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Saiteja P, Deepthi B, Krishnasamy S, Sravani M, Krishnamurthy S. Intravenous cyclophosphamide therapy in children with calcineurin inhibitor-resistant steroid-resistant nephrotic syndrome in a resource-limited setting. Pediatr Nephrol 2024; 39:1149-1160. [PMID: 37947902 DOI: 10.1007/s00467-023-06187-3] [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: 06/08/2023] [Revised: 09/01/2023] [Accepted: 09/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND In pediatric steroid-resistant nephrotic syndrome (SRNS), calcineurin inhibitors (CNIs) are recommended as first-line therapy, with efficacy ranging between 60 and 80%, implying a substantial proportion will exhibit CNI resistance. Which alternate immunosuppressive therapy should be used in non-genetic pediatric SRNS exhibiting CNI resistance is especially relevant in low- to middle-income countries (LMIC), where the prohibitive costs of certain drugs such as monoclonal antibodies often determine therapy choice. METHODS The primary objective was to assess the efficacy of intravenous cyclophosphamide in a proportion of children aged 1-18 years with CNI-resistant SRNS with a complete response (CR) or partial response (PR) at 6 months from commencement of pulse therapy. The secondary objectives were to assess the proportion and profile of infections and adverse effects. RESULTS Of 90 children with idiopathic SRNS presenting between January 2013 and December 2022, 29 (32.2%) had CNI resistance and were enrolled. They were administered monthly intravenous cyclophosphamide pulses (6 pulses). Median (IQR) duration of follow-up was 48 (29.5, 63.5) months. At the end of 6 months of cyclophosphamide therapy, 13 (44.8%) attained CR and 4 (13.8%) attained PR, with an overall cyclophosphamide success rate of 58.6%. The efficacy of intravenous cyclophosphamide was higher in secondary (9/10; 90%) versus primary CNI resistance (8/19; 42.1%) (p = 0.029). Three children (3/29; 10.3%) developed systemic infections within 12 months of initiation of cyclophosphamide therapy, similar to the rate of systemic infections among children receiving CNI for SRNS management (6/41; 14.6%) (p = 0.85). CONCLUSIONS It is prudent to try intravenous cyclophosphamide in CNI-resistant SRNS in LMIC, given the reasonable cost and good efficacy rates (58.6%).
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Affiliation(s)
- Paraselli Saiteja
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Bobbity Deepthi
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Sudarsan Krishnasamy
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Madhileti Sravani
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Sriram Krishnamurthy
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
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Trautmann A, Seide S, Lipska-Ziętkiewicz BS, Ozaltin F, Szczepanska M, Azocar M, Jankauskiene A, Zurowska A, Caliskan S, Saeed B, Morello W, Emma F, Litwin M, Tsygin A, Fomina S, Wasilewska A, Melk A, Benetti E, Gellermann J, Stajic N, Tkaczyk M, Baiko S, Prikhodina L, Csaicsich D, Medynska A, Krisam R, Breitschwerdt H, Schaefer F. Outcomes of steroid-resistant nephrotic syndrome in children not treated with intensified immunosuppression. Pediatr Nephrol 2022; 38:1499-1511. [PMID: 36315273 PMCID: PMC10060323 DOI: 10.1007/s00467-022-05762-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND The aim of the current PodoNet registry analysis was to evaluate the outcome of steroid-resistant nephrotic syndrome (SRNS) in children who were not treated with intensified immunosuppression (IIS), focusing on the potential for spontaneous remission and the role of angiotensin blockade on proteinuria reduction. METHODS Ninety-five pediatric patients who did not receive any IIS were identified in the PodoNet Registry. Competing risk analyses were performed on 67 patients with nephrotic-range proteinuria at disease onset to explore the cumulative rates of complete or partial remission or progression to kidney failure, stratified by underlying etiology (genetic vs. non-genetic SRNS). In addition, Cox proportional hazard analysis was performed to identify factors predicting proteinuria remission. RESULTS Eighteen of 31 (58.1%) patients with non-genetic SRNS achieved complete remission without IIS, with a cumulative likelihood of 46.2% at 1 year and 57.7% at 2 years. Remission was sustained in 11 children, and only two progressed to kidney failure. In the genetic subgroup (n = 27), complete resolution of proteinuria occurred very rarely and was never sustained; 6 (21.7%) children progressed to kidney failure at 3 years. Almost all children (96.8%) received proteinuria-lowering renin-angiotensin-aldosterone system (RAAS) antagonist treatment. On antiproteinuric treatment, partial remission was achieved in 7 of 31 (22.6%) children with non-genetic SRNS and 9 of 27 children (33.3%) with genetic SRNS. CONCLUSION Our results demonstrate that spontaneous complete remission can occur in a substantial fraction of children with non-genetic SRNS and milder clinical phenotype. RAAS blockade increases the likelihood of partial remission of proteinuria in all forms of SRNS. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Agnes Trautmann
- Division of Pediatric Nephrology, University Center for Pediatrics and Adolescent Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
| | - Svenja Seide
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Beata S Lipska-Ziętkiewicz
- Rare Diseases Centre and Clinical Genetics Unit, Department of Biology and Medical Genetics, Medical University of Gdansk, Gdansk, Poland
| | - Fatih Ozaltin
- Department of Pediatric Nephrology, Nephrogenetics Laboratory and Center for Biobanking and Genomics, Hacettepe University, Ankara, Turkey
| | - Maria Szczepanska
- Department of Pediatrics, School of Medicine With the Division of Dentistry, Zabrze, Poland
| | - Marta Azocar
- Pediatric Nephrology, Hospital Luis Calvo Mackenna-Facultad de Medicina Universidad de Chile, Santiago de, Chile
| | - Augustina Jankauskiene
- Pediatric Center, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Alexandra Zurowska
- Department of Pediatrics, Medical University of Gdansk, Nephrology & Hypertension, Gdansk, Poland
| | - Salim Caliskan
- Pediatric Nephrology Department, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Bassam Saeed
- Farah Association for Child With Kidney Disease in Syria, Damascus, Syria
| | - William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milano, Italy
| | - Francesco Emma
- Department of Pediatric Subspecialties, Nephrology and Dialysis Unit, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Mieczyslaw Litwin
- Department of Pediatric Nephrology, The Children's Memorial Health Center, Warsaw, Poland
| | - Alexey Tsygin
- National Medical and Research Center for Children's Health, Moscow, Russia
| | - Svitlana Fomina
- Department of Pediatric Nephrology, State Institution "Institute of Nephrology of NAMS of Ukraine", Kyiv, Ukraine
| | - Anna Wasilewska
- Department of Pediatric Nephrology, University Hospital, Bialystok, Poland
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Jutta Gellermann
- Clinic for Pediatric Nephrology, Charite Hospital, Berlin, Germany
| | - Natasa Stajic
- Department of Pediatric Nephrology, Institute of Mother and Healthcare of Serbia, Belgrade, Serbia
| | - Marcin Tkaczyk
- Pediatric Nephrology Division, Polish Mothers Memorial Hospital Research Institute, Lodz, Poland
| | - Sergey Baiko
- National Center for Pediatric Nephrology and Renal Replacement Therapy, Belarusian State Medical University, Minsk, Belarus
| | - Larisa Prikhodina
- Division of Inherited & Acquired Kidney Diseases, Research & Clinical Institute for Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Dagmar Csaicsich
- Department of Pediatrics, Medical University Vienna, Vienna, Austria
| | - Anna Medynska
- Department of Pediatric Nephrology, Wroclaw Medical University, Wroclaw, Poland
| | - Regina Krisam
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Heike Breitschwerdt
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Franz Schaefer
- Division of Pediatric Nephrology, University Center for Pediatrics and Adolescent Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany
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How immunosuppressive drugs may directly target podocytes in glomerular diseases. Pediatr Nephrol 2022; 37:1431-1441. [PMID: 34244853 DOI: 10.1007/s00467-021-05196-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022]
Abstract
Podocytes are the direct target of immunologic injury in many immune-mediated glomerular diseases, leading to proteinuria and subsequent kidney failure. Immunosuppressive agents such as steroids, calcineurin inhibitors, and rituximab are the commonly used treatment strategies in this context for their immunotherapeutic or anti-inflammatory properties. However, in recent years, studies have demonstrated that immunosuppressive agents can have a direct effect on podocytes, introducing the concept of the non-immunologic mechanism of kidney protection by immunomodulators. In this review, we focus on the mechanisms by which these agents may directly target the podocyte independent of their systemic effects and examine their clinical significance.
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Second and Third Generational Advances in Therapies of the Immune-Mediated Kidney Diseases in Children and Adolescents. CHILDREN 2022; 9:children9040536. [PMID: 35455580 PMCID: PMC9030090 DOI: 10.3390/children9040536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/06/2022] [Accepted: 04/08/2022] [Indexed: 11/17/2022]
Abstract
Therapy of immune-mediated kidney diseases has evolved during recent decades from the non-specific use of corticosteroids and antiproliferative agents (like cyclophosphamide or azathioprine), towards the use of more specific drugs with measurable pharmacokinetics, like calcineurin inhibitors (cyclosporine A and tacrolimus) and mycophenolate mofetil, to the treatment with biologic drugs targeting detailed specific receptors, like rituximab, eculizumab or abatacept. Moreover, the data coming from a molecular science revealed that several drugs, which have been previously used exclusively to modify the upregulated adaptive immune system, may also exert a local effect on the kidney microstructure and ameliorate the functional instability of podocytes, reducing the leak of protein into the urinary space. The innate immune system also became a target of new therapies, as its specific role in different kidney diseases has been de novo defined. Current therapy of several immune kidney diseases may now be personalized, based on the detailed diagnostic procedures, including molecular tests. However, in most cases there is still a space for standard therapies based on variable protocols including usage of steroids with the steroid-sparing agents. They are used as a first-line treatment, while modern biologic agents are selected as further steps in cases of lack of the efficacy or toxicity of the basic therapies. In several clinical settings, the biologic drugs are effective as the add-on therapy.
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Mantan M, Agrwal S, Dabas A, Batra V. Childhood steroid-resistant nephrotic syndrome: Long-term outcomes from a Tertiary Care Center. Indian J Nephrol 2022; 32:320-326. [PMID: 35967537 PMCID: PMC9364992 DOI: 10.4103/ijn.ijn_258_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/14/2021] [Accepted: 09/18/2021] [Indexed: 11/04/2022] Open
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 748] [Impact Index Per Article: 249.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Schijvens AM, Sinha A, Bagga A, Schreuder MF. Need for uniform definitions in childhood nephrotic syndrome. Nephrol Dial Transplant 2021; 36:941-945. [PMID: 33367868 DOI: 10.1093/ndt/gfaa338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/12/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anne M Schijvens
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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8
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Liu Z, Yoon J, Wichaidit C, Jaykumar AB, Dbouk HA, Embry AE, Liu L, Henderson JM, Chang AN, Cobb MH, Miller RT. Control of Podocyte and Glomerular Capillary Wall Structure and Elasticity by WNK1 Kinase. Front Cell Dev Biol 2021; 8:618898. [PMID: 33604334 PMCID: PMC7884762 DOI: 10.3389/fcell.2020.618898] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/31/2020] [Indexed: 11/25/2022] Open
Abstract
Cytoskeletal structure and its regulation are essential for maintenance of the differentiated state of specific types of cells and their adaptation to physiologic and pathophysiologic conditions. Renal glomerular capillaries, composed of podocytes, endothelial cells, and the glomerular basement membrane, have distinct structural and biophysical properties and are the site of injury in many glomerular diseases. Calcineurin inhibitors, immunosuppressant drugs used for organ transplantation and auto-immune diseases, can protect podocytes and glomerular capillaries from injury by preserving podocyte cytoskeletal structure. These drugs cause complications including hypertension and hyperkalemia which are mediated by WNK (With No Lysine) kinases as well as vasculopathy with glomerulopathy. WNK kinases and their target kinases oxidative stress-responsive kinase 1 (OSR1) and SPS1-related proline/alanine-rich kinase (SPAK) have fundamental roles in angiogenesis and are activated by calcineurin inhibitors, but the actions of these agents on kidney vasculature, and glomerular capillaries are not fully understood. We investigated WNK1 expression in cultured podocytes and isolated mouse glomerular capillaries to determine if WNK1 contributes to calcineurin inhibitor-induced preservation of podocyte and glomerular structure. WNK1 and OSR1/SPAK are expressed in podocytes, and in a pattern similar to podocyte synaptopodin in glomerular capillaries. Calcineurin inhibitors increased active OSR1/SPAK in glomerular capillaries, the Young’s modulus (E) of glomeruli, and the F/G actin ratio, effects all blocked by WNK inhibition. In glomeruli, WNK inhibition caused reduced and irregular synaptopodin-staining, abnormal capillary and foot process structures, and increased deformability. In cultured podocytes, FK506 activated OSR1/SPAK, increased lamellipodia, accelerated cell migration, and promoted traction force. These actions of FK506 were reduced by depletion of WNK1. Collectively, these results demonstrate the importance of WNK1 in regulation of the podocyte actin cytoskeleton, biophysical properties of glomerular capillaries, and slit diaphragm structure, all of which are essential to normal kidney function.
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Affiliation(s)
- Zhenan Liu
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States.,Medicine Service, VA North Texas Health Care System, Dallas, TX, United States
| | - Joonho Yoon
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States.,Medicine Service, VA North Texas Health Care System, Dallas, TX, United States
| | - Chonlarat Wichaidit
- Department of Pharmacology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Ankita B Jaykumar
- Department of Pharmacology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Hashem A Dbouk
- Department of Pharmacology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Addie E Embry
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Liping Liu
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joel M Henderson
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Audrey N Chang
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States.,Medicine Service, VA North Texas Health Care System, Dallas, TX, United States
| | - Melanie H Cobb
- Department of Pharmacology, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Richard Tyler Miller
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, United States.,Medicine Service, VA North Texas Health Care System, Dallas, TX, United States
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9
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Yang CW, Chen FY, Chang FP, Ho Y, Wu BS, Yang AH, Tarng DC, Yang CY. IgM mesangial deposition as a risk factor for relapses of adult-onset minimal change disease. BMC Nephrol 2021; 22:25. [PMID: 33435901 PMCID: PMC7802152 DOI: 10.1186/s12882-021-02234-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 01/06/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Immunoglobulin M (IgM) mesangial deposition in pediatric minimal change disease (MCD) has been reported to be associated with steroid dependence and poor renal outcomes. However, the evidence linking the impacts of IgM mesangial deposition to the treatment prognosis in adult-onset MCD is still elusive. METHODS In this retrospective cohort study, 37 adult patients with MCD received kidney biopsies from January 2010 to May 2020. Immunofluorescence microscopy was performed and the patients dichotomized according to IgM mesangial deposition (12 patients with positive IgM deposition; 25 patients with negative IgM deposition). We analyzed the clinical features, the dosage of immunosuppressive agents, and the response to treatment for 2 years between the two groups. RESULTS Analysis of the clinical symptoms, the dosage of immunosuppressive treatment, and the time to remission revealed no statistical difference between the groups. However, compared to the negative IgM group, the frequency of relapses was significantly higher in the positive IgM group during the two-year follow-up period (the negative IgM group 0.25 episodes/year; the positive IgM group 0.75 episodes/year, p = 0.029). Furthermore, multivariate linear regression revealed that the positivity of IgM mesangial deposition is independently associated with the frequency of relapses (regression coefficient B 0.450, 95% CI 0.116-0.784, p = 0.010). CONCLUSIONS Our findings indicated that adult-onset MCD patients with IgM mesangial deposition have a high risk of relapses. Therefore, intensive monitoring of disease activity should be considered in MCD adults with IgM mesangial deposition.
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Affiliation(s)
- Cheng-Wen Yang
- Division of Nephrology, Department of Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
| | - Fan-Yu Chen
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Fu-Pang Chang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yang Ho
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Bo-Sheng Wu
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - An-Hang Yang
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Der-Cherng Tarng
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department and Institute of Physiology, National Yang-Ming University, Taipei, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan
| | - Chih-Yu Yang
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, No. 201, Section 2, Shih-Pai Road, Beitou District, Taipei, 11217, Taiwan.
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
- Institute of Clinical Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
- Center for Intelligent Drug Systems and Smart Bio-devices (IDS2B), Hsinchu, Taiwan.
- Stem Cell Research Center, National Yang-Ming University, Taipei, Taiwan.
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11
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Lee JM, Kronbichler A, Shin JI, Oh J. Current understandings in treating children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2021; 36:747-761. [PMID: 32086590 PMCID: PMC7910243 DOI: 10.1007/s00467-020-04476-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 12/22/2019] [Accepted: 01/07/2020] [Indexed: 12/27/2022]
Abstract
Steroid-resistant nephrotic syndrome (SRNS) remains a challenge for paediatric nephrologists. SRNS is viewed as a heterogeneous disease entity including immune-based and monogenic aetiologies. Because SRNS is rare, treatment strategies are individualized and vary among centres of expertise. Calcineurin inhibitors (CNI) have been effectively used to induce remission in patients with immune-based SRNS; however, there is still no consensus on treating children who become either CNI-dependent or CNI-resistant. Rituximab is a steroid-sparing agent for patients with steroid-sensitive nephrotic syndrome, but its efficacy in SRNS is controversial. Recently, several novel monoclonal antibodies are emerging as treatment option, but their efficacy remains to be seen. Non-immune therapies, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, have been proven efficacious in children with SRNS and are recommended as adjuvant agents. This review summarizes and discusses our current understandings in treating children with idiopathic SRNS.
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Affiliation(s)
- Jiwon M. Lee
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, South Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752 South Korea ,Division of Pediatric Nephrology, Severance Children’s Hospital, Seoul, South Korea ,Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Oh
- Department of Pediatrics Nephrology, University Hamburg-Eppendorf, Martinistrasse, 52 20246, Hamburg, Germany.
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Ehren R, Benz MR, Brinkkötter PT, Dötsch J, Eberl WR, Gellermann J, Hoyer PF, Jordans I, Kamrath C, Kemper MJ, Latta K, Müller D, Oh J, Tönshoff B, Weber S, Weber LT. Pediatric idiopathic steroid-sensitive nephrotic syndrome: diagnosis and therapy -short version of the updated German best practice guideline (S2e) - AWMF register no. 166-001, 6/2020. Pediatr Nephrol 2021; 36:2971-2985. [PMID: 34091756 PMCID: PMC8445869 DOI: 10.1007/s00467-021-05135-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 01/21/2023]
Abstract
Idiopathic nephrotic syndrome is the most frequent glomerular disease in children in most parts of the world. Children with steroid-sensitive nephrotic syndrome (SSNS) generally have a good prognosis regarding the maintenance of normal kidney function even in the case of frequent relapses. The course of SSNS is often complicated by a high rate of relapses and the associated side effects of repeated glucocorticoid (steroid) therapy. The following recommendations for the treatment of SSNS are based on the comprehensive consideration of published evidence by a working group of the German Society for Pediatric Nephrology (GPN) based on the systematic Cochrane reviews on SSNS and the guidelines of the KDIGO working group (Kidney Disease - Improving Global Outcomes).
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Affiliation(s)
- Rasmus Ehren
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany.
| | - Marcus R Benz
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Paul T Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Jörg Dötsch
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Wolfgang R Eberl
- Department of Pediatrics, Städtisches Klinikum Braunschweig, Braunschweig, Germany
| | - Jutta Gellermann
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Peter F Hoyer
- Center for Children and Adolescents, Pediatric Clinic II, University of Duisburg-Essen, Essen, Germany
| | - Isabelle Jordans
- Bundesverband Niere eV (German National Kidney-Patients Association), Mainz, Germany
| | - Clemens Kamrath
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Medical School, Hamburg, Germany
| | - Kay Latta
- Clementine Kinderhospital Frankfurt, Frankfurt, Germany
| | - Dominik Müller
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Jun Oh
- Division of Pediatric Nephrology, Hepatology and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Stefanie Weber
- Department of Pediatrics II, University Children's Hospital, Philipps-University Marburg, Marburg, Germany
| | - Lutz T Weber
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
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Trautmann A, Vivarelli M, Samuel S, Gipson D, Sinha A, Schaefer F, Hui NK, Boyer O, Saleem MA, Feltran L, Müller-Deile J, Becker JU, Cano F, Xu H, Lim YN, Smoyer W, Anochie I, Nakanishi K, Hodson E, Haffner D. IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2020; 35:1529-1561. [PMID: 32382828 PMCID: PMC7316686 DOI: 10.1007/s00467-020-04519-1] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 02/06/2023]
Abstract
Idiopathic nephrotic syndrome newly affects 1-3 per 100,000 children per year. Approximately 85% of cases show complete remission of proteinuria following glucocorticoid treatment. Patients who do not achieve complete remission within 4-6 weeks of glucocorticoid treatment have steroid-resistant nephrotic syndrome (SRNS). In 10-30% of steroid-resistant patients, mutations in podocyte-associated genes can be detected, whereas an undefined circulating factor of immune origin is assumed in the remaining ones. Diagnosis and management of SRNS is a great challenge due to its heterogeneous etiology, frequent lack of remission by further immunosuppressive treatment, and severe complications including the development of end-stage kidney disease and recurrence after renal transplantation. A team of experts including pediatric nephrologists and renal geneticists from the International Pediatric Nephrology Association (IPNA), a renal pathologist, and an adult nephrologist have now developed comprehensive clinical practice recommendations on the diagnosis and management of SRNS in children. The team performed a systematic literature review on 9 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, formulated recommendations and formally graded them at a consensus meeting, with input from patient representatives and a dietician acting as external advisors and a voting panel of pediatric nephrologists. Research recommendations are also given.
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Affiliation(s)
- Agnes Trautmann
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Marina Vivarelli
- Department of Pediatric Subspecialties, Division of Nephrology and Dialysis, Bambino Gesù Pediatric Hospital and Research Center, Rome, Italy
| | - Susan Samuel
- Department of Pediatrics, Section of Pediatric Nephrology, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Debbie Gipson
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Aditi Sinha
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Ng Kar Hui
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Olivia Boyer
- Laboratory of Hereditary Kidney Diseases, Imagine Institute, INSERM U1163, Paris Descartes University, Paris, France
- Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Necker Hospital, APHP, 75015, Paris, France
| | - Moin A Saleem
- Department of Pediatric Nephrology, Bristol Royal Hospital for Children, University of Bristol, Bristol, UK
| | - Luciana Feltran
- Hospital Samaritano and HRim/UNIFESP, Federal University of São Paulo, São Paulo, Brazil
| | | | - Jan Ulrich Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Francisco Cano
- Department of Nephrology, Luis Calvo Mackenna Children's Hospital, University of Chile, Santiago, Chile
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Yam Ngo Lim
- Department of Pediatrics, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - William Smoyer
- The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ifeoma Anochie
- Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Elisabeth Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead and the Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany.
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Center for Rare Diseases, Hannover Medical School Children's Hospital, Hannover, Germany.
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14
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Liu ID, Willis NS, Craig JC, Hodson EM. Interventions for idiopathic steroid-resistant nephrotic syndrome in children. Cochrane Database Syst Rev 2019; 2019:CD003594. [PMID: 31749142 PMCID: PMC6868353 DOI: 10.1002/14651858.cd003594.pub6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The majority of children who present with their first episode of nephrotic syndrome achieve remission with corticosteroid therapy. Children who fail to respond to corticosteroids in the first episode of nephrotic syndrome (initial resistance) or develop resistance after one or more responses to corticosteroids (delayed resistance) may be treated with immunosuppressive agents including calcineurin inhibitors (CNI) (cyclosporin or tacrolimus) and with non-immunosuppressive agents such as angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB). However, response to these agents is limited so newer agents are being assessed for efficacy. This is an update of a review first published in 2004 and updated in 2006, 2010 and 2016. OBJECTIVES To evaluate the benefits and harms of different interventions used in children with idiopathic nephrotic syndrome, who do not achieve remission following four weeks or more of daily corticosteroid therapy. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies to 17 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs were included if they compared different immunosuppressive agents or non-immunosuppressive agents with placebo, prednisone or other agent given orally or parenterally in children aged three months to 18 years with steroid-resistant nephrotic syndrome (SRNS). Studies, which enrolled children and adults but in which paediatric data could not be separated from adult data, were also included. DATA COLLECTION AND ANALYSIS Two authors independently searched the literature, determined study eligibility, assessed risk of bias and extracted data. For dichotomous outcomes, results were expressed as risk ratios (RR) and 95% confidence intervals (CI). For continuous outcomes, results were expressed as mean difference (MD) and 95% CI. Data were pooled using the random effects model. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS Twenty-five studies (1063 participants) were included. Fourteen studies were at low risk of bias for sequence generation and allocation concealment. Five and 19 studies were at low risk of performance and detection bias. Fourteen, 14 and 13 studies were at low risk of attrition bias, reporting bias and other bias respectively. Cyclosporin compared with placebo or no treatment may increase the number of participants who achieve complete remission (4 studies, 74 participants: RR 3.50, 95% CI 1.09 to 11.20) or complete or partial remission (4 studies, 74 children: RR 3.15, 95% CI 1.04 to 9.57) by 6 months (low certainty evidence). It is uncertain whether cyclosporin increases the likelihood of worsening hypertension or reduces the likelihood of end-stage kidney disease (very low certainty evidence). CNI compared with IV cyclophosphamide (CPA) may increase the number of participants with complete or partial remission at 3 to 6 months (2 studies, 156 children: RR 1.98, 95% CI 1.25 to 3.13) (low certainty evidence) and probably reduces the number with treatment failure (non response, serious infection, persistently elevated creatinine (1 study, 124 participants: RR 0.32, 95% CI 0.18 to 0.58) (moderate certainty evidence) with little or no increase in serious infections (1 study, 131 participants: RR 0.49, 95% CI 0.16 to 1.56) (moderate certainty evidence). Tacrolimus compared with cyclosporin may make little or no difference to the number who achieve complete or partial remission (2 studies, 58 participants: RR 1.05, 95% CI 0.87 to 1.25) (low certainty evidence) or in the number with worsening hypertension (2 studies, 58 participants: RR 0.41, 95% CI 0.08 to 2.15) (low certainty evidence). Cyclosporin compared with mycophenolate mofetil (MMF) and dexamethasone probably makes little or no difference to the number who achieve complete or partial remission (1 study, 138 participants: RR 2.14, 95% CI 0.87 to 5.24) (moderate certainty evidence) and makes little or no difference to the number dying (1 study, 138 participants: RR 2.14, 95% CI 0.87 to 5.24) or with 50% reduction in glomerular filtration rate (GFR) (1 study, 138 participants: RR 2.29, 95% CI 0.46 to 11.41) (low certainty evidence). Among children, who have achieved complete remission, tacrolimus compared with MMF may increase the number of children who maintain complete or partial response for 12 months (1 study, 60 children: RR 2.01, 95% CI 1.32 to 3.07) (low certainty evidence). Oral CPA with prednisone compared with prednisone alone may make little or no difference to the number who achieve complete remission (2 studies, 84 children: RR 1.06, 95% CI 0.61 to 1.87) (low certainty evidence). IV CPA compared with oral CPA (2 studies, 61 children: RR 1.58, 95% CI 0.65 to 3.85) and IV compared with oral CPA plus IV dexamethasone (1 study, 49 children: RR 1.13, 95% CI 0.65 to 1.96) may make little or no difference to the number who achieve complete remission (low certainty evidence). It is uncertain whether rituximab and cyclosporin compared with cyclosporin increases the likelihood of remission because the certainty of the evidence is very low. It is uncertain whether adalimumab or galactose compared with conservative therapy increases the likelihood of remission because the certainty of the evidence is very low. Two studies reported that ACEi may reduce proteinuria in children with SRNS. One study reported that the dual angiotensin II and endothelin Type A receptor antagonist, sparsentan, may reduce proteinuria more effectively than the angiotensin receptor blocker, irbesartan. AUTHORS' CONCLUSIONS To date RCTs have demonstrated that CNIs may increase the likelihood of complete or partial remission compared with placebo/no treatment or CPA. For other regimens assessed, it remains uncertain whether the interventions alter outcomes because the certainty of the evidence is low. Further adequately powered, well designed RCTs are needed to evaluate other regimens for children with idiopathic SRNS. Since SRNS represents a spectrum of diseases, future studies should enrol children from better defined groups of patients with SRNS.
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Affiliation(s)
- Isaac D Liu
- National University Health SystemDepartment of Paediatrics1E Kent Ridge Road, NUHS Tower Block, Level 12SingaporeSingapore119228
| | - Narelle S Willis
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Elisabeth M Hodson
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
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Li HY, Zhang X, Zhou T, Zhong Z, Zhong H. Efficacy and safety of cyclosporine a for patients with steroid-resistant nephrotic syndrome: a meta-analysis. BMC Nephrol 2019; 20:384. [PMID: 31646979 PMCID: PMC6813125 DOI: 10.1186/s12882-019-1575-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 10/09/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The purpose of this study was to determine efficacy and safety of cyclosporine A (CsA) for patients with steroid-resistant nephrotic syndrome (SRNS). METHODS The Cochrane Library and PubMed were searched to extract the associated studies on Oct 10, 2018, and the meta-analysis method was used to pool and analyze the applicable investigations included in this study. The P(opulation) I(ntervention) C(omparison) O(utcome) of the study were defined as follows: P: Patients with SRNS; I: treated with CsA, cyclophosphamide (CYC), tacrolimus (TAC) or placebo/not treatment (P/NT); C: CsA vs. placebo/nontreatment (P/NT), CsA vs. CYC, CsA vs. TAC; O: complete remission (CR), total remission (TR; complete or partial remission (PR)), urine erythrocyte number, proteinuria levels, albumin, proteinuria, serum creatinine, and plasma cholesterol, etc. Data were extracted and pooled using RevMan 5.3. RESULTS In the therapeutic regimen of CsA vs. placebo/nontreatment (P/NT), the results indicated that the CsA group had high values of CR, TR, and low values of proteinuria, serum creatinine, and plasma cholesterol when compared with those in the placebo group. In comparing CsA vs. cyclophosphamide (CYC), the results indicated that the CsA group had higher TR than the CYC group. In comparing CsA vs. tacrolimus (TAC), the results revealed insignificant differences in CR, and TR between the CsA and TAC groups. The safety of CsA was also assessed. The incidence of gum hyperplasia in CsA group was higher than that in the P/NT group, with no differences in incidence of infections or hypertension between CsA and P/NT groups. There was no difference in the incidence of hypertension between the CsA and TAC groups. CONCLUSIONS CsA is an effective and safe agent in the therapy of patients with SRNS.
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Affiliation(s)
- Hong-Yan Li
- Department of Nephrology, Huadu District People's Hospital of Guangzhou, Southern Medical University, Guangzhou, China
| | - Xialan Zhang
- Department of Obestetrics and Gynecology, the Second Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
| | - Tianbiao Zhou
- Department of Nephrology, the Second Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China.
| | - Zhiqing Zhong
- Department of Nephrology, the Second Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
| | - Hongzhen Zhong
- Department of Nephrology, the Second Affiliated Hospital of Shantou University Medical College, Shantou, 515041, China
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16
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Esezobor CI, Asinobi AO, Okafor HU, Akuse R, Gbadegesin R. National survey found that managing childhood nephrotic syndrome in Nigeria varied widely and did not comply with the best evidence. Acta Paediatr 2018; 107:2193-2198. [PMID: 29786149 DOI: 10.1111/apa.14409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/21/2018] [Accepted: 05/16/2018] [Indexed: 12/01/2022]
Abstract
AIM This study explored any variations in managing childhood nephrotic syndrome between specialist centres in Nigeria and how closely the care reflected the best available evidence. METHODS In 2016, the heads of Nigerian paediatric nephrology units were asked to complete a study questionnaire that focused on managing nephrotic syndrome. RESULTS Of the 31 clinicians we approached, 81% returned the completed questionnaire. The majority (64%) had received paediatric nephrology training and 40% had practised for at least 10 years. We found that 60% prescribed an initial daily prednisolone for four weeks before reducing the dose and 32% prescribed it for six weeks. However, more marked variations were observed with the total steroid duration for new-onset nephrotic syndrome, with 16%, 44% and 40% prescribing prednisolone for 8, 12 and at least 16 weeks, respectively. Similarly, 56% prescribed prednisolone for less than eight weeks before diagnosing steroid-resistant nephrotic syndrome (SRNS) and 12% rarely requested a kidney biopsy for SRNS. In addition, 32% of the respondents preferred cyclophosphamide to calcineurin inhibitors for SRNS. CONCLUSION There were significant variations in the management of childhood nephrotic syndrome in Nigeria and the diagnosis and treatment of SRNS differed substantially from the best available evidence.
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Affiliation(s)
- Christopher I. Esezobor
- Department of Paediatrics; Faculty of Clinical Sciences; College of Medicine; University of Lagos; Lagos State Nigeria
| | - Adanze O. Asinobi
- Department of Paediatrics; College of Medicine; University of Ibadan; Ibadan Oyo State Nigeria
| | - Henrietta U. Okafor
- Department of Paediatrics; University of Nigeria Teaching Hospital (UNTH); Ituku-Ozalla Enugu State Nigeria
| | - Rosamund Akuse
- Department of Paediatrics; Ahmadu Bello University Teaching Hospital; Zaria Kaduna State Nigeria
| | - Rasheed Gbadegesin
- Department of Pediatrics; Division of Nephrology; Duke University Medical Center; Durham NC USA
- Duke Molecular Physiology Institute; Durham NC USA
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17
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Abstract
Zusammenfassung
Das steroid-resistente nephrotische Syndrom (SRNS) mit dem histomorphologischen Korrelat der fokal-segmentalen Glomerulosklerose (FSGS) stellt eine bedeutende Ursache für eine terminale Niereninsuffizienz im Kindesalter, aber auch bei erwachsenen Patienten dar. Das Erkrankungsspektrum zeichnet sich durch eine große genetische Heterogenität aus, wobei auch nicht genetische Ursachen bei der FSGS beobachtet werden. Die genetische Grundlage des SRNS/FSGS-Komplexes ist v. a. für ältere Kinder/Jugendliche und Erwachsene bisher noch unzureichend verstanden. Die eindeutige Abgrenzung genetischer SRNS/FSGS-Ursachen ist unerlässlich, da sich bereits heute hieraus eine Vielzahl an klinischen Implikationen ergeben. Die Identifikation unbekannter Erkrankungsallele oder Erkrankungsgene kann zudem Erkenntnisse bringen, die ein gänzlich neues Verständnis der Pathomechanismen ermöglichen. Durch umfassende genetische Untersuchungen besteht die Möglichkeit, die ungelöste genetische Basis der Rekurrenz der FSGS-Erkrankung bei bislang Varianten-negativen Patienten zu finden.
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Affiliation(s)
- Julia Hoefele
- Aff1 Institut für Humangenetik Klinikum rechts der Isar, Technische Universität München Trogerstr. 32 81675 München Deutschland
| | - Bodo B. Beck
- Aff2 0000 0000 8852 305X grid.411097.a Institut für Humangenetik Uniklinik Köln Kerpener Str. 34 50937 Köln Deutschland
| | - Lutz T. Weber
- Aff3 0000 0000 8852 305X grid.411097.a Klinik und Poliklinik für Kinder- und Jugendmedizin Uniklinik Köln Kerpener Str. 62 50937 Köln Deutschland
| | - Paul Brinkkötter
- Aff4 0000 0000 8852 305X grid.411097.a Klinik II für Innere Medizin Uniklinik Köln Kerpener Str. 62 50937 Köln Deutschland
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18
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Ehren R, Benz MR, Doetsch J, Fichtner A, Gellermann J, Haffner D, Höcker B, Hoyer PF, Kästner B, Kemper MJ, Konrad M, Luntz S, Querfeld U, Sander A, Toenshoff B, Weber LT. Initial treatment of steroid-sensitive idiopathic nephrotic syndrome in children with mycophenolate mofetil versus prednisone: protocol for a randomised, controlled, multicentre trial (INTENT study). BMJ Open 2018; 8:e024882. [PMID: 30309995 PMCID: PMC6252704 DOI: 10.1136/bmjopen-2018-024882] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Idiopathic nephrotic syndrome is the most common glomerular disease in childhood with an incidence of 1.8 cases per 100 000 children in Germany. The treatment of the first episode implies two aspects: induction of remission and sustainment of remission. The recent Kidney Disease Improving Global Outcomes, American Academy of Pediatrics and German guidelines for the initial treatment of the first episode of a nephrotic syndrome recommend a 12-week course of prednisone. Despite being effective, this treatment is associated with pronounced glucocorticoid-associated toxicity due to high-dose prednisone administration over a prolonged period of time. The aim of the INTENT study (Initial treatment of steroid-sensitive idiopathic nephrotic syndrom in children with mycophenolate mofetil versus prednisone: protocol for a randomised, controlled, multicentre trial) is to show that an alternative treatment regimen with mycophenolic acid is not inferior regarding sustainment of remission, but with lower toxicity compared with treatment with glucocorticoids only. METHODS AND DESIGN The study is designed as an open, randomised, controlled, multicentre trial. 340 children with a first episode of steroid-sensitive nephrotic syndrome and who achieved remission by a standard prednisone regimen will be enrolled in the trial and randomised to one of two treatment arms. The standard care group will be treated with prednisone for a total of 12 weeks; in the experimental group the treatment is switched to mycophenolate mofetil, also for a total of 12 weeks in treatment duration. The primary endpoint is the occurrence of a treated relapse within 24 months after completion of initial treatment. ETHICS AND DISSEMINATION Ethics approval for this trial was granted by the ethics committee of the Medical Faculty of the University of Heidelberg (AFmu-554/2014). The study results will be published in accordance with the Consolidated Standards of Reporting Trials statement and the Standard Protocol Items: Recommendations for Interventional Trials guidelines. Our findings will be submitted to major international paediatric nephrology and general paediatric conferences and submitted for publication in a peer-reviewed, open-access journal. TRIAL REGISTRATION NUMBER DRKS0006547; EudraCT2014-001991-76; Pre-result. DATE OF REGISTRATION 30 October 2014; 24 February 2017.
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Affiliation(s)
- Rasmus Ehren
- Department of Pediatrics, University Children’s Hospital Köln, University Hospital Köln, Köln, Germany
| | - Marcus R Benz
- Department of Pediatrics, University Children’s Hospital Köln, University Hospital Köln, Köln, Germany
| | - Jorg Doetsch
- Department of Pediatrics, University Children’s Hospital Köln, University Hospital Köln, Köln, Germany
| | - Alexander Fichtner
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Jutta Gellermann
- Department of Pediatrics, University Children’s Hospital Berlin, University Hospital Berlin Charité, Berlin, Germany
| | - Dieter Haffner
- Department of Pediatrics, University Children’s Hospital Hannover, University Hospital Hannover, Hannover, Germany
| | - Britta Höcker
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Peter F Hoyer
- Department of Pediatrics, University Children’s Hospital Essen, University Hospital Essen, Essen, Germany
| | - Bärbel Kästner
- KKS (Coordination Center for Clinical Trials), University Hospital of Heidelberg, Heidelberg, Germany
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Klinik Nord – Heidberg, Hamburg, Germany
| | - Martin Konrad
- Department of Pediatrics, University Children’s Hospital Münster, University Hospital Münster, Münster, Germany
| | - Steffen Luntz
- KKS (Coordination Center for Clinical Trials), University Hospital of Heidelberg, Heidelberg, Germany
| | - Uwe Querfeld
- Department of Pediatrics, University Children’s Hospital Berlin, University Hospital Berlin Charité, Berlin, Germany
| | - Anja Sander
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Burkhard Toenshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Lutz T Weber
- Department of Pediatrics, University Children’s Hospital Köln, University Hospital Köln, Köln, Germany
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Difficult-to-treat idiopathic nephrotic syndrome: established drugs, open questions and future options. Pediatr Nephrol 2018; 33:1641-1649. [PMID: 28879428 DOI: 10.1007/s00467-017-3780-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 10/18/2022]
Abstract
The idiopathic nephrotic syndrome in childhood can be classified according to the International Study of Kidney Disease in Children (ISKDC) based on the response to steroids. Typically, steroid-sensitive nephrotic syndrome (SSNS) is characterised by minimal changes in disease (MCD) histology, whereas in steroid-resistant nephrotic syndrome (SRNS) focal segmental glomerulosclerosis (FSGS) is the most prevalent lesion. Patients with SSNS may develop frequent relapses and/or steroid dependency, which can be difficult to treat. New studies confirm the value of calcineurin inhibitors (CNIs) and mycophenolic acid in preventing relapses of SSNS. Rituximab also plays an important role, but many questions regarding initial dosing, repetitions of courses, and long-term side effects remain unclear. SRNS, especially when unresponsive to treatment, can lead to chronic kidney disease. In particular, treatment with CNIs has improved the prognosis and recent data indicate that treatment can even be discontinued in many patients with full remission. In CNI-unresponsive SRNS, rituximab is less effective than in SSNS and the role of other biologicals (such as ofatumumab, abatacept, and others) remains unclear. A significant proportion of children with FSGS have genetic causes and most patients do not respond to immunosuppression, although individual patients with partial and even complete response have been documented. Future studies should evaluate treatments leading to long-term remission without maintenance immunosuppression in SSNS; in both genetic and immune-mediated SRNS, novel options to decrease the number of treatment-unresponsive patients seem mandatory, as they are at a high risk of developing end-stage renal disease.
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20
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Liu Y, Yang R, Yang C, Dong S, Zhu Y, Zhao M, Yuan F, Gui K. Cyclophosphamide versus cyclosporine A therapy in steroid-resistant nephrotic syndrome: a retrospective study with a mean 5-year follow-up. J Int Med Res 2018; 46:4506-4517. [PMID: 30185089 PMCID: PMC6259365 DOI: 10.1177/0300060518782017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Objective To compare the clinical efficacy of cyclophosphamide (CTX) and cyclosporine A (CSA) in initial treatment of children with steroid-resistant nephrotic syndrome (SRNS). Methods Prospectively maintained databases were reviewed to retrospectively compare two cohorts with SRNS that received peroral administration of 2 to 2.5 mg/kg/d CTX for 3 to 6 months or 1 to 5 mg/kg/d CSA for 2 years until the primary analysis cut-off date during 2007 to 2011. The time to first on-study relapse of SRNS was the primary endpoint. The effective rate was the second endpoint. Results A total of 127 children with SRNS were included (CTX-treated cohort: n = 62; CSA-treated cohort: n = 65), with a mean 5-year follow-up. CTX-treated children showed a significantly delayed time to first on-study relapse of SRNS compared with CSA-treated children (hazard ratio 0.66, 95% confidence interval 0.32–1.75). The relapse rate (rate/year) in CTX-treated children (1.1 ± 0.1) at the 24-month follow-up was significantly higher than that with CSA (0.4 ± 0.2). This difference persisted until the final follow-up. Conclusions CSA is associated with a significantly lower relapse rate and significantly higher effective rate compared with CTX, especially in children with minimal change disease.
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Affiliation(s)
- Yanwei Liu
- 1 Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510700, China
| | - Ruikun Yang
- 1 Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510700, China
| | - Chen Yang
- 2 Department of Physical Examination, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510700, China
| | - Shuhong Dong
- 1 Department of Pediatrics, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510700, China
| | - Ying Zhu
- 3 Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510700, China
| | - Mingdong Zhao
- 4 Department of Orthopaedics, Jinshan Hospital, Fudan University, Shanghai, 201508, China
| | - Fenglai Yuan
- 5 Department of Orthopaedics and Central Laboratory, The Third Hospital Affiliated to Nantong University, Wuxi, Jiangsu, 214041, China
| | - Keke Gui
- 4 Department of Orthopaedics, Jinshan Hospital, Fudan University, Shanghai, 201508, China
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Jellouli M, Charfi R, Maalej B, Mahfoud A, Trabelsi S, Gargah T. Rituximab in The Management of Pediatric Steroid-Resistant Nephrotic Syndrome: A Systematic Review. J Pediatr 2018; 197:191-197.e1. [PMID: 29680473 DOI: 10.1016/j.jpeds.2018.01.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/14/2017] [Accepted: 01/02/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of rituximab in children with steroid-resistant nephrotic syndrome. STUDY DESIGN A systematic review evaluating the efficacy and safety of rituximab in children with steroid-resistant nephrotic syndrome was performed. Data from studies, performed before April 2017 were collected, from MEDLINE, Cochrane Library, Scopus, and Web of Science. Study eligibility criteria included clinical trials and observational studies with a minimal sample size of 5 patients, regarding treatment with rituximab in children with steroid-resistant nephrotic syndrome. Independent extraction of articles by 2 investigators using predefined data fields was performed. RESULTS We included 7 case series and 1 open-label randomized controlled trial. Among them, 3 studies were multicenter. A total of 226 patients were included. Mean age at onset was 5.6 ± 1.1 years. Mean number of rituximab administrations was 3.1 ± 1.1 infusions per patient. Remission was observed in 89 patients (46.4%). Remission was seen in 40.8% patients with initial steroid-resistant nephrotic syndrome and 52.8% patients with late steroid-resistant nephrotic syndrome. Good initial response to rituximab therapy was observed in 63.2% patients with minimal change nephrotic syndrome, 39.2% patients with focal and segmental glomerulosclerosis, 1 patient had diffuse mesangial hypercellularity, and 1 patient had IgM nephropathy. Sustained remission ranged from 18% to 93.7%. Five serious adverse events were observed. CONCLUSIONS Rituximab exhibited a satisfactory profile regarding efficacy and safety indicating that this agent is a promising therapy for steroid-resistant nephrotic syndrome and should be further investigated by randomized clinical trials.
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Affiliation(s)
- Manel Jellouli
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia.
| | - Rim Charfi
- Department of Clinical Pharmacology, National Center of Pharmacovigilance, Faculty of Medicine of Tunis, Clinical and Experimental Pharmacology Laboratory LR16SP02, Tunis El Manar University, Tunis, Tunisia
| | - Bayen Maalej
- Department of Pediatrics, Pediatric Emergency and Intensive Care, Hedi Chaker Hospital, Sfax, Tunisia
| | - Abdelmajid Mahfoud
- Department of Pediatrics, Pediatric Emergency and Intensive Care, Hedi Chaker Hospital, Sfax, Tunisia
| | - Sameh Trabelsi
- Department of Clinical Pharmacology, National Center of Pharmacovigilance, Faculty of Medicine of Tunis, Clinical and Experimental Pharmacology Laboratory LR16SP02, Tunis El Manar University, Tunis, Tunisia
| | - Tahar Gargah
- Department of Pediatric Nephrology, Charles Nicolle Hospital, Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
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Trautmann A, Lipska-Ziętkiewicz BS, Schaefer F. Exploring the Clinical and Genetic Spectrum of Steroid Resistant Nephrotic Syndrome: The PodoNet Registry. Front Pediatr 2018; 6:200. [PMID: 30065916 PMCID: PMC6057105 DOI: 10.3389/fped.2018.00200] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/25/2018] [Indexed: 02/05/2023] Open
Abstract
Background: Steroid resistant nephrotic syndrome (SRNS) is a rare condition, accounting for 10-15% of all children with idiopathic nephrotic syndrome. SRNS can be caused by genetic abnormalities or immune system dysfunction. The prognosis of SRNS varies from permanent remission to progression to end-stage kidney disease, and post-transplant recurrence is common. Objectives: The PodoNet registry project aims to explore the demographics and phenotypes of immune-mediated and genetic forms of childhood SRNS, to assess genotype-phenotype correlations, to evaluate clinical management and long-term outcomes, and to search for novel genetic entities and diagnostic and prognostic biomarkers in SRNS. Methods: In 2009, an international registry for SRNS was established to collect retro- and prospective information on renal and extrarenal disease manifestations, histopathological and genetic findings and information on family history, pharmacotherapy responsiveness and long-term outcomes. To date, more than 2,000 patients have been enrolled at 72 pediatric nephrology centers, constituting the largest pediatric SRNS cohort assembled to date. Results: In the course of the project, traditional Sanger sequencing was replaced by NGS-based gene panel screening covering over 30 podocyte-related genes complemented by whole exome sequencing. These approaches allowed to establish genetic diagnoses in 24% of the patients screened, widened the spectrum of genetic disease entities presenting with SRNS phenotype (COL4A3-5, CLCN5), and contributed to the discovery of new disease causing genes (MYOE1, PTPRO). Forty two percent of patients responded to intensified immunosuppression with complete or partial remission of proteinuria, whereas 58% turned out multi-drug resistant. Medication responsiveness was highly predictive of a favorable long-term outcome, whereas the diagnosis of genetic disease was associated with a high risk to develop end-stage renal disease during childhood. Genetic SRNS forms were generally resistant to immunosuppressive treatment, justifying to avoid such pharmacotherapies altogether once a genetic diagnosis is established. Even symptomatic anti-proteinuric treatment with RAS antagonists seems to be challenging and of limited efficacy in genetic forms of SRNS. The risk of post-transplant disease recurrence was around 30% in non-genetic SRNS whereas it is negligible in genetic cases. Conclusion: In summary, the PodoNet Registry has collected detailed clinical and genetic information in a large SRNS cohort and continues to generate fundamental insights regarding demographic and etiological disease aspects, genotype-phenotype associations, the efficacy of therapeutic strategies, and long-term patient and renal outcomes including post-transplant disease recurrence.
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Affiliation(s)
- Agnes Trautmann
- Division of Pediatric Nephrology, University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
- *Correspondence: Agnes Trautmann
| | - Beata S. Lipska-Ziętkiewicz
- Clinical Genetics Unit, Department of Biology and Medical Genetics, Medical University of Gdańsk, Gdańsk, Poland
| | - Franz Schaefer
- Division of Pediatric Nephrology, University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
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Pokrajac D, Kamber AH, Karasalihovic Z. Children with Steroid-Resistant Nephrotic Syndrome: A Single -Center Experience. Mater Sociomed 2018; 30:84-88. [PMID: 30061794 PMCID: PMC6029918 DOI: 10.5455/msm.2018.30.84-88] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Nephrotic syndrome (NS) is one of the most frequent glomerular diseases among children. While most of the children with primary NS respond to steroid treatment, 10 to 20% of the patients are steroid-resistant, and the best therapy for such cases has never been defined. Objective The present study aimed to evaluate steroid-resistant nephrotic syndrome (SRNS) patients. Materials and methods Our research included 50 children (56% female and 44% male) with NS. NS was defined as the presence of edema, massive proteinuria, hypoalbuminemia and hyperlipidemia. Patients with NS were treated according to international protocol. SRNS was diagnosed in patients with idiopathic NS based on lack of complete remission despite treatment with steroids. Renal biopsy was performed in 22 patients with SRNS at the Pediatric Clinic II of the University Clinical Center in Sarajevo (UCCS). Histopathologic analyzes of renal biopsy were performed at the Department of Pathology, University Clinical Center in Tuzla (UCCT). Patients with SRNS, after kidney biopsy were treated with nonsteroidal immunosuppressant's. Results Eight (36.4%) of the 22 patients who had undergone renal biopsies had minimal change disease (MCNS) and seven (31.8%) had focal segmental glomerulosclerosis (FSGS). The immunosuppressive drugs used in SRNS were Cyclosporine (CsA), Cyclophosphamide (CYC), Mycophenolat mofetil (MMF) and Rituximab (RTX). Three patients (13.6%) did not respond to any treatment and had developed end - stage renal disease (ESRD). Conclusion With current treatments, some children will ultimately achieve a sustained remission with one of the second line or third line of the proposed drugs. Patients with refractory NS will go to progression towards ESRD. The rapid development of molecular genetics will give a new contribution to the pathogenesis and treatment of this disease.
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Affiliation(s)
- Danka Pokrajac
- Pediatric Clinic II, University Clinical Center Sarajevo, Sarajevo, Bosnia and Herzegovina
| | | | - Zinaida Karasalihovic
- Department of Pathology, University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina
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Jiang X, Shen W, Xu X, Shen X, Li Y, He Q. Immunosuppressive therapy for steroid-resistant nephrotic syndrome: a Bayesian network meta-analysis of randomized controlled studies. Clin Exp Nephrol 2017; 22:562-569. [PMID: 29080118 DOI: 10.1007/s10157-017-1484-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/04/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this study was to conduct a meta-analysis examining the efficacy of cyclophosphamide, cyclosporin, and tacrolimus in treating steroid resistant nephrotic syndrome. METHODS Medline, Cochrane, EMBASE, and Google Scholar were searched until May 02, 2017 using the keywords: immunosuppressive therapy, steroid-resistant nephrotic syndrome, cyclophosphamide, cyclosporine A, and tacrolimus. Inclusion criteria were randomized controlled trials (RCTs) including patients with SRNS treated with an immunosuppressive therapy or placebo. RESULTS Seven RCTs were included, and the number of patients ranged from 30 to 131. Conventional pair-wise meta-analysis indicated a higher odds of complete or partial remission with tacrolimus as compared to cyclophosphamide [odds ratio (OR) 4.908, 95% confidence interval (CI) 2.278-10.576, P < 0.001], and cyclophosphamide (OR 0.143, 95% CI 0.028-0.721, P = 0.019) and placebo (OR 0.043, 95% CI 0.012-0.157, P < 0.001) were associated with a lower likelihood of complete or partial remission than cyclosporine. Bayesian analysis indicated that tacrolimus and cyclosporine were the best and the second-best agents for inducing a complete or partial remission (rank probability = 0.53 for tacrolimus and 0.46 for cyclosporine). CONCLUSION As compared to cyclophosphamide and cyclosporin, tacrolimus is more effective at inducing remission in patients with SRNS.
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Affiliation(s)
- Xinxin Jiang
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Wei Shen
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Xiujun Xu
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Xiaogang Shen
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Yiwen Li
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Qiang He
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China.
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25
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Trautmann A, Schnaidt S, Lipska-Ziętkiewicz BS, Bodria M, Ozaltin F, Emma F, Anarat A, Melk A, Azocar M, Oh J, Saeed B, Gheisari A, Caliskan S, Gellermann J, Higuita LMS, Jankauskiene A, Drozdz D, Mir S, Balat A, Szczepanska M, Paripovic D, Zurowska A, Bogdanovic R, Yilmaz A, Ranchin B, Baskin E, Erdogan O, Remuzzi G, Firszt-Adamczyk A, Kuzma-Mroczkowska E, Litwin M, Murer L, Tkaczyk M, Jardim H, Wasilewska A, Printza N, Fidan K, Simkova E, Borzecka H, Staude H, Hees K, Schaefer F. Long-Term Outcome of Steroid-Resistant Nephrotic Syndrome in Children. J Am Soc Nephrol 2017; 28:3055-3065. [PMID: 28566477 PMCID: PMC5619960 DOI: 10.1681/asn.2016101121] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 04/17/2017] [Indexed: 02/05/2023] Open
Abstract
We investigated the value of genetic, histopathologic, and early treatment response information in prognosing long-term renal outcome in children with primary steroid-resistant nephrotic syndrome. From the PodoNet Registry, we obtained longitudinal clinical information for 1354 patients (disease onset at >3 months and <20 years of age): 612 had documented responsiveness to intensified immunosuppression (IIS), 1155 had kidney biopsy results, and 212 had an established genetic diagnosis. We assessed risk factors for ESRD using multivariate Cox regression models. Complete and partial remission of proteinuria within 12 months of disease onset occurred in 24.5% and 16.5% of children, respectively, with the highest remission rates achieved with calcineurin inhibitor-based protocols. Ten-year ESRD-free survival rates were 43%, 94%, and 72% in children with IIS resistance, complete remission, and partial remission, respectively; 27% in children with a genetic diagnosis; and 79% and 52% in children with histopathologic findings of minimal change glomerulopathy and FSGS, respectively. Five-year ESRD-free survival rate was 21% for diffuse mesangial sclerosis. IIS responsiveness, presence of a genetic diagnosis, and FSGS or diffuse mesangial sclerosis on initial biopsy as well as age, serum albumin concentration, and CKD stage at onset affected ESRD risk. Our findings suggest that responsiveness to initial IIS and detection of a hereditary podocytopathy are prognostic indicators of favorable and poor long-term outcome, respectively, in children with steroid-resistant nephrotic syndrome. Children with multidrug-resistant sporadic disease show better renal survival than those with genetic disease. Furthermore, histopathologic findings may retain prognostic relevance when a genetic diagnosis is established.
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Affiliation(s)
- Agnes Trautmann
- Division of Pediatric Nephrology, University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Sven Schnaidt
- Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | | | - Monica Bodria
- Dipartimento di Medicina Clinica e Sperimentale, University of Studies of Parma, Parma, Italy
- Division of Nephrology, Dialysis and Transplantation, IRCCS Giannina Gaslini, Genoa, Italy
| | - Fatih Ozaltin
- Department of Pediatric Nephrology, Nephrogenetics Laboratory and Center for Biobanking and Genomics, Hacettepe University, Ankara, Turkey
| | - Francesco Emma
- Nephrology and Dialysis Unit, Children's Hospital Bambino Gesù, Istitutio di Ricovero e Cura a Carattere Scientificio (IRCCS), Rome, Italy
| | - Ali Anarat
- Pediatric Nephrology Department, Cukurova University Medical Faculty, Adana, Turkey
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Marta Azocar
- Pediatric Nephrology, Hospital Luis Calvo Mackenna-Facultad de Chile, Santiago, Chile
| | - Jun Oh
- Department of Pediatric Nephrology, University Children's Hospital, Hamburg, Germany
| | - Bassam Saeed
- Department of Pediatric Nephrology, Kidney Hospital of Damascus, Damascus, Syria
| | - Alaleh Gheisari
- Pediatric Nephrology Department, Isfahan University of Medical Science, St. Al Zahra Hospital, Isfahan, Iran
| | - Salim Caliskan
- Pediatric Nephrology Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Jutta Gellermann
- Clinic for Pediatric Nephrology, Charite Hospital, Berlin, Germany
| | | | | | - Dorota Drozdz
- Department of Pediatric Nephrology, Jagiellonian University Medical College, Krakow, Poland
| | - Sevgi Mir
- Department of Pediatric Nephrology, Ege University Medical Faculty, Izmir, Turkey
| | - Ayse Balat
- Department of Pediatric Nephrology, Gaziantep University Medical Faculty, Gaziantep, Turkey
| | - Maria Szczepanska
- Department of Pediatrics, Division of Dentistry, School of Medicine, Zabrze, Poland
| | - Dusan Paripovic
- Department of Pediatric Nephrology, University Children's Hospital, Belgrade, Serbia
| | | | - Radovan Bogdanovic
- Department of Pediatric Nephrology, Institute of Mother Child and Healthcare of Serbia, Belgrade, Serbia
| | - Alev Yilmaz
- Department of Pediatric Nephrology, Istanbul Medical Faculty, Istanbul, Turkey
| | - Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mere Enfant, Hospices Civils de Lyon, Lyon, France
| | - Esra Baskin
- Department of Pediatric Nephrology, Baskent University Hospital, Ankara, Turkey
| | - Ozlem Erdogan
- Department of Pediatric Nephrology, Sami Ulus Children's Hospital, Ankara, Turkey
| | - Giuseppe Remuzzi
- Clinical Research Center for Rare Diseases Aldo & Cele Daccò, IRCCS, Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
- Department of Biomedical and Clinical Science L. Sacco, University of Milan, Milan, Italy
| | | | | | - Mieczyslaw Litwin
- Department of Pediatric Nephrology, Centrum Zdrowia Dziecka, Warsaw, Poland
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Women's and Child's Health, Hospital of Padua, Padua, Italy
| | - Marcin Tkaczyk
- Pediatric Nephrology Division, Polish Mothers Memorial Hospital Research Institute, Lodz, Poland
| | - Helena Jardim
- Department of Pediatric Nephrology, Centre Hospitalar, Porto, Portugal
| | - Anna Wasilewska
- Department of Pediatric Nephrology, University Hospital, Bialystok, Poland
| | - Nikoleta Printza
- First Pediatric Department, Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Kibriya Fidan
- Pediatric Nephrology Department, Gazi University Hospital, Ankara, Turkey
| | - Eva Simkova
- Department of Pediatric Nephrology, Dubai Hospital, Dubai, United Arab Emirates
| | - Halina Borzecka
- Department of Pediatric Nephrology, Medical University, Lublin, Poland; and
| | - Hagen Staude
- Department of Pediatric Nephrology, University Children's Hospital, Rostock, Germany
| | - Katharina Hees
- Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Franz Schaefer
- Division of Pediatric Nephrology, University Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany;
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Li S, Yang H, Guo P, Ao X, Wan J, Li Q, Tan L. Efficacy and safety of immunosuppressive medications for steroid-resistant nephrotic syndrome in children: a systematic review and network meta-analysis. Oncotarget 2017; 8:73050-73062. [PMID: 29069848 PMCID: PMC5641191 DOI: 10.18632/oncotarget.20377] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/07/2017] [Indexed: 12/28/2022] Open
Abstract
Background Conventional meta-analyses and randomized controlled trials have shown inconsistent results regarding the efficacy of immunosuppressants for pediatric steroid-resistant nephrotic syndrome (SRNS). Objective To conduct a network meta-analysis aimed at evaluating the efficacy and safety of available immunosuppressive agents in pediatric patients with SRNS. Study methods MEDLINE, the Cochrane Central Register of Controlled Trials, and EMBASE were searched on January 2017. Data from randomized controlled trials (RCTs) were included. The main outcomes analyzed were efficacy [number/portion with complete remission (CR), number/portion with partial remission (PR), and total number/portion in remission (TR)] and safety [adverse secondary event (ASE) rates]. Results A meta-analysis of 18 RCTs showed that tacrolimus was more efficacious for achieving CR than intravenous (i.v.) cyclophosphamide, mycophenolate mofetil (MMF), oral cyclophosphamide, leflunomide, chlorambucil, azathioprine, and plaebo/nontreatment (P/NT), and more efficacious than i.v. cyclophosphamide, oral cyclophosphamide, and P/NT in terms of TR outcomes. Cyclosporin was associated with a greater CR rate than i.v. cyclophosphamide, MMF, oral cyclophosphamide, chlorambucil, azathioprine, or P/NT, and associated with a greater TR rate than i.v. cyclophosphamide, oral cyclophosphamide, or P/NT. MMF was found to be more efficacious than i.v. cyclophosphamide and oral cyclophosphamide in terms of TR. Conclusions Tacrolimus and cyclosporine may be preferred initial treatments for children with SRNS. MMF may be another option for this patient population. Further studies of the efficacy and safety of these three drugs in children with SRNS should be pursued.
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Affiliation(s)
- Shaojun Li
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Haiping Yang
- Department of Nephrology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Pengfei Guo
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Xiaoxiao Ao
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Key Laboratory of Pediatrics in Chongqing, Chongqing, China
| | - Junli Wan
- Department of Nephrology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Key Laboratory of Pediatrics in Chongqing, Chongqing, China
| | - Qiu Li
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Nephrology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Liping Tan
- Department of Emergency, Children's Hospital of Chongqing Medical University, Chongqing, China.,Key Laboratory of Pediatrics in Chongqing, Chongqing, China
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Chiou YY, Lee YC, Chen MJ. Cyclosporine-based immunosuppressive therapy for patients with steroid-resistant focal segmental glomerulosclerosis: a meta-analysis. Curr Med Res Opin 2017; 33:1389-1399. [PMID: 28436233 DOI: 10.1080/03007995.2017.1322567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Focal segmental glomerulosclerosis (FSGS) is a leading cause of end-stage kidney disease that requires immunosuppressive treatment as therapy. Few studies have been specifically designed to assess the efficacy of cyclosporine (CSA) in patients with steroid-resistant FSGS. This study investigated the efficacy of CSA-based therapy in steroid-resistant FSGS. METHODS Medline, Cochrane, EMBASE, and Google Scholar databases were searched through April 30, 2014 using the keywords "cyclosporine", "steroid-resistant", "focal segmental glomerulosclerosis", and "FSGS". Studies with an adult and children with steroid-resistant primary FSGS treated with CSA-based therapy with or without steroid use were included. Complete, partial, and overall remission were the primary outcomes. Change in proteinuria, serum creatinine, and estimated glomerular filtration rate (eGFR) following treatment were secondary outcomes. RESULTS Seven randomized controlled trials with a total of 373 patients were included. Five studies were included in the meta-analysis to assess complete, partial, and overall remission of FSGS. Compared with other treatments, CSA-based therapy resulted in a significantly greater partial remission rate (p = .018), but complete (p = .226) or overall remission rate (p = .050). CSA-based therapy also resulted in similar change in proteinuria (p = .084), serum creatinine (p = .772), and eGFR (p = .155) compared with other therapy. Study limitations included small sample size and heterogeneity in age and comparative treatments across the studies. CONCLUSIONS Cyclosporin-based treatments provided a significantly better partial remission rate as compared with other therapies.
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Affiliation(s)
- Yuan-Yow Chiou
- a Department of Pediatrics, Institute of Clinical Medicine, College of Medicine , National Cheng Kung University , No.1, Daxue Rd., East Dist. , Tainan City 701 , Taiwan , PR China
- b Division of Pediatric Nephrology, Department of Pediatrics , National Cheng Kung University Hospital , No.138, Shengli Rd., North Dist. , Tainan City 704 , Taiwan , PR China
| | - Yi-Che Lee
- c Division of Nephrology, Department of Internal Medicine , E-DA Hospital/I-Shou University , No.1, Yida Rd., Yanchao Dist. , Kaohsiung City 824 , Taiwan , PR China
| | - Mei-Ju Chen
- d Department of Long Term Care , Chung Hwa University of Medical Technology , No.89, Wenhua 1st St., Rende Dist. , Tainan City 717 , Taiwan
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Abstract
Steroid-resistant nephrotic syndrome (SRNS) poses a therapeutic challenge for the paediatric nephrologist. As relentless progression to renal failure occurs with continued proteinuria, such patients will be treated with different cytotoxic medications with variable success rates and side-effects. We present here our findings on administering the anticancer drug vincristine for SRNS patients at a single centre in Sri Lanka. Methods. Between 2002 and 2007, fifty-four children presenting with steroid and cyclophosphamide resistance were treated with vincristine at 1.5 mg/m2 in weekly intravenous pulses for 8 weeks along with a tapering steroid regimen of 6 months. All patients were closely followed up for 5 years. Results. Of the 54 patients 39 were males and 15 were females (age range 3.5–11.6 years, median 6.1 years). At the end of the treatment course, 21 patients achieved complete remission while 7 had partial remission and no response was seen in 26 patients. Sustained remission at 6, 12, 24, and 60 months were 15 (27.78%), 11 (20.37%), 9 (16.67%), and 7 (12.96%), respectively. Most side-effects observed were reversible and no serious side-effects were noted during vincristine therapy. Conclusion. Although its therapeutic mechanisms in nephrotic syndrome are still not elucidated, vincristine appears to be a potent alternative that could be considered for treating SRNS.
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Sinha A, Gupta A, Kalaivani M, Hari P, Dinda AK, Bagga A. Mycophenolate mofetil is inferior to tacrolimus in sustaining remission in children with idiopathic steroid-resistant nephrotic syndrome. Kidney Int 2017; 92:248-257. [PMID: 28318625 DOI: 10.1016/j.kint.2017.01.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 01/04/2017] [Accepted: 01/19/2017] [Indexed: 12/17/2022]
Abstract
Studies of nephrotic syndrome show that substitution of calcineurin inhibitors by mycophenolate mofetil (MMF) enables sustained remission and corticosteroid sparing and avoids therapy associated adverse effects. However, controlled studies in patients with steroid resistance are lacking. Here we examined the effect of switching from therapy with tacrolimus to MMF on disease course in an open-label, one-to-one randomized, controlled trial on children (one to 18 years old), recently diagnosed with steroid-resistant nephrotic syndrome, at a referral center in India. Following six months of therapy with tacrolimus, patients with complete or partial remission were randomly assigned such that 29 received MMF while 31 received tacrolimus along with tapering prednisolone on alternate days for 12 months. On intention-to-treat analyses, the proportion of patients with a favorable outcome (sustained remission, infrequent relapses) at one year was significantly lower (44.8%) in the MMF group than in the tacrolimus group (90.3%). The incidence of relapses was significantly higher for patients treated with MMF than tacrolimus (mean difference: 1.05 relapses per person-year). While there was no difference in the proportion of patients with sustained remission, the risk of recurrence of steroid resistance was significantly higher for patients receiving MMF compared to tacrolimus (mean difference: 20.7%). Compared to tacrolimus, patients receiving MMF had a significantly (71%) lower likelihood of a favorable outcome and significantly increased risk of treatment failure (frequent relapses, steroid resistance). Thus, replacing tacrolimus with MMF after six months of tacrolimus therapy for steroid-resistant nephrotic syndrome in children is associated with significant risk of frequent relapses or recurrence of resistance. These findings have implications for guiding the duration of therapy with tacrolimus for steroid-resistant nephrotic syndrome.
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Affiliation(s)
- Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Aarti Gupta
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Mani Kalaivani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Amit K Dinda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
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Hodson EM, Craig JC. How randomised trials have improved the care of children with kidney disease. Pediatr Nephrol 2016; 31:2191-2200. [PMID: 27488519 DOI: 10.1007/s00467-016-3455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 06/24/2016] [Accepted: 06/27/2016] [Indexed: 10/21/2022]
Abstract
Randomised controlled trials (RCTs) provide the most reliable way to evaluate the benefits and harms of interventions. Participants are divided into groups using methods that balance the characteristics (both known and unknown) of the participants between treatment groups; thus, differences in outcomes are due to the interventions administered. From Cochrane Kidney and Transplant's Specialised Register, a comprehensive registry of trials in kidney disease, we identified 482 trials involving children. The vast majority concerned urinary tract infection (UTI; 134) and nephrotic syndrome (136). Most were small, with a median enrolment of 46 children, with only 26 trials enrolling 200 or more participants, and of these, 18 involved children with UTI. We discuss a number of important advances in the care of children with UTI with or without vesico-ureteric reflux, nephrotic syndrome, chronic kidney disease (CKD) and kidney transplantation that have been driven largely by trials in these conditions.
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Affiliation(s)
- Elisabeth M Hodson
- Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW, 2145, Australia. .,Sydney School of Public Health, University of Sydney, Sydney, Australia.
| | - Jonathan C Craig
- Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW, 2145, Australia.,Sydney School of Public Health, University of Sydney, Sydney, Australia
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Hodson EM, Wong SC, Willis NS, Craig JC. Interventions for idiopathic steroid-resistant nephrotic syndrome in children. Cochrane Database Syst Rev 2016; 10:CD003594. [PMID: 27726125 PMCID: PMC6457874 DOI: 10.1002/14651858.cd003594.pub5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The majority of children who present with their first episode of nephrotic syndrome achieve remission with corticosteroid therapy. Children who fail to respond may be treated with immunosuppressive agents including calcineurin inhibitors (cyclosporin or tacrolimus) and with non-immunosuppressive agents such as angiotensin-converting enzyme inhibitors (ACEi). Optimal combinations of these agents with the least toxicity remain to be determined. This is an update of a review first published in 2004 and updated in 2006 and 2010. OBJECTIVES To evaluate the benefits and harms of different interventions used in children with idiopathic nephrotic syndrome, who do not achieve remission following four weeks or more of daily corticosteroid therapy. SEARCH METHODS We searched Cochrane Kidney and Transplant's Specialised Register (up to 2 March 2016) through contact with the Information Specialist using search terms relevant to this review. SELECTION CRITERIA RCTs and quasi-RCTs were included if they compared different immunosuppressive agents or non-immunosuppressive agents with placebo, prednisone or other agent given orally or parenterally in children aged three months to 18 years with SRNS. DATA COLLECTION AND ANALYSIS Two authors independently searched the literature, determined study eligibility, assessed risk of bias and extracted data. For dichotomous outcomes, results were expressed as risk ratios (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model. MAIN RESULTS Nineteen RCTs (820 children enrolled; 773 evaluated) were included. Most studies were small. Eleven studies were at low risk of bias for allocation concealment and only four studies were at low risk of performance bias. Fifteen, eight and 10 studies were at low risk of detection bias, attrition bias and reporting bias respectively. Cyclosporin when compared with placebo or no treatment significantly increased the number of children who achieved complete remission. However this was based on only eight children who achieved remission with cyclosporin compared with no children who achieved remission with placebo/no treatment in three small studies (49 children: RR 7.66, 95% CI 1.06 to 55.34). Calcineurin inhibitors significantly increased the number with complete or partial remission compared with IV cyclophosphamide (2 studies, 156 children: RR 1.98, 95% CI 1.25 to 3.13; I2 = 20%). There was no significant differences in the number who achieved complete remission between tacrolimus versus cyclosporin (1 study, 41 children: RR 0.86, 95% CI 0.44 to 1.66), cyclosporin versus mycophenolate mofetil plus dexamethasone (1 study, 138 children: RR 2.14, 95% CI 0.87 to 5.24), oral cyclophosphamide with prednisone versus prednisone alone (2 studies, 91 children: RR 1.06, 95% CI 0.61 to 1.87), IV versus oral cyclophosphamide (1 study, 11 children: RR 3.13, 95% CI 0.81 to 12.06), IV cyclophosphamide versus oral cyclophosphamide plus IV dexamethasone (1 study, 49 children: RR 1.13, 95% CI 0.65 to 1.96), and azathioprine with prednisone versus prednisone alone (1 study, 31 children: RR 0.94, 95% CI 0.15 to 5.84). One study found no significant differences between three agents (cyclophosphamide, mycophenolate mofetil, leflunomide) used in combination with tacrolimus and prednisone. One study found no significant difference in the percentage reduction in proteinuria (31 children: -12; 95% CI -73 to 110) between rituximab with cyclosporin/prednisolone and cyclosporin/prednisolone alone. Two studies reported ACEi significantly reduced proteinuria. AUTHORS' CONCLUSIONS To date RCTs have demonstrated that calcineurin inhibitors increase the likelihood of complete or partial remission compared with placebo/no treatment or cyclophosphamide. For other regimens assessed, it remains uncertain whether the interventions alter outcomes because the certainty of the evidence is low. Further adequately powered, well designed RCTs are needed to evaluate other regimens for children with idiopathic SRNS. Since SRNS represents a spectrum of diseases, future studies should enrol children from better defined groups of patients with SRNS.
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Affiliation(s)
| | - Sophia C Wong
- The Prince of Wales HospitalRandwick, SydneyAustralia
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Fu HD, Qian GL, Jiang ZY. Comparison of second-line immunosuppressants for childhood refractory nephrotic syndrome: a systematic review and network meta-analysis. J Investig Med 2016; 65:65-71. [PMID: 27489255 DOI: 10.1136/jim-2016-000163] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2016] [Indexed: 11/03/2022]
Abstract
Although, most patients respond initially to therapy for nephrotic syndrome, about 70% of patients have a relapse. Currently, there is no consensus about the most appropriate second-line agent in children who continue to suffer a relapse. This network meta-analysis was designed to compare the efficacy and safety of the commonly used immunosuppressive agents in second-line therapeutic agents (ie, cyclophosphamide, cyclosporine, tacrolimus and mycophenolate mofetil) for refractory childhood nephrotic syndrome. MEDLINE, Cochrane, EMBASE and Google Scholar databases were searched until October 17, 2015 using the following search terms: cyclophosphamide, cyclosporine, tacrolimus, mycophenolate mofetil and childhood nephrotic syndrome. Randomized controlled trials, prospective 2-arm studies and cohort studies were included. 7 studies with 391 patients were included. Bayesian network meta-analysis found that treatment with mycophenolate mofetil had the greatest odds of relapse compared with tacrolimus (pooled OR=49.72, 95% credibility interval (CrI) 1.65 to 2483.32), cyclophosphamide (pooled OR=72.05, 95% CrI 1.44 to 13633.33) and cyclosporine (pooled OR=11.42, 95% CrI 1.03 to 131.60). Rank probability analysis found cyclophosphamide was the best treatment with the lowest relapse rate as compared with other treatments (rank probability=0.58), and tacrolimus was ranked as the second best (rank probability=0.38). Our findings support the use of cyclophosphamide and tacrolimus in treating children with relapsing nephrotic syndrome.
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Affiliation(s)
- Hai-Dong Fu
- Department of Nephrology, The Children's Hospital of Zhejiang University, Hangzhou, China
| | - Gu-Ling Qian
- Department of Inherited Metabolic Disease, The Children's Hospital of Zhejiang University, Hangzhou, China
| | - Zheng-Yang Jiang
- Department of Medicine, Montefiore New Rochelle Hospital, Albert Einstein College of Medicine, New Rochelle, New York, USA
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Suyama K, Kawasaki Y, Miyazaki K, Kanno S, Ono A, Suzuki Y, Ohara S, Hosoya M. Rituximab and low-dose cyclosporine combination therapy for steroid-resistant focal segmental glomerulosclerosis. Pediatr Int 2016; 58:219-23. [PMID: 26275234 DOI: 10.1111/ped.12804] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 07/28/2015] [Accepted: 08/10/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND We investigated the efficacy of rituximab and low-dose cyclosporine combination therapy for focal segmental glomerulosclerosis (FSGS) in children with steroid-resistant nephrotic syndrome (SRNS). METHODS Five FSGS children with SRNS were treated twice with rituximab and low-dose cyclosporine (CyA) combination therapy (RTX-CyAT). The clinical features and laboratory data were investigated before and after RTX-CyAT, and the outcomes were assessed. RESULTS Prednisolone (PSL) was discontinued 3 months after RTX-CyAT in all patients. The number of CD19-positive cells decreased to <1% of all white blood cells in all patients at 1 month after RTX-CyAT, and was maintained at this level for 259.6 ± 68.2 days. All patients remained in remission for the duration of the decrease in CD19-positive cells to <1%. Two patients also remained in remission throughout the observation period, with three patients having a single relapse at 333 ± 89 days (range, 231-376 days) after RTX-CyAT. In all patients, the mean steroid and CyA doses after RTX-CyAT were lower than those before RTX-CyAT. CONCLUSIONS RTX-CyAT is effective in FSGS patients with SRNS and may ameliorate the side-effects of PSL and immunosuppressive drugs.
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Affiliation(s)
- Kazuhide Suyama
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Kyohei Miyazaki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Syuto Kanno
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Atsushi Ono
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Yuichi Suzuki
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Shinichiro Ohara
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, Japan
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Inaba A, Hamasaki Y, Ishikura K, Hamada R, Sakai T, Hataya H, Komaki F, Kaneko T, Mori M, Honda M. Long-term outcome of idiopathic steroid-resistant nephrotic syndrome in children. Pediatr Nephrol 2016; 31:425-34. [PMID: 26335197 DOI: 10.1007/s00467-015-3174-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 07/13/2015] [Accepted: 07/15/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Several recent studies have shown improved short-term outcome of steroid-resistant nephrotic syndrome (SRNS) in children; however, only a few studies have evaluated the long-term outcome. The aims of our study were to obtain detailed data and analyze the long-term outcome of children with SRNS. METHODS Sixty-nine children with idiopathic SRNS were enrolled and divided into two groups based on initial histopathological patterns: focal segmental glomerulosclerosis (FSGS) and minimal change (MC)/diffuse mesangial proliferation (DMP). The effects of initial treatment with the immunosuppressant of choice (cyclosporine or cyclophosphamide) on renal survival, remission, and incidence of complications were analyzed in both groups (4 subgroups). RESULTS The renal survival rate was significantly different among the four different subgroups based on different combinations of initial histopathological pattern (FSGS vs. MC/DMP) and initial immunosuppressant used for treating SRNS (cyclosporine vs. cyclophosphamide) (P = 0.013), with renal survival in the FSGS (cyclophosphamide) subgroup being especially low (54.6 %). Disease- and/or treatment-associated complications were relatively low; however, hypertension at last examination was observed in a considerable number of patients (31.9 %). CONCLUSIONS Our results suggest that a recently developed therapeutic regimen with cyclosporine considerably improves both the initial remission rate and the long-term renal survival rate of children with idiopathic SRNS.
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Affiliation(s)
- Aya Inaba
- Department of Pediatrics, Yokohama City University Medical Center, Kanagawa, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, 6-11-1, Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Shiga, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Fumiyo Komaki
- Community Health Welfare Division, Kawasaki Saiwai Ward Office Health and Welfare Center, Kanagawa, Japan
| | - Tetsuji Kaneko
- Department of Clinical Research, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Teikyo Academic Research Center, Teikyo University, Tokyo, Japan
| | - Masaaki Mori
- Department of Pediatrics, Yokohama City University Medical Center, Kanagawa, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Klaassen I, Özgören B, Sadowski CE, Möller K, van Husen M, Lehnhardt A, Timmermann K, Freudenberg F, Helmchen U, Oh J, Kemper MJ. Response to cyclosporine in steroid-resistant nephrotic syndrome: discontinuation is possible. Pediatr Nephrol 2015; 30:1477-83. [PMID: 25903641 DOI: 10.1007/s00467-015-3109-3] [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: 09/09/2014] [Revised: 03/11/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Steroid-resistant nephrotic syndrome (SRNS) is still regarded as a serious disease although treatment with cyclosporine (CSA) has improved outcome. However, the duration of treatment in responders is unclear, and treatment of patients with genetic causes is a matter of debate. METHODS Thirty-six patients with SRNS were studied retrospectively. Median age at presentation was 3.2 (range, 0.06-15.0) and median follow-up 15.5 years (range, 1.8-27.7), respectively; 23 (64%) had focal segmental glomerulosclerosis (FSGS) on biopsy. In 33/36 patients (92%), genetic testing was performed for at least three most common genes known to be mutated in SRNS. RESULTS Nineteen patients (53%), especially those with minimal change nephrotic syndrome (MCNS) at initial biopsy (p < 0.002), entered complete remission with CSA monotherapy, including one patient with compound heterozygous NPHS1 and dominant ACTN4 mutation, respectively. Ten patients entered partial remission (28%, all FSGS), including two with NPHS2 mutations. Seven patients (six FSGS, one MCNS) did not respond to treatment. In 15 of 19 responders to CSA, treatment was stopped after a median of 3.1 years (range, 0.5-14) and no further relapses occurred in 11/15 (73%) patients with median follow-up of 9.7 years. CONCLUSIONS CSA monotherapy is effective in SRNS. Discontinuation of CSA is possible in many patients with complete remission.
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Affiliation(s)
- Ilka Klaassen
- Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
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38
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Clinical practice guideline for pediatric idiopathic nephrotic syndrome 2013: medical therapy. Clin Exp Nephrol 2015; 19:6-33. [DOI: 10.1007/s10157-014-1030-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Velásquez Jones L. [Treatment of idiopathic nephrotic syndrome in children]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2014; 71:315-322. [PMID: 29421622 DOI: 10.1016/j.bmhimx.2014.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 07/10/2014] [Indexed: 11/18/2022] Open
Abstract
The annual incidence of the nephrotic syndrome has been estimated to be 1-3 per 100,000 children<16 year of age. In children, the most common cause of nephrotic syndrome is idiopathic nephrotic syndrome (INS). INS is defined by the presence of proteinuria and hypoalbuminemia and by definition is a primary disease. Renal biopsy study shows non-specific histological abnormalities of the kidney including minimal changes, focal and segmental glomerular sclerosis, and diffuse mesangial proliferation. Steroid therapy is applied in all cases of INS. Renal biopsy is usually not indicated before starting corticosteroid therapy. The majority of patients (80-90%) are steroid-responsive. Children with INS who do not achieve a complete remission with corticosteroid therapy commonly present focal and segmental glomerular sclerosis and require treatment with calcineurin inhibitors (cyclosporine or tacrolimus), mycophenolate mofetil or rituximab, plus renin-angiotensin system blockade. In this article we review the recent accepted recommendations for the treatment of children with INS.
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Affiliation(s)
- Luis Velásquez Jones
- Departamento de Nefrología Dr. Gustavo Gordillo Paniagua, Hospital Infantil de México Federico Gómez, México D.F., México.
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40
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Becknell B, Greenbaum LA, Smoyer WE. A new 'tac' for childhood nephrotic syndrome. Kidney Int 2014; 82:1049-51. [PMID: 23128115 DOI: 10.1038/ki.2012.272] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Calcineurin inhibitors (CNIs) are frequent first-line agents in children with steroid-resistant nephrotic syndrome (SRNS). However, limited randomized controlled trial (RCT) data are available comparing CNIs with alternative therapies. Gulati and colleagues report their experience with tacrolimus versus cyclophosphamide in childhood SRNS. Their results establish clear superiority of tacrolimus over cyclophosphamide and give further proof that RCTs in childhood SRNS are both feasible and vital for improving the standard of care.
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Affiliation(s)
- Brian Becknell
- Section of Nephrology, Nationwide Children's Hospital, Columbus, Ohio, USA
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Giglio S, Provenzano A, Mazzinghi B, Becherucci F, Giunti L, Sansavini G, Ravaglia F, Roperto RM, Farsetti S, Benetti E, Rotondi M, Murer L, Lazzeri E, Lasagni L, Materassi M, Romagnani P. Heterogeneous genetic alterations in sporadic nephrotic syndrome associate with resistance to immunosuppression. J Am Soc Nephrol 2014; 26:230-6. [PMID: 25060053 DOI: 10.1681/asn.2013111155] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
In children, sporadic nephrotic syndrome can be related to a genetic cause, but to what extent genetic alterations associate with resistance to immunosuppression is unknown. In this study, we designed a custom array for next-generation sequencing analysis of 19 target genes, reported as possible causes of nephrotic syndrome, in a cohort of 31 children affected by sporadic steroid-resistant nephrotic syndrome and 38 patients who exhibited a similar but steroid-sensitive clinical phenotype. Patients who exhibited extrarenal symptoms, had a familial history of the disease or consanguinity, or had a congenital onset were excluded. We identified a genetic cause in 32.3% of the children with steroid-resistant disease but zero of 38 children with steroid-sensitive disease. Genetic alterations also associated with lack of response to immunosuppressive agents in children with steroid-resistant disease (0% of patients with alterations versus 57.9% of patients without alterations responded to immunosuppressive agents), whereas clinical features, age at onset, and pathologic findings were similar in steroid-resistant patients with and without alterations. These results suggest that heterogeneous genetic alterations in children with sporadic forms of nephrotic syndrome associate with resistance to steroids as well as immunosuppressive treatments. In these patients, a comprehensive screening using such an array may, thus, be useful for genetic counseling and may help clinical decision making in a fast and cost-efficient manner.
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Affiliation(s)
- Sabrina Giglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio," and Medical Genetics and
| | - Aldesia Provenzano
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio," and
| | | | - Francesca Becherucci
- Pediatric Nephrology Units, Meyer Children's University Hospital, Florence, Italy
| | | | - Giulia Sansavini
- Pediatric Nephrology Units, Meyer Children's University Hospital, Florence, Italy
| | - Fiammetta Ravaglia
- Pediatric Nephrology Units, Meyer Children's University Hospital, Florence, Italy
| | - Rosa Maria Roperto
- Pediatric Nephrology Units, Meyer Children's University Hospital, Florence, Italy
| | - Silvia Farsetti
- Pediatric Nephrology Units, Meyer Children's University Hospital, Florence, Italy
| | - Elisa Benetti
- Department of Pediatrics, University of Padua, Padua, Italy; and
| | - Mario Rotondi
- Unit of Internal Medicine and Endocrinology, Fondazione Salvatore Maugeri IRCCS, University of Pavia, Pavia, Italy
| | - Luisa Murer
- Department of Pediatrics, University of Padua, Padua, Italy; and
| | - Elena Lazzeri
- Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Laura Lasagni
- Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy
| | - Marco Materassi
- Pediatric Nephrology Units, Meyer Children's University Hospital, Florence, Italy
| | - Paola Romagnani
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio," and Pediatric Nephrology Units, Meyer Children's University Hospital, Florence, Italy; Excellence Centre for Research, Transfer and High Education for the Development of DE NOVO Therapies (DENOTHE), University of Florence, Florence, Italy;
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Samuel S, Bitzan M, Zappitelli M, Dart A, Mammen C, Pinsk M, Cybulsky AV, Walsh M, Knoll G, Hladunewich M, Bargman J, Reich H, Humar A, Muirhead N. Canadian Society of Nephrology Commentary on the 2012 KDIGO Clinical Practice Guideline for Glomerulonephritis: Management of Nephrotic Syndrome in Children. Am J Kidney Dis 2014; 63:354-62. [DOI: 10.1053/j.ajkd.2013.12.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 12/03/2013] [Indexed: 11/11/2022]
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Straatmann C, Ayoob R, Gbadegesin R, Gibson K, Rheault MN, Srivastava T, Tran CL, Gipson DS, Greenbaum LA, Smoyer WE, Vehaskari VM. Treatment outcome of late steroid-resistant nephrotic syndrome: a study by the Midwest Pediatric Nephrology Consortium. Pediatr Nephrol 2013; 28:1235-41. [PMID: 23633037 PMCID: PMC10561674 DOI: 10.1007/s00467-013-2483-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 03/10/2013] [Accepted: 04/02/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Idiopathic nephrotic syndrome (NS) in children is classified as steroid sensitive or steroid resistant. Steroid sensitivity typically portends a low risk of permanent renal failure. However, some initially steroid-sensitive patients later develop steroid resistance. These patients with late steroid resistance (LSR) are often treated with immunosuppressant medications, but the effect of these additional drugs on the long-term prognosis of LSR is still unknown. METHODS A retrospective chart review was performed on patients diagnosed with idiopathic NS and subsequent LSR during the 8-year study period from 2002 up to and including 2009, with a minimum of 2 years of follow-up. Primary outcome measures were proteinuria and renal function. RESULTS A total of 29 patients were classified as having LSRNS. The majority of patients received treatment with calcineurin inhibitors and/or mycophenolate mofetil. Seven patients received three or more non-steroid immunosuppressant medications. Sustained complete or partial remission was achieved in 69 % of patients. Three developed end-stage renal disease, and all others maintained normal renal function. There were 13 episodes of serious adverse events, none of which were fatal or irreversible. CONCLUSION Most patients with LSRNS responded to immunosuppressive therapy by reduction or resolution of proteinuria and preservation of renal function. The results suggest that immunosuppressive treatment is a viable option in NS patients who develop LSR.
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Affiliation(s)
- Caroline Straatmann
- Department of Pediatrics, Louisiana State University Health Sciences Center, 200 Henry Clay Avenue, New Orleans, LA 70118, USA.
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Li X, Xu N, Li H, Han F, Wang R, He Q, He X, Chen J. Tacrolimus as rescue therapy for adult-onset refractory minimal change nephrotic syndrome with reversible acute renal failure. Nephrol Dial Transplant 2013; 28:2306-12. [PMID: 23787554 DOI: 10.1093/ndt/gft207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Some adult patients with minimal change nephrotic syndrome (MCNS) who are refractory to steroid treatment or combination with immunosuppressive drug developed reversible acute renal failure (ARF) due to persistent severe hypoalbuminemia and proteinuria. It is a challenge to find rescue therapies that are effective and safe in treating such difficult patients. METHODS In this prospective observational study, 13 patients with adult-onset MCNS, all unresponsive to treatment with a steroid or a steroid with other immunosuppressive drugs, were studied from January 2005 to February 2009. All patients developed ARF before enrollment. Oral tacrolimus (TAC) was started at 1 mg/day (target trough levels of 3-6 ng/mL) before serum creatinine (SCr) decreased to ≤133 μmol/L, and then increased doses were given (target trough level of 5-10 ng/mL) when SCr decreased to ≤133 μmol/L. Primary outcome variables were remission, and recovery from ARF. Secondary outcome variables were time to recovery from ARF, time to remission, relapse rate, changes in SCr and estimated glomerular filtration rate (eGFR). RESULTS One patient discontinued TAC due to deterioration of ARF, and 12 patients recovered from ARF. The mean time to recovery from ARF was 15.8 ± 4.4 days. Nine patients (69.2%) experienced complete remission (CR) and two patients (15.4%) experienced partial remission (PR). The mean time to PR and CR was 4.8 ± 2.7 and 9.4 ± 2.3 weeks, respectively. After a mean follow-up of 69.6 months, 36.4% (4/11) of patients who had remission experienced relapses. One patient who was resistant to TAC therapy had a doubling of serum creatinine concentration during follow-up. CONCLUSIONS TAC may be a suitable therapeutic option for treatment of adult-onset refractory MCNS with reversible ARF.
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Affiliation(s)
- Xiayu Li
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, PR China
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Ito S, Kamei K, Ogura M, Udagawa T, Fujinaga S, Saito M, Sako M, Iijima K. Survey of rituximab treatment for childhood-onset refractory nephrotic syndrome. Pediatr Nephrol 2013; 28:257-64. [PMID: 23052656 DOI: 10.1007/s00467-012-2319-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 09/08/2012] [Accepted: 09/10/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND Rituximab (RTX) is a promising option for treating childhood-onset steroid-dependent (SDNS), frequently relapsing (FRNS), and steroid-resistant (SRNS) nephrotic syndrome. METHODS We retrospectively surveyed RTX treatment for these conditions to evaluate its indications, efficacy and adverse events. Questionnaires were sent to 141 hospitals in Japan. RESULTS Seventy-four patients (52 SDNS; 3 FRNS; 19 SRNS) were treated with RTX because of resistance to various immunosuppressive agents. Most patients received a single administration of RTX (85%). Forty-one of 53 SDNS/FRNS (77%) and 5 of 17 SRNS (29%) patients successfully discontinued prednisolone (16 SDNS/FRNS and 6 SRNS achieved their first discontinuation since onset), and 17 out of 53 SDNS/FRNS patients (31%) discontinued cyclosporine. However, 28 of the 53 patients (51%) relapsed. Although immunosuppressive agents did not extend B cell depletion, relapses were significantly less if immunosuppressive agents were continued after RTX (P = 0.006; hazard ratio = 0.2). Among the SRNS patients, complete (n = 6) and partial remission (n = 6) were achieved. No life-threatening adverse events were experienced. CONCLUSIONS Although this was a multi-center survey where treatment of nephrotic syndrome varied between centers, the steroid-sparing effect of RTX in SDNS/FRNS was excellent. If single administration of RTX is chosen, continuation of immunosuppressive agents is recommended for prevention of relapse.
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Affiliation(s)
- Shuichi Ito
- Division of Pediatric Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan.
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Ibrahim Seif E, Abdel-Salam Ibrahim E, Galal Elhefnawy N, Ibrahim Salman M. Histological patterns of idiopathic steroid resistant nephrotic syndrome in Egyptian children: A single centre study. J Nephropathol 2013; 2:53-60. [PMID: 24475425 DOI: 10.5812/nephropathol.8997] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 10/20/2012] [Accepted: 10/25/2012] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND BACKGROUND Idiopathic steroid resistant nephrotic syndrome (ISRNS) represents about 10-20% of children with nephrotic syndrome with variable outcome. OBJECTIVES To determine the histological patterns of ISRNS in Egyptian children and the histological details of the commonest types which might be the reason for the steroid resistance. PATIENTS AND METHODS The study included 53 cases with ISRNS. Their renal biopsies were retrieved from the archive of Electron microscopy unit and pathology department, Ain Shams University Specialized Hospital (ASUSH) in the duration from 2005-2011. The biopsies were examined histologically, with immunohistochemistry, and by electron microscopy. RESULTS They were 36 males (67.9%) and 17 females (32.1%), the age at diagnosis ranged from 1.5- 16 years with a mean of 6.71 years. Lower limb oedema was the commonest presentation (100%), haematuria was revealed in (17%) of cases. Histological examination showed three major patterns; Focal segmental glomerulosclerosis (FSGS) in 30.2%, minimal change glomerulopathy (MCG) in 24.5% and IgA nephropathy in 13.2 %. Mesangial hypercellularity was very common among MCG patients (85.3% ±6.7). Tubulointerstitial inflammation and fibrosis were common among cases with IgA nephropathy (40.4% ±11, 53.7% ±8 respectively). CONCLUSIONS ISRNS in Egyptian children could be attributed mainly to three major diseases (FSGS, MCG and IgA nephropathy). Mesangial hypercellularity and severe tubulointerstitial disease might be the major causes for steroid resistance in MCG and IgA nephropathy respectively. Renal biopsy with electron microscopy examination should be done for all children with nephrotic syndrome at first time of presentation for proper assignment of treatment protocol.
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Affiliation(s)
- Elham Ibrahim Seif
- Electron microscopy unit and Pathology department. Ain Shams University Specialized Hospital (ASUSH),Faculty of Medicine-Ain Shams University, Cairo, Egypt
| | - Eman Abdel-Salam Ibrahim
- Electron microscopy unit and Pathology department. Ain Shams University Specialized Hospital (ASUSH),Faculty of Medicine-Ain Shams University, Cairo, Egypt
| | - Nadia Galal Elhefnawy
- Electron microscopy unit and Pathology department. Ain Shams University Specialized Hospital (ASUSH),Faculty of Medicine-Ain Shams University, Cairo, Egypt
| | - Manal Ibrahim Salman
- Electron microscopy unit and Pathology department. Ain Shams University Specialized Hospital (ASUSH),Faculty of Medicine-Ain Shams University, Cairo, Egypt
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Canetta PA, Radhakrishnan J. Impact of the National Institutes of Health Focal Segmental Glomerulosclerosis (NIH FSGS) clinical trial on the treatment of steroid-resistant FSGS. Nephrol Dial Transplant 2012; 28:527-34. [DOI: 10.1093/ndt/gfs563] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Oh J, Kemper MJ. Second-line options for refractory steroid-sensitive and -resistant nephrotic syndrome. Expert Rev Clin Pharmacol 2012; 3:527-37. [PMID: 22111681 DOI: 10.1586/ecp.10.31] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although initially, many children with idiopathic nephrotic syndrome respond to steroid therapy, a repeated course for patients with relapses often causes significant steroid toxicity. Patients with frequent relapses or steroid dependency thus require alternative treatment, and so far, cyclophosphamide or levamisole have been regarded as first-choice options, although the latter is no longer available in many countries. Data are accumulating that mycophenolic acid may be an alternative for these patients. Calcineurin inhibitors (cyclosporine A or tacrolimus) are usually effective and are often used after cytotoxic treatment, but long-term treatment is necessary, raising concerns regarding the accumulation of side effects. Still, some patients show a tendency to relapse even on this maintenance regimen and some even have a refractory course that creates a medical dilemma. For this situation, recent data have demonstrated an effect of monoclonal antibodies directed to B cells - rituximab, a drug that may also prove to be a therapeutic option in less complicated cases. Patients that do not respond to initial steroid treatment need genetic testing and a renal biopsy, since focal segmental glomerulosclerosis may be present. Treatment options include pulse methylprednisolone, often in addition to calcineurin inhibitors (mainly cyclosporine but also, recently, tacrolimus). Cyctotoxic treatment, especially intravenous cyclophosphamide, has been found to be effective in steroid-resistant nephrotic syndrome by some studies but is inferior to calcineurin inhibitors. In addition, mycophenolic acid and rituximab have been used in children with primary focal segmental glomerulosclerosis; however, response seems to be inferior in comparison with patients with steroid-sensitive nephrotic syndrome. Taken together, idiopathic nephrotic syndrome, including steroid-sensitive as well as steroid-resistant patients, is a potentially serious disorder. Although much progress has been made in recent years and a wide arsenal of immunological interventions is available, some patients have a treatment refractory course. Prospective studies or at least standardization of treatment for complicated cases is urgently needed.
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Affiliation(s)
- Jun Oh
- Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, D-20246 Hamburg, Germany
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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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