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Primack WA, Chevalier RL, Friedman A, Lemley KV, Norwood VF, Schwartz GJ, Silverstein D, Kaskel F. The first randomized controlled trial in pediatric nephrology: the history of the International Study of Kidney Disease in Children (ISKDC). Pediatr Nephrol 2023; 38:3947-3954. [PMID: 36625931 DOI: 10.1007/s00467-022-05838-1] [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: 08/26/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 01/11/2023]
Abstract
The International Study of Kidney Disease in Children (ISKDC), begun in 1966, conducted the first international collaborative randomized blinded controlled trial in pediatric nephrology and one of the first in either pediatrics or nephrology. For this trial, the ISKDC developed the criteria, such as those for response and relapse, used today to describe the clinical course of the nephrotic syndrome, and the trial generated the nephropathologic terminology and criteria which largely remain the current standards. Over an approximately 20-year span, the ISKDC followed the natural history and evaluated the therapeutic effectiveness of therapies in over 500 children with the nephrotic syndrome from three continents. It published 14 peer-reviewed studies and several reports and commentaries, many of which helped create current standards of practice for therapy of childhood nephrotic syndrome and consequently remain highly cited today. The ISKDC continues to be an important model for subsequent collaborative studies and was the impetus for the development of regional and national pediatric nephrology societies leading to the recognition and growth of pediatric nephrology as a separate subspecialty. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
| | - Robert L Chevalier
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | | | - Kevin V Lemley
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Victoria F Norwood
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | | | | | - Frederick Kaskel
- Department of Pediatrics (Montefiore), Albert Einstein College of Medicine, Bronx, NY, USA
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Benz MR, Ehren R, Tönshoff B, Weber LT. Nephrotisches Syndrom im Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0677-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Anigilaje EA, Fashie AP, Ochi C. Childhood nephrotic syndrome at the University of Abuja Teaching Hospital, Abuja, Nigeria: a preliminary report supports high steroid responsiveness. Sudan J Paediatr 2019; 19:126-139. [PMID: 31969741 PMCID: PMC6962266 DOI: 10.24911/sjp.106-1547399573] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 11/12/2019] [Indexed: 12/21/2022]
Abstract
The response to steroid in childhood nephrotic syndrome (CNS) varies across geographical regions, depending on aetiology, genetics, and the underlying pathology. Recently, there is an increasing steroid responsiveness among Nigerian children with nephrotic syndrome (NS). This is the first report of CNS at the University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria, between 15th January 2016 and 30th June 2018. Prednisolone was administered to all the children with NS according to the regimen of the International Study of Kidney Disease in Children. There were 46 children aged 17 months to 18 years, including 37 males and 9 females. The peak age was 6-10 years with a mean age of 8.2 ± 4.4 years. Forty-one (89.1%) had idiopathic NS (INS). Secondary NS occurred in five (10.9%) children with hepatitis B infection, sickle cell anaemia, haemolytic-uraemic syndrome, and post-infectious glomerulonephritis (two cases). Plasmodium malariae was not seen. Overall, steroid-sensitive NS (SSNS) was seen in 34 (73.9%) and in 32 (78%) with INS. Five (16.7%) of the 30 with SSNS relapsed on follow-up. Twelve (26.1%) were resistant to steroid (steroid-resistant NS, SRNS). Renal biopsies in five SRNS revealed focal segmental glomerulosclerosis in three, minimal change lesion in one, and severe interstitial fibrosis/glomerulosclerosis in another one. Four (8.7%) children who had SRNS died. A child with SRNS is surviving on renal transplant from a living-unrelated donor. The study supports the notion that steroid responsiveness is increasing among ethnic black Nigerian children. Pre-treatment renal biopsy may be unwarranted.
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Affiliation(s)
| | - Andrew Patrick Fashie
- Nephrology Unit, Department of Paediatrics, University of Abuja Teaching Hospital, Abuja, Nigeria
| | - Clement Ochi
- Nephrology Unit, Department of Paediatrics, University of Abuja Teaching Hospital, Abuja, Nigeria
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Does cyclophosphamide still play a role in glomerular diseases? Autoimmun Rev 2018; 17:1022-1027. [PMID: 30107267 DOI: 10.1016/j.autrev.2018.04.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 04/26/2018] [Indexed: 02/06/2023]
Abstract
Cyclophosphamide is a prodrug that is converted to inactive carboxy-cyclophosphamide, acrolein and phosphoramide mustard, an agent that adds alkyl groups to oxygen and nitrogen atoms of guanine, one of the four nitrogen bases that form the DNA nucleotides, causing DNA cross-links and introducing DNA breaks. These cytotoxic and mutagenic effects mainly occur in proliferating cells. Repair mechanisms may prevent DNA damage in quiescent cells, but they may be insufficient to contrast the side effects of cyclophosphamide if high doses of the drug are used. Most adverse events are dose- and age-dependent. Phosphoramide mustard can cause bone marrow toxicity, gonadal toxicity, and may favor the development of leukemia, bladder cancer and other types of malignancy. Acrolein can produce hemorrhagic cystitis and even bladder fibrosis when given for prolonged periods. A number of precautional measures should be taken to prevent these untoward events. In particular, long-term administration and high doses of cyclophosphamide should be avoided whenever possible. Today the indications to cyclophosphamide in glomerular diseases are more restricted than in the past, but the drug is still used as a steroid-sparing agent in steroid-sensitive minimal change disease and focal segmental glomerulosclerosis. In membranous nephropathy, cyclophosphamide, alternated or associated with corticosteroids, proved to be beneficial in obtaining remission of nephrotic syndrome and preserving renal function. Cyclophosphamide is considered as a first-line treatment for rapidly progressive glomerulonephritis and the hectic phases of lupus nephritis. In conclusion, cyclophosphamide is a cheap drug that may be useful in a number of glomerular diseases but it may lead to severe side effects. A close monitoring of blood count and clinical conditions, as well as low cumulative doses of cyclophosphamide are strongly recommended when using the drug in patients with renal diseases.
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Baek HS, Park KS, Kang HG, Ko CW, Cho MH. Initial steroid regimen in idiopathic nephrotic syndrome can be shortened based on duration to first remission. KOREAN JOURNAL OF PEDIATRICS 2015. [PMID: 26213548 PMCID: PMC4510353 DOI: 10.3345/kjp.2015.58.6.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Purpose The use of a 12-week steroid regimen (long-term therapy, LT) for the first episode of idiopathic nephrotic syndrome (NS) reportedly induces a more sustained remission and lower relapse rate than previous regimens, including an 8-week steroid regimen (short-term therapy, ST). Here, we assessed the potential for selective application of 2 steroid regimens (LT vs. ST) based on the days to remission (early responders [ER] vs. late responders [LR]) for the first idiopathic NS episode in children. Methods Patients were divided into 4 subgroups (ST+ER, ST+LR, LT+ER, and LT+LR) according to the initial steroid regimen used and rapidity of response; the baseline characteristics, relapse rates, and cumulative percentage of children with sustained remission were then compared among the 4 subgroups. Results Fifty-four children received ST, and the remaining 45 children received LT. As observed in previous studies, children receiving LT showed significantly lower relapse rates during the first year after the first NS episode than those receiving ST. The ST+ER group showed significantly lower relapse rates during the first one year and two years after the first NS episode than the the ST+LR group, whereas there were no significant differences of the relapse rates and duration to the first relapse between the ST+ER and LT+ER groups. Conclusion We suggest that the initial steroid regimen in idiopathic NS patients can be shortened according to the duration to remission i.e., LT in patients achieving remission after the first week of steroid therapy, and ST in those achieving remission within the first week of steroid therapy.
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Affiliation(s)
- Hee Sun Baek
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Ki-Soo Park
- Department of Preventive Medicine and Institute of Health Sciences, Gyeongsang National University Hospital, Jinju, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Cheol Woo Ko
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| | - Min Hyun Cho
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
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Calcium and vitamin D for osteoprotection in children with new-onset nephrotic syndrome treated with steroids: a prospective, randomized, controlled, interventional study. Pediatr Nephrol 2014; 29:1025-32. [PMID: 24414607 DOI: 10.1007/s00467-013-2720-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 11/22/2013] [Accepted: 12/02/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND There are no robust guidelines on strategies to prevent the adverse skeletal effects of glucocorticoids in children. OBJECTIVES To evaluate the role of prophylactic calcium and vitamin D on bone health in children with new-onset nephrotic syndrome (NS) treated with short-term (12 weeks), high-dose glucocorticoids. METHODS Prospective, randomized, controlled, single blind, interventional study conducted on 41 steroid-naïve pre-pubertal children (29 boys, 12 girls). All children received prednisolone for 12 weeks (60 mg/m(2)/day daily for 6 weeks, followed by 40 mg/m(2)/day alternate days for 6 weeks). Recruited children were randomized into the intervention group (IG; vitamin D 1,000 IU/day and elemental calcium 500 mg/day) and the control group (CG). Bone mineral content (BMC) and bone mineral density (BMD) at the lumbar spine (L1-L4) were estimated at baseline and at 12 weeks. Mean percentage changes in BMC and BMD in IG and CG were compared. RESULTS Children in the IG showed an increase of 11.2 % in BMC versus the CG, who showed an 8.9 % fall (p < 0.0001). Net intervention-attributable difference in BMC was 20.1 %. BMD increased in both groups (IG 2.8 % vs CG 0.74 %), but the difference was not statistically significant (p = 0.27). CONCLUSIONS Short-term, high-dose glucocorticoid therapy decreases the BMC of the lumbar spine in steroid-naïve children with NS. Vitamin D and calcium co-administration not only prevents this decline, but also enhances BMC of the lumbar spine.
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Pravitsitthikul N, Willis NS, Hodson EM, Craig JC. Non-corticosteroid immunosuppressive medications for steroid-sensitive nephrotic syndrome in children. Cochrane Database Syst Rev 2013:CD002290. [PMID: 24166716 DOI: 10.1002/14651858.cd002290.pub4] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND About 80% to 90% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. Of these children, around half relapse frequently, and are at risk of adverse effects from corticosteroids. Non-corticosteroid immunosuppressive medications are used to prolong periods of remission in these children; however, these medications have significant potential adverse effects. Currently, there is no consensus about the most appropriate second line agent in children who are steroid sensitive, but who continue to relapse. This is the third update of a review first published in 2001 and updated in 2005 and 2008. OBJECTIVES To evaluate the benefits and harms of non-corticosteroid immunosuppressive medications in relapsing SSNS in children. SEARCH METHODS For this update we searched the Cochrane Renal Group's Specialised Register to June 2013. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs were included if they compared non-corticosteroid immunosuppressive medications with placebo, prednisone or no treatment, different non-corticosteroid immunosuppressive medications and different doses, durations or routes of administration of the same non-corticosteroid immunosuppressive medication. DATA COLLECTION AND ANALYSIS Two authors independently assessed the risk of bias of the included studies and extracted data. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS We identified 32 studies (1443 children) of which one study is still ongoing. In the 31 studies with data, risk of bias assessment indicated that 11 (37%) and 16 (53%) studies were at low risk of bias for sequence generation and allocation concealment respectively. Six (29%) studies were at low risk of performance and detection bias. Twenty seven (87%) and 19 (60%) studies were at low risk of incomplete and selective reporting respectively. Alkylating agents (cyclophosphamide and chlorambucil) significantly reduced the risk of relapse at six to 12 months (RR 0.43, 95% CI 0.31 to 0.60) and 12 to 24 months (RR 0.20, 95% CI 0.09 to 0.46) compared with prednisone alone. There was no significant difference in relapse risk at two years between chlorambucil and cyclophosphamide (RR 1.31, 95% CI 0.80 to 2.13). There was no significant difference at one year between intravenous and oral cyclophosphamide (RR 0.99, 95% CI 0.76 to 1.29). Cyclosporin was as effective as cyclophosphamide (RR 1.07, 95% CI 0.48 to 2.35) and chlorambucil (RR 0.82, 95% CI 0.44 to 1.53) at the end of therapy while levamisole (RR 0.47, 95% CI 0.24 to 0.89) was more effective than steroids alone. However the effects of cyclosporin and levamisole were not sustained once treatment was stopped. In one small study cyclosporin significantly reduced the relapse rate compared with mycophenolate mofetil (MD 0.75, 95% CI 0.01 to 1.49). Limited data from a cross-over study suggested that cyclosporin was more effective than mycophenolate mofetil in maintaining remission. In steroid- and cyclosporin-dependent disease, rituximab significantly reduced the risk of relapse at three months compared with conventional therapy. Mizoribine and azathioprine were no more effective than placebo or prednisone alone in maintaining remission. AUTHORS' CONCLUSIONS Eight-week courses of cyclophosphamide or chlorambucil and prolonged courses of cyclosporin and levamisole reduce the risk of relapse in children with relapsing SSNS compared with corticosteroids alone. Limited data indicate that mycophenolate mofetil and rituximab are valuable additional medications for relapsing SSNS. However clinically important differences in efficacy are possible and further comparative studies are still needed.
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Affiliation(s)
- Nanthiya Pravitsitthikul
- Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145
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Tsampalieros A, Gupta P, Denburg MR, Shults J, Zemel BS, Mostoufi-Moab S, Wetzsteon RJ, Herskovitz RM, Whitehead KM, Leonard MB. Glucocorticoid effects on changes in bone mineral density and cortical structure in childhood nephrotic syndrome. J Bone Miner Res 2013; 28:480-8. [PMID: 23044926 PMCID: PMC3578070 DOI: 10.1002/jbmr.1785] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Revised: 09/14/2012] [Accepted: 09/20/2012] [Indexed: 12/13/2022]
Abstract
The impact of glucocorticoids (GC) on skeletal development has not been established. The objective of this study was to examine changes in volumetric bone mineral density (vBMD) and cortical structure over 1 year in childhood nephrotic syndrome (NS) and to identify associations with concurrent GC exposure and growth. Fifty-six NS participants, aged 5 to 21 years, were enrolled a median of 4.3 (0.5 to 8.1) years after diagnosis. Tibia peripheral quantitative computed tomography (pQCT) scans were obtained at enrollment and 6 and 12 months later. Sex, race, and age-specific Z-scores were generated for trabecular vBMD (TrabBMD-Z), cortical vBMD (CortBMD-Z), and cortical area (CortArea-Z) based on >650 reference participants. CortArea-Z was further adjusted for tibia length-for-age Z-score. Quasi-least squares regression was used to identify determinants of changes in pQCT Z-scores. At enrollment, mean TrabBMD-Z (-0.54 ± 1.32) was significantly lower (p = 0.0001) and CortBMD-Z (0.73 ± 1.16, p < 0.0001) and CortArea-Z (0.27 ± 0.91, p = 0.03) significantly greater in NS versus reference participants, as previously described. Forty-eight (86%) participants were treated with GC over the study interval (median dose 0.29 mg/kg/day). On average, TrabBMD-Z and CortBMD-Z did not change significantly over the study interval; however, CortArea-Z decreased (p = 0.003). Greater GC dose (p < 0.001), lesser increases in tibia length (p < 0.001), and lesser increases in CortArea-Z (p = 0.003) were independently associated with greater increases in CortBMD-Z. Greater increases in tibia length were associated with greater declines in CortArea-Z (p < 0.01); this association was absent in reference participants (interaction p < 0.02). In conclusion, GC therapy was associated with increases in CortBMD-Z, potentially related to suppressed bone formation and greater secondary mineralization. Conversely, greater growth and expansion of CortArea-Z (ie, new bone formation) were associated with declines in CortBMD-Z. Greater linear growth was associated with impaired expansion of cortical area in NS. Studies are needed to determine the fracture implications of these findings.
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Affiliation(s)
- Anne Tsampalieros
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Pooja Gupta
- Department of Internal Medicine, Emory University Hospital
| | - Michelle R Denburg
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Justine Shults
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
- Department of Biostatistics and Epidemiology, Perlman School of Medicine at the University of Pennsylvania
| | - Babette S Zemel
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Rachel J Wetzsteon
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Rita M Herskovitz
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Krista M Whitehead
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
| | - Mary B. Leonard
- Department of Pediatrics, Children’s Hospital of Philadelphia, Perlman School of Medicine at the University of Pennsylvania
- Department of Biostatistics and Epidemiology, Perlman School of Medicine at the University of Pennsylvania
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Kim SY, Lee SS, Kim MU, Lee JM, Kang SJ, Kim YJ, Park YH. Significance of electron dense deposits in patients with minimal change nephrotic syndrome. KOREAN JOURNAL OF PATHOLOGY 2012; 46:137-41. [PMID: 23109993 PMCID: PMC3479775 DOI: 10.4132/koreanjpathol.2012.46.2.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 03/12/2012] [Accepted: 03/12/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND Minimal change nephritic syndrome (MCNS) is characterized by a lack of obvious abnormalities on light microscopy, but its electron microscopic findings include the negative immunofluorescence findings and the diffuse effacement of the epithelial cell foot processes. Rarely the presence of electron dense deposits (EDDs) has been reported, but its clinical significance remains obscure. METHODS Eleven patients with MCNS who had the EDD deposited were enrolled in the current study. We compared the clinical characteristics, laboratory results and response to steroid treatment between the two group: the EDD group (n=11; the male-to-female ratio, 8:3) and the non-EDD group (n=13, 8:5). RESULTS There were no significant differences in most of the laboratory results or response to steroid treatment between the two groups. The frequency of relapses per year was significantly higher in the EDD group (1.1±0.7 times vs. 0.5±0.6 times; p=0.023). These EDDs were found in the mesangium or paramesangium. With no respect to the characteristics of EDDs, our results showed that they did not cause poor treatment outcomes except for the annual frequency of relapse. CONCLUSIONS Further large-scale studies are warrented to determine the immunologic and prognostic significance of EDDs in patients with MCNS.
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Affiliation(s)
- Sae Yoon Kim
- Department of Pediatirics, Yeungnam University College of Medicine, Daegu, Korea
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Liu X, Li W, Liang Z, Zhang X, Guo Y, Gong T, Zhang Z. Prednisolone-Glucose Derivative Conjugate: Synthesis, Biodistribution and Pharmacodynamics Evaluation. Arch Pharm (Weinheim) 2012; 345:925-33. [DOI: 10.1002/ardp.201200232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2012] [Revised: 07/18/2012] [Accepted: 07/19/2012] [Indexed: 11/08/2022]
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Absar A, Diamond M, Sonia Y, Arshalooz R, Safia A, Waqar K, Shahid P. Ten year experience of pediatric kidney biopsies from a single center in Pakistan. Indian J Nephrol 2011; 20:190-2. [PMID: 21206680 PMCID: PMC3008947 DOI: 10.4103/0971-4065.73446] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
There are many established registries of kidney biopsies around the world. In addition, there are several reports available in literature from many countries on pediatric kidney biopsy. This study was done to determine the indications and pathological patterns of kidney biopsies of children referred to our hospital, and compare our data with the data available from other countries. This is a cross-sectional study of pediatric kidney biopsies over a 10-year period, from January 1997 to December 2006. All biopsies were done in Aga Khan University Hospital, Karachi, Pakistan. Age range was from 1 to 14 years. Data were analyzed for indications and histopathological diagnosis. A total of 54 kidney biopsies were included in the initial analysis. Here 13 samples were excluded and final analysis was done on the remaining 41 samples. The most common indication of kidney biopsy was nephrotic syndrome in 25 samples (61%). The most common histopathology was minimal change disease in 15 (37%), followed by focal segmental glomerulosclerosis in 5 (12%) of the biopsies.
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Affiliation(s)
- A Absar
- Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi - 74800, Pakistan
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Esfahani ST, Madani A, Asgharian F, Ataei N, Roohi A, Moghtaderi M, Rahimzadeh P, Moradinejad MH. Clinical course and outcome of children with steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2011; 26:1089-93. [PMID: 21399898 DOI: 10.1007/s00467-011-1837-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 02/17/2011] [Accepted: 02/22/2011] [Indexed: 11/24/2022]
Abstract
We conducted a retrospective study on children with primary nephrotic syndrome (NS) to evaluate the clinical course and outcome of children with steroid-sensitive NS (SSNS). The medical records of 226 children, median 3.46 years (min 1.00, max 15.08) who referred to our clinics with SSNS between January 1978 and September 2005 were reviewed and entered into the study. Minimum duration of follow-up was 5 years and maximum 20 years (median 7.25 years). Of 226 patients who were treated with corticosteroids, 38 (16.8%) had no relapse but the remaining 188 (83.2%) patients experienced several relapses of which 128 patients (56.6%) required additional immunosuppressive agents for the remission. Of these, 122 (95%) were treated with levamisole, 22 (17%) with cyclosporine, 36 (28%) with cyclophosphamide, and ten (7.8 %) treated with mycophenolate mofetil. Several patients had to switch from one medication to others due to lack of response. On the last follow-up visit, 64(28.3%) patients were still under treatment, some patients had taken all of the above-mentioned drugs but still had multiple recurrences. Only 103 (45.5%) patients were in remission off the drug more than 3 years. This study shows that nearly one-third of pediatric patients with SSNS experience frequent relapses despite the combination of multiple immunosuppressive medications, which may continue until adulthood.
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Affiliation(s)
- Seyed Taher Esfahani
- Department of Pediatric Nephrology, Children's Medical Center, No. 62, Dr. Gharib St. Azadi Ave, Tehran 14197, Iran.
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Affiliation(s)
- Roberto Gordillo
- Albert Einstein College of Medicine/Children's Hospital at Montefiore, Division of Pediatric Nephrology, Bronx, NY, USA
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Divergent effects of glucocorticoids on cortical and trabecular compartment BMD in childhood nephrotic syndrome. J Bone Miner Res 2009; 24:503-13. [PMID: 19016583 PMCID: PMC2659517 DOI: 10.1359/jbmr.081101] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Glucocorticoid (GC) effects on skeletal development have not been established. The objective of this pQCT study was to assess volumetric BMD (vBMD) and cortical dimensions in childhood steroid-sensitive nephrotic syndrome (SSNS), a disorder with minimal independent deleterious skeletal effects. Tibia pQCT was used to assess trabecular and cortical vBMD, cortical dimensions, and muscle area in 55 SSNS (age, 5-19 yr) and >650 control participants. Race-, sex-, and age-, or tibia length-specific Z-scores were generated for pQCT outcomes. Bone biomarkers included bone-specific alkaline phosphatase and urinary deoxypyridinoline. SSNS participants had lower height Z-scores (p < 0.0001) compared with controls. In SSNS, Z-scores for cortical area were greater (+0.37; 95% CI = 0.09, 0.66; p = 0.01), for cortical vBMD were greater (+1.17; 95% CI = 0.89, 1.45; p < 0.0001), and for trabecular vBMD were lower (-0.60; 95% CI, = -0.89, -0.31; p < 0.0001) compared with controls. Muscle area (+0.34; 95% CI = 0.08, 0.61; p = 0.01) and fat area (+0.56; 95% CI = 0.27, 0.84; p < 0.001) Z-scores were greater in SSNS, and adjustment for muscle area eliminated the greater cortical area in SSNS. Bone formation and resorption biomarkers were significantly and inversely associated with cortical vBMD in SSNS and controls and were significantly lower in the 34 SSNS participants taking GCs at the time of the study compared with controls. In conclusion, GCs in SSNS were associated with significantly greater cortical vBMD and cortical area and lower trabecular vBMD, with evidence of low bone turnover. Lower bone biomarkers were associated with greater cortical vBMD. Studies are needed to determine the fracture implications of these varied effects.
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Therapie des steroidsensiblen nephrotischen Syndroms. Monatsschr Kinderheilkd 2009. [DOI: 10.1007/s00112-008-1867-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Muller-Berghaus J, Kemper MJ, Hoppe B, Querfeld U, Muller-Wiefel DE, Morahan G, Schadendorf D, Tenbrock K. The clinical course of steroid-sensitive childhood nephrotic syndrome is associated with a functional IL12B promoter polymorphism. Nephrol Dial Transplant 2008; 23:3841-4. [DOI: 10.1093/ndt/gfn395] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Long-term follow-up after cyclophosphamide and cyclosporine-A therapy in steroid-dependent and -resistant nephrotic syndrome. Pediatr Nephrol 2008; 23:1085-92. [PMID: 18324421 DOI: 10.1007/s00467-008-0771-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2007] [Revised: 12/29/2007] [Accepted: 01/02/2008] [Indexed: 10/22/2022]
Abstract
A retrospective study was made on 37 children with idiopathic nephrotic syndrome (INS). At the beginning, all patients were steroid sensitive but received more than one steroid course (median 4). Following several relapses, they became steroid dependent or steroid resistant. Group 1 consisted of 22 children [3 focal segmental glomerulosclerosis (FSGS), 19 minimal-change NS (MCNS)] who received cyclophosphamide (CP) orally for 2.5 +/- 0.5 months. Group 2 consisted of 15 children (7 FSGS, 8 MCNS) who received cyclosporine-A (CSA) for 28 +/- 15 months. The level of proteinuria decreased significantly and remained low during the follow-up. The relapse-free period was significantly longer in the CP group (CP 30 +/- 21.5; CSA 26.2 +/- 18 months, p < 0.001). The relapse rate decreased significantly in both groups and remained in this lower level during the follow-up (from 3.4 +/- 2.8 to 0.1 +/- 0.2/year in group 1, and from 3.7 +/- 3.1 to 0.6 +/- 0.8/year in group 2). At the end of the 5-year follow-up, 20/22 patients (90.9%) and 10/15 patients (66.6%) were in remission in groups 1 and 2 respectively, with or without treatment (p < 0.05). In the long term, both CP and CSA is effective second-line therapy following steroid monotherapy in INS patients, but the relapse rate was lower and the relapse free period was significantly longer in the CP-treated group.
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Abstract
BACKGROUND Eighty to 90% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. About half relapse frequently and are at risk of the adverse effects of corticosteroids. Non-corticosteroid immunosuppressive agents are used to prolong periods of remission in these children, however these agents have significant potential adverse effects. Currently there is no consensus as to the most appropriate second line agent in children who are steroid sensitive, but who continue to relapse. OBJECTIVES To evaluate the benefits and harms of non-corticosteroid immunosuppressive agents in relapsing SSNS in children. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, reference lists, conference abstracts and contact with known investigators. Search date: September 2007 SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs were included if they compared non-corticosteroid agents with placebo, prednisone or no treatment, different doses and/or durations of the same non-corticosteroid agent, different non-corticosteroid agents. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as relative risk (RR) with 95% confidence intervals (CI). MAIN RESULTS We identified 26 studies (1173 children). Cyclophosphamide (RR 0.44, 95% CI 0.26 to 0.73) and chlorambucil (RR 0.15, 95% CI 0.02 to 0.95) significantly reduced the relapse risk at six to twelve months compared with prednisone alone. There was no difference in relapse risk at two years between chlorambucil and cyclophosphamide (RR 1.31, 95% CI 0.80 to 2.13). There was no difference at one year between intravenous and oral cyclophosphamide (RR 0.99, 95% CI 0.76 to 1.29). Cyclosporin was as effective as cyclophosphamide (RR 1.07, 95% CI 0.48 to 2.35) and chlorambucil (RR 0.82, 95% CI 0.44 to 1.53) and levamisole (RR 0.43, 95% CI 0.27 to 0.68) was more effective than steroids alone but the effects were not sustained once treatment was stopped. There was no difference in the risk for relapse between mycophenolate mofetil and cyclosporin (RR 5.00, 95% CI 0.68 to 36.66) but CI were large. Mizoribine and azathioprine were no more effective than placebo or prednisone alone in maintaining remission. AUTHORS' CONCLUSIONS Eight week courses of cyclophosphamide or chlorambucil and prolonged courses of cyclosporin and levamisole reduce the risk of relapse in children with relapsing SSNS compared with corticosteroids alone. Clinically important differences in efficacy are possible and further comparative studies are still needed.
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Affiliation(s)
- E M Hodson
- Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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21
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Abstract
BACKGROUND In nephrotic syndrome (NS) protein leaks from the blood to the urine through the glomeruli resulting in hypoproteinaemia and generalised oedema. While the majority of children with NS respond to corticosteroids, 70% experience a relapsing course. Corticosteroids have reduced the mortality rate to around 3%. However corticosteroids have well recognised potentially serious adverse effects such as obesity, poor growth, hypertension, diabetes mellitus and osteoporosis. OBJECTIVES To determine the benefits and harms of corticosteroid regimens in preventing relapse in children with steroid sensitive NS (SSNS). SEARCH STRATEGY We searched CENTRAL, Cochrane Renal Group Specialised Register, MEDLINE and EMBASE without language restriction, reference lists of articles and contact with known investigators. Date of last search: December 2006 SELECTION CRITERIA Randomised controlled trials performed in children (three months to 18 years) in their initial or subsequent episode of SSNS, comparing different durations, total doses or other dose strategies using any corticosteroid agent, with outcome data at six months or more. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. Results were expressed as relative risk (RR) with 95% confidence intervals (CI) or mean difference (WMD). Meta-regression was used to explore potential between-study differences due to baseline risk of relapse, study quality and interventions. MAIN RESULTS Twenty four trials were identified. Six trials comparing two months of prednisone or prednisolone with three months or more in the first episode showed longer duration significantly reduced the risk of relapse at 12 to 24 months (RR 0.70, 95% CI 0.58 to 0.84). There was an inverse linear relationship between treatment duration and risk of relapse (RR = 1.26 - 0.112 duration; P = 0.03). Four trials showed that six months of prednisone was more effective than three months in reducing the risk for relapse (RR 0.57; 95% CI 0.45 to 0.71). Deflazacort was significantly more effective in maintaining remission than prednisone in children who frequently relapsed in a single study (RR 0.44, 95% CI 0.25 to 0.78). There were no increases in adverse events. AUTHORS' CONCLUSIONS Children in their first episode of SSNS should be treated for at least three months with an increase in benefit for up to seven months of treatment. For a baseline risk for relapse following the first episode of 60% with two months of therapy, daily prednisone or prednisolone given for four weeks followed by alternate-day therapy for six months would reduce the number of children relapsing by 33%.
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Affiliation(s)
- E M Hodson
- Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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Affiliation(s)
- Abiodun A Omoloja
- Nephrology Department, The Children's Medical Center, Dayton, Ohio, USA
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23
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Abstract
Glucocorticoids inhibit osteoblasts through multiple mechanisms, which results in significant reductions in bone formation. The growing skeleton may be especially vulnerable to adverse glucocorticoid effects on bone formation, which could possibly compromise trabecular and cortical bone accretion. Although decreased bone mineral density has been described in various pediatric disorders that require glucocorticoids, and a population-based study reported increased fracture risk in children who require >4 courses of glucocorticoids, some of the detrimental bone effects attributed to glucocorticoids may be caused by the underlying inflammatory disease. For example, inflammatory cytokines that are elevated in chronic disease, such as tumor necrosis factor alpha, suppress bone formation and promote bone resorption through mechanisms similar to glucocorticoid-induced osteoporosis. Summarized in this review are changes in bone density and dimensions during growth, the effects of glucocorticoids and cytokines on bone cells, the potential confounding effects of the underlying inflammatory-disease process, and the challenges in interpreting dual-energy x-ray absorptiometry results in children with altered growth and development in the setting of glucocorticoid therapy. Two recent studies of children treated with chronic glucocorticoids highlight the differences in the effect of underlying disease, as well as the importance of associated alterations in growth and development.
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Affiliation(s)
- Mary B Leonard
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Geier P, Jurencák R, Zapletalová J. Treatment of the first episode of nephrotic syndrome in children. Pediatr Nephrol 2006; 21:1779-80; author reply 1781-2. [PMID: 16902786 DOI: 10.1007/s00467-006-0205-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Revised: 04/21/2006] [Accepted: 04/24/2006] [Indexed: 10/24/2022]
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Hoyer PF, Brodeh J. Initial treatment of idiopathic nephrotic syndrome in children: prednisone versus prednisone plus cyclosporine A: a prospective, randomized trial. J Am Soc Nephrol 2006; 17:1151-7. [PMID: 16540560 DOI: 10.1681/asn.2005090922] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Previous studies of the Arbeitsgemeinschaft für Pädiatrische Nephrologie in children with steroid-sensitive nephrotic syndrome have shown that the length of initial prednisone therapy has an impact on the subsequent relapse rate. The aim of this randomized, prospective, multicenter study was to reduce the number of relapses further by increasing the initial immunosuppression: Patients with an initial attack of nephrotic syndrome were randomly allocated to treatment with 6 wk of 60 mg/m(2) per d prednisone followed by 6 wk of 40 mg/m(2) per 48 h (Pred group) or to the same prednisone treatment plus 8 wk of cyclosporine (Pred+CsA group). The primary end point was first relapse; follow-up was truncated at 2 yr. In the Pred+CsA group (n = 49 patients), the first relapse occurred later compared with the Pred group (n = 55 patients) (median 22.8 versus 12.5 mo). After 6 mo, 10.4% of patients in the Pred+CsA group experienced a first relapse versus 31.5% in the Pred group (P = 0.01); after 1 yr, 36.5 versus 51% (P = 0.15); and after 2 yr, 51 versus 50%. The mean relapse rate per patient was 0.12 versus 0.57 after 6 mo (P = 0.01), 0.63 versus 1.03 after 1 yr (P = 0.02), and 1.03 versus 2.06 after 2 yr (not significant). The significant benefit for adding CsA was lost after 9 to 12 mo. GFR remained unchanged. The subsequent treatment rate with cyclophosphamide was lower in the CsA group (five versus 12 patients) after 2 yr. With the use of logistic regression statistics, children who were younger than 7 yr show a significantly better sustained remission rate with initial CsA treatment for the 2-yr observation time (P = 0.03). It remains questionable, however, whether the intensified initial treatment with CsA could be recommended generally.
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Affiliation(s)
- Peter F Hoyer
- Department of Pediatric Nephrology, University Clinic Essen, Hufelandstrasse 55, D-45122 Essen, Germany.
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26
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Durkan A, Hodson EM, Willis NS, Craig JC. Non-corticosteroid treatment for nephrotic syndrome in children. Cochrane Database Syst Rev 2005:CD002290. [PMID: 15846634 DOI: 10.1002/14651858.cd002290.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Eighty to ninety per cent of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. About half relapse frequently and are at risk of the adverse effects of corticosteroids. Non-corticosteroid immunosuppressive agents are used to prolong periods of remission in children who relapse frequently. However these non-corticosteroid agents also have significant potential adverse effects. Currently there is no consensus as to the most appropriate second line agent in children who are steroid sensitive, but who continue to relapse. OBJECTIVES To evaluate the benefits and harms of non-corticosteroid immunosuppressive agents in relapsing SSNS in children. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, reference lists of articles, abstracts from proceedings and contact with known investigators. Search date: August 2004 SELECTION CRITERIA RCTs or quasi-RCTs were included if they were undertaken in children with relapsing SSNS, if they compared non-corticosteroid agents with placebo, prednisone or no treatment, different doses and/or durations of the same non-corticosteroid agent, different non-corticosteroid agents and outcome data at six months. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as relative risk (RR) with 95% confidence intervals (CI). MAIN RESULTS Twenty trials involving 923 children were identified. Cyclophosphamide (three trials: RR 0.44, 95% CI 0.26 to 0.73) and chlorambucil (two trials: RR 0.13, 95% CI 0.03 to 0.57) significantly reduced the relapse risk at six to twelve months compared with prednisone alone. In the single chlorambucil versus cyclophosphamide trial, there was no observed difference in relapse risk at two years (RR 1.31, 95% CI 0.80 to 2.13). Cyclosporin was as effective as cyclophosphamide (one trial: RR 1.07, 95% CI 0.48 to 2.35) and chlorambucil (one trial: RR 0.82, 95% CI 0.44 to 1.53) but the effect was not sustained when cyclosporin was ceased. During treatment, levamisole (three trials: RR 0.60, 95% CI 0.45 to 0.79) was more effective than steroids alone but the effect was not sustained. Mizoribine (one trial) and azathioprine (two trials) were no more effective than placebo or prednisone alone in maintaining remission. AUTHORS' CONCLUSIONS Eight week courses of cyclophosphamide or chlorambucil and prolonged courses of cyclosporin and levamisole reduce the risk of relapse in children with relapsing SSNS compared with corticosteroids alone. Clinically important differences in efficacy among these agents are possible and further comparative trials are still needed.
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27
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Abstract
The management of idiopathic nephrotic syndrome (INS) in children includes immunosuppressive and symptomatic treatment. The response to corticosteroid therapy is the best prognostic marker of the disease. The majority of children with INS (about 85%) are steroid-sensitive as they normalize proteinuria within 4 weeks of daily, oral prednisone administration. The most of steroid-sensitive patients (94%) has minimal change of nephrotic syndrome, while the majority (80.5%-94.4%) of those who are steroid-resistant has focal segmental glomerulosclerosis or mesangioproliferative glomerulonephritis. Initial therapy of INS consists of 60 mg/m2/day prednisone daily for 4 weeks followed by 40 mg/m2 on alternate days for 4 weeks, thereafter decreasing alternate day therapy every month by 25% over the next 4 months. Thus, the overall duration of the initial corticosteroids course is 6 months that may be significantly protective against the future development of frequent relapses. Approximately 30% of patients experience only one attack and are cured after the first course of therapy; 10-20% have only 3 or 4 steroid-responsive episodes before permanent cure; the remaining 40-50% of patients are frequent relapsers, or steroid-dependent. Standard relapse therapy consists of 60 mg/m2/ day prednisone until urine is protein free for at least 3 days, followed by 40 mg/m2 on alternate days for 4 weeks. The treatment of frequent-relapses and steroid-dependent INS includes several different regimens: maintenance (6 months) alternate steroid therapy just above steroid threshold (0.1-0.5 mg/kg/48h), levamisole, alkylating agents (cyclophosphamide or chlorambucil) or cyclosporine. The worse prognosis is expected in steroid-resistant patients who are the most difficult to treat. Renal biopsy should be performed in them. At present, there is no consensus on therapeutic regimen for steroid-resistant patients. The following immunosuppressive drugs have been used with varying success: cyclosporine, intravenous methyl prednisone pulses alone or combined with or followed by alkylating agents, plasma-exchange, and angiotensin-converting enzyme (ACE) inhibitors. Symptomatic treatment includes: 1) dietary regimen with normal protein intake and salt restriction, 2) calcium and vitamin D are prescribed with steroids, 3) diuretics should be used in case of severe edema, 4) infusion of albumin in case of severe hypovolemia, 5) treatment of hypertension, 6) anticoagulant therapy, and 7) prophylactic antibiotics in high-risk patients.
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28
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Abstract
BACKGROUND In nephrotic syndrome protein leaks from the blood to the urine through the glomeruli resulting in hypoproteinaemia and generalised oedema. While the majority of children with nephrotic syndrome respond to corticosteroids, 70% experience a relapsing course. Corticosteroid usage has reduced the mortality rate to around 3%, however they have known serious adverse effects. OBJECTIVES To determine the benefits and harms of corticosteroid regimens in preventing relapse in children with steroid sensitive nephrotic syndrome (SSNS). SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Renal Group Specialised Register, MEDLINE and EMBASE without language restriction, reference lists of articles, abstracts from conference proceedings and contact with known investigators. Date of most recent search: October 2004 SELECTION CRITERIA Randomised controlled trials performed in children (three months to 18 years) in their initial or subsequent episode of SSNS, comparing different durations, total doses or other dose strategies using any corticosteroid agent, with outcome data at six months or more. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed trial quality and extracted data. Statistical analyses were performed using a random effects model and results expressed as relative risk (RR) with 95% confidence intervals (CI).Meta-regression was used to explore potential between-study differences due to baseline risk of relapse, study quality and interventions. MAIN RESULTS Nineteen trials were identified. Six trials comparing two months of prednisone with three months or more in the first episode showed longer duration significantly reduced the risk of relapse at 12 to 24 months (RR 0.70; 95% CI 0.58 to 0.84). There was an inverse linear relationship between treatment duration and risk of relapse (RR = 1.26 - 0.112 duration; P = 0.03). There was a significant reduction in the number of frequent relapsers and the mean relapse rate/patient/year. Deflazacort was significantly more effective in maintaining remission than prednisone in children who frequently relapsed (RR 0.44; 95% CI 0.25 to 0.78). There were no increases in adverse events. AUTHORS' CONCLUSIONS Children in their first episode of SSNS should be treated for at least three months with an increase in benefit being demonstrated for up to seven months of treatment For a baseline risk for relapse following the first episode of 60% with two months of prednisone, daily prednisone for four weeks followed by alternate-day therapy for six months would reduce the number of children relapsing by 33%. Deflazacort deserves further study for frequent relapsers.
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Affiliation(s)
- E M Hodson
- Centre for Kidney Research, Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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29
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Shimoyama H, Nakajima M, Naka H, Maruhashi Y, Akazawa H, Ueda T, Nishiguchi M, Yamoto Y, Kamitsuji H, Yoshioka A. Up-regulation of interleukin-2 mRNA in children with idiopathic nephrotic syndrome. Pediatr Nephrol 2004; 19:1115-21. [PMID: 15309604 DOI: 10.1007/s00467-004-1569-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2003] [Revised: 05/21/2004] [Accepted: 05/24/2004] [Indexed: 11/25/2022]
Abstract
The current hypothesis for the pathogenesis of childhood idiopathic nephrotic syndrome (INS) favors the involvement of a T cell-mediated immune response. Various cytokines derived from T cells may play a critical role in INS. Previous studies have measured serum or urine cytokine levels and suggest an imbalance of the T cell-mediated immune response. To elucidate the true profile of T cell-derived cytokines, we determined interleukin (IL)-2, interferon (IFN)-gamma, IL-4, IL-10, and tumor necrosis factor (TNF)-alpha mRNA expression in children with INS. We collected mRNA from peripheral blood mononuclear cells together with plasma and urine from nine children in the acute and remission phases of INS. Expression of IL-2, IFN-gamma, IL-4, IL-10, and TNF-alpha mRNA was determined by a quantitative real-time PCR assay. Plasma and urine cytokine concentrations were measured using a specific enzyme-linked immunosorbent assay. These data were compared between the acute and remission phase in the same patients. The IL-2 mRNA levels were significantly higher in the acute phase than in the remission phase, whilst no significant difference was found in the other cytokines investigated. There was no significant difference in the plasma and urine cytokine concentrations between the acute and remission phase. Our results indicate increased expression of IL-2 mRNA in the acute phase of INS, suggesting that IL-2, at least in part, might be involved in the pathophysiology of childhood INS.
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Kemper MJ, Kuwertz-Broeking E, Bulla M, Mueller-Wiefel DE, Neuhaus TJ. Recurrence of severe steroid dependency in cyclosporin A-treated childhood idiopathic nephrotic syndrome. Nephrol Dial Transplant 2004; 19:1136-41. [PMID: 14993510 DOI: 10.1093/ndt/gfh066] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In patients with steroid-dependent nephrotic syndrome (SDNS), long-term remission (LTR) can usually be achieved with cyclosporin A (CSA), after alternative treatment with cytotoxic drugs or levamisole has failed. Nevertheless, severe SDNS recurs in some patients despite CSA maintenance therapy. Few data are available on the clinical course and treatment strategies in these patients. METHODS We carried out a retrospective chart analysis of 46 patients with SDNS treated with CSA, after failure of cytotoxic treatment with cyclophosphamide (CPO). Median age at primary manifestation was 3.0 years (range 0.8-6.9) and median current age is 20.4 years (range 8.6-29.1). Patients were recruited from three centres caring for a total of 186 patients with steroid-sensitive nephrotic syndrome. RESULTS In 14 of the 46 patients (30%; 10 male), severe SDNS recurred again despite CSA maintenance therapy. Seven patients relapsed beyond the age of 18 years. Nine of 14 patients received a further course of cytotoxic treatment as first intervention: six were treated with chlorambucil (CLA) and three with CPO. Four of the CLA-treated patients remained in LTR in contrast to none after CPO. Five patients received levamisole after CSA: only one went into LTR, while in one other CSA could be discontinued although further relapses occurred. One further patient was switched to CLA after levamisole, finally inducing LTR. Overall, six patients required two or more drugs, and in four of these CSA maintenance ultimately had to be restarted. CONCLUSION We conclude that SDNS can recur in patients despite CSA maintenance therapy. Treatment strategies for this subgroup of patients are complex and should be standardized to optimize long-term outcome. A subgroup of patients with childhood SDNS continues to relapse into adulthood.
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Affiliation(s)
- Markus J Kemper
- Pediatric Nephrology, University Children's Hospital, Zurich, Switzerland.
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31
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Abstract
Childhood nephrotic syndrome is a rare condition with an incidence of 1-2 per 100000 children aged below 16 years. Untreated idiopathic nephrotic syndrome (INS) is associated with increased risks of life-threatening infection, thromboembolism, lipid abnormalities, and malnutrition. The aim of the management of INS in children is to induce and maintain complete remission with resolution of proteinuria and edema without serious adverse effects of therapy. The majority of children have corticosteroid sensitive idiopathic nephrotic syndrome (CSINS), and in these children, corticosteroid therapy is the mainstay of therapy to induce remission. Data from a meta-analysis of randomized controlled trials (RCTs) indicate that prolonged courses of corticosteroids (up to 7 months) given in the first episode of CSINS reduce the risk of relapse. Nevertheless, many children relapse, and are at risk of corticosteroid toxicity if frequent courses of corticosteroids are required. Data from RCTs supports the use of alkylating agents (cyclophosphamide, chlorambucil), cyclosporine, and levamisole in these children to achieve prolonged periods of remission. The specific management of corticosteroid-resistant idiopathic nephrotic syndrome (CRINS) is more difficult since few therapies are consistently effective, and data from RCTs are limited. In such children, cyclosporine, alkylating agents, and high dose intravenous methylprednisone may be used. In addition to specific therapies for INS, supportive therapies are commonly used to control edema (loop diuretics, aldosterone antagonists, albumin infusions, angiotensin-converting enzyme inhibitors), reduce the risk of infection (antibacterials, pneumococcal vaccination) and thromboembolism (aspirin [acetylsalicylic acid]), and to control hyperlipidemia (HMG-CoA reductase inhibitors), especially in children with CRINS.
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Affiliation(s)
- Elisabeth Hodson
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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32
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Abstract
Idiopathic childhood nephrotic syndrome generally has a favorable long-term prognosis. Prompt administration of and improved guidelines for monitoring therapy have decreased morbidity and mortality. The treatment goal is to induce prompt remission while minimizing complications and adverse events. Aggressive therapy induces remission and decreases the frequency of relapse in most patient populations; however, such treatment often results in unnecessary toxicity. We critically assessed the current clinical evidence that supports each pharmacologic therapy. For each drug regimen, the risks and monitoring parameters required to reduce complications and optimize therapy are discussed. Some of the treatments are the common corticosteroid approaches, cytotoxic therapies (chlorambucil, cyclophosphamide), cyclosporine, less frequently used drugs (e.g., levamisole), and experimental therapies. Further studies are needed to identify the most effective and least toxic therapeutic regimens for inducing and maintaining remission in children with nephrotic syndrome.
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Affiliation(s)
- Renee F Robinson
- Department of Pediatrics, College of Medicine and Public Health, The Ohio State University, Columbus, Ohio, USA.
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McBryde KD, Kershaw DB, Smoyer WE. Pediatric steroid-resistant nephrotic syndrome. Curr Probl Pediatr Adolesc Health Care 2001; 31:280-307. [PMID: 11733743 DOI: 10.1067/mps.2001.119800] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- K D McBryde
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, USA
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34
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Durkan AM, Hodson EM, Willis NS, Craig JC. Immunosuppressive agents in childhood nephrotic syndrome: a meta-analysis of randomized controlled trials. Kidney Int 2001; 59:1919-27. [PMID: 11318964 DOI: 10.1046/j.1523-1755.2001.0590051919.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Many children with steroid-sensitive nephrotic syndrome (SSNS) relapse frequently and receive immunosuppressive agents. In this systematic review of randomized controlled trials (RCTs), the benefits and harms of these immunosuppressive agents are evaluated. METHODS RCTs with outcome data at six months or more that evaluated noncorticosteroid agents in relapsing SSNS were included. A summary relative risk for relapse at 6 to 12 months was calculated using a random effects model. RESULTS Seventeen trials involving 631 children were identified. Cyclophosphamide [3 trials; relative risk (RR) 0.44, 95% confidence interval (CI), 0.26 to 0.73] and chlorambucil (2 trials; RR 0.13, 95% CI, 0.03 to 0.57) significantly reduced the relapse risk at 6 to 12 months compared with prednisone alone. In the single chlorambucil versus cyclophosphamide trial, there was no observed difference in relapse risk at two years (RR 1.31, 95% CI, 0.80 to 2.13). Cyclosporine was as effective as cyclophosphamide (1 trial; RR 1.07, 95% CI, 0.48 to 2.35) and chlorambucil (1 trial; RR 0.82, 95% CI, 0.44 to 1.53), but the effect was not sustained when cyclosporine was ceased. During treatment, levamisole (3 trials; RR 0.60, 95% CI, 0.45 to 0.79) was more effective than steroids alone, but the effect was not sustained. CONCLUSIONS Cyclophosphamide, chorambucil, cyclosporine, and levamisole reduce the risk of relapse in children with relapsing SSNS compared with prednisone alone. Clinically important differences in efficacy among these agents are possible, and further comparative trials are still needed. Meanwhile, the choice between these agents depends on physician and patient preferences related to therapy duration and complication type and frequency.
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Affiliation(s)
- A M Durkan
- Centre for Kidney Research, The Children's Hospital at Westmead, New South Wales, Australia
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35
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Prandota J, Pankow-Prandota L, Kotecki L, Noga L. Plasma proteinase inhibitor activity and hemostasis tests in children with nephrotic syndrome. Effect of prednisone alone and prednisone plus epsilon-aminocaproic acid treatment regimens: a preliminary report. Am J Ther 2001; 8:97-107. [PMID: 11304663 DOI: 10.1097/00045391-200103000-00004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neutrophil-derived proteinases cause glomerular injury by proteolysis of the glomerular basement membrane and alterations in glomerular metabolism. Recently, a marked elevation of the plasma elastase complex with alpha1-proteinase inhibitor (alpha 1-PI) both in the acute phase and during remission of nephrotic syndrome (NS) compared with age-matched controls was reported. In experimental immune-mediated glomerulonephritis epsilon-aminocaproic acid (EACA) significantly reduced albuminuria, and it was suggested that this may be linked with the antiproteolytic activity of the drug. We studied plasma antithrombin III (AT-III), alpha 1-PI, alpha 2-antiplasmin (alpha 2-A), alpha 2-macroglobulin (alpha 2-M) activity, and some blood coagulation and fibrinolysis tests in children with frequently relapsing prednisone-responsive NS. Also, the effect of prednisone alone (Group I, n = 9) and prednisone plus EACA (Group II, n = 10) treatment regimens on the studied parameters was estimated. All investigations were performed on admission to the hospital and after approximately 13 days of prednisone alone therapy (Group I), as well as before the administration of prednisone plus EACA and 24 hours after the last dose of EACA, ie, after approximately 5 days of treatment (Group II). Prednisone was administered at the usual dose of approximately 2 mg/kg/d and EACA was given orally at the doses of 72 to 230 mg/kg of body weight per day for 3 to 10 days. In the acute phase of disease, NS patients (n = 19) were shown to have a statistically significant decrease of plasma AT-III (16.4 +/- 4.7 vs. 21.9 +/- 2.5 IU/mL) and alpha 1-PI (1.28 +/- 0.6 vs. 1.97 +/- 0.34 IU/mL) activity, as well as a marked increase in plasma alpha 2-M activity (14.96 +/- 5.81 vs. 9.6 +/- 1.6 IU/mL), and fibrinogen concentration (5.51 +/- 1.78 vs. 2.96 +/- 0.34 g/L) compared to the age-matched controls; no significant changes in plasma alpha 2-A activity, plasminogen concentration, euglobulin clot lysis time, activated partial thromboplastin time (APTT), or thromboplastin time were noted. In children treated with prednisone alone, a marked increase in plasma AT-III (by 76%, P < 0.001) and alpha 2-A (36%, P < 0.019) activity, and a significant decrease of the plasma fibrinogen concentration (6.07 +/- 1.66 vs. 3.17 +/- 1.64 g/L, P < 0.001), and APTT (45.1 +/- 7.6 vs. 33.8 +/- 4.4 s, P < 0.001) were found. Prednisone plus EACA therapy resulted in a significant increase in plasma AT-III activity (by 53%, P < 0.003), whereas plasma fibrinogen concentration and APTT remained unchanged. However, statistically significant differences between the pre- and posttreatment plasma AT-III, alpha 1-PI, and alpha 2-A activities in these patients were observed. There was also a relationship between EACA dose and the percentage change in plasma alpha 2-A activity. In a few patients receiving prednisone plus EACA regimen, side effects that included purulent rhinitis, pharyngitis, increases in body temperature, loose stools, and an approximately 20% to 30% decrease in systolic and diastolic arterial blood pressure were observed. Thus, although the prednisone plus EACA treatment regimen seems to offer new therapeutic possibilities in some patients with NS, it should not be used in acute phase of the disease.
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Affiliation(s)
- J Prandota
- Department of Pediatrics, J. Korczak Memorial Children's Hospital, Wroclaw, Poland
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36
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Hodson EM, Knight JF, Willis NS, Craig JC. Corticosteroid therapy in nephrotic syndrome: a meta-analysis of randomised controlled trials. Arch Dis Child 2000; 83:45-51. [PMID: 10868999 PMCID: PMC1718389 DOI: 10.1136/adc.83.1.45] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To determine the benefits and toxicity of different corticosteroid regimes in preventing relapse in steroid responsive nephrotic syndrome. DESIGN Meta-analysis of randomised controlled trials. SUBJECTS Twelve trials involving 868 children aged 3 months to 18 years. MAIN OUTCOME MEASURE Frequency of relapse. RESULTS A meta-analysis of five trials, which compared two months of prednisone with three months or more in the first episode, showed that the longer duration significantly reduced the risk of relapse at 12-24 months (relative risk 0.73; 95% confidence interval 0.60 to 0.89) without an increase in adverse events. There was an inverse linear relation (relative risk 1.382 (SE 0.215) - 0.133 (SE 0.048) duration; r(2) = 0.66; p = 0.05) between the duration of treatment and risk of relapse. CONCLUSIONS Children in their first episode of steroid responsive nephrotic syndrome should be treated with prednisone for at least three months, with an increase in benefit being shown for up to seven months of treatment.
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Affiliation(s)
- E M Hodson
- Centre for Kidney Research, Royal Alexandra Hospital for Children, PO Box 3515, Parramatta, Sydney, NSW 2124, Australia.
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37
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Frank C, Herrmann M, Fernandez S, Dirnecker D, Böswald M, Kolowos W, Ruder H, Haas JP. Dominant T cells in idiopathic nephrotic syndrome of childhood. Kidney Int 2000; 57:510-7. [PMID: 10652027 DOI: 10.1046/j.1523-1755.2000.00870.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Because of several studies, idiopathic nephrotic syndrome (INS) of childhood is suspected to have an immunologic pathogenesis with T cells playing a major role. To investigate this hypothesis further, we studied the diversity of the CDR3 region of the T-cell receptor (TCR) beta-chain from peripheral T cells isolated from patients with INS. METHODS The study was performed over a three-year period to obtain longitudinal data on the repertoire of peripheral T cells. mRNA from peripheral mononuclear cells (PBMCs) of seven INS patients and two healthy controls (NHD) was prepared and analyzed for CDR3 length polymorphism of TCR beta-chain by spectratyping. RESULTS All INS patients presented individually skewed spectratype histograms in at least one Vbeta-family. Patients suffering from a frequent relapsing course of INS or a focal global sclerosis showed some alterations to persist in all samples isolated in the observation period (up to 3 years). In addition, sequence analyses of the beta-chain of the TCR CDR3 region confirmed clonal expansion of peripheral T cells in those patients who had displayed spectratype alterations. CONCLUSIONS The data give strong evidence for an direct involvement of CD8+ T cells in the complicated course of INS.
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MESH Headings
- Age of Onset
- Amino Acid Sequence
- CD4-Positive T-Lymphocytes/chemistry
- CD4-Positive T-Lymphocytes/immunology
- CD8-Positive T-Lymphocytes/chemistry
- CD8-Positive T-Lymphocytes/immunology
- Child
- Complementarity Determining Regions
- Gene Expression/immunology
- Genes, T-Cell Receptor beta/genetics
- Genes, T-Cell Receptor beta/immunology
- Humans
- Immunoglobulin Variable Region/genetics
- Molecular Sequence Data
- Nephrotic Syndrome/etiology
- Nephrotic Syndrome/immunology
- Nephrotic Syndrome/physiopathology
- Polymorphism, Genetic
- Receptors, Antigen, T-Cell, alpha-beta/chemistry
- Receptors, Antigen, T-Cell, alpha-beta/genetics
- Receptors, Antigen, T-Cell, alpha-beta/immunology
- Sequence Analysis, DNA
- T-Lymphocyte Subsets/immunology
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Affiliation(s)
- C Frank
- Children's Hospital and Institute for Clinical Immunology, Friedrich-Alexander University, Erlangen-Nuremberg,and Children's Rheumatology Hospital, Garmisch-Partenkirchen, Germany
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38
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Bargman JM. Management of minimal lesion glomerulonephritis: evidence-based recommendations. KIDNEY INTERNATIONAL. SUPPLEMENT 1999; 70:S3-16. [PMID: 10369190 DOI: 10.1046/j.1523-1755.1999.07002.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The treatment of idiopathic minimal lesion disease in children has been extensively studied in randomized controlled trials, however, there is less information available for adults. This article summarizes evidence-based recommendations for management. The first attack should be treated with prednisone or prednisolone at 60 mg/m2 per day (up to a maximum of 80 mg/day) for four to six weeks, followed by 40 mg/m2 of prednisone every other day for another four to six weeks (grade A). Relapse should be treated with 60 mg/m2/day of prednisone (up to 80 mg/day) only until the urine becomes protein free for three days, and then an alternate day regimen of 40 mg/m2 should be used for another month (grade A). Patients with frequently relapsing disease will have a significant reduction in relapse frequency after eight weeks of an alkylating agent (grade A). Less rigorous studies have suggested benefit with long-term, alternate-day corticosteroid (grade D) or the antihelminthic agent levamisole (grade D). For patients with steroid-dependent disease, an 8- or 12-week course with cyclophosphamide can induce remission (grade D). In true steroid-resistant disease, observational studies have suggested that a course of cyclosporine may sometimes induce remission or restore steroid responsiveness (grade D). Large retrospective studies in adults suggest that therapeutic response is slower than in children, but adults experience fewer relapses and more prolonged remission.
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Affiliation(s)
- J M Bargman
- Division of Nephrology, The Toronto Hospital, University of Toronto, Ontario, Canada
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Tanaka H, Onodera N, Waga S. Long-term azathioprine therapy in two children with steroid-dependent minimal-change nephrotic syndrome. TOHOKU J EXP MED 1999; 187:273-8. [PMID: 10458484 DOI: 10.1620/tjem.187.273] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Long-term azathioprine therapy as an alternative treatment to cyclophosphamide was done in 2 children with steroid-dependent minimal-change nephrotic syndrome (MCNS). They had already been treated with prednisolone, intravenous methyl-prednisolone pulse therapy, cyclophosphamide and mizoribine. Although cyclophosphamide had been proved to be effective in maintaining their remission, the cumulative dose of the agent limited another course of cyclophosphamide therapy. Since ciclosporine therapy is much expensive, a trial of azathioprine (2 mg/kg per day) was started, and the therapy resulted in inducing sustained remission and reducing prednisolone. The patients were well tolerated the long-term azathioprine therapy over a year. Although the efficacy of azathioprine in the management of childhood MCNS might be restricted, we therefore suggest that this agent should be reconsidered as an alternative treatment to cyclophosphamide.
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Affiliation(s)
- H Tanaka
- Division of Pediatrics, Iwate Prefectural Kitakami Hospital, Japan
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40
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DENG CHUN, TOKIEDA KEIKO, SCHEINMAN JONI, CHAN JAMESCM. New treatment modalities for paediatric kidney disease. Nephrology (Carlton) 1996. [DOI: 10.1111/j.1440-1797.1996.tb00175.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Andenmatten F, Bianchetti MG, Gerber HA, Zimmermann A, Meregalli P, Lüthy C, Oetliker OH. Outcome of idiopathic childhood nephrotic syndrome. A 20 year experience. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 1995; 29:15-9. [PMID: 7618045 DOI: 10.3109/00365599509180533] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
112 patients with idiopathic childhood nephrotic syndrome have been referred from 1970 through 1989 at the Department of Pediatrics, University of Berne. One patient remitted spontaneously without medication. Ninety-eight patients responded to prednisone: 15 had a single bout of nephrosis, 47 developed a tendency towards relapses and 36 steroid dependence. In 28 patients with tendency towards relapses cure took place on either prednisone alone or prednisone plus cyclophosphamide. In 18 patients with steroid dependency cure took place on prednisone alone or prednisone plus cyclophosphamide. Thirteen patients failed to respond to steroids. The course of the disease was more benign in 68 patients with minimal change disease as compared with 14 patients with focal and segmental glomerular sclerosis. Immunofluorescence studies demonstrated mesangial IgM deposits in 14 out of 54 patients, but this finding was not a marker for poor steroid response or progression to renal failure. The course of the disease was especially unfavourable in patients with persisting nephrosis on completion of the initial course of steroid therapy. In conclusion it appears appropriate to define the disease in terms of steroid responsiveness as steroid resistant patients sometimes show normal glomeruli, steroid responsive sometimes have focal and segmental glomerular sclerosis or mesangial IgM deposits, and decisions depend more on the steroid responsiveness than on the histological features.
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Affiliation(s)
- F Andenmatten
- Department of Pediatrics, University of Berne, Switzerland
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Hulton SA, Neuhaus TJ, Dillon MJ, Barratt TM. Long-term cyclosporin A treatment of minimal-change nephrotic syndrome of childhood. Pediatr Nephrol 1994; 8:401-3. [PMID: 7947023 DOI: 10.1007/bf00856511] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
We evaluated the efficacy of long-term cyclosporin A (CyA) treatment in the maintenance of remission in 40 children with steroid-dependent minimal-change nephrotic syndrome (MCNS). CyA was given in an initial dose of 5 mg/kg per day, adjusted to maintain a trough whole blood level of 50-150 ng/ml. All the 40 children received CyA for 1 year. In 18 patients, CyA was continued for a further period of at least a year without interruption; 9 patients had a second course of CyA therapy after an interval of at least 1 month. Of the 40 children 29 (72%) had one or more relapses during treatment with CyA, with 16 (40%) relapsing during the 1st year. During the second period of CyA, 10 (56%) of the 18 children treated continuously relapsed, whereas all the 9 children who had an interrupted course of therapy relapsed. CyA was discontinued at one time in 27 patients, all of whom subsequently relapsed, with a median time to relapse of 26 days. Long-term prednisolone in addition to CyA was required to maintain remission in 16 (40%) of the whole group. The results suggest that the long-term use of CyA is able to maintain remission of MCNS, although 40% of the patients also required low-dose alternate-day steroids; patients appeared to fare worse if the CyA course was interrupted; no patient experienced a long-term remission after CyA was stopped.
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Affiliation(s)
- S A Hulton
- Renal Unit, Hospital for Sick Children, London, UK
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44
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Nyberg E, Bohman SO, Berg U. Glomerular volume and renal function in children with different types of the nephrotic syndrome. Pediatr Nephrol 1994; 8:285-9. [PMID: 7917852 DOI: 10.1007/bf00866336] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Glomerular hypertrophy has been suggested to be an important factor in the pathogenesis of focal glomerular sclerosis. The aim of the present study was to analyse retrospectively the renal biopsies of 58 children (0.2-16.1 years of age) with different types of the nephrotic syndrome, minimal change nephrotic syndrome (MCNS), diffuse mesangial proliferation (DMP) and focal segmental glomerulosclerosis (FSGS). Glomerular surface area was measured and glomerular volume was calculated and related to steroid responsiveness and to renal function, measured by clearances of inulin and para-aminohippuric acid. Glomerular volume correlated with body surface area (BSA) and age. Because of this, patients with FSGS and DMP were matched according to BSA and age, with corresponding MCNS patients. Glomerular volumes of FSGS and DMP patients were significantly larger than those of MCNS patients. In the MCNS patients, significant correlations were found between glomerular volumes and glomerular filtration rate and effective renal plasma flow. Steroid-dependent and steroid-resistant patients showed larger glomeruli than the steroid-responsive children. We suggest that hyperfiltration and hyperperfusion, among other factors, may contribute to glomerular hypertrophy, mesangial proliferation and glomerulosclerosis.
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Affiliation(s)
- E Nyberg
- Department of Paediatrics, Danderyd Hospital, Stockholm, Sweden
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Primack WA, Schulman SL, Kaplan BS. An analysis of the approach to management of childhood nephrotic syndrome by pediatric nephrologists. Am J Kidney Dis 1994; 23:524-7. [PMID: 8154487 DOI: 10.1016/s0272-6386(12)80373-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The value of a renal biopsy for a child with frequently relapsing corticosteroid-responsive or corticosteroid-dependent nephrotic syndrome is unresolved. This was the subject of two independent surveys done by North American pediatric nephrologists. In one study, 59% of the respondents indicated that they would nearly always perform a biopsy prior to starting cytotoxic therapy, while 23% would do so rarely. Less experienced pediatric nephrologists were more inclined to recommend a biopsy (P < 0.05). The indications for a renal biopsy were to provide prognostic information and to make decisions concerning further therapy. In the second survey, 33% of pediatric nephrologists said they would perform a renal biopsy in children with frequent relapses, while 91% would recommend a biopsy in children with corticosteroid resistance (P < 0.001). Once a biopsy was performed, therapy was based on the histopathologic findings regardless of the previous clinical response to corticosteroids. At this time, there is no standard approach to the evaluation and management of children with frequently relapsing, corticosteroid-dependent nephrotic syndrome. Some physicians rely on their clinical acumen, whereas others depend on the histopathologic findings.
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Affiliation(s)
- W A Primack
- Department of Pediatrics, Fallon Clinic, University of Massachusetts School of Medicine, Worcester
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46
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Welch TR. Current management of selected childhood renal diseases. CURRENT PROBLEMS IN PEDIATRICS 1992; 22:432-51. [PMID: 1478111 DOI: 10.1016/0045-9380(92)90043-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- T R Welch
- Department of Pediatrics, University of Cincinnati
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