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Treatment of idiopathic nephrotic syndrome at onset: a comparison between 8- and 12-week regimens in everyday clinical practice. Pediatr Nephrol 2022:10.1007/s00467-022-05824-7. [PMID: 36434353 DOI: 10.1007/s00467-022-05824-7] [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: 04/25/2022] [Revised: 11/08/2022] [Accepted: 11/09/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal steroid treatment at onset of idiopathic nephrotic syndrome is still debated. The aim of this study was to analyze the clinical outcome at 24 months of follow-up in patients admitted to our unit for the first episode of steroid-sensitive nephrotic syndrome comparing two different steroid regimens. METHODS We collected data on patients treated from 1992 to 2007 with prednisone according to the International Study on Kidney Diseases in Children 8-week regimen and since 2008 according to the Arbeitsgemeinschaft fur Padiatrische Nephrologie 12-week regimen. The primary outcome was to evaluate cumulative prednisone dosage at 12 and 24 months of follow-up in the two groups. As secondary outcomes, we considered mean relapse rate per patient; number of children without relapses at 6, 12, and 24 months; and number of patients who developed frequent relapses and steroid-dependent disease. RESULTS Data were collected on 127 patients. Sixty-one subjects received the 8-week regimen and 66 the 12-week regimen. The mean cumulative prednisone dose at 12 and 24 months was not different, and the rate of patients without relapses was lower at 6 and 12 months in patients treated with the 8-week course, while no difference was observed at 24 months. CONCLUSIONS Despite the limitations of a retrospective study with limited follow-up, our data indicate that switching treatment from a shorter to a longer scheme did not improve the clinical outcome at 24 months of observation. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Zion E, Borovitz Y, Alfandary H, Haskin O, Levi S, Shoham S, Davidovits M, Dagan A. A Clinical Response-Adjusted Steroid Treatment Protocol for Children With Newly Diagnosed Idiopathic Nephrotic Syndrome. Am J Kidney Dis 2022; 80:473-482.e1. [PMID: 35659571 DOI: 10.1053/j.ajkd.2022.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 04/08/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE Prednisone protocols for children with idiopathic nephrotic syndrome (INS) are generally similar in dose and duration, despite wide variations in time to response. We assessed the feasibility of a novel clinical treatment protocol characterized by a shorter duration and lower cumulative dose for children with early clinical response. STUDY DESIGN Nonrandomized pilot clinical trial. SETTING & PARTICIPANTS The study population included 59 children with newly diagnosed INS treated between 2014 and 2019 who responded to treatment within 8 days. INTERVENTION The intervention group (n = 27) was treated with a response-adjusted protocol during which responders received an 8-week course of tapering doses of prednisone. The usual care group (n =32) was treated with the standard protocol (prednisone, 60 mg/m2/24 hours for 6 weeks, followed by 40 mg/m2/48 hours for 4 weeks, followed by a slow taper for a total of 24 weeks). OUTCOME Consent rate, cumulative prednisone dose, the development of frequently relapsing or steroid-dependent nephrotic syndrome (FRNS or SDNS, respectively), relapses per year, treatment with steroid-sparing therapies, and adverse effects of steroid therapy over 3 years of follow-up observation. RESULTS The consent rate was 88%. The mean cumulative steroid dose for the initial treatment was 70 mg/kg and 141 mg/kg (P < 0.001) in the intervention and usual care groups, respectively. None of the patients in the intervention group relapsed while on faster steroid taper down. The occurrence of FRNS and SDNS in the intervention group was not statistically different than in the usual care group, hazard ratios were 0.80 (95% CI, 0.37-1.73) and 0.61 (95% CI, 0.30-1.27), respectively. The proportions of relapse-free patients were similar (P = 0.5), and adverse steroid events did not differ between the groups. LIMITATIONS Lack of randomization and small sample size. CONCLUSIONS These findings demonstrate the feasibility of a shortened duration of steroid dosing for INS when patients demonstrate an initial clinical response to treatment. A larger study is needed to characterize the relative efficacy and toxicity of this novel treatment regimen. FUNDING This study received no funding. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCTO2649413.
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Affiliation(s)
- Elena Zion
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Department A, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.
| | - Yael Borovitz
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Hadas Alfandary
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Orly Haskin
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shelly Levi
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Shoval Shoham
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Miriam Davidovits
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Dagan
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Late Onset of ANCA Vasculitis as a Side Effect of Levamisole Treatment in Nephrotic Syndrome. Medicina (B Aires) 2022; 58:medicina58050650. [PMID: 35630067 PMCID: PMC9147217 DOI: 10.3390/medicina58050650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/02/2022] [Accepted: 05/08/2022] [Indexed: 12/15/2022] Open
Abstract
Levamisole is effectively used in steroid-dependent nephrotic syndrome and the more frequent side effects reported are cytopenia and liver enzymes alterations. Several studies have demonstrated that this drug can induce high titers of circulating perinuclear antineutrophil cytoplasmic autoantibodies (ANCA) and vasculitis, most of them occurring in the case of prolonged use. A four-year-old boy that was affected with steroid-dependent nephrotic syndrome was treated with Levamisole as a steroid-sparing agent at a dose of 2 mg/kg/48 h. After initiation of the treatment, the number of relapses drastically decreased, enabling a significant reduction in the cumulative steroid dose. Levamisole was well tolerated, and was therefore administered for several years. At the age of 15, he was also diagnosed with celiac disease. After nine years of continuous Levamisole treatment, he presented with a high fever, hand and foot joint arthritis, and increased levels of total and direct bilirubin. Since the symptoms started two days after the injection of the second dose of the COVID-19 vaccine, it was initially concluded that these manifestations were rare vaccination side effects. Therefore, he did not receive any specific treatments, and Levamisole was continued at the same dose. After an initial improvement, two months later, the patient presented with the same symptoms. Suspecting Levamisole-induced vasculitis, an ANCA titer was measured and this returned positive. Clinical manifestations and double positivity for both myeloperoxidase (MPO) and anti-proteinase 3 (PR3) antibodies argued against the fact that that these findings were secondary to vaccination, cocaine abuse, or celiac disease. Assuming that we were facing a rare drug reaction, Levamisole was promptly interrupted. This resulted in a rapid remission of fever and arthritis improvement, and a decrease in ANCA titers. By reporting this case, we want to raise awareness among clinicians regarding a rare complication of treatment with Levamisole that is often misdiagnosed due to the fact that the current literature lacks univocal guidelines regarding the precise timing of ANCA titrations and the duration of the treatment.
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Kalra S, Daryani H, Saxena A, Bhandari S, Sharma S. Infectious complications in children with nephrotic syndrome: Can they be prevented? Med J Armed Forces India 2022; 78:170-174. [PMID: 35463546 PMCID: PMC9023548 DOI: 10.1016/j.mjafi.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 10/10/2020] [Indexed: 11/28/2022] Open
Abstract
Background Sixty percent of children with nephrotic syndrome have frequently relapsing or steroid-dependent course. Serious infections like peritonitis, cellulitis, pneumonia etc. and anasarca with reduced urine output and complications there of including acute kidney injury and thromboembolism contribute significantly to morbidity and mortality in these children. Methods Questionnaire-based module to study infectious complications in children with nephrotic syndrome was circulated through survey monkey portal to paediatric nephrologists in our country. Twenty-two responded. Forty percent said that they saw patients with severe infections once a month. Fish bone analysis conducted on such patients reporting to our centre over next 3 months revealed that only 22% regularly monitored urine protein by dipstick. We proposed that reduction in time to report relapse by regularly monitoring urine protein could reduce complications in these children. Six urine protein dipsticks were handed over to patients who presented >7 days since relapse or with severe infection or anasarca in the last 1 year. These children were followed up for the next 1 year and given six more urine dipsticks every 3 months. Results Twenty-three patients were given urine protein dipsticks. Nine of them had 12 severe complications in the previous 6 months. None had any serious infections/anasarca on follow-up. Sixteen new patients had 14 serious complications in this time. Conclusions Early detection of relapse by home monitoring of urine protein by dipsticks was effective in significantly reducing the number of patients with severe infections and anasarca with reduced urine output.
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Affiliation(s)
- Suprita Kalra
- Associate Professor (Pediatrics), Army Hospital (R&R), New Delhi, India
- Corresponding author.
| | | | - Apoorv Saxena
- Resident, Department of Pediatrics, Armed Forces Medical College, Pune, India
| | - Sumit Bhandari
- Assistant Professor (Orthopaedics), Base Hospital, Delhi Cantt, India
| | - Shobha Sharma
- Professor (Pediatrics), VMMC & Safdarjung Hospital, New Delhi, India
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Zotta F, Vivarelli M, Emma F. Update on the treatment of steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:303-314. [PMID: 33665752 DOI: 10.1007/s00467-021-04983-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
Steroid-sensitive nephrotic syndrome (SSNS) is a rare condition that develops primarily in preadolescent children after the age of 1 year. Since the 1950s, oral corticosteroids have been the mainstay of treatment of all children presenting with nephrotic syndrome, with most patients responding within 4 weeks to an oral course of prednisone (PDN). However, corticosteroids have important side effects and 60-80 % of patients relapse, developing frequently relapsing or steroid-dependent forms. For these reasons, many patients require second-line steroid-sparing immunosuppressive medications that have considerably improved relapse-free survival, while avoiding many PDN-related toxicities. Since most patients will eventually heal from their disease with a normal kidney function, the morbidity of SSNS is primarily related to side effects of drugs that are used to maintain prolonged remission. Therefore, treatment is essentially based on balancing the use of different drugs to achieve permanent remission with the lowest cumulative number of side effects. Treatment choice is based on the severity of SSNS, on patient age, and on drug tolerability. This review provides an update of currently available therapeutic strategies for SSNS.
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Affiliation(s)
- Federica Zotta
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marina Vivarelli
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesco Emma
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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Behera MR, Kumar CM, Biswal SR, Reddy PVK, Reddy GBP, Polakampalli N, Kumar R, Sahu SK. Clinico-Biochemical Profile and Identification of Independent Risk Factors of Frequent Relapse in Childhood-Onset Steroid-Sensitive Nephrotic Syndrome. Cureus 2022; 14:e21765. [PMID: 35251836 PMCID: PMC8890592 DOI: 10.7759/cureus.21765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2022] [Indexed: 11/05/2022] Open
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Christian MT, Maxted AP. Optimizing the corticosteroid dose in steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:37-47. [PMID: 33611671 PMCID: PMC7896825 DOI: 10.1007/s00467-021-04985-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
The use of corticosteroids in the treatment of steroid-sensitive nephrotic (SSNS) syndrome in children has evolved surprisingly slowly since the ISKDC consensus over 50 years ago. From a move towards longer courses of corticosteroid to treat the first episode in the 1990s and 2000s, more recent large, well-designed randomized controlled trials (RCTs) have unequivocally shown no benefit from an extended course, although doubt remains whether this applies across all age groups. With regard to prevention of relapses, daily ultra-low-dose prednisolone has recently been shown to be more effective than low-dose alternate-day prednisolone. Daily low-dose prednisolone for a week at the time of acute viral infection seems to be effective in the prevention of relapses but the results of a larger RCT are awaited. Recently, corticosteroid dosing to treat relapses has been questioned, with data suggesting lower doses may be as effective. The need for large RCTs to address the question of whether corticosteroid doses can be reduced was the conclusion of the authors of the recent corticosteroid therapy for nephrotic syndrome in children Cochrane update. This review summarizes development in thinking on corticosteroid use in SSNS and makes suggestions for areas that merit further scrutiny.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK.
| | - Andrew P Maxted
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK
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Pasini A, Bertulli C, Casadio L, Corrado C, Edefonti A, Ghiggeri G, Ghio L, Giordano M, La Scola C, Malaventura C, Maringhini S, Mastrangelo AP, Materassi M, Mencarelli F, Messina G, Monti E, Morello W, Puccio G, Romagnani P, Montini G. Childhood Idiopathic Nephrotic Syndrome: Does the Initial Steroid Treatment Modify the Outcome? A Multicentre, Prospective Cohort Study. Front Pediatr 2021; 9:627636. [PMID: 34307246 PMCID: PMC8295604 DOI: 10.3389/fped.2021.627636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/12/2021] [Indexed: 12/02/2022] Open
Abstract
Background: A great majority of children with idiopathic nephrotic syndrome will relapse after successful treatment of the initial episode. The possibility that different steroid dosing regimens at onset, adjusted for risk factors, can reduce the rate of relapse represents an interesting option to investigate. Objectives: To evaluate the effect of the initial steroid regimen, adjusted for time to remission (TTR), on the frequency of relapses and steroid dependence, and to verify the influence of prognostic factors on disease course. Methods: A multicentre, prospective, cohort study. Children with nephrotic syndrome, with TTR ≤ 10 days (Group A), were given a 20-week prednisone regimen (2,828 mg/m2) and those with a TTR >10 days, a 22-week regimen (3,668 mg/m2) (Group B). Previously published retrospective data from the same centers were also evaluated. Main outcomes were: relapse rate, number of frequent relapsers + steroid dependent children and total prednisone dose after induction. Results: 143 children were enrolled. Rate of relapsed subjects (77 vs. 79%) and frequent relapsers + steroid dependent subjects (40 vs. 53%) did not differ between Groups A and B, or between the retrospective and prospective cohorts. The cumulative prednisone dose taken after the induction treatment was similar in both groups and in the retrospective and prospective cohorts. TTR was not associated with relapse risk. Age at onset and total serum protein were significantly lower in relapsing patients. At ROC analysis, the best cut-off was 5.3 years for age at onset and 4.2 g/dL for total serum protein. According to these cut-offs, older children with higher total serum protein had a higher relapse free survival rate (58%) than younger children with lower total serum protein (17%). Conclusions: TTR was not found to be a prognostic factor of relapse; because of this, different steroid regimens, adjusted for TTR, did not modify the relapse rate in any relevant measure. Conversely, younger age and low total serum protein were independent predictors of relapse risk, however this outcome was not modified by higher prednisone regimens. Clinical Trial Registration:https://www.ClinicalTrials.gov/, identifier: NCT01386957 (www.nefrokid.it).
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Affiliation(s)
- Andrea Pasini
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Bertulli
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Casadio
- Unità Operativa Complessa of Paediatrics and Neonatology, Local Health Authority of Romagna, Ravenna, Italy
| | - Ciro Corrado
- Pediatric Nephrology Unit, Children's Hospital “G. Di Cristina”, A.R.N.A.S. “Civico”, Palermo, Italy
| | - Alberto Edefonti
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - GianMarco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, Laboratory on Pathophysiology of Uremia, Istituto G. Gaslini, Genoa, Italy
| | - Luciana Ghio
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Giordano
- Nephrology Unit, Giovanni XXIII Children's Hospital, Bari, Italy
| | - Claudio La Scola
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Malaventura
- Section of Pediatrics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Silvio Maringhini
- Pediatric Nephrology Unit, Children's Hospital “G. Di Cristina”, A.R.N.A.S. “Civico”, Palermo, Italy
| | - Antonio P. Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Materassi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Francesca Mencarelli
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Messina
- Nephrology Unit, Giovanni XXIII Children's Hospital, Bari, Italy
| | - Elena Monti
- Specialty School of Paediatrics - Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Paola Romagnani
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
- Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
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Veltkamp F, Rensma LR, Bouts AHM. Incidence and Relapse of Idiopathic Nephrotic Syndrome: Meta-analysis. Pediatrics 2021; 148:peds.2020-029249. [PMID: 34193618 DOI: 10.1542/peds.2020-029249] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Idiopathic nephrotic syndrome (INS) in children is a disease with considerable morbidity, yet the incidence and risk for relapse have not been systematically reviewed. OBJECTIVE To estimate the overall pooled weighted incidence and risk for relapse of INS in children. DATA SOURCES Medline and Embase (until December 2020). STUDY SELECTION All studies reporting incidence (per 100 000 children per year) and/or risk for relapse (the proportion of patients who experience ≥1 relapse) of INS in children (age: <18 years) were eligible. DATA EXTRACTION After quality assessment, data were extracted: study (design, localization, and sample size) and patient (age, sex, steroid response, and ethnicity) characteristics, incidence, and risk for relapse. RESULTS After screening, 73 studies were included for analysis (27 incidence, 54 relapse). The overall pooled weighted estimate and corresponding prediction interval (PI) of the incidence was 2.92 (95% PI: 0.00-6.51) per 100 000 children per year. Higher incidences were found in non-Western countries (P < .001). Incidence tended to be lower in white children, but this was not significant. The overall pooled weighted estimate of the risk for relapse was 71.9% (95% PI: 38.8-95.5). Between 1945 and 2011, incidence did not change (P = .39), yet the risk for relapse decreased significantly (P = .024), from 87.4% to 66.2%. LIMITATIONS There was no full-text availability (n = 33), considerable heterogeneity, and limited studies from Africa, Latin America, and Asia. CONCLUSIONS INS has a low incidence with ethnic variation but high risk for relapse. Although corticosteroids have significantly reduced the risk for relapse, it remains unacceptably high, underscoring the need for alternative treatment strategies.
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Affiliation(s)
- Floor Veltkamp
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Leonie R Rensma
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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Results of the PROPINE randomized controlled study suggest tapering of prednisone treatment for relapses of steroid sensitive nephrotic syndrome is not necessary in children. Kidney Int 2020; 99:475-483. [PMID: 33152448 DOI: 10.1016/j.kint.2020.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/24/2020] [Accepted: 09/03/2020] [Indexed: 01/16/2023]
Abstract
Corticosteroid-related toxicity in children with steroid-sensitive nephrotic syndrome is primarily related to the cumulative dose of prednisone. To optimize treatment of relapses, we conducted the PROPINE study, a multicentric, open-label, randomized, superiority trial. Seventy-eight relapsing children aged 3-17 years who had not received steroid-sparing medications during the previous 12 months were randomized to receive, from day five after remission, either 18 doses of 40 mg/m2 of prednisone on alternate days (short arm), or the same cumulative dose tapered over double the time (long arm). Patients were monitored with an ad-hoc smartphone application, allowing daily reporting. The primary outcome was the six-month relapse rate at which time, 23/40 and 16/38 patients had relapsed in the long and short arms, respectively (no significant difference). Additionally, 40/78 patients were also enrolled in a secondary crossover study and were allocated to the opposite arm. Altogether, at six months, the relapse rate was 32/40 and 28/40 in the long and short arms, respectively (no significant difference). A post-hoc analysis excluding 30 patients treated with low-dose prednisone maintenance therapy failed to show significant differences between the two arms. No differences in adverse events, blood pressure and weight gain were observed. Thus, our data do not support the prescription of prolonged tapering schedules for relapses of steroid-sensitive nephrotic syndrome in children.
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Carter SA, Mistry S, Fitzpatrick J, Banh T, Hebert D, Langlois V, Pearl RJ, Chanchlani R, Licht CP, Radhakrishnan S, Brooke J, Reddon M, Levin L, Aitken-Menezes K, Noone D, Parekh RS. Prediction of Short- and Long-Term Outcomes in Childhood Nephrotic Syndrome. Kidney Int Rep 2019; 5:426-434. [PMID: 32280840 PMCID: PMC7136435 DOI: 10.1016/j.ekir.2019.12.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 10/31/2019] [Accepted: 12/18/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction It is unknown whether steroid sensitivity and other putative risk factors collected at baseline can predict the disease course of idiopathic nephrotic syndrome in childhood. We determined whether demographic, clinical, and family reported factors at presentation can predict outcomes in idiopathic nephrotic syndrome. Methods An observational cohort of 631 children aged 1 to 18 years diagnosed with idiopathic nephrotic syndrome between 1993 and 2016 were followed up until clinic discharge, 18 years of age, end-stage kidney disease (ESKD), or the last clinic visit. Baseline characteristics were age, sex, ethnicity, and initial steroid sensitivity. Of these, 287 (38%) children also reported any family history of kidney disease, preceding infection, microscopic hematuria, and history of asthma/allergies. The outcomes were complete remission after initial steroid course, need for a second-line agent, frequently relapsing disease, and long-term remission. The discriminatory power of the models was described using the c-statistic. Results Overall, 25.7% of children had no further disease after their initial steroid course. In addition, 31.2% developed frequently relapsing disease; however, 77.7% were disease-free at 18 years of age. Furthermore, 1% of children progressed to ESKD. Logistic regression modeling using the different baseline exposures did not significantly improve the prediction of outcomes relative to the observed frequencies (maximum c-statistic, 0.63; 95% confidence interval [CI], 0.59–0.67). The addition of steroid sensitivity did not improve outcome prediction of long-term outcomes (c-statistic, 0.63; 95% CI, 0.54–0.70). Conclusions Demographic, clinical, and family reported characteristics, specifically steroid sensitivity, are not useful in predicting relapse rates or long-term remission in idiopathic nephrotic syndrome. Further studies are needed to address factors that contribute to long-term health.
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Affiliation(s)
- Simon A. Carter
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Shilan Mistry
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Genetics and Genome Biology, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Fitzpatrick
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tonny Banh
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Diane Hebert
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Valerie Langlois
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel J. Pearl
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Brampton Civic Hospital, William Osler Health Services, Brampton, Ontario, Canada
- Pediatric Nephrology Clinic, Peel Memorial Centre for Integrated Health and Wellness, William Osler Health Services, Brampton, Ontario, Canada
| | - Rahul Chanchlani
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Pediatric Nephrology, McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Christoph P.B. Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Program in Cell Biology, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Seetha Radhakrishnan
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Josefina Brooke
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michele Reddon
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Leo Levin
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Damien Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rulan S. Parekh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada
- Department of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
- Department of Health, Policy, Management and Evaluation, University of Toronto, Ontario, Canada
- Correspondence: Rulan Parekh, Division of Nephrology, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
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12
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Colucci M, Carsetti R, Rosado MM, Cascioli S, Bruschi M, Candiano G, Corpetti G, Giardino L, Serafinelli J, Giannone C, Ghiggeri GM, Rastaldi MP, Sitia R, Emma F, Vivarelli M. Atypical IgM on T cells predict relapse and steroid dependence in idiopathic nephrotic syndrome. Kidney Int 2019; 96:971-982. [DOI: 10.1016/j.kint.2019.04.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 03/28/2019] [Accepted: 04/05/2019] [Indexed: 01/06/2023]
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13
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An evaluation of phase angle, bioelectrical impedance vector analysis and impedance ratio for the assessment of disease status in children with nephrotic syndrome. BMC Nephrol 2019; 20:331. [PMID: 31438871 PMCID: PMC6704501 DOI: 10.1186/s12882-019-1511-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 08/02/2019] [Indexed: 11/25/2022] Open
Abstract
Background Oedema, characterized by accumulation of extracellular water (ECW), is one of the major clinical manifestations in children suffering from nephrotic syndrome (NS). The lack of a simple, inexpensive and harmless method for assessing ECW may be solved by the use of the bioelectrical impedance analysis (BIA) technique. The aims of this study were to examine whether phase angle (PA), bioelectrical impedance vector analysis (BIVA) and the impedance ratio (IR) reflect change in disease status in children with NS. Methods Eight children (age range: 2–10 years) with active NS (ANS group) were enrolled. In five of these (ANS* subgroup), impedance was also measured at remission (NSR group). Thirty-eight healthy children (age range: 2–10 years) were included as healthy controls (HC group). Whole-body impedance was measured with a bioimpedance spectroscopy device (Xitron 4200) with surface electrodes placed on the wrist and ankle. Results Values of PA, BIVA and IR were found to be significantly lower (p-value range < 0.001 to < 0.01) in the ANS patients compared to the HC and NSR groups. No significant differences were observed between the NSR and HC groups. Conclusion The studied parameters can be used to assess change in disease status in NS patients. Data were consistent with NS being associated with expansion of ECW. Electronic supplementary material The online version of this article (10.1186/s12882-019-1511-y) contains supplementary material, which is available to authorized users.
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14
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Webb NJ, Woolley RL, Lambe T, Frew E, Brettell EA, Barsoum EN, Trompeter RS, Cummins C, Wheatley K, Ives NJ. Sixteen-week versus standard eight-week prednisolone therapy for childhood nephrotic syndrome: the PREDNOS RCT. Health Technol Assess 2019; 23:1-108. [PMID: 31156083 DOI: 10.3310/hta23260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal corticosteroid regimen for treating the presenting episode of steroid-sensitive nephrotic syndrome (SSNS) remains uncertain. Most UK centres use an 8-week regimen, despite previous systematic reviews indicating that longer regimens reduce the risk of relapse and frequently relapsing nephrotic syndrome (FRNS). OBJECTIVES The primary objective was to determine whether or not an extended 16-week course of prednisolone increases the time to first relapse. The secondary objectives were to compare the relapse rate, FRNS and steroid-dependent nephrotic syndrome (SDNS) rates, requirement for alternative immunosuppressive agents and corticosteroid-related adverse events (AEs), including adverse behaviour and costs. DESIGN Randomised double-blind parallel-group placebo-controlled trial, including a cost-effectiveness analysis. SETTING One hundred and twenty-five UK paediatric departments. PARTICIPANTS Two hundred and thirty-seven children presenting with a first episode of SSNS. Participants aged between 1 and 15 years were randomised (1 : 1) according to a minimisation algorithm to ensure balance of ethnicity (South Asian, white or other) and age (≤ 5 or ≥ 6 years). INTERVENTIONS The control group (n = 118) received standard course (SC) prednisolone therapy: 60 mg/m2/day of prednisolone in weeks 1-4, 40 mg/m2 of prednisolone on alternate days in weeks 5-8 and matching placebo on alternate days in weeks 9-18 (total 2240 mg/m2). The intervention group (n = 119) received extended course (EC) prednisolone therapy: 60 mg/m2/day of prednisolone in weeks 1-4; started at 60 mg/m2 of prednisolone on alternate days in weeks 5-16, tapering by 10 mg/m2 every 2 weeks (total 3150 mg/m2). MAIN OUTCOME MEASURES The primary outcome measure was time to first relapse [Albustix® (Siemens Healthcare Limited, Frimley, UK)-positive proteinuria +++ or greater for 3 consecutive days or the presence of generalised oedema plus +++ proteinuria]. The secondary outcome measures were relapse rate, incidence of FRNS and SDNS, other immunosuppressive therapy use, rates of serious adverse events (SAEs) and AEs and the incidence of behavioural change [using Achenbach Child Behaviour Checklist (ACBC)]. A comprehensive cost-effectiveness analysis was performed. The analysis was by intention to treat. Participants were followed for a minimum of 24 months. RESULTS There was no significant difference in time to first relapse between the SC and EC groups (hazard ratio 0.87, 95% confidence interval 0.65 to 1.17; log-rank p = 0.3). There were also no differences in the incidence of FRNS (SC 50% vs. EC 53%; p = 0.7), SDNS (44% vs. 42%; p = 0.8) or requirement for other immunosuppressive therapy (56% vs. 54%; p = 0.8). The total prednisolone dose received following completion of study medication was 5475 mg vs. 6674 mg (p = 0.07). SAE rates were not significantly different (25% vs. 17%; p = 0.1) and neither were AEs, except poor behaviour (yes/no), which was less frequent with EC treatment. There were no differences in ACBC scores. EC therapy was associated with a mean increase in generic health benefit [0.0162 additional quality-adjusted life-years (QALYs)] and cost savings (£4369 vs. £2696). LIMITATIONS Study drug formulation may have prevented some younger children who were unable to swallow whole or crushed tablets from participating. CONCLUSIONS This trial has not shown any clinical benefit for EC prednisolone therapy in UK children. The cost-effectiveness analysis suggested that EC therapy may be cheaper, with the possibility of a small QALY benefit. FUTURE WORK Studies investigating EC versus SC therapy in younger children and further cost-effectiveness analyses are warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN16645249 and EudraCT 2010-022489-29. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 26. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nicholas Ja Webb
- Department of Paediatric Nephrology, University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Tosin Lambe
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Emma N Barsoum
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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15
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Bioimpedance Resistance Indices and Cell Membrane Capacitance Used to Assess Disease Status and Cell Membrane Integrity in Children with Nephrotic Syndrome. ScientificWorldJournal 2019; 2019:4274856. [PMID: 31210755 PMCID: PMC6532278 DOI: 10.1155/2019/4274856] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/17/2019] [Indexed: 11/17/2022] Open
Abstract
Background Accumulation of extracellular water (ECW) is a major clinical manifestation of nephrotic syndrome (NS) in children. Bioimpedance spectroscopy (BIS) is a simple, noninvasive technique that reflects body water volumes. BIS can further measure cell membrane capacitance (CM), which may be altered in NS. The aims of the study were to explore how BIS measurements could reflect disease status in NS, while avoiding prediction equations which are often only validated in adult populations. Methods The study involved 8 children (2-10 years) with active NS (ANS group), 5 of which were also studied at NS remission (NSR group), as well as 38 healthy children of similar age (HC group). BIS measurements determined resistances RINF, RE, and RI (reflecting total body water, extracellular water, and intracellular water) and CM. Also resistance indices based on height (H) were considered, RI = H2/R. Results It was found that RE and RINF were significantly lower in the ANS group than in both NSR and HC groups (p < 0.001). Corresponding resistance indices were significantly higher in the ANS group than in the NSR (p < 0.01) and the HC (p < 0.05) groups, in accordance with elevated water volumes in NS patients. Indices of intracellular water were not significantly different between groups. CM was significantly lower in the ANS group than in NSR and HC groups (p < 0.05). Conclusion BIS could distinguish children with active NS from well-treated and healthy children. Studies with more children are warranted.
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Goonewardene ST, Tang C, Tan LTH, Chan KG, Lingham P, Lee LH, Goh BH, Pusparajah P. Safety and Efficacy of Pneumococcal Vaccination in Pediatric Nephrotic Syndrome. Front Pediatr 2019; 7:339. [PMID: 31456997 PMCID: PMC6700369 DOI: 10.3389/fped.2019.00339] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 07/29/2019] [Indexed: 12/04/2022] Open
Abstract
Nephrotic syndrome affects both children and adults. Idiopathic nephrotic syndrome is reported to be one of the most frequent renal pathologies in childhood. Nephrotic children are at high risk for severe pneumococcal infections as one of the life-threatening complications of nephrotic syndrome due to involvement of the immunosuppressive regimen and the acquired immune deficiency induced by nephrotic syndrome including decreased plasma IgG and low complement system components. Aiming to prevent pneumococcal infection is of paramount importance especially in this era of ever-increasing pneumococcal resistance to penicillins and cephalosporins. The pneumococcal vaccines currently available are inactivated vaccines-the two main forms in use are polysaccharide vaccines and conjugated vaccines. However, the data supporting the use of these vaccines and to guide the timing and dosage recommendations is still limited for nephrotic children. Thus, this review discusses the evidences of immunogenicity and safety profile of both vaccinations on nephrotic patients as well as the effect of nephrotic syndrome treatment on vaccine seroresponses.
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Affiliation(s)
- Shamitha Thishakya Goonewardene
- Medical Health and Translational Research Group, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia.,Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia.,Biofunctional Molecule Exploratory Research Group, School of Pharmacy, Monash University Malaysia, Subang Jaya, Malaysia
| | - Calyn Tang
- Medical Health and Translational Research Group, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia.,Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia.,Biofunctional Molecule Exploratory Research Group, School of Pharmacy, Monash University Malaysia, Subang Jaya, Malaysia
| | - Loh Teng-Hern Tan
- Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia.,Institute of Biomedical and Pharmaceutical Sciences, Guangdong University of Technology, Guangzhou, China
| | - Kok-Gan Chan
- Division of Genetics and Molecular Biology, Institute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur, Malaysia.,International Genome Centre, Jiangsu University, Zhenjiang, China
| | - Prithvy Lingham
- Medical Health and Translational Research Group, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia
| | - Learn-Han Lee
- Novel Bacteria and Drug Discovery Research Group, Microbiome and Bioresource Research Strength Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia.,Health and Well-being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Bey-Hing Goh
- Biofunctional Molecule Exploratory Research Group, School of Pharmacy, Monash University Malaysia, Subang Jaya, Malaysia.,Health and Well-being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Bandar Sunway, Malaysia
| | - Priyia Pusparajah
- Medical Health and Translational Research Group, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Subang Jaya, Malaysia.,Health and Well-being Cluster, Global Asia in the 21st Century Platform, Monash University Malaysia, Bandar Sunway, Malaysia
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17
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Dakshayani B, Lakshmanna M, Premalatha R. Predictors of frequent relapsing and steroid-dependent nephrotic syndrome in children. TURK PEDIATRI ARSIVI 2018; 53:24-30. [PMID: 30083071 PMCID: PMC6070226 DOI: 10.5152/turkpediatriars.2018.5749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 11/11/2017] [Indexed: 06/08/2023]
Abstract
AIM To determine the predictors of frequent relapses and steroid dependency in children with steroid-sensitive nephrotic syndrome. MATERIAL AND METHODS All children aged six months to 18 years with steroid-sensitive nephrotic syndrome registered in the nephrology clinic between 2003 and 2015 at a tertiary center who were followed up for at least 1year after onset were included in the study. RESULTS Two hundred seventy-seven patients with steroid-sensitive nephrotic syndrome who were followed up for at least 1 year from onset of disease were included. There were 157 infrequent relapsers and 120 frequent relapsers (frequent relapses and or steroid-dependent). Compared with infrequent relapsers, frequent relapsers had a significantly lower age at onset (51.53±40.42 vs. 61.97±40.66 months; p=0.035), lesser time for first relapse (time from the start of initial treatment to first relapse (8.65±11.99 vs. 23.46±24.05 months; p<0.001) and a higher number of relapses with infection (8.65±11.99 vs. 1.25±1.85; p<0.001). On multivariate logistic regression analysis, time for first relapse less than six months [OR: 3.93; 95% CI: (1.97-7.82)] and concomitant infection during relapses [OR: 1.82; 95% CI:(1.56-2.14)] were significant predictors of frequent relapses, and males were less likely to become frequent relapsers [OR: 0.48; 95% CI:(0.24-0.93)]. Kaplan-Meier analysis and the log-rank test also showed that a first relapse within six months was associated with frequent relapses. Age at onset and inadequate steroid therapy at onset did not determine frequent relapses. CONCLUSION Shorter time for first relapse and concomitant infection during relapses can predict future frequent relapses. These predictors may be useful to counsel patients, to follow them up more closely, and to develop better treatment protocols and relapse-specific interventions.
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18
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Predictors of poor outcome in children with steroid sensitive nephrotic syndrome. Nefrologia 2018; 38:420-424. [PMID: 29429831 DOI: 10.1016/j.nefro.2017.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 11/19/2017] [Accepted: 11/28/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Nearly 50% of the children with steroid sensitive nephrotic syndrome (SSNS) have a frequently relapsing (FR) or steroid dependent (SD) course, experiencing steroid toxicities and complications of immunosuppression. The study aimed to compare parameters between children with infrequent relapsing (IFR) and FR/SD nephrotic syndrome and to identify the factors associated with a FR/SD course. METHODS A retrospective analysis of medical records from 2009 to 2014, of children with SSNS attending the pediatric nephrology clinic in a tertiary care medical college and hospital. RESULTS Out of 325 children (226 males) with SSNS, 213 were IFR and 112 were FRNS/SDNS. The median age of onset was 34 (IQR 24-48) months. The median time to the first relapse was 4 (IQR 3-7) months and 6 (IQR 4-12) months in FR/SD and IFR group respectively. Multivariate logistic regression analysis showed "adequate treatment (≥12 weeks) of the first episode" (odds ratio 0.56, 95% CI 0.34-0.91; p value=0.02) and "shorter median time to the first relapse" (odds ratio 1.04, 95% CI=1.01-1.08; p value=0.04) to be independent predictors of FR/SD course. An ROC curve was constructed which showed that time to first relapse <5.5 months was associated with a sensitivity of 69% and specificity of 60% in predicting a FR/SD course. CONCLUSION Adequate treatment of the first episode is associated with less chance of an FR/SD course. After treatment of first episode, the first relapse occurring within 5.5 months may predict a frequently relapsing or steroid dependent course.
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19
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Population Pharmacokinetics of Prednisolone in Relation to Clinical Outcome in Children With Nephrotic Syndrome. Ther Drug Monit 2017; 38:534-45. [PMID: 27120177 DOI: 10.1097/ftd.0000000000000308] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The relapse frequency in children with nephrotic syndrome (NS) is highly variable despite standardized prednisolone treatment regimens. Existing evidence on the relationship between prednisolone pharmacokinetics (PK) and clinical response in children with NS is scarce and limited. The aim of this study was to develop a pediatric popPK model for prednisolone based on our previous model based on healthy adults using salivary measurements in children with NS and to correlate clinical outcome with between-subject variability in prednisolone exposure. METHODS The pharmacokinetics of prednisolone in a well-defined, prospective cohort consisting of 104 children with NS while in remission was determined. Pharmacokinetic parameters were analyzed in relation to relapse patterns and side effects. Noninvasive salivary prednisolone measurements were performed using a sparse sampling strategy. A population pharmacokinetic approach was used to derive individual estimates of apparent clearance (CL/F) and apparent volume of distribution (V/F) from the salivary concentration-time curve, followed by calculation of the area under the curve (AUC) of free prednisolone. The individual free serum prednisolone exposure from prednisolone in saliva was derived from the salivary concentration-time curves. Genetic polymorphisms of CYP3A4, CYP3A5, ABCB1, NR1L2, and POR were explored in relation to between-subject variability of CL/F. RESULTS Moderate interindividual variability was found for CL/F (CV, 44.7%). Unexplained random between-subject variability (eta) of CL/F was lower in patients carrying 1 or 2 ABCB1 3435C>T alleles compared to wild type: median -0.04 (interquartile range, -0.17 to 0.21) and 0.00 (-0.11 to 0.16) versus 0.17 (-0.08 to 0.47), P = 0.046. Exposure to free prednisolone was not associated with frequent relapses or adverse effects. CONCLUSIONS This study provides evidence for the possibility of prednisolone drug monitoring through salivary measurements and this may be of particular usefulness in pediatric patients. However, the observed variability in prednisolone exposure, in the therapeutic dose range studied, is not considered to be a major determinant of clinical outcome in children with NS.
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20
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Kim JH, Park E, Hyun HS, Cho MH, Ahn YH, Choi HJ, Kang HG, Ha IS, Cheong HI. Long-term repeated rituximab treatment for childhood steroid-dependent nephrotic syndrome. Kidney Res Clin Pract 2017; 36:257-263. [PMID: 28904877 PMCID: PMC5592893 DOI: 10.23876/j.krcp.2017.36.3.257] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 06/30/2017] [Accepted: 07/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Rituximab (RTX) can be used as a rescue therapy for steroid-dependent nephrotic syndrome (SDNS). However, the efficacy and safety of long-term, repeated use of RTX are not established. This study was conducted to assess the efficacy and safety of long-term, repeated RTX treatment in children. METHODS Eighteen consecutive child patients with SDNS who were treated with three or more cycles of RTX for one year or longer were recruited, and their medical records were retrospectively reviewed. RESULTS The patients were followed for 4.7 ± 1.9 years and received 5.2 ± 2.3 cycles of RTX over 2.8 ± 1.1 years. Approximately 70% of the additional RTX cycles were administered due to recovery of B-cells without relapse. The relapse rate decreased from 3.4 ± 2.0 per year initially to 0.4 ± 0.8 per year at the third year after RTX treatment. Approximately 10% of the RTX infusions were accompanied by mild infusion reactions. Eight patients showed sustained remission without any oral medication after the last cycle of RTX, while 10 patients had one or more episodes of relapse after the last cycle of RTX. The relapse rate in the latter group decreased from 2.8 ± 1.5 per year before RTX treatment to 1.3 ± 0.8 per year after cessation of RTX treatment. No significant differences in clinical parameters were found between the two groups. CONCLUSION This retrospective study showed that pre-emptive and long-term, repeated RTX treatment is relatively effective and safe in children with SDNS. However, well-designed prospective studies are needed to confirm these findings.
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Affiliation(s)
- Ji Hyun Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Eujin Park
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Hye Sun Hyun
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Myung Hyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Yo Han Ahn
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Hyun Jin Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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Abdel-Hafez MA, Abou-El-Hana NM, Erfan AA, El-Gamasy M, Abdel-Nabi H. Predictive risk factors of steroid dependent nephrotic syndrome in children. J Nephropathol 2017; 6:180-186. [PMID: 28975099 PMCID: PMC5607981 DOI: 10.15171/jnp.2017.31] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/20/2017] [Indexed: 12/23/2022] Open
Abstract
Background:
Development of steroid dependency is one of the difficult problems in the
management of children with idiopathic nephrotic syndrome, leading to increased
morbidity, complications and cost of treatment. Thus, predicting early in the disease
course will be useful in counseling parents and may improve treatment strategy.
Objectives:
To determine the clinical characteristics that can predict the development of
steroid dependency early in the initial episodes of steroid sensitive nephrotic syndrome
(SSNS).
Patients and Methods:
The study included 52 children with SSNS. Their ages ranged from
3 to 16 years. Patients were divided into two groups. Group A consisted of 24 patients
with steroid dependency or frequent relapses nephrotic syndrome and group B consisted
of 28 patients with complete remission or recurrent nephrotic syndrome. Data obtained
retrospectively from patients’ files.
Results:
Children who require a cumulative steroid dose equal or more than 140 mg/kg
to maintain remission during the first 6 months of the disease are at high risk to require
steroid sparing agents (SSA) for disease control, and who did not achieve remission by
day 20 of the initial prednisone course became steroid dependent with 96% specificity but
with low sensitivity (50%). All steroid dependent children in this study showed relapses
associated significantly with upper respiratory tract infections.
Conclusions:
Cumulative steroid dose in the first 6 months of treatment and the need of
more than 20 days to achieve initial remission can predict steroid dependency in children
with nephrotic syndrome.
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Affiliation(s)
| | | | - Adel Ali Erfan
- Pediatric Department, Faculty of Medicine, Tanta University, Egypt
| | | | - Hend Abdel-Nabi
- Pediatric Department, Faculty of Medicine, Tanta University, Egypt
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22
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Liern M, Codianni P, Vallejo G. [Comparative study of the conventional scheme and prolonged treatment with steroids on primary steroid-sensitive nephrotic syndrome in children]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2016; 73:309-317. [PMID: 29384123 DOI: 10.1016/j.bmhimx.2016.07.005] [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: 04/23/2016] [Revised: 07/06/2016] [Accepted: 07/25/2016] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND In the steroid-sensitive nephrotic syndrome (SSNS) the prolonged treatment with steroids could decrease the frequency of relapses. We conducted a comparative study of prolonged steroid scheme and the usual treatment of primary SSNS to assess: the number of patients with relapses, mean time to treatment initiation, to remission and to first relapse, total number of relapses, total cumulative dose of steroids, and the steroid toxicity. METHODS Patients were divided into two groups: group A (27 patients) received 16-β-methylprednisolone for 12 weeks, reducing the steroid until week 24. Group B (29 patients) received 16-β-methylprednisolone for 12 weeks and placebo until week 24. RESULTS Cumulative incidence rate of relapse (person/years) for group A was of 36/100 and 66/100 for group B (p=0.04). Average elapsed time to first relapse was of 114 days for group A and of 75 days to for group B (p=0.01). The difference in time for initial response to treatment and up to achieve remission between both groups was not significant. Total cumulative relapses were 9 for group A and 17 for group B (p=0.04). Total patients with relapses were 3 for group A and 7 for group B (p=0.17). Cumulative average dose per patient was 5,243mg/m2 for group A and 4,306mg/m2 for group B (p=0.3), and serum cortisol was 14μg/dl for group A and 16μg/dl for group B (p=0.4). There were no steroid toxicity differences between groups. CONCLUSIONS The duration of the treatment had an impact on the number of relapses without increasing steroid toxicity.
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Affiliation(s)
- Miguel Liern
- Servicio de Nefrología, Hospital General de Niños Dr. Ricardo Gutiérrez, Ciudad de Buenos Aires, Argentina.
| | - Paola Codianni
- Servicio de Nefrología, Hospital General de Niños Dr. Ricardo Gutiérrez, Ciudad de Buenos Aires, Argentina
| | - Graciela Vallejo
- Servicio de Nefrología, Hospital General de Niños Dr. Ricardo Gutiérrez, Ciudad de Buenos Aires, Argentina
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Cuzzoni E, De Iudicibus S, Stocco G, Favretto D, Pelin M, Messina G, Ghio L, Monti E, Pasini A, Montini G, Decorti G. In vitro sensitivity to methyl-prednisolone is associated with clinical response in pediatric idiopathic nephrotic syndrome. Clin Pharmacol Ther 2016; 100:268-74. [PMID: 27007551 DOI: 10.1002/cpt.372] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/10/2016] [Accepted: 03/14/2016] [Indexed: 12/17/2022]
Abstract
The aim of this study was to evaluate the in vitro steroid sensitivity as a predictor of clinical response to glucocorticoids in childhood idiopathic nephrotic syndrome (INS). Seventy-four patients (median age 4.33, interquartile range [IQR] 2.82-7.23; 63.5% male) were enrolled in a prospective multicenter study: in vitro steroid inhibition of patients' peripheral blood mononuclear cell proliferation was evaluated by [methyl-(3) H] thymidine incorporation assay at disease onset (T0) and after 4 weeks (T4) of treatment. Steroid dependence was associated with increased in vitro sensitivity at T4 assessed both as drug concentration inducing 50% of inhibition (IC50 ; odds ratio [OR] = 0.48, 95% confidence interval [CI] = 0.24-0.85; P = 0.0094) and maximum inhibition at the highest drug concentration (Imax ; OR = 1.13, 95% CI = 1.02-1.31; P = 0.017). IC50 > 4.4 nM and Imax < 92% at T4 were good predictors for optimal clinical response. These results suggest that this test may be useful for predicting the response to glucocorticoid therapy in pediatric INS.
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Affiliation(s)
- E Cuzzoni
- PhD, School in Sciences of Reproduction and Development, University of Trieste, Trieste, Italy
| | - S De Iudicibus
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - G Stocco
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - D Favretto
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - M Pelin
- Department of Life Sciences, University of Trieste, Trieste, Italy
| | - G Messina
- Policlinico Giovanni XIII di Bari, Bari, Italy
| | - L Ghio
- Pediatric Nephrology and Dialysis Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - E Monti
- Nephrology and Dialysis Unit, Department of Pediatrics, Bologna, Italy
| | - A Pasini
- Nephrology and Dialysis Unit, Department of Pediatrics, Bologna, Italy
| | - G Montini
- Pediatric Nephrology and Dialysis Unit, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - G Decorti
- Department of Life Sciences, University of Trieste, Trieste, Italy
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Dinçel N, Yılmaz E, Kaplan Bulut İ, Hacıkara Ş, Mir S. The long-term outlook to final outcome and steroid treatment results in children with idiopathic nephrotic syndrome. Ren Fail 2015; 37:1267-72. [DOI: 10.3109/0886022x.2015.1073051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Metz DK, Kausman JY. Childhood nephrotic syndrome in the 21st century: What's new? J Paediatr Child Health 2015; 51:497-504. [PMID: 25266706 DOI: 10.1111/jpc.12734] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2014] [Indexed: 11/28/2022]
Abstract
Childhood nephrotic syndrome is a condition managed by general paediatricians and paediatric nephrologists. Whether treating a first presentation or a relapse, the clinician requires expertise in order to minimise the risk of serious complications and optimise long-term care. Indeed, many children suffer a difficult relapsing course in their disease, warranting consideration of second-line therapies. The last two decades have witnessed a growing knowledge of the condition and increased complexity of diagnostic and therapeutic options, which poses a challenge for the general paediatrician, given the condition's relative rarity in daily practice. This review aims to familiarise the reader with some of the most important recent developments and particularly to provide an insight into what management options are available and when it may be appropriate to seek advice from a nephrologist.
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Uwaezuoke SN. Steroid-sensitive nephrotic syndrome in children: triggers of relapse and evolving hypotheses on pathogenesis. Ital J Pediatr 2015; 41:19. [PMID: 25888239 PMCID: PMC4379699 DOI: 10.1186/s13052-015-0123-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 03/04/2015] [Indexed: 01/09/2023] Open
Abstract
Nephrotic syndrome remains the most common manifestation of glomerular disease in childhood. Minimal change nephropathy is the most common cause of the syndrome in children. Despite its initial high response rate to corticosteroids and its favorable prognosis, relapses are common leading to increased morbidity and cost of treatment.This review seeks to appraise the common triggers of relapse and to highlight the evolving hypotheses about the pathogenesis of the syndrome. Literature search was conducted through PubMed, Google web search and Cochrane Database of Systematic reviews using relevant search terms.Acute respiratory infections and urinary tract infections are the most frequent infectious triggers of relapse. Targeted interventions like initiating corticosteroid or its dose-adjustment during episodes of acute respiratory infection and zinc supplementation are reportedly effective in reducing relapse rates. Hypotheses on pathogenesis of the syndrome have evolved from the concepts of 'immune dysregulation', 'increased glomerular permeability' to 'podocytopathy'.Although development of drugs which can regulate the pathways for podocyte injury offers future hope for effective and targeted treatment, the relapse-specific interventions currently contribute to significant reduction in disease morbidity.
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Affiliation(s)
- Samuel N Uwaezuoke
- Department of Paediatric Nephrology Unit, University of Nigeria Teaching Hospital, Postal code- 400001, Ituku-Ozalla, Enugu, Enugu State, Nigeria.
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27
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Sinha A, Menon S, Bagga A. Nephrotic Syndrome: State of the Art. CURRENT PEDIATRICS REPORTS 2015. [DOI: 10.1007/s40124-014-0066-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Extending initial prednisolone treatment in a randomized control trial from 3 to 6 months did not significantly influence the course of illness in children with steroid-sensitive nephrotic syndrome. Kidney Int 2015; 87:217-24. [DOI: 10.1038/ki.2014.240] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 05/25/2014] [Accepted: 05/29/2014] [Indexed: 11/08/2022]
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Sureshkumar P, Hodson EM, Willis NS, Barzi F, Craig JC. Predictors of remission and relapse in idiopathic nephrotic syndrome: a prospective cohort study. Pediatr Nephrol 2014; 29:1039-46. [PMID: 24488504 DOI: 10.1007/s00467-013-2736-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 12/11/2013] [Accepted: 12/16/2013] [Indexed: 01/24/2023]
Abstract
BACKGROUND Although most children with idiopathic nephrotic syndrome will respond to corticosteroid therapy, 80-90 % suffer one or more relapses. METHODS Using Cox proportional hazard models, we analyzed predictors of remission and relapse in 1-year follow-up data on children aged below 15 years with new-onset nephrotic syndrome. RESULTS Of 129 children, 107 achieved remission with corticosteroid therapy and 86 subsequently relapsed. Boys achieved remission more often than girls (adjusted hazard ratio [AHR] 1.52, 95 % confidence interval (CI) 1.02-2.3). Boys relapsed significantly more frequently than girls (AHR 1.77, 95 % CI 1.11-2.83) and were more likely to have frequently relapsing disease (AHR 3.3, 95 % CI 1.18-9.23). The risk of first relapse increased with the number of days to first remission (AHR 1.02, 95 % CI 1.01-1.04). The risk for a frequently relapsing course increased with a shorter time from remission to first relapse (AHR 0.92, 95 % CI 0.87-0.97). CONCLUSIONS In idiopathic nephrotic syndrome, boys are more likely to respond initially, more likely to relapse, and to be classified as having frequently relapsing nephrotic syndrome. A decrease in time from remission to first relapse predicts for a frequently relapsing course.
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Affiliation(s)
- Premala Sureshkumar
- Centre for Kidney Research, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, Sydney, NSW 2145, Australia
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Teeninga N, Kist-van Holthe JE, van den Akker ELT, Kersten MC, Boersma E, Krabbe HG, Knoers NVAM, van der Heijden AJ, Koper JW, Nauta J. Genetic and in vivo determinants of glucocorticoid sensitivity in relation to clinical outcome of childhood nephrotic syndrome. Kidney Int 2014; 85:1444-53. [PMID: 24429396 DOI: 10.1038/ki.2013.531] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 10/15/2013] [Accepted: 10/31/2013] [Indexed: 01/29/2023]
Abstract
Following initial glucocorticoid treatment, the clinical course in children with nephrotic syndrome is highly variable. Intrinsic sensitivity to glucocorticoids might be a determinant of this variability. Functional polymorphisms of the glucocorticoid receptor gene NR3C1 have been associated with either relatively impaired (GR-9β) or increased (BclI) glucocorticoid sensitivity. Here, in a prospective, well-defined cohort of children with nephrotic syndrome, we evaluated both carriage of GR-9β+TthIII-1 and BclI haplotypes in 113 children and a dexamethasone suppression test in 90 children in relation to their clinical outcome over a median follow-up of 4.4 years. Carriers of GR-9β+TthIII-1 had a significantly higher incidence of steroid dependence 13/25 (52%) compared with noncarriers 19/75 (25%) with a hazard ratio adjusted for gender, age, and descent of 3.04 with 95% confidence interval 1.37-6.74. Both first and frequent relapses happened significantly more often in GR-9β+TthIII-1 carriers than in noncarriers. There were no significant differences in therapeutic outcomes between carriers and noncarriers of the BclI haplotype. Results of the dexamethasone test showed no associations with clinical outcome. Thus, the GR-9β+TthIII-1 haplotype of the glucocorticoid receptor gene offers new insights into the clinical course of children with nephrotic syndrome.
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Affiliation(s)
- Nynke Teeninga
- Division of Nephrology, Department of Pediatrics, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Joana E Kist-van Holthe
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
| | - Erica L T van den Akker
- Division of Endocrinology, Department of Pediatrics, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Marie C Kersten
- Division of Nephrology, Department of Pediatrics, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Eric Boersma
- Division of Epidemiology, Department of Cardiology, Thorax Centre, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Hans G Krabbe
- Department of Clinical Chemistry, Medlon, MST Hospital, Enschede, The Netherlands
| | - Nine V A M Knoers
- Department of Medical Genetics, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Albert J van der Heijden
- Division of Nephrology, Department of Pediatrics, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jan W Koper
- Division of Endocrinology, Department of Internal Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands
| | - Jeroen Nauta
- Division of Nephrology, Department of Pediatrics, Erasmus MC University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
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Harambat J, Godron A, Ernould S, Rigothier C, Llanas B, Leroy S. Prediction of steroid-sparing agent use in childhood idiopathic nephrotic syndrome. Pediatr Nephrol 2013. [PMID: 23179197 DOI: 10.1007/s00467-012-2365-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND About half of children with steroid-sensitive idiopathic nephrotic syndrome (INS) will develop steroid dependency or a frequently relapsing course requiring steroid-sparing agents (SSA). Because of the adverse effects of prolonged steroid treatment, the early identification of children at high risk of requiring SSA may be a useful diagnostic tool to tailor the therapeutic strategy. The aim of this study was to identify predictors of the need for SSA and derive a predictive model. METHODS This was a retrospective hospital-based cohort study which included all children with steroid-responsive INS followed for at least 4.5 months. Cox regression modeling and decision curve analysis were performed. RESULTS A total of 120 children (81 boys) with INS were included and followed up for a median time of 6.7 (range 0.4-24.1) years. Median age at diagnosis was 3.4 years. Seventy-two (60 %) children required a SSA after a median time of 10 months following initial diagnosis. Male children, age at disease onset, methylprednisolone pulse use, and time to achieve first remission were significantly associated with the outcome. Time to achieve remission only remained significant after adjustment: hazard ratio (HR) =1.9 [95 % confidence interval (CI) 1.5-2.5] if considered as a continuous variable, and HR=4.1 (95 % CI 1.9-8.6) when dichotomized using the 9-day threshold. The area under the receiver operating curve of the related predictive model was 0.81 (95 % CI 0.74-0.89), and the decision curve analysis demonstrated that this model performed better than any other strategy. CONCLUSIONS Time to first remission is a strong predictor of the need for SSA in pediatric INS. Further prospective and impact studies are warranted to confirm the accuracy and benefit of our prediction model.
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Affiliation(s)
- Jérôme Harambat
- Service de Pédiatrie, Centre de référence Maladies Rénales Rares du Sud Ouest, Centre Hospitalier Universitaire de Bordeaux, Place Amélie Raba Léon, 33076, Bordeaux, France.
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Teeninga N, Kist-van Holthe JE, van Rijswijk N, de Mos NI, Hop WCJ, Wetzels JFM, van der Heijden AJ, Nauta J. Extending prednisolone treatment does not reduce relapses in childhood nephrotic syndrome. J Am Soc Nephrol 2013; 24:149-59. [PMID: 23274956 DOI: 10.1681/asn.2012070646] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Prolonged prednisolone treatment for the initial episode of childhood nephrotic syndrome may reduce relapse rate, but whether this results from the increased duration of treatment or a higher cumulative dose remains unclear. We conducted a randomized, double-blind, placebo-controlled trial in 69 hospitals in The Netherlands. We randomly assigned 150 children (9 months to 17 years) presenting with nephrotic syndrome to either 3 months of prednisolone followed by 3 months of placebo (n=74) or 6 months of prednisolone (n=76), and median follow-up was 47 months. Both groups received equal cumulative doses of prednisolone (approximately 3360 mg/m(2)). Among the 126 children who started trial medication, relapses occurred in 48 (77%) of 62 patients who received 3 months of prednisolone and 51 (80%) of 64 patients who received 6 months of prednisolone. Frequent relapses, according to international criteria, occurred with similar frequency between groups as well (45% versus 50%). In addition, there were no statistically significant differences between groups with respect to the eventual initiation of prednisolone maintenance and/or other immunosuppressive therapy (50% versus 59%), steroid dependence, or adverse effects. In conclusion, in this trial, extending initial prednisolone treatment from 3 to 6 months without increasing cumulative dose did not benefit clinical outcome in children with nephrotic syndrome. Previous findings indicating that prolonged treatment regimens reduce relapses most likely resulted from increased cumulative dose rather than the treatment duration.
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Affiliation(s)
- Nynke Teeninga
- Department of Pediatrics, Division of Nephrology, Erasmus University Medical Centre—Sophia Children’s Hospital, Rotterdam, The Netherlands.
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33
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Disease course in steroid sensitive nephrotic syndrome. Indian Pediatr 2012; 49:881-7. [DOI: 10.1007/s13312-012-0220-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 02/10/2012] [Indexed: 10/27/2022]
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Andersen RF, Palmfeldt J, Jespersen B, Gregersen N, Rittig S. Plasma and urine proteomic profiles in childhood idiopathic nephrotic syndrome. Proteomics Clin Appl 2012; 6:382-93. [DOI: 10.1002/prca.201100081] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
| | - Johan Palmfeldt
- Research Unit for Molecular Medicine; Aarhus University Hospital; Skejby; Aarhus; Denmark
| | - Bente Jespersen
- Department of Nephrology; Aarhus University Hospital; Skejby; Aarhus; Denmark
| | - Niels Gregersen
- Research Unit for Molecular Medicine; Aarhus University Hospital; Skejby; Aarhus; Denmark
| | - Søren Rittig
- Department of Peadiatrics; Aarhus University Hospital; Skejby; Aarhus; Denmark
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37
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Sellier-Leclerc AL, Baudouin V, Kwon T, Macher MA, Guérin V, Lapillonne H, Deschênes G, Ulinski T. Rituximab in steroid-dependent idiopathic nephrotic syndrome in childhood--follow-up after CD19 recovery. Nephrol Dial Transplant 2011; 27:1083-9. [PMID: 21810762 DOI: 10.1093/ndt/gfr405] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anne-Laure Sellier-Leclerc
- Department of Pediatric Nephrology, Robert Debré Hospital, Assistance Publique Hopitaux de Paris, Paris, France.
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Long-term follow-up after cyclophosphamide therapy in steroid-dependent nephrotic syndrome. Pediatr Nephrol 2011; 26:915-20. [PMID: 21399901 DOI: 10.1007/s00467-011-1825-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Revised: 02/06/2011] [Accepted: 02/08/2011] [Indexed: 10/18/2022]
Abstract
Cyclophosphamide (CP) has been used for over 40 years in patients with steroid-sensitive nephrotic syndrome (SSNS) presenting frequent relapses or steroid dependence (SD). We evaluated retrospectively and tried to identify parameters possibly associated with a prolonged and sustained remission (PSR+) ≥5 years in 108 children with steroid-dependent nephrotic syndrome (SDNS) treated with oral CP. Patients had a follow-up time ≥5 years and were divided into two groups according to achievement of PSR (+ and -). Gender, histological injury, cumulative doses of CP, age of onset of illness, and start of treatment and prednisone dose on the occasion of relapse were analyzed. The overall cumulative sustained remission for 5 and 10 years was 25 and 21.6%, respectively. The only factor that influenced a PSR was the degree of SD: the group PSR+ relapsed at prednisone dose of 0.96 ± 0.51 mg/kg vs. 1.29 ± 0.59 mg/kg in group PSR- (p = 0.01). Also, patients who relapsed in the presence of prednisone doses ≤1.4 mg/kg showed a cumulative sustained remission of 43, 35, and 32.7% at 2, 5, and 10 years, respectively, versus 22.5, 12.5, and 5% in those with prednisone >1.4 mg/kg (p = 0.001). Our findings suggest that patients with SDNS who relapse on prednisone dose >1.4 mg/kg are especially prone to an unfavorable response to CP use.
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Early identification of steroid dependency in Japanese children with steroid-sensitive nephrotic syndrome undergoing short-term initial steroid therapy. Pediatr Nephrol 2011; 26:485-6. [PMID: 20730450 DOI: 10.1007/s00467-010-1642-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 07/27/2010] [Accepted: 08/02/2010] [Indexed: 10/19/2022]
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