Anthony Tang
- Houston Methodist Cancer Center, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Rui Hua
- State Key Laboratory of Medical Chemical Biology, College of Life Sciences, Frontiers Science Center for Cell Responses, Nankai University, Tianjin, China
| | - Rakesh Verma
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Hiroyuki Mori
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Yang Zhang
- Department of Computational Medicine and Bioinformatics and Department of Biological Chemistry and
| | - Chih-Chi Andrew Hu
- Houston Methodist Cancer Center, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Ming Liu
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Puneet Garg
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - Shengyi Sun
- Center for Molecular Medicine and Genetics, Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Markus Bitzer
- Division of Nephrology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ling Qi
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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15
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Expression Pattern of α-Tubulin, Inversin and Its Target Dishevelled-1 and Morphology of Primary Cilia in Normal Human Kidney Development and Diseases. Int J Mol Sci 2021; 22:ijms22073500. [PMID: 33800671 PMCID: PMC8037028 DOI: 10.3390/ijms22073500] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
The spatiotemporal expression of α-tubulin, inversin and dishevelled-1 (DVL-1) proteins associated with the Wnt-signaling pathway, and primary cilia morphology were analyzed in developing kidneys (14th–38th developmental weeks), healthy postnatal (1.5- and 7-years old) and pathologically changed human kidneys, including multicystic dysplastic kidneys (MCDK), focal segmental glomerulosclerosis (FSGS) and nephrotic syndrome of the Finnish type (CNF). The analysis was performed by double immunofluorescence, electron microscopy, semiquantitative and statistical methods. Cytoplasmic co-expression of α-tubulin, inversin and DVL-1 was observed in the proximal convoluted tubules (pct), distal convoluted tubules (dct) and glomeruli (g) of analyzed tissues. During kidney development, the overall expression of α-tubulin, inversin and DVL-1 decreased, while in the postnatal period slightly increased. The highest expressions of α-tubulin and inversin characterized dct and g, while high DVL-1 characterized pct. α-tubulin, inversin and DVL-1 expression pattern in MCDK, FSGS and CNF kidneys significantly differed from the healthy control. Compared to healthy kidneys, pathologically changed kidneys had dysmorphic primary cilia. Different expression dynamics of α-tubulin, inversin and DVL-1 during kidney development could indicate that switch between the canonical and noncanonical Wnt-signaling is essential for normal kidney morphogenesis. In contrast, their disturbed expression in pathological kidneys might be associated with abnormal primary cilia, leading to chronic kidney diseases.
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16
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Singh S, Mishra OP, Mandal PP, Patel PS, Sharma SS, Saini H, Rani K, Chandrasekhar S, Singh MP. Thyroid function in patients with idiopathic nephrotic syndrome. Int Urol Nephrol 2021; 53:1859-1864. [PMID: 33432478 DOI: 10.1007/s11255-020-02778-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 12/26/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Albumin is the major protein excreted in urine in patients with nephrotic syndrome (NS). However, low-molecular-weight proteins including some binding proteins are also excreted. Thyroid hormone and its binding globulins are excreted in urine in excess in nephrotic syndrome. Therefore, it has been postulated that patients with nephrotic syndrome may show hypothyroidism, subclinical or overt. METHODS In this prospective observational study, patients of idiopathic nephrotic syndrome aged 1-40 years of both gender were included. Serum T3, T4 and TSH were assayed at diagnosis and repeated at 12 weeks or at remission whichever was earlier. Renal biopsy was performed as required. RESULTS Among 100 patients taken for analysis (42 children, 58 adult), 30 cases were of first episode, 40 were of frequent relapse/steroid-dependent NS, and 30 patients had steroid-resistant NS (SRNS). Three (3%) cases had overt hypothyroidism and 18 (18%) patients had subclinical hypothyroidism. Most hypothyroid cases belonged to SRNS subgroup. Mean Serum T3, T4 and TSH values showed significant improvement in remission in comparison to nephrosis state (P < 0.01). Serum TSH had significant positive correlation (r = 0.391, P < 0.01) with 24-h proteinuria and negative correlation with serum albumin (r = - 0.303, P < 0.01) in nephrosis. CONCLUSION Hypothyroidism is common among nephrotic syndrome patients especially in SRNS subgroup. Therefore, routine screening is recommended in steroid-resistant nephrotic syndrome patients.
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Affiliation(s)
- Shivendra Singh
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Om Prakash Mishra
- Division of Pediatric Nephrology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Partha Pratim Mandal
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
| | - Prem Shankar Patel
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Shiv Shankar Sharma
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Harish Saini
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Khushboo Rani
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Sreenidhi Chandrasekhar
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Manjit Pal Singh
- Department of Nephrology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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17
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Boyer O, Schaefer F, Haffner D, Bockenhauer D, Hölttä T, Bérody S, Webb H, Heselden M, Lipska-Zie˛tkiewicz BS, Ozaltin F, Levtchenko E, Vivarelli M. Management of congenital nephrotic syndrome: consensus recommendations of the ERKNet-ESPN Working Group. Nat Rev Nephrol 2021; 17:277-289. [PMID: 33514942 PMCID: PMC8128706 DOI: 10.1038/s41581-020-00384-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 01/30/2023]
Abstract
Congenital nephrotic syndrome (CNS) is a heterogeneous group of disorders characterized by nephrotic-range proteinuria, hypoalbuminaemia and oedema, which manifest in utero or during the first 3 months of life. The main cause of CNS is genetic defects in podocytes; however, it can also be caused, in rare cases, by congenital infections or maternal allo-immune disease. Management of CNS is very challenging because patients are prone to severe complications, such as haemodynamic compromise, infections, thromboses, impaired growth and kidney failure. In this consensus statement, experts from the European Reference Network for Kidney Diseases (ERKNet) and the European Society for Paediatric Nephrology (ESPN) summarize the current evidence and present recommendations for the management of CNS, including the use of renin-angiotensin system inhibitors, diuretics, anticoagulation and infection prophylaxis. Therapeutic management should be adapted to the clinical severity of the condition with the aim of maintaining intravascular euvolaemia and adequate nutrition, while preventing complications and preserving central and peripheral vessels. We do not recommend performing routine early nephrectomies but suggest that they are considered in patients with severe complications despite optimal conservative treatment, and before transplantation in patients with persisting nephrotic syndrome and/or a WT1-dominant pathogenic variant.
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Affiliation(s)
- Olivia Boyer
- grid.412134.10000 0004 0593 9113Department of Pediatric Nephrology, Reference center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France ,grid.508487.60000 0004 7885 7602Laboratory of Hereditary Kidney Diseases, Imagine Institute, INSERM U1163, Paris Descartes University, Paris, France
| | - Franz Schaefer
- grid.7700.00000 0001 2190 4373Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Dieter Haffner
- grid.10423.340000 0000 9529 9877Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Hannover, Germany ,grid.10423.340000 0000 9529 9877Center for Congenital Kidney Diseases, Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Detlef Bockenhauer
- grid.424537.30000 0004 5902 9895UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tuula Hölttä
- grid.15485.3d0000 0000 9950 5666Department of Pediatric Nephrology and Transplantation, The New Children’s Hospital, HUS Helsinki University Hospital, Helsinki, Finland
| | - Sandra Bérody
- grid.412134.10000 0004 0593 9113Department of Pediatric Nephrology, Reference center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France
| | - Hazel Webb
- grid.424537.30000 0004 5902 9895UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Beata S. Lipska-Zie˛tkiewicz
- grid.11451.300000 0001 0531 3426Clinical Genetics Unit, Department of Biology and Medical Genetics, Medical University of Gdańsk, Gdańsk, Poland ,grid.11451.300000 0001 0531 3426Centre for Rare Diseases, Medical University of Gdańsk, Gdańsk, Poland
| | - Fatih Ozaltin
- grid.14442.370000 0001 2342 7339Department of Pediatric Nephrology and Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elena Levtchenko
- grid.5596.f0000 0001 0668 7884Division of Pediatric Nephrology, Department of Pediatrics, University Hospitals Leuven; Department of Development & Regeneration, University of Leuven, Leuven, Belgium
| | - Marina Vivarelli
- grid.414125.70000 0001 0727 6809Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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18
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Dobbie LJ, Lamb A, Eskell L, Ramage IJ, Reynolds BC. Thromboprophylaxis in congenital nephrotic syndrome: 15-year experience from a national cohort. Pediatr Nephrol 2021; 36:1183-1194. [PMID: 33089377 PMCID: PMC8009789 DOI: 10.1007/s00467-020-04793-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 09/02/2020] [Accepted: 09/19/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Congenital nephrotic syndrome (CNS) is an ultra-rare disease associated with a pro-thrombotic state and venous thromboembolisms (VTE). There is very limited evidence evaluating thromboprophylaxis in patients with CNS. This study aimed to determine the doses and duration of treatment required to achieve adequate thromboprophylaxis in patients with CNS. METHODS From 2005 to 2018 children in Scotland with a confirmed genetic or histological diagnosis of CNS were included if commenced on thromboprophylaxis. The primary study endpoint was stable drug monitoring. Secondary outcomes included VTE or significant haemorrhage. RESULTS Eight patients were included; all initially were commenced on low-molecular weight heparin (enoxaparin). Four patients maintained therapeutic anti-Factor Xa levels (time 3-26 weeks, dose 3.2-5.07 mg/kg/day), and one patient developed a thrombosis (Anti-Factor Xa: 0.27 IU/ml). Four patients were subsequently treated with warfarin. Two patients maintained therapeutic INRs (time 6-11 weeks, dose 0.22-0.25 mg/kg/day), and one patient had two bleeding events (Bleed 1: INR 6, Bleed 2: INR 5.5). CONCLUSIONS Achieving thromboprophylaxis in CNS is challenging. Similar numbers of patients achieved stable anticoagulation on warfarin and enoxaparin. Enoxaparin dosing was nearly double the recommended starting doses for secondary thromboprophylaxis. Bleeding events were all associated with supra-therapeutic anticoagulation.
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Affiliation(s)
| | - Angela Lamb
- grid.415571.30000 0004 4685 794XDepartment of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Lucy Eskell
- grid.415571.30000 0004 4685 794XDepartment of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Ian J. Ramage
- grid.8756.c0000 0001 2193 314XUniversity of Glasgow, Glasgow, UK ,grid.415571.30000 0004 4685 794XDepartment of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
| | - Ben C. Reynolds
- grid.8756.c0000 0001 2193 314XUniversity of Glasgow, Glasgow, UK ,grid.415571.30000 0004 4685 794XDepartment of Paediatric Nephrology, Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF UK
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19
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Boyer O, Bérody S. Congenital nephrotic syndrome: is early aggressive treatment needed?-No. Pediatr Nephrol 2020; 35:1991-1996. [PMID: 32462257 DOI: 10.1007/s00467-020-04556-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 11/27/2022]
Abstract
The management of infants with congenital nephrotic syndrome (CNS) is very challenging as they are prone to severe complications such as hemodynamic disturbances, infections, thromboses, and impaired growth, and most will develop end-stage kidney disease (ESKD) within a few years. Since the seventies, an "aggressive" approach, including daily albumin infusions, early nephrectomies, dialysis, and transplantation, has dramatically improved survival and morbidity. More recent case-note reviews have reported successful conservative treatment (using optimized nutrition, complication prophylaxis, and delayed renal replacement therapy), which led to similarly good outcomes and low complication rates. This questions the indications for early preemptive bilateral nephrectomy and dialysis given the mortality and morbidity rates in dialysis in infants and their life-long management with possible repeated transplantations. Two large series provide the most recent evidences supporting the conservative management: firstly, at least 55% children with CNS are not spontaneously in ESKD at the age of 2 years; secondly, albumin tapering/discontinuation and hospital discharge are possible before nephrectomy; and lastly, CNS complication rates are similar in case of preemptive nephrectomies or conservative care. Until now, no clear genotype-phenotype correlation has been identified to guide clinical management. Taken together, these data support the safety of conservative care until ESKD in a subset of patients with CNS.
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Affiliation(s)
- Olivia Boyer
- Néphrologie Pédiatrique, Centre de Référence MARHEA, Centre de Référence du Syndrome Néphrotique Idiopathique de l'enfant et l'adulte, Hôpital Necker - Enfants Malades, APHP, Inserm U1163, Institut Imagine, Université de Paris, Paris, France.
| | - Sandra Bérody
- Unité de Soins Intensifs et Réanimation Néonatale, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
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20
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Lipska-Ziętkiewicz BS, Ozaltin F, Hölttä T, Bockenhauer D, Bérody S, Levtchenko E, Vivarelli M, Webb H, Haffner D, Schaefer F, Boyer O. Genetic aspects of congenital nephrotic syndrome: a consensus statement from the ERKNet-ESPN inherited glomerulopathy working group. Eur J Hum Genet 2020; 28:1368-1378. [PMID: 32467597 PMCID: PMC7608398 DOI: 10.1038/s41431-020-0642-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 03/03/2020] [Accepted: 03/10/2020] [Indexed: 01/23/2023] Open
Abstract
Congenital nephrotic syndrome (CNS) is a heterogeneous group of disorders presenting with massive proteinuria within the first 3 months of life almost inevitably leading to end-stage kidney disease. The Work Group for the European Reference Network for Kidney Diseases (ERKNet) and the European Society for Pediatric Nephrology (ESPN) has developed consensus statement on genetic aspects of CNS diagnosis and management. The presented expert opinion recommends genetic diagnostics as the key diagnostic test to be ordered already during the initial evaluation of the patient, discusses which phenotyping workup should be performed and presents known genotype-phenotype correlations.
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Affiliation(s)
- Beata Stefania Lipska-Ziętkiewicz
- Clinical Genetics Unit, Department of Biology and Medical Genetics, Medical University of Gdańsk, Gdańsk, Poland.
- Centre for Rare Diseases, Medical University of Gdańsk, Gdańsk, Poland.
| | - Fatih Ozaltin
- Department of Pediatric Nephrology and Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Tuula Hölttä
- Department of Pediatric Nephrology and Transplantation, The New Children's Hospital, HUS Helsinki University Hospital, Helsinki, Finland
| | - Detlef Bockenhauer
- UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sandra Bérody
- Department of Pediatric Nephrology, Reference Center for Hereditary Kidney Diseases (MARHEA), Necker Hospital, APHP, 75015, Paris, France
| | - Elena Levtchenko
- Division of Pediatric Nephrology, Department of Pediatrics, University Hospitals Leuven; Department of Development & Regeneration, University of Leuven, Leuven, Belgium
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital and Research Center, Rome, Italy
| | - Hazel Webb
- UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
- Center for Congenital Kidney Diseases, Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany.
| | - Olivia Boyer
- Department of Pediatric Nephrology, Reference Center for Hereditary Kidney Diseases (MARHEA), Necker Hospital, APHP, 75015, Paris, France
- Laboratory of Hereditary Kidney Diseases, Imagine Institute, INSERM, Paris Descartes University, U1163, Paris, France
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21
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Dufek S, Holtta T, Trautmann A, Ylinen E, Alpay H, Ariceta G, Aufricht C, Bacchetta J, Bakkaloglu SA, Bayazit A, Cicek RY, Dursun I, Duzova A, Ekim M, Iancu D, Jankauskiene A, Klaus G, Paglialonga F, Pasini A, Printza N, Said Conti V, do Sameiro Faria M, Schmitt CP, Stefanidis CJ, Verrina E, Vidal E, Vondrak K, Webb H, Zampetoglou A, Bockenhauer D, Edefonti A, Shroff R. Management of children with congenital nephrotic syndrome: challenging treatment paradigms. Nephrol Dial Transplant 2020; 34:1369-1377. [PMID: 30215773 DOI: 10.1093/ndt/gfy165] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 04/24/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Management of children with congenital nephrotic syndrome (CNS) is challenging. Bilateral nephrectomies followed by dialysis and transplantation are practiced in most centres, but conservative treatment may also be effective. METHODS We conducted a 6-year review across members of the European Society for Paediatric Nephrology Dialysis Working Group to compare management strategies and their outcomes in children with CNS. RESULTS Eighty children (50% male) across 17 tertiary nephrology units in Europe were included (mutations in NPHS1, n = 55; NPHS2, n = 1; WT1, n = 9; others, n = 15). Excluding patients with mutations in WT1, antiproteinuric treatment was given in 42 (59%) with an increase in S-albumin in 70% by median 6 (interquartile range: 3-8) g/L (P < 0.001). Following unilateral nephrectomy, S-albumin increased by 4 (1-8) g/L (P = 0.03) with a reduction in albumin infusion dose by 5 (2-9) g/kg/week (P = 0.02). Median age at bilateral nephrectomies (n = 29) was 9 (7-16) months. Outcomes were compared between two groups of NPHS1 patients: those who underwent bilateral nephrectomies (n = 25) versus those on conservative management (n = 17). The number of septic or thrombotic episodes and growth were comparable between the groups. The response to antiproteinuric treatment, as well as renal and patient survival, was independent of NPHS1 mutation type. At final follow-up (median age 34 months) 20 (80%) children in the nephrectomy group were transplanted and 1 died. In the conservative group, 9 (53%) remained without dialysis, 4 (24%; P < 0.001) were transplanted and 2 died. CONCLUSION An individualized, stepwise approach with prolonged conservative management may be a reasonable alternative to early bilateral nephrectomies and dialysis in children with CNS and NPHS1 mutations. Further prospective studies are needed to define indications for unilateral nephrectomy.
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Affiliation(s)
- Stephanie Dufek
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tuula Holtta
- Department of Pediatric Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Agnes Trautmann
- Center for Pediatric & Adolescent Medicine, Heidelberg, Germany
| | - Elisa Ylinen
- Department of Pediatric Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harika Alpay
- School of Medicine, Marmara University, Istanbul, Turkey
| | - Gema Ariceta
- Hospital MaternoInfantil de la Vall d'Hebron, Barcelona, Spain
| | | | | | - Sevcan A Bakkaloglu
- Department of Pediatric Nephrology, Gazi University Hospital, Ankara, Turkey
| | - Aysun Bayazit
- Department of Pediatric Nephrology, Cukurova University, Adana, Turkey
| | | | - Ismail Dursun
- Department of Pediatric Nephrology, Erciyes University, Kayseri, Turkey
| | - Ali Duzova
- Division of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Sihhiye, Ankara, Turkey
| | | | - Daniela Iancu
- Center for Nephrology, University College London, London, UK
| | | | | | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Pasini
- Azienda Ospedaliero-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - Nikoleta Printza
- Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
| | | | | | | | | | | | - Enrico Vidal
- Department of Pediatrics, University Hospital of Padova, Padova, Italy
| | - Karel Vondrak
- Pediatric Nephrology, University Hospital Motol, Prague, Czech Republic
| | - Hazel Webb
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Detlef Bockenhauer
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Alberto Edefonti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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22
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Abstract
Enteral nutritional support is an important component of the care provided to infants receiving long-term peritoneal dialysis. In the majority of published experiences on this subject, the use of the nasogastric tube has facilitated the provision of required calorie and protein intake and resulted in an improved patient outcome. Advantages of the nasogastric route of nutritional support include the ease of administration, while recurrent emesis remains the most troublesome and frequent shortterm complication associated with its use. Impaired oralmotor development may also result from nonoral feeding and should be addressed throughout the course of tube feeding. The outcome of infants with ESRD receiving CPD has markedly improved since the introduction of NG feedings as a regular component of dialysis patient care. While complications associated with NG feedings have been documented, the benefits associated with this route of nutritional supplementation have been great. Currently, an increasing number of infants/ young children on CPD are receiving supplemental nutrition with the use of the gastrostomy tube/button (31). However, the risks associated with this route of therapy in the CPD population, especially in terms of infection, are as yet not well defined (32). Once the risk/benefit ratio of gastrostomy tube/button placement is determined, future efforts should be directed towards better defining how the two routes of enteral nutritional support (e.g., NG tube, gastrostomy tube/button) may best complement one another.
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Affiliation(s)
| | - Lynette Weis
- Department of Pediatric Nutrition, The Children's Mercy Hospital, Kansas City, Missouri, U.S.A
| | - Leslie Johnson
- Department of Pediatric Nutrition, The Children's Mercy Hospital, Kansas City, Missouri, U.S.A
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23
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Hölttä TM, Rönnholm KA, Jalanko H, Ala-Houhala M, Antikainen M, Holmberg C. Peritoneal Dialysis in Children under 5 Years of Age. Perit Dial Int 2020. [DOI: 10.1177/089686089701700609] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective We report our experience with maintenance peritoneal dialysis (PD) in small children. Design This is a retrospective analysis of the patient records of all children under the age of 5 years treated with continuous peritoneal dialysis (CPD) between 1986 and 1994 in Finland. Setting Treatment was started and the patients were seen at the outpatient clinic at the Hospital for Children and Adolescents, University of Helsinki, every 3 months. Between these visits, they had controls at their local hospital every 2 -4 weeks. Patients The most common primary renal disease in these 34 patients was congenital nephrotic syndrome of the Finnish type (27 patients). Others were: congenital nephrotic syndrome (3 patients), polycystic kidney disease (1), urethral valve (1), neuroblastoma (1), and renal dysplasia (1). Results Mean age at onset was 1.6 years and median treatment time 9.3 months. Time spent in hospital decreased from 270 days/year in the 1980s to 150 days/year in the 1990s. Two children died (5.9%). The peritonitis rate on continuous cyclic peritoneal dialysis was 1:11.5 patient-months. Hernias were diagnosed in 29% of the patients. After 3 months half of the patients were on antihypertensive medication. Pulmonary edema was diagnosed once in 12 patients and twice in 2 patients. During the first 6 months on PD the mean height standard deviation score (hSDS) increased from -2.13 to -1.66 (p < 0.0001). The 6-month change in hSDS before initiation and 6 months after the start of CPD increased from -0.12 ± 0.68 to +0.59 ± 0.64 (p = 0.0008). Conclusions Our results indicate that peritoneal dialysis is feasible and safe in small children. Mortality was low and growth was good. The major challenges presented by CPD therapy were maintenance of optimal nutrition, avoidance of peritonitis, and control of volemia.
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Affiliation(s)
- Tuula M. Hölttä
- Division of Pediatric Nephrology and Transplantation, University of Tampere, Tampere, Finland
| | - Kai A.R. Rönnholm
- Division of Pediatric Nephrology and Transplantation, University of Tampere, Tampere, Finland
| | - Hannu Jalanko
- Division of Pediatric Nephrology and Transplantation, University of Tampere, Tampere, Finland
| | - Marja Ala-Houhala
- Hospital for Children and Adolescents, University of Helsinki, Helsinki; Department of Pediatrics, University of Tampere, Tampere, Finland
| | - Marjatta Antikainen
- Division of Pediatric Nephrology and Transplantation, University of Tampere, Tampere, Finland
| | - Christer Holmberg
- Division of Pediatric Nephrology and Transplantation, University of Tampere, Tampere, Finland
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24
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Ghalloussi D, Rousset-Rouvière C, Popovici C, Garaix F, Saut N, Saultier P, Tsimaratos M, Chambost H, Alessi MC, Baccini V. Bernard-Soulier syndrome: first human case due to a homozygous deletion of GP9 gene. Br J Haematol 2020; 188:e87-e90. [PMID: 32030720 DOI: 10.1111/bjh.16374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Caroline Rousset-Rouvière
- Department of Multidisciplinary Pediatrics, Pediatric Nephrology Unit, La Timone, University Hospital of Marseille, Marseille, France
| | - Cornel Popovici
- Genetic Department, La Timone, University Hospital of Marseille, Marseille, France
| | - Florentine Garaix
- Department of Multidisciplinary Pediatrics, Pediatric Nephrology Unit, La Timone, University Hospital of Marseille, Marseille, France
| | - Noémie Saut
- Hematology Laboratory, La Timone University Hospital of Marseille, Marseille, France
| | - Paul Saultier
- Department of Pediatric Hematology, La Timone Hospital, Marseille, France
| | - Michel Tsimaratos
- Department of Multidisciplinary Pediatrics, Pediatric Nephrology Unit, La Timone, University Hospital of Marseille, Marseille, France
| | - Hervé Chambost
- Department of Pediatric Hematology, La Timone Hospital, Marseille, France
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25
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Congenital nephrotic syndrome: is early aggressive treatment needed? Yes. Pediatr Nephrol 2020; 35:1985-1990. [PMID: 32377865 PMCID: PMC7501131 DOI: 10.1007/s00467-020-04578-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 04/05/2020] [Accepted: 04/16/2020] [Indexed: 12/24/2022]
Abstract
Congenital nephrotic syndrome (CNS) was primarily considered one disease entity. Hence, one treatment protocol was proposed in the beginning to all CNS patients. Today, with the help of gene diagnostics, we know that CNS is a heterogeneous group of disorders and therefore, different treatment protocols are needed. The most important gene defects causing CNS are NPHS1, NPHS2, WT1, LAMB2, and PLCE1. Before active treatment, all infants with CNS died. It was stated already in the mid-1980s that intensive medical therapy followed by kidney transplantation (KTx) should be the choice of treatment for infants with severe CNS. In Finland, early aggressive treatment protocol was adopted from the USA and further developed for treatment of children with the Finnish type of CNS. The aim of this review is to state reasons for "early aggressive treatment" including daily albumin infusions, intensified nutrition, and timely bilateral nephrectomy followed by KTx at the age of 1-2 years.
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26
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Serramontmany E, Muñoz M, Fernández-Polo A, Morillo M, Gómez-Ganda L, Cañete-Ramírez C, Ariceta G. Home Albumin Infusion Therapy, Another Alternative Treatment in Patients With Congenital Nephrotic Syndrome of the Finnish Type. Front Pediatr 2020; 8:614535. [PMID: 33520897 PMCID: PMC7841340 DOI: 10.3389/fped.2020.614535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Congenital nephrotic syndrome of the Finnish type (CNF) is a rare, severe glomerular disease caused by mutations in the NPHS1 gene, which codes for nephrin. It is characterised by massive proteinuria and severe edoema. Progression to end-stage kidney failure occurs during early childhood and the only curative treatment is kidney transplantation. Nowadays, patients need aggressive medical treatment, which includes daily albumin infusions (for months) until they get clinical stability to receive transplant. Objective: In our paediatric hospital, we implemented a multidisciplinary program for the home infusion of albumin with outpatient follow-up. The aim of the study was to assess the safety and efficacy of this program for the first four years of its implementation. Material and Methods: Retrospective observational study of CNF paediatric patients treated with home albumin infusion therapy from March 2014 to July 2018 at a tertiary care paediatric hospital. Information on albumin administration was obtained from the electronic prescription assistance program and details on clinical and care-related variables from the hospital's electronic information systems. Results: Four patients with CNF received albumin infusions for 18, 21, 22 months, and 3 years. The treatment was safe, and the complication rates were to be expected considering the severity of disease. Patients required a median of two hospital admissions a year (19 in total); 47% due to catheter-related complications, but there were just three catheter infections. Conclusions: In our experience, home albumin infusion therapy is safe and effective and helps to improve children health and quality of life.
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Affiliation(s)
| | - Marina Muñoz
- Pediatric Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - María Morillo
- Nursery Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Laura Gómez-Ganda
- Pharmacy Department, Vall d'Hebron University Hospital, Barcelona, Spain
| | | | - Gema Ariceta
- Pediatric Nephrology Department, Vall d'Hebron University Hospital, Barcelona, Spain
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27
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Jacob A, Habeeb SM, Herlitz L, Simkova E, Shekhy JF, Taylor A, Abuhammour W, Abou Tayoun A, Bitzan M. Case Report: CMV-Associated Congenital Nephrotic Syndrome. Front Pediatr 2020; 8:580178. [PMID: 33330277 PMCID: PMC7728737 DOI: 10.3389/fped.2020.580178] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 11/02/2020] [Indexed: 01/13/2023] Open
Abstract
Background: Congenital nephrotic syndrome, historically defined by the onset of large proteinuria during the first 3 months of life, is a rare clinical disorder, generally with poor outcome. It is caused by pathogenic variants in genes associated with this syndrome or by fetal infections disrupting podocyte and/or glomerular basement membrane integrity. Here we describe an infant with congenital CMV infection and nephrotic syndrome that failed to respond to targeted antiviral therapy. Case and literature survey highlight the importance of the "tetrad" of clinical, virologic, histologic, and genetic workup to better understand the pathogenesis of CMV-associated congenital and infantile nephrotic syndromes. Case Presentation: A male infant was referred at 9 weeks of life with progressive abdominal distention, scrotal edema, and vomiting. Pregnancy was complicated by oligohydramnios and pre-maturity (34 weeks). He was found to have nephrotic syndrome and anemia, normal platelet and white blood cell count, no splenomegaly, and no syndromic features. Diagnostic workup revealed active CMV infection (positive CMV IgM/PCR in plasma) and decreased C3 and C4. Maternal anti-CMV IgG was positive, IgM negative. Kidney biopsy demonstrated focal mesangial proliferative and sclerosing glomerulonephritis with few fibrocellular crescents, interstitial T- and B-lymphocyte infiltrates, and fibrosis/tubular atrophy. Immunofluorescence was negative. Electron microscopy showed diffuse podocyte effacement, but no cytomegalic inclusions or endothelial tubuloreticular arrays. After 4 weeks of treatment with valganciclovir, plasma and urine CMV PCR were negative, without improvement of the proteinuria. Unfortunately, the patient succumbed to fulminant pneumococcal infection at 7 months of age. Whole exome sequencing and targeted gene analysis identified a novel homozygous, pathogenic variant (2071+1G>T) in NPHS1. Literature Review and Discussion: The role of CMV infection in isolated congenital nephrotic syndrome and the corresponding pathological changes are still debated. A search of the literature identified only three previous reports of infants with congenital nephrotic syndrome and evidence of CMV infection, who also underwent kidney biopsy and genetic studies. Conclusion: Complete workup of congenital infections associated with nephrotic syndrome is warranted for a better understanding of their pathogenesis ("diagnostic triad" of viral, biopsy, and genetic studies). Molecular testing is essential for acute and long-term prognosis and treatment plan.
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Affiliation(s)
- Anju Jacob
- Department of Pediatrics, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Shameer M Habeeb
- Department of Pediatrics, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.,Kidney Centre of Excellence, Al Jalila Children's Speciality Hospital, Dubai, United Arab Emirates
| | - Leal Herlitz
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, United States
| | - Eva Simkova
- Department of Pediatrics, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.,Kidney Centre of Excellence, Al Jalila Children's Speciality Hospital, Dubai, United Arab Emirates
| | - Jwan F Shekhy
- Department of Pediatrics, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Alan Taylor
- Department of Pediatrics, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.,Al Jalila Genomics Center, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Walid Abuhammour
- Department of Pediatrics, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.,Section of Infectious Diseases, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates
| | - Ahmad Abou Tayoun
- Department of Pediatrics, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.,Al Jalila Genomics Center, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.,Department of Genetics, Mohammad Bin Rashid University of Medicine and Health Sciences, Dubai, United Arab Emirates
| | - Martin Bitzan
- Department of Pediatrics, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates.,Kidney Centre of Excellence, Al Jalila Children's Speciality Hospital, Dubai, United Arab Emirates
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28
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Reynolds BC, Oswald RJA. Diagnostic and Management Challenges in Congenital Nephrotic Syndrome. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2019; 10:157-167. [PMID: 31908565 PMCID: PMC6930517 DOI: 10.2147/phmt.s193684] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 12/05/2019] [Indexed: 12/21/2022]
Abstract
Congenital Nephrotic Syndrome (CNS) is defined as nephrotic range proteinuria, hypoalbuminaemia and edema in the first three months of life. CNS is most commonly genetic in cause, with international variance in the incidence of causative mutations. Initially defined by the histopathological appearance, increasingly sophisticated and accessible genetic analyses now provide a body of evidence to suggest that there is a disparity between the histological appearance, the genotype of individuals and the severity of the clinical disease. Through the evolution of management approaches CNS has changed from being an invariably fatal condition to one with appreciable ongoing morbidity and mortality but comparably good outcomes to other causes of paediatric end-stage renal disease, especially following transplantation. This review briefly summarises the more commonly recognised genetic mutations leading to CNS, addresses common management decisions, and concludes with potential therapies for the future.
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29
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Dufek S, Ylinen E, Trautmann A, Alpay H, Ariceta G, Aufricht C, Bacchetta J, Bakkaloglu S, Bayazit A, Caliskan S, do Sameiro Faria M, Dursun I, Ekim M, Jankauskiene A, Klaus G, Paglialonga F, Pasini A, Printza N, Conti VS, Schmitt CP, Stefanidis C, Verrina E, Vidal E, Webb H, Zampetoglou A, Edefonti A, Holtta T, Shroff R. Infants with congenital nephrotic syndrome have comparable outcomes to infants with other renal diseases. Pediatr Nephrol 2019; 34:649-655. [PMID: 30374605 DOI: 10.1007/s00467-018-4122-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/12/2018] [Accepted: 10/18/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Children with congenital nephrotic syndrome (CNS) commonly develop end stage renal failure in infancy and require dialysis, but little is known about the complications and outcomes of dialysis in these children. METHODS We conducted a retrospective case note review across members of the European Society for Pediatric Nephrology Dialysis Working Group to evaluate dialysis management, complications of dialysis, and outcomes in children with CNS. RESULTS Eighty children (50% male) with CNS were identified form 17 centers over a 6-year period. Chronic dialysis was started in 44 (55%) children at a median age of 8 (interquartile range 4-14) months. Of these, 17 (39%) were on dialysis by the age of 6 months, 30 (68%) by 1 year, and 40 (91%) by 2 years. Peritoneal dialysis (PD) was the modality of choice in 93%, but 34% switched to hemodialysis (HD), largely due to catheter malfunction (n = 5) or peritonitis (n = 4). The peritonitis rate was 0.77 per patient-year. Weight and height SDS remained static after 6 months on dialysis. In the overall cohort, at final follow-up, 29 children were transplanted, 18 were still on dialysis (15 PD, 3 HD), 19 were in pre-dialysis chronic kidney disease (CKD), and there were 14 deaths (8 on dialysis). Median time on chronic dialysis until transplantation was 9 (6-18) months, and the median age at transplantation was 22 (14-28) months. CONCLUSIONS Infants with CNS on dialysis have a comparable mortality, peritonitis rate, growth, and time to transplantation as infants with other primary renal diseases reported in international registry data.
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MESH Headings
- Age Factors
- Child, Preschool
- Disease Progression
- Europe
- Female
- Humans
- Infant
- Infant, Newborn
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/etiology
- Kidney Failure, Chronic/mortality
- Kidney Failure, Chronic/therapy
- Kidney Transplantation/adverse effects
- Kidney Transplantation/mortality
- Male
- Nephrotic Syndrome/congenital
- Nephrotic Syndrome/diagnosis
- Nephrotic Syndrome/mortality
- Nephrotic Syndrome/therapy
- Peritoneal Dialysis
- Renal Dialysis/adverse effects
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/etiology
- Renal Insufficiency, Chronic/mortality
- Renal Insufficiency, Chronic/therapy
- Retrospective Studies
- Risk Factors
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Stephanie Dufek
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Elisa Ylinen
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Agnes Trautmann
- Center for Pediatric and Adolescent Medicine, Heidelberg, Germany
| | - Harika Alpay
- School of Medicine, Marmara University, Istanbul, Turkey
| | - Gema Ariceta
- Hospital Universitari Vall d'Hebron. Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | | | | | | | | | | | | | | | | | | | - Fabio Paglialonga
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Pasini
- Azienda Ospedaliero-Universitaria Sant'Orsola-Malpighi, Bologna, Italy
| | - Nikoleta Printza
- 1st Pediatric Department, Aristotle University, Thessaloniki, Greece
| | | | | | | | | | | | - Hazel Webb
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | | | - Alberto Edefonti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tuula Holtta
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rukshana Shroff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
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30
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The long journey through renal filtration: new pieces in the puzzle of slit diaphragm architecture. Curr Opin Nephrol Hypertens 2018; 26:148-153. [PMID: 28212178 DOI: 10.1097/mnh.0000000000000322] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW The podocyte slit diaphragm is probably the least understood component of the kidney filtration barrier. In this review, we aim to integrate the most recent findings on the molecular make-up and structural architecture of this specialized cell-cell junction into a current concept of glomerular filtration. RECENT FINDINGS Analysis of cryopreserved mammalian tissue revealed a bipartite composition of the slit diaphragm. Single NEPH1 molecules span the lower part of the slit close to the glomerular basement membrane whereas NEPHRIN molecules are positioned in the apical part toward Bowman's space. This molecular arrangement could lead to heterogeneous ellipsoidal and circular pores, which are mainly located in the central region of the slit diaphragm. SUMMARY Despite having been first identified in the 1970s, the slit diaphragm's structural architecture has not been fully elucidated to date and remains an area of intense research and scientific debate. The slit diaphragm has been initially described as a rigid 'zipper-like' structure in which periodic, rod-like units extend from a podocyte foot processes to a linear central bar, giving rise to homogeneous 4 × 14 nm pores. Several recent findings have challenged these long-held beliefs and instead pointed to an unanticipated complexity of slit diaphragm structure. High-resolution ultrastructural analysis found evidence that the slit diaphragm is a dynamic and adjustable cell-cell junction that forms a nonclogging barrier within the renal filtration system.
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31
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Bérody S, Heidet L, Gribouval O, Harambat J, Niaudet P, Baudouin V, Bacchetta J, Boudaillez B, Dehennault M, de Parscau L, Dunand O, Flodrops H, Fila M, Garnier A, Louillet F, Macher MA, May A, Merieau E, Monceaux F, Pietrement C, Rousset-Rouvière C, Roussey G, Taque S, Tenenbaum J, Ulinski T, Vieux R, Zaloszyc A, Morinière V, Salomon R, Boyer O. Treatment and outcome of congenital nephrotic syndrome. Nephrol Dial Transplant 2018; 34:458-467. [DOI: 10.1093/ndt/gfy015] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/24/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sandra Bérody
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
| | - Laurence Heidet
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | | | - Jérome Harambat
- Centre Hospitalier Universitaire de Bordeaux, Néphrologie pédiatrique, Bordeaux, France
| | - Patrick Niaudet
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | - Veronique Baudouin
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Hôpital Universitaire Robert Debré, Néphrologie pédiatrique, Paris, France
| | | | | | | | | | - Olivier Dunand
- CHU Felix Guyon, Pédiatrie, Saint-Denis, La Reunion, France
| | | | - Marc Fila
- Centre Hospitalier Regional Universitaire de Montpellier, Néphrologie pédiatrique, Montpellier, France
| | - Arnaud Garnier
- Centre Hospitalier Universitaire de Toulouse, Néphrologie pédiatrique, Toulouse, France
| | | | - Marie-Alice Macher
- Hôpital Universitaire Robert Debré, Néphrologie pédiatrique, Paris, France
| | - Adrien May
- Centre Hospitalier Sud Francilien, Pédiatrie, Corbeil-Essonnes, France
| | | | | | | | | | - Gwenaëlle Roussey
- Centre Hospitalier Universitaire de Nantes, Néphrologie pédiatrique, Nantes, France
| | - Sophie Taque
- Centre Hospitalier Universitaire de Rennes, Pédiatrie, Rennes, France
| | - Julie Tenenbaum
- Centre Hospitalier Regional Universitaire de Montpellier, Néphrologie pédiatrique, Montpellier, France
| | - Tim Ulinski
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Hôpital Armand-Trousseau, Néphrologie pédiatrique, Paris, France
| | - Rachel Vieux
- Centre Hospitalier Universitaire de Nancy, Pédiatrie, Nancy, France
| | | | | | - Rémi Salomon
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | - Olivia Boyer
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
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Abstract
Idiopathic steroid-resistant nephrotic syndrome (SRNS) is most frequently characterized by focal segmental glomerulosclerosis (FSGS) but also other histological lesions, such as diffuse mesangial sclerosis. In the past two decades, a multitude of genetic causes of SRNS have been discovered raising the question of effective treatment in this cohort. Although no controlled studies are available, this review will discuss treatment options including pharmacologic interventions aiming at the attenuation of proteinuria in genetic causes of SRNS, such as inhibitors of the renin-angiotensin-aldosterone system and indomethacin. Also, the potential impact of other interventions to improve podocyte stability will be addressed. In this respect, the treatment with cyclosporine A (CsA) is of interest, since a podocyte stabilizing effect has been demonstrated in various experimental models. Although clinical response to CsA in children with genetic forms of SRNS is inferior to sporadic SRNS, some recent studies show that partial and even complete response can be achieved even in individual patients inherited forms of nephrotic syndrome. Ideally, improved pharmacologic and molecular approaches to induce partial or even complete remission will be available in the future, thus slowing or even preventing the progression toward end-stage renal disease.
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Affiliation(s)
- Markus J Kemper
- AK Nord Heidberg, Asklepios Medical School GmbH, Hamburg, Germany
| | - Anja Lemke
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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Hamasaki Y, Muramatsu M, Hamada R, Ishikura K, Hataya H, Satou H, Honda M, Nakanishi K, Shishido S. Long-term outcome of congenital nephrotic syndrome after kidney transplantation in Japan. Clin Exp Nephrol 2017; 22:719-726. [PMID: 29185126 DOI: 10.1007/s10157-017-1508-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Congenital nephrotic syndrome is difficult to manage, particularly the Finnish type (CNF), with patients experiencing severe edema, sepsis and thrombosis before kidney transplantation. Further, nephrosis and thrombosis remain problematic after transplantation. METHODS Of 22 CNF patients managed at our hospital, 14 who underwent kidney transplantation were retrospectively studied. CNF was diagnosed according to standard criteria. RESULTS The study population consisted of 3 males and 11 females. Mean gestation period was 36 ± 1.4 weeks and mean birth weight was 2442 ± 454 g (mean placenta to body weight ratio: 0.4). All patients started dialysis at 2.4 ± 1.3 years and underwent kidney transplantation at 5.2 ± 2.0 years. The kidneys were donated by the parents (n = 13), and cadaver (n = 2), including overlap. Mean follow-up period after transplantation was 14.3 ± 8.9 years, and mean age at last observation was 19.5 ± 8.5 years. Two patients had recurrent proteinuria after kidney transplantation; one underwent retransplantation following graft failure and eventually required dialysis, while the second had complete remission after intensive immunosuppressive therapy. There were no cases of thrombosis or serious infections. Mean eGFR at the time of last observation was 57.3 ± 16.5 ml/min/1.73 m2, while mean height SD score was - 2.1 ± 0.9 at the time of transplantation and - 1.5 ± 1.5 at last observation. CONCLUSIONS Long-term outcome in these 14 CNF patients showed satisfactory graft survival, improved height SD score, and favorable development. Although recurrent proteinuria after transplant was not predictive, it was associated with graft survival rate.
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Affiliation(s)
- Yuko Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, 6-11-1 Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan. .,Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.
| | - Masaki Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroyuki Satou
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Seiichiro Shishido
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, 6-11-1 Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan.,Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
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34
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Abstract
Thyroid hormones influence renal development, kidney hemodynamics, glomerular filtration rate and sodium and water homeostasis. Hypothyroidism and hyperthyroidism affect renal function by direct renal effects as well as systemic hemodynamic, metabolic and cardiovascular effects. Hypothyroidism has been associated with increased serum creatinine and decreased glomerular filtration rate. The reverse effects have been reported in thyrotoxicosis. Most of renal manifestations of thyroid dysfunction are reversible with treatment. Kidney disease may also cause thyroid dysfunction by several mechanisms. Nephrotic syndrome has been associated to changes in serum thyroid hormone concentrations. Different forms of glomerulonephritis and tubulointerstitial disease may be linked to thyroid derangements. A high prevalence of thyroid hormone alteration has been reported in acute kidney injury. Thyroid dysfunction is highly prevalent in chronic kidney disease patients. Subclinical hypothyroidism and low triiodothyronine syndrome are common features in patients with chronic kidney disease. Patients treated by both hemodialysis and peritoneal dialysis, and renal transplantation recipients, exhibit thyroid hormone alterations and thyroid disease with higher frequency than that found in the general population. Drugs used in the therapy of thyroid disease may lead to renal complications and, similarly, drugs used in kidney disorders may be associated to thyroid alterations. Lastly, low thyroid hormones, especially low triiodothyronine levels, in patients with chronic kidney disease have been related to a higher risk of cardiovascular disease and all-cause mortality. Interpretation of the interactions between thyroid and renal function is a challenge for clinicians involved in the treatment of patients with thyroid and kidney disease.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. De Colmenar, Km 9,100, 28034, Madrid, Spain.
| | - María Auxiliadora Bajo
- Department of Nephrology, Hospital La Paz, Madrid, Spain
- Department of Health Sciences, Universidad Autónoma de Madrid, Madrid, Spain
| | - Rafael Selgas
- Department of Nephrology, Hospital La Paz, Madrid, Spain
- Department of Health Sciences, Universidad Autónoma de Madrid, Madrid, Spain
| | - Juan José Díez
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. De Colmenar, Km 9,100, 28034, Madrid, Spain
- Department of Medicine, University de Alcalá de Henares, Madrid, Spain
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Timing of renal replacement therapy does not influence survival and growth in children with congenital nephrotic syndrome caused by mutations in NPHS1: data from the ESPN/ERA-EDTA Registry. Pediatr Nephrol 2016; 31:2317-2325. [PMID: 27761660 DOI: 10.1007/s00467-016-3517-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 09/05/2016] [Accepted: 09/06/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Congenital nephrotic syndrome (CNS) of the Finnish type, NPHS1, is the most severe form of CNS. Outcomes of renal replacement therapy (RRT) in NPHS1 patients in Europe were analysed using data from the ESPN/ERA-EDTA Registry. As NPHS1 is most prevalent in Finland and the therapeutic approach differs from that in many other countries, we compared outcomes in Finnish and other European patients. METHODS NPHS1 mutations were confirmed in 170 children with CNS who initiated RRT (dialysis or renal transplantation) between 1991 and 2012. Finnish (n = 66) and non-Finnish NPHS1 patients (n = 104) were compared with respect to treatment policy, age at first RRT and renal transplantation (RTX), patient and graft survival, estimated glomerular filtration rate (eGFR) and growth. Age-matched patients with congenital anomalies of the kidney and urinary tract (CAKUT) served as controls. RESULTS Finnish NPHS1 patients were significantly younger than non-Finnish patients, both at the start of RRT and at the time of RTX. We found similar overall 5-year patient survival on RRT (91 %) and graft survival (89 %) in both NPHS1 groups and CAKUT controls. At the start of RRT, height standard deviation score (SDS) was higher in Finnish patients than in non-Finnish patients (mean [95 % CI]: -1.31 [-2.13 to -0.49] and -3.0 [-4.22 to -1.91], p < 0.01 respectively), but not at 5 years of age. At 5 years of age height and body mass index (BMI) SDS were similar to those of CAKUT controls. CONCLUSIONS Overall, 5-year patient and graft survival of both Finnish and non-Finnish NPHS1 patients on RRT were excellent and comparable with CAKUT patients with equally early RRT onset and was independent of the timing of RRT initiation and RTX.
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Spahiu L, Merovci B, Jashari H, Këpuska AB, Rugova BE. Congenital Nephrotic Syndrome - Finish Type. Med Arch 2016; 70:232-4. [PMID: 27594755 PMCID: PMC5010061 DOI: 10.5455/medarh.2016.70.232-234] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 04/20/2016] [Indexed: 11/23/2022] Open
Abstract
Introduction: Identification of the NPHS1 gene, which encodes nephrin, was followed by many studies demonstrating its mutation as a frequent cause of congenital nephrotic syndrome (CNS). While this gene is found in 98% of Finnish children with this syndrome, non-Finnish cases have lower level of incidence ranging from 39 to 80%. Case report: This report describes the clinical presentation of a two-week-old neonate who presented with periorbital and lower extremities edema, abdominal distention, heavy proteinuria, serum hypoproteinemia and failure to thrive. Genetic analysis revealed NHPS1 gene mutation leading to CNS-Finnish type diagnosis. Conclusion: Through this case we want to create awareness about diagnosis and treatment challenges in developing countries for rare congenital diseases.
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Affiliation(s)
- Lidvana Spahiu
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Republic of Kosovo
| | - Besart Merovci
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Republic of Kosovo
| | - Haki Jashari
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Republic of Kosovo; Department of Public Health and Clinical Medicine, Umeå University, Sweden
| | | | - Blerta Elezi Rugova
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Republic of Kosovo
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Domiciliary administration of intravenous albumin in congenital nephrotic syndrome. Pediatr Nephrol 2015; 30:2045-50. [PMID: 26248471 DOI: 10.1007/s00467-015-3177-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 07/10/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Early management of congenital nephrotic syndrome invariably includes the frequent administration of intravenous human albumin solution. The safety and feasibility of intravenous administration of albumin in the patients' home setting has not previously been reported. CASE-DIAGNOSIS/TREATMENT We report a series of seven paediatric patients whose parents were trained in the administration of albumin via a central venous catheter at home, with the aim of minimising hospital admission or attendances. We describe the clinical course of these patients and complication rates ascribed to this strategy. CONCLUSIONS Our results demonstrate that home albumin infusion can be performed safely.
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Cil O, Besbas N, Duzova A, Topaloglu R, Peco-Antić A, Korkmaz E, Ozaltin F. Genetic abnormalities and prognosis in patients with congenital and infantile nephrotic syndrome. Pediatr Nephrol 2015; 30:1279-87. [PMID: 25720465 DOI: 10.1007/s00467-015-3058-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/08/2015] [Accepted: 01/19/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Congenital nephrotic syndrome (CNS) and infantile nephrotic syndrome (INS) are caused primarily by mutations in genes that encode structural and regulatory proteins of the glomerular filtration barrier. The aim of this study was to determine genotype-phenotype correlations and prognosis in patients with CNS and INS. METHODS NPHS1, NPHS2, LAMB2 and the eighth and ninth exons of WT1 were sequenced in 80 and 22 patients with CNS and INS, respectively. Genotype-phenotype correlations and survival were evaluated. RESULTS Causative mutations were identified in 64.7 % of patients, of which NPHS1 mutations were the most common (37.4 %). The mutation detection rate was twofold higher in CNS patients than in INS patients (72.5 vs. 36.2 %). The most commonly mutated gene in CNS patients was NPHS1 (46.3 %) versus NPHS2 (13.6 %) and WT1 (13.6 %) in INS patients. NPHS2 mutations, female patients with NPHS1 mutations, and NPHS1 mutations affecting the transmembrane or intracellular domains of nephrin were associated with longer survival. CONCLUSIONS Based on our present findings, the likelihood of identification of a genetic cause decreases with increasing age at diagnosis. The underlying genetic abnormality should be identified as early as possible, as this knowledge will facilitate clinicians in their prognostic prediction and enable patients to receive appropriate genetic counseling.
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Affiliation(s)
- Onur Cil
- Department of Pediatric Nephrology, Hacettepe University, Ankara, Turkey
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39
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Abstract
It has been argued that the oedema of kwashiorkor is not caused by hypoalbuminaemia because the oedema disappears with dietary treatment before the plasma albumin concentration rises. Reanalysis of this evidence and a review of the literature demonstrates that this was a mistaken conclusion and that the oedema is linked to hypoalbuminaemia. This misconception has influenced the recommendations for treating children with severe acute malnutrition. There are close pathophysiological parallels between kwashiorkor and Finnish congenital nephrotic syndrome (CNS) pre-nephrectomy; both develop protein-energy malnutrition and hypoalbuminaemia, which predisposes them to intravascular hypovolaemia with consequent sodium and water retention, and makes them highly vulnerable to develop hypovolaemic shock with diarrhoea. In CNS this is successfully treated with intravenous albumin boluses. By contrast, the WHO advise the cautious administration of hypotonic intravenous fluids in kwashiorkor with shock, which has about a 50% mortality. It is time to trial intravenous bolus albumin for the treatment of children with kwashiorkor and shock.
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40
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An update: the role of Nephrin inside and outside the kidney. SCIENCE CHINA-LIFE SCIENCES 2015; 58:649-57. [PMID: 25921941 DOI: 10.1007/s11427-015-4844-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/27/2015] [Indexed: 12/18/2022]
Abstract
Nephrin is a key molecule in podocytes to maintain normal slit diaphragm structure. Nephin interacts with many other podocyte and slit diaphragm protein and also mediates important cell signaling pathways in podocytes. Loss of nephrin during the development leads to the congenital nephrotic syndrome in children. Reduction of nephrin expression is often observed in adult kidney diseases including diabetic nephropathy and HIV-associated nephropathy. The critical role of nephrin has been confirmed by different animal models with nephrin knockout and knockdown. Recent studies demonstrate that knockdown of nephrin expression in adult mice aggravates the progression of unilateral nephrectomy and Adriamycin-induced kidney disease. In addition to its critical role in maintaining normal glomerular filtration unit in the kidney, nephrin is also expressed in other organs. However, the exact role of nephrin in kidney and extra-renal organs has not been well characterized. Future studies are required to determine whether nephrin could be developed as a drug target to treat patients with kidney disease.
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Abstract
OBJECTIVE The aim of this work was to analyze the evolution of the 1st renal transplantation in children with nephrotic syndrome in the 1st year of life (NSFL). METHODS In this retrospective study of 15 patients (8 women and 7 men) with NSFL receiving transplants from 1989 to 2013, 9 had NS of Finnish type, 4 diffuse mesangial sclerosis, 1 minimal changes, and 1 collapsing glomerulopathy. We analyzed the clinical and analytic situation at 4 time points: before dialysis, before transplantation, 3 months after transplantation, and long-term evolution. RESULTS Mean follow-up was 72.8 months (range, 1 month to 16.9 years); mean age at diagnosis was 2.21 months (range, 0-8.2 months); mean age at onset of replacement therapy was 22.9 ± 16.4 months (range, 3.8-55.4 months); and mean time on dialysis was 14.9 months (range, 2-44 months). Age at transplantation was 3.1 years (range, 1.8 to 7.7 years), with 6 living-donor transplantations (LDTs) and 9 cadaveric (CDTs). Ten patients required nephrectomy before transplantation (9 bilateral) to control proteinuria after 3.1 ± 3.8 months on dialysis, 1 during transplantation, and 3 after transplantation (2 persistent proteinuria, 1 hypertension). Mean time on dialysis for LDTs was 5.4 ± 2.7 months versus 13.2 ± 6.9 months for CDTs (P < .005). Mean age of cadaveric donors was 6.2 ± 2.4 years and that of living donors 35.5 ± 7.9 years. As complications, there was 1 bleeding from venous anastomosis and 1 urinary leakage after surgery. After 6 ± 5.2 years of evolution, actuarial survival at both 1 and 7 years was 92.9%. One graft was lost owing to acute rejection 1 month after transplantation and 2 others owing to chronic rejection >9 years after transplantation. None had disease recurrence. CONCLUSIONS Short-term complications did not differ from the rest of population if transplantation occurred with standard albumin levels, for which most required pre-transplantation nephrectomy because dialysis failed to reduce proteinuria.
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42
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Abstract
Glomerular disorders in infancy can include nephrotic and nephritic syndromes. Congenital nephrotic syndrome (CNS) is most commonly caused by single gene mutations in kidney proteins, but may also be due to congenital infections or passive transfer of maternal antibodies that target kidney proteins. Prenatal findings of increased maternal serum α-fetoprotein and enlarged placenta suggest CNS. Neonatal nephritis is rare; its causes may overlap with those of CNS and include primary glomerulonephritis, systemic disease, infections, and transplacental transfer of maternal antibodies. These syndromes in the neonate can cause significant morbidity and mortality, making urgent diagnosis and treatment necessary.
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Affiliation(s)
- Michelle N Rheault
- Division of Pediatric Nephrology, University of Minnesota Children's Hospital, 2450 Riverside Avenue, MB680, Minneapolis, MN 55454, USA.
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Steroids combined with levothyroxine to treat children with idiopathic nephrotic syndrome: a retrospective single-center study. Pediatr Nephrol 2014; 29:1033-8. [PMID: 24389651 DOI: 10.1007/s00467-013-2727-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 11/25/2013] [Accepted: 12/06/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND The clinical efficacy and safety of low-dose levothyroxine in the treatment of idiopathic nephritic syndrome accompanied by thyroid dysfunction have not been established. METHODS One hundred and sixty-four patients were divided into three groups according to the levels of thyroid hormone and treatment. The thyroid status, efficacy and adverse reactions of thyroid treatment were observed in each group. RESULTS Thyroid dysfunction was found in 73 patients. 40 cases were treated with steroids combined with levothyroxine. Proteinuria, cholesterol and thyroid-stimulating hormone (TSH) levels were significantly higher in patients with thyroid dysfunction, whereas serum albumin and free and total T3 and T4 levels were lower than those of euthyroid patients. The time for proteinuria remission in patients receiving levothyroxine therapy was shorter and their serum albumin higher than for patients without levothyroxine treatment. CONCLUSIONS Thyroid hormonal changes are related to the degree of both proteinuria and serum albumin in patients with INS. Combined treatment with low-dose levothyroxine supplementation and steroids in children with INS and thyroid dysfunction is associated with reduced proteinuria and increased plasma albumin compared with patients treated with steroids only.
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Laakkonen H, Taskinen S, Rönnholm K, Holmberg C, Sandberg S. Parent-child and spousal relationships in families with a young child with end-stage renal disease. Pediatr Nephrol 2014; 29:289-95. [PMID: 24018797 DOI: 10.1007/s00467-013-2618-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 08/07/2013] [Accepted: 08/23/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND End-stage renal disease (ESRD) leads to the need for dialysis and renal transplantation (Tx). Peritoneal dialysis (PD) of young children is normally performed at home by the parents and affects the whole family. We studied the coping of families with a young child with ESRD by interviewing the parents of 19 children. METHODS The spousal and parent-child relationships were assessed by using the Psychosocial Assessment of Childhood Experiences (PACE) and the Brief Measure of Expressed Emotion, respectively. A control group of 22 families with a healthy child was used for the parent-child relationship evaluation. RESULTS The spousal relationship at the start of PD was good or fairly good in most of the families and remained good in half of the families following renal Tx. Lack of support from close relatives and renal Tx were associated with a poorer relationship quality. Almost all parents expressed much or fairly much emotional warmth towards the child throughout the study, but there was a trend towards increased criticism over time. No differences in the degree of expressed warmth or criticism were noted between the index parents and controls. CONCLUSIONS Overall, the study families appeared to cope well despite the serious illness of their child and the demands of the treatments.
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Affiliation(s)
- Hanne Laakkonen
- Department of Pediatric Nephrology and Transplantation, Children's' Hospital, Helsinki University Central Hospital, Helsinki, Finland,
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Clinico-pathological correlations of congenital and infantile nephrotic syndrome over twenty years. Pediatr Nephrol 2014; 29:2173-80. [PMID: 24902943 PMCID: PMC4176949 DOI: 10.1007/s00467-014-2856-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 04/16/2014] [Accepted: 05/12/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND Nephrotic syndrome (NS) presenting early in life is caused by heterogeneous glomerular diseases. We retrospectively evaluated whether histological diagnosis in children presenting with NS in the first year of life predicts remission or progression to end-stage kidney disease (ESKD). METHODS This is a single centre retrospective review of all children diagnosed with NS before one year of age between 1990 and 2009. All subjects had a renal biopsy, which was independently blindly reviewed by a single renal pathologist for the purpose of this study. RESULTS Forty-nine children (25 female) who presented at 0.1-11.6 (median 1.6) months were included with 31 presenting within the first three months of life. Histopathological review diagnostic categories were; 13 Mesangial proliferative glomerulopathy (MesGN), 12 Focal and segmental glomerulosclerosis (FSGS), 11 Finnish type changes, eight Diffuse Mesangial Sclerosis (DMS), three Minimal change disease (MCD) and one each of Dense Deposit Disease (DDD) and Membranous nephropathy. Two children died from haemorrhagic complications of the biopsy. Eight children achieved remission (four MesGN, one Finnish type changes, one FSGS, one MCD and one membranous) with patient and renal survival of 73 % and 43 %, respectively, at follow-up duration of 5-222 (median 73) months (with five lost to follow-up). All children with Finnish-type histopathological changes presented within five months of age. Due to the historical nature of the cohort, genetic testing was only available for 14 children, nine of whom had an identifiable genetic basis (seven NPHS1, one PLCE1 and one ITGA3) with none of these nine children achieving remission. All of them had presented within four months of age and required renal replacement therapy, and two died. CONCLUSIONS Histopathological findings are varied in children presenting with NS early in life. Whilst groups of histological patterns of disease are associated with differing outcomes, accurate prediction of disease course in a specific case is difficult and more widespread genetic testing may improve the understanding of this group of diseases and their optimal management.
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Holmberg C, Jalanko H. Congenital nephrotic syndrome and recurrence of proteinuria after renal transplantation. Pediatr Nephrol 2014; 29:2309-17. [PMID: 24682440 PMCID: PMC4212136 DOI: 10.1007/s00467-014-2781-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 01/27/2014] [Accepted: 01/31/2014] [Indexed: 01/16/2023]
Abstract
Renal transplantation (RTx) is the only curative treatment for most cases of congenital and infantile nephrotic syndrome (NS) caused by genetic defects in glomerular podocyte proteins. The outcome of RTx in these children is usually excellent, with no recurrence of nephrotic syndrome. A subgroup of patients with the Finnish type of congenital nephrosis (CNF), shows, however, a clear risk for post-RTx proteinuria. Most of these patients have a homozygous truncating mutation (Fin-major mutation) in the nephrin gene (NPHS1), leading to total absence of the major podocyte protein, nephrin. After RTx, these patients develop anti-nephrin antibodies resulting in nephrotic range proteinuria. Plasma exchange combined with cyclophosphamide and anti-CD20 antibodies has proved to be successful therapy for these episodes. NS recurrence has also occurred in a few patients with mutations in the podocin gene (NPHS2). No anti-podocin antibodies have been detectable, and the pathophysiology of the recurrence remains open. While most of these episodes have resolved, the optimal therapy remains to be determined.
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Affiliation(s)
- Christer Holmberg
- Children's Hospital, University of Helsinki and Helsinki University Central Hospital, PO Box 281, Helsinki, 00290, Finland,
| | - Hannu Jalanko
- Children’s Hospital, University of Helsinki and Helsinki University Central Hospital, PO Box 281, Helsinki, 00290 Finland
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Büscher AK, Weber S. Educational paper: the podocytopathies. Eur J Pediatr 2012; 171:1151-60. [PMID: 22237399 DOI: 10.1007/s00431-011-1668-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 12/20/2011] [Indexed: 02/07/2023]
Abstract
In the recent past, hereditary podocytopathies have increasingly been recognized to be involved in the development of steroid-resistant nephrotic syndrome (SRNS). Mutations in podocyte genes substantially alter the development and structural architecture of the podocyte including its interdigitating foot processes. These constitute the basis of the slit diaphragm which is an essential part of the glomerular filtration barrier. Depending on the affected protein, the clinical course is variable with respect to onset and severity of the disease as well as treatment options. In general, hereditary podocytopathies are associated with a poorer renal outcome than the non-genetic variants. In addition, they require a different approach with respect to the applied therapeutic strategies as most patients do not respond to immunosuppressive agents. Therefore, genetic testing of podocyte genes should be considered as a routine diagnostic tool for patients with SRNS because the identification of a genetic origin has a direct implication on clinical course, renal outcome, and genetic counseling. In this educational paper, we will give an overview over the podocyte genes identified so far to be involved into the pathophysiology of hereditary podocytopathies.
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Affiliation(s)
- Anja K Büscher
- Pediatric Nephrology, Pediatrics II, University-Children's Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany.
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Chaudhuri A, Kambham N, Sutherland S, Grimm P, Alexander S, Concepcion W, Sarwal M, Wong C. Rituximab treatment for recurrence of nephrotic syndrome in a pediatric patient after renal transplantation for congenital nephrotic syndrome of Finnish type. Pediatr Transplant 2012; 16:E183-7. [PMID: 21672106 DOI: 10.1111/j.1399-3046.2011.01519.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Congenital nephrotic syndrome (CNS) of the Finnish type due to mutation in the NPHS-1 gene results in massive proteinuria due to structural abnormality in the glomerular slit diaphragm, and is usually refractory to immunosuppressive therapy. Patients eventually require bilateral nephrectomy and renal replacement therapy, with transplantation being the ultimate goal. Post-transplant recurrence of nephrotic syndrome occurs in about 25% of children and is thought to be immune-mediated secondary to antibodies formed against the nephrin protein in renal allograft. Conventional therapy with calcineurin inhibitors (CNI), cyclophosphamide and corticosteroids with or without plasmapheresis often fails to achieve remission resulting in graft loss in 12-16%. There is limited experience with use of rituximab (RTX) in pediatric organ transplant recipients. We report the first case of post-transplant recurrence of nephrotic syndrome in a 4-yr-old child with CNS due to NPHS-1 mutation in whom CNI, corticosteroid and cyclophosphamide therapy was unsuccessful, but who achieved remission after depletion of B cells with RTX, associated with a decrease in the level of anti-nephrin antibodies. The child remains in remission 5 yr following treatment. Our experience suggests that activated B cells may play a pivotal role in the recurrence of nephrosis after renal transplantation in children with CNS.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics, Stanford University, Stanford, CA 94305, USA
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Dagan A, Cleper R, Krause I, Blumenthal D, Davidovits M. Hypothyroidism in children with steroid-resistant nephrotic syndrome. Nephrol Dial Transplant 2011; 27:2171-5. [PMID: 22167590 DOI: 10.1093/ndt/gfr665] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Non-autoimmune hypothyroidism has been reported in children with congenital nephrotic syndrome. The hypothyroid state was attributed to massive prolonged thyroid hormone loss. However, this endocrine abnormality has not been reported in steroid-resistant nephrotic syndrome (SRNS) despite similar long-standing proteinuria. METHOD We describe all the patients with SRNS in our clinic's follow-up who developed non-autoimmune hypothyroidism. RESULTS Five children aged 3-11 years at diagnosis of SRNS and followed for 5-42 months developed hypothyroidism (depressed free thyroxin and elevated thyrotropin levels) without evidence of autoimmune thyroiditis. The diagnosis of hypothyroidism was not temporarily related to disease duration or renal function. The disease was resistant to all therapies, renal function deteriorated in all the patients within 1.5-14.5 years from diagnosis. Despite thyroxine treatment and a decline in renal function, thyroid hormone level normalized only after reaching end stage renal disease (ESRD) and hemodialysis start. Nephrotic syndrome recurrence after kidney transplantation (in three patients with focal segmental glomerulosclerosis) was not accompanied by recurrent hypothyroidism. CONCLUSION It is our impression that non-autoimmune hypothyroidism is a potential significant complication of SRNS, and should be actively sought for especially in cases with renal function deterioration. Hypothyroidism usually resolved when these patients reach ESRD. The incidence and pathogenesis of this condition require further study.
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Affiliation(s)
- Amit Dagan
- Institute of Nephrology, Schneider Children’s Medical Center of Israel, Petach Tikva, Israel.
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Malaki M, Ghaffari S, Ghaffari S, Rastkar B, Goldust M, Malaki P, Sahar B. Cardiac findings in congenital nephrotic syndrome. J Cardiovasc Thorac Res 2011; 3:83-5. [PMID: 24250960 DOI: 10.5681/jcvtr.2011.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Accepted: 07/26/2011] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Congenital nephrotic syndrome is a severe debilitating problem associated with extra renal manifestation such as diverse cardiac findings. METHODS During four years, 6 cases diagnosed as congenital nephritic syndrome in base of definitive criteria their documents reviewed and echocardiographic evaluation has been done for all with or without cardiac sign or symptoms, results gathered and expressed as incidence. RESULTS All cases have some grades of structural or functional defects from simple form like as tricuspid regurgitation to complex defects. It may be run in consecutively in siblings of a family from non consanguine parents. CONCLUSION Pulmonary stenosis may occur in all parts subvalvualr, valvular and peripheral parts of pulmonary artery, left ventricular hypertrophy and mitral regurgitation observed in some, moderate tricuspid regurgitation observed in half of cases due to pulmonary hypertension or right ventricular hypertrophy due to pulmonary stenosis.
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Affiliation(s)
- Majid Malaki
- Department of Pediatric Nephrology, Tabriz University of Medical Sciences, Tabriz, Iran
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