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Inoki Y, Nishi K, Osaka K, Kaneda T, Akiyama M, Sato M, Ogura M, Kamei K. Association between the time of initial relapse and subsequent relapses in patients with childhood-onset idiopathic nephrotic syndrome. Pediatr Nephrol 2024; 39:2393-2401. [PMID: 38267591 DOI: 10.1007/s00467-024-06286-9] [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: 10/09/2023] [Revised: 12/27/2023] [Accepted: 12/27/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Nephrotic syndrome relapse within 6 months is a known risk factor for steroid-dependent nephrotic syndrome/frequently relapsing nephrotic syndrome (SDNS/FRNS), but the risk of early development of SDNS/FRNS and initiation of immunosuppression therapy remains unknown. METHODS Patients with childhood-onset idiopathic nephrotic syndrome who had the first relapse within 6 months were enrolled. We analyzed the relationship between the time of the first relapse or the time of initial remission and incidence of SDNS/FRNS or initiation of immunosuppression therapy. RESULTS Forty-five patients were enrolled. Twenty out of 23 patients (87%) with the first relapse within 30 days after discontinuing initial steroid therapy experienced a second relapse within 30 days after discontinuing steroid therapy. Additionally, most patients in this group (96%) experienced a second relapse within 6 months after the onset and were diagnosed as SDNS/FRNS at this time. In this group, the incidence of SDNS/FRNS development within 6 months was 96%. In contrast, the incidence of SDNS/FRNS development within 6 months was 18% in patients with the first relapse more than 30 days after steroid discontinuation. The incidence of initiation of immunosuppressive agents within 6 months was 83% in the former group and 14% in the latter group. CONCLUSIONS Most patients with the first relapse within 30 days after discontinuing steroid therapy developed SDNS/FRNS and were administered immunosuppressive agents within 6 months. Thus, it might be reasonable to start immunosuppression therapy in this group without waiting for the second relapse.
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Affiliation(s)
- Yuta Inoki
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-Ku, Tokyo, 157-8535, Japan
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kentaro Nishi
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-Ku, Tokyo, 157-8535, Japan
| | - Kei Osaka
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-Ku, Tokyo, 157-8535, Japan
- Department of Pediatrics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomoya Kaneda
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-Ku, Tokyo, 157-8535, Japan
| | - Misaki Akiyama
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-Ku, Tokyo, 157-8535, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-Ku, Tokyo, 157-8535, Japan
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-Ku, Tokyo, 157-8535, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1, Okura, Setagaya-Ku, Tokyo, 157-8535, Japan.
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Alenazi SA. Incidence and Pathological Patterns of Nephrotic Syndrome among Infants and Children: A Systematic Review. Cureus 2024; 16:e58331. [PMID: 38752042 PMCID: PMC11095912 DOI: 10.7759/cureus.58331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2024] [Indexed: 05/18/2024] Open
Abstract
Nephrotic syndrome (NS) is known to be a prevalent chronic illness in young patients. Periorbital swelling in children with this condition is a recurring symptom, either with or without generalized edema. The current study aimed to examine the incidence and pattern of nephrotic syndrome in infants and children by thoroughly examining the recently available literature. A thorough search of PubMed, SCOPUS, Web of Science, Science Direct, and Google Scholar was conducted, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model, to find pertinent material. The Rayyan software (Qatar Computing Research Institute, Ar-Rayyan, Qatar) was utilized during the whole process. Data from a total of 1418 patients from nine trials were considered in this study. Numerous factors influenced the incidence, mean age, sex dominance, and histological patterns in various sample groups. The current findings conclude that variations in socioeconomic, regional, and genetic factors influence the development and pattern of these diseases. The prevalence of pediatric renal disorders differs throughout countries. Season of occurrence, response to corticosteroid treatment, and histopathologic findings appear to differ amongst the diagnosed cases.
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Affiliation(s)
- Shehab A Alenazi
- Department of Pediatrics, Faculty of Medicine, Northern Border University, Arar, SAU
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Choi N, Min J, Kim JH, Kang HG, Ahn YH. Efficacy and safety of long-term repeated use of rituximab in pediatric patients with nephrotic syndrome. Pediatr Nephrol 2024; 39:771-780. [PMID: 37682369 DOI: 10.1007/s00467-023-06124-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND We aimed to investigate the efficacy and safety of repeated use of rituximab (RTX) in pediatric patients with nephrotic syndrome (NS). METHODS Retrospective review of 50 patients with steroid-dependent NS (SDNS) who had received more than three cycles of RTX was conducted; each consisted of one to four infusions until B lymphocytes were depleted. RESULTS The median age of starting the first RTX cycle was 12.4 years (interquartile ranges (IQR) 10.2-14.6). During a median follow-up period of 6.3 (IQR 3.6-8.6) years, patients received a median of 5.0 RTX cycles (IQR 4.0-7.3). The number of relapses decreased from a median of 2.0 relapses per year (IQR 1.0-3.0) to 0.2 relapses per year (IQR 0.0-0.5) after long-term RTX treatments (P < 0.001). Longer relapse-free periods were associated with more than four RTX cycles, longer B-cell depletion, older age at each RTX treatment, and lower cholesterol levels. B lymphocytes recovered to 1% at a median of 5.9 months (95% confidence interval 5.7-6.1) after RTX administration. Factors related to a longer period of B-cell depletion included more than five RTX cycles, a higher dose of RTX, older age at treatment, and concurrent use of antimetabolites. During repeated RTX treatments, 8.0%, 6.0%, and 2.0% of patients developed hypogammaglobulinemia, severe infection, and severe neutropenia, respectively. CONCLUSIONS Long-term repeated use of RTX may be effective and safe in pediatric NS patients. Furthermore, the redosing of RTX could be chosen by considering predictive factors for relapse-free and B-cell depletion periods.
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Affiliation(s)
- Naye Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeesu Min
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Chungnam National University Sejong Hospital, Sejong, Republic of Korea
| | - Ji Hyun Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
- Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Yo Han Ahn
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.
- Kidney Research Institute, Seoul National University Medical Research Center, Seoul, Republic of Korea.
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Genetic nephrotic syndrome associated with disturbed function of glomerular slit membrane and podocyte cytoskeleton in children. Clin Exp Nephrol 2023; 27:101-109. [PMID: 36482266 DOI: 10.1007/s10157-022-02305-x] [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: 10/05/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Genetic nephrotic syndrome is caused by pathogenic variants in genes encoding proteins necessary for the stability and functionality of the glomerular filtration barrier. To date, more than 70 genes associated with steroid-resistant nephrotic syndrome have been identified. We review the clinical and molecular aspects of genetic nephrotic syndrome with a particular focus on genes associated with slit membrane and podocyte cytoskeleton defects. Sanger sequencing and next-generation sequencing are widely used in the identification of novel gene variants and help us gain a better understanding of the disease. Despite these findings, therapy is mainly supportive and focused on the reduction of proteinuria and management of chronic kidney disease with an unfavorable outcome for a significant proportion of cases. Positive therapeutic effects of immunosuppressive drugs have been reported in some patients; however, their long-time administration cannot be generally recommended. CONCLUSION Personalized treatment based on understanding the distinct disease pathogenesis is needed. With this, it will be possible to avoid harmful immunosuppressive therapy and improve outcomes and quality of life for pediatric patients suffering from genetic nephrotic syndrome.
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The Calcium-Sensing Receptor Stabilizes Podocyte Function in Proteinuric Humans and Mice. Kidney Int 2022; 101:1186-1199. [DOI: 10.1016/j.kint.2022.01.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/15/2021] [Accepted: 01/21/2022] [Indexed: 12/30/2022]
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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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Bajeer I, Khatri S, Hashmi S, Lanewala A. Factors Predicting Short Term Outcome in Children With Idiopathic Nephrotic Syndrome: A Prospective Cohort Study. Cureus 2022; 14:e21538. [PMID: 35223311 PMCID: PMC8864329 DOI: 10.7759/cureus.21538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The objective of the article is to determine the risk factors associated with relapses in children with idiopathic nephrotic syndrome (INS). Material and methods Fifty-seven children with the first episode of INS were included and followed up prospectively for a minimum period of one year to identify the risk factors related to relapses. The study subjects were divided into early (less than eight days) and late (equal to or more than eight days) responder groups and were compared in terms of the number of days to achieve complete remission, time to first relapse, and the pattern of relapse at the last follow-up. Results Of the 57 children, 32 (56%) were male and 25 (44%) female. The mean age of the study cohort was 5.3 ± 3 years. Sixteen (55%) children with ages ranging from one to four years had a higher propensity to develop relapse, although the p-value (p=0.11) was not significant. Gender analysis did not reveal any significant correlation (p=0.32); however, a higher proportion of males (n=17; 63%) responded within eight days of starting steroids than female counterparts (n=10; 37%). Microscopic hematuria at the disease onset was seen in 12 (21%) children, and out of them, five (41.6%) remained in complete remission. The mean time to achieve complete remission was 8.1 ± 3.5 days, while the early responder group had delayed time to first relapse as compared to the late responders (3.1 ± 5.2 vs. 1.6± 3.8; p=0.21). Among all the study participants, a significant number of children (n=20; 51%) were in complete remission at their last follow-up visit. Baseline serum albumin, cholesterol, body mass index (BMI), and serum creatinine had no significant difference. Conclusion The delayed response to steroids and younger age at presentation can predict the time to first relapse and number of relapses in children with INS, respectively.
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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: 8] [Impact Index Per Article: 2.7] [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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Udagawa T, Matsuyama Y, Okutsu M, Motoyoshi Y, Okada M, Tada N, Kikuchi E, Shimoda M, Kanamori T, Omori T, Takahashi M, Imai K, Endo A, Fujiwara T, Morio T. Association between Immunoglobulin M and Steroid Resistance in Children with Nephrotic Syndrome: A Retrospective Multicenter Study in Japan. KIDNEY360 2021; 2:487-493. [PMID: 35369027 PMCID: PMC8785997 DOI: 10.34067/kid.0004432020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 01/11/2021] [Indexed: 02/04/2023]
Abstract
Background The prognosis of steroid-resistant nephrotic syndrome (SRNS) in children is poorer than steroid-sensitive cases. Diagnosis of SRNS is made after observing the response to the initial 4-week corticosteroid therapy, which might be accompanied by side effects. However, predictive indicators at initial diagnosis remain unknown. We aimed to investigate whether selectivity index (SI) and other indicators at initial diagnosis-for example, serum IgM and total serum protein-albumin ratio (TA ratio, total serum protein level over albumin level)-can predict SRNS. Methods A total of 80 children were enrolled from seven hospitals in Japan between January 2008 and December 2019 (mean age, 4.7 years; 65% male). Of the children enrolled, 13 (16%, M/F=5:8) had been diagnosed as steroid resistant after initial treatment with steroids. The association between serum IgM (tertile categories: low, 24-133; middle, 134-169; and high, 169.1-510 mg/dl), SI (<0.2 or ≥0.2), and TA ratio (tertile categories: low, 1.8-2.6; middle, 2.62-3.75; and high, 3.8-15.3) at initial diagnosis and steroid resistance was evaluated with logistic regression, adjusting for age and sex. Results Low levels of serum IgM were significantly associated with steroid resistance (adjusted odds ratio, 6.94; 95% CI, 1.12 to 43.11). TA ratio and SI were not significantly associated with steroid resistance. Conclusions Low levels of serum IgM at initial diagnosis might predict steroid resistance among Japanese children with idiopathic nephrotic syndrome.
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Affiliation(s)
- Tomohiro Udagawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Matsuyama
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mika Okutsu
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yaeko Motoyoshi
- Department of Pediatrics, Tokyo Kita Medical Center Hospital, Tokyo, Japan
| | - Mari Okada
- Department of Pediatrics, Musashino Red Cross Hospital, Tokyo, Japan
| | - Norimasa Tada
- Department of Pediatrics, Tsuchiura General Hospital, Ibaraki, Japan
| | - Eriko Kikuchi
- Department of Pediatrics, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Masuhiro Shimoda
- Department of Pediatrics, Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Toru Kanamori
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan,Department of Pediatrics, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Tae Omori
- Department of Pediatrics, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Masaki Takahashi
- Department of Pediatrics, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Kohsuke Imai
- Department of Community Pediatrics, Perinatal, and Maternal Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akifumi Endo
- Medical Innovation Promotion Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
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Time to Relapse and Its Predictors among Children with Nephrotic Syndrome in Comprehensive Specialized Hospitals, Tigray, Ethiopia, 2019. Int J Pediatr 2020; 2020:8818953. [PMID: 33299427 PMCID: PMC7704192 DOI: 10.1155/2020/8818953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/16/2020] [Accepted: 10/29/2020] [Indexed: 01/19/2023] Open
Abstract
Background Relapse in children with nephrotic syndrome leads to a variety of complications due to prolonged treatment and potential dependency on steroids. However, there is no study conducted to determine the incidence and predictive factors of relapse for nephrotic syndrome in Ethiopia, especially in children. Thus, this study aimed to assess the incidence of relapse and its predictors among children with nephrotic syndrome in Ethiopia. Methods A retrospective study was conducted by reviewing all charts of children with an initial diagnosis of the nephrotic syndrome in tertiary hospitals from 2011 to 2018. Charts of children with a diagnosis of steroid-resistant cases were excluded. The extraction tool was used for data collection, Epi-data manager V-4.4.2 for data entry, and Stata V-14 for cleaning and analysis. Kaplan-Meier curve, log-rank test, life table, and crude hazard ratios were used to describe the data and adjusted hazard ratios with 95% CI and P value for analysis. Median relapse time, incidence rate of relapse, and cumulative relapse probabilities at a certain time interval were computed. Bivariable and multivariate analyses were performed using the Cox proportional hazard regression to identify the factors associated with relapse. Any variable at P < 0.25 in the bivariable analysis was transferred to multivariate analysis. Then, the adjusted hazard ratio with 95% CI and P ≤ 0.05 was used to report the association and to test the statistical significance, respectively. Finally, texts, tables, and graphs were used to present the results. Results and Conclusion. Majority, 64.5% (40/66), of relapses were recorded in the first 12 months of follow-up. The incidence rate of relapse was 42.6 per 1000 child-month-observations with an overall 1454 child-month-observations and the median relapse time of 16 months. Having undernutrition [AHR = 3.44; 95% CI 1.78-6.65], elevated triglyceride [AHR = 3.37; 95% CI 1.04-10.90], decreased serum albumin level [AHR = 3.51; 95% CI 1.81-6.80], and rural residence [AHR = 4.00; 95% CI 1.49-10.76] increased the hazard of relapse. Conclusion and Recommendation. Relapse was higher in the first year of the follow-up period. Undernutrition, hypoalbuminemia, hypertriglyceridemia, and being from rural areas were independent predictors of relapse. A focused evaluation of those predictors during the initial diagnosis of the disease is compulsory.
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Abstract
Background: Nephrotic syndrome is the most common glomerular disease affecting children, characterized by heavy proteinuria, edema, hypoalbuminemia, and hyperlipidemia. The mainstay treatment is with prednisolone, whose response is of prognostic significance. Steroid response rates vary across geographical regions, which may be due to the role of genetic and environmental risk factors among different ethnic groups. There is a paucity of data on response to treatment with prednisolone in pediatric patients with nephrotic syndrome in the Tigray region, Northern Ethiopia. Objectives: To assess the pattern of response to prednisolone in pediatric patients treated for nephrotic syndrome at Ayder Comprehensive Specialized Hospital from 2014 to 2019. Methods: A record-based retrospective study was conducted at Ayder Comprehensive Specialized Hospital Mekelle City, Ethiopia. Data was collected and recorded on a predesigned form. Sixty-three patients fulfilled the inclusion criteria, whose data was entered, coded, and analyzed using the statistical software package (SPSS) version 20. Variables of interest included age, gender, blood pressure, presence of hematuria, acute kidney injury, biopsy, secondary causes of nephrotic syndrome, and response to steroid therapy. Data was presented in tables and graphs. Results: The age of the patients ranged from 1 - 17 years, with a median age of 3 years. Fifty-one patients (81%) were males, with a male to female ratio of 4.2:1. Hematuria was present in 66.7%, whereas hypertension was seen in 49.2% of the patients. Thirty-nine patients (61.9%) were responsive to prednisolone, 24 cases (38.1%) were resistant, 8 (20.5%) were steroid-dependent and 19 (48.7%) had relapses. Younger age (AOR 16.671, 95% CI: 1.645 - 168.904 P = 0.017) and high cholesterol values (AOR 1.013, 95% CI: 1.005 - 1.021 P = 0.01) were independent factors associated with steroid responsiveness. Conclusions: The steroid response rate in this study is similar to that in Asian and some African countries. Most patients in our hospital had atypical features of nephrotic syndrome. Younger age and high cholesterol levels were independent factors affecting steroid response.
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Larkins NG, Liu ID, Willis NS, Craig JC, Hodson EM. Non-corticosteroid immunosuppressive medications for steroid-sensitive nephrotic syndrome in children. Cochrane Database Syst Rev 2020; 4:CD002290. [PMID: 32297308 PMCID: PMC7160055 DOI: 10.1002/14651858.cd002290.pub5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND About 80% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. Of these children, half relapse frequently, and are at risk of adverse effects from corticosteroids. While non-corticosteroid immunosuppressive medications prolong periods of remission, they have significant potential adverse effects. Currently, there is no consensus about the most appropriate second-line agent in children who are steroid sensitive, but who continue to relapse. In addition, these medications could be used with corticosteroids in the initial episode of SSNS to prolong the period of remission. This is the fourth update of a review first published in 2001 and updated in 2005, 2008 and 2013. OBJECTIVES To evaluate the benefits and harms of non-corticosteroid immunosuppressive medications in SSNS in children with a relapsing course of SSNS and in children with their first episode of nephrotic syndrome. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 10 March 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs were included if they involved children with SSNS and compared non-corticosteroid immunosuppressive medications with placebo, corticosteroids (prednisone or prednisolone) or no treatment; compared different non-corticosteroid immunosuppressive medications or different doses, durations or routes of administration of the same non-corticosteroid immunosuppressive medication. DATA COLLECTION AND ANALYSIS Two authors independently assessed study eligibility, risk of bias of the included studies and extracted data. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). The certainty of the evidence was assessed using GRADE. MAIN RESULTS We identified 43 studies (91 reports) and included data from 2428 children. Risk of bias assessment indicated that 21 and 24 studies were at low risk of bias for sequence generation and allocation concealment respectively. Nine studies were at low risk of performance bias and 10 were at low risk of detection bias. Thirty-seven and 27 studies were at low risk of incomplete and selective reporting respectively. Rituximab (in combination with calcineurin inhibitors (CNI) and prednisolone) versus CNI and prednisolone probably reduces the number of children who relapse at six months (5 studies, 269 children: RR 0.23, 95% CI 0.12 to 0.43) and 12 months (3 studies, 198 children: RR 0.63, 95% CI 0.42 to 0.93) (moderate certainty evidence). At six months, rituximab resulted in 126 children/1000 relapsing compared with 548 children/1000 treated with conservative treatments. Rituximab may result in infusion reactions (4 studies, 252 children: RR 5.83, 95% CI 1.34 to 25.29). Mycophenolate mofetil (MMF) and levamisole may have similar effects on the number of children who relapse at 12 months (1 study, 149 children: RR 0.90, 95% CI 0.70 to 1.16). MMF may have a similar effect on the number of children relapsing compared to cyclosporin (2 studies, 82 children: RR 1.90, 95% CI 0.66 to 5.46) (low certainty evidence). MMF compared to cyclosporin is probably less likely to result in hypertrichosis (3 studies, 140 children: RR 0.23, 95% CI 0.10 to 0.50) and gum hypertrophy (3 studies, 144 children: RR 0.09, 95% CI 0.07 to 0.42) (low certainty evidence). Levamisole compared with steroids or placebo may reduce the number of children with relapse during treatment (8 studies, 474 children: RR 0.52, 95% CI 0.33 to 0.82) (low certainty evidence). Levamisole compared to cyclophosphamide may make little or no difference to the risk for relapse after 6 to 9 months (2 studies, 97 children: RR 1.17, 95% CI 0.76 to 1.81) (low certainty evidence). Cyclosporin compared with prednisolone may reduce the number of children who relapse (1 study, 104 children: RR 0.33, 95% CI 0.13 to 0.83) (low certainty evidence). Alkylating agents compared with cyclosporin may make little or no difference to the risk of relapse during cyclosporin treatment (2 studies, 95 children: RR 0.91, 95% CI 0.55 to 1.48) (low certainty evidence) but may reduce the risk of relapse at 12 to 24 months (2 studies, 95 children: RR 0.51, 95% CI 0.35 to 0.74), suggesting that the benefit of the alkylating agents may be sustained beyond the on-treatment period (low certainty evidence). Alkylating agents (cyclophosphamide and chlorambucil) compared with prednisone probably reduce the number of children, who experience relapse at six to 12 months (6 studies, 202 children: RR 0.44, 95% CI 0.32 to 0.60) and at 12 to 24 months (4 studies, 59 children: RR 0.20, 95% CI 0.09 to 0.46) (moderate certainty evidence). IV cyclophosphamide may reduce the number of children with relapse compared with oral cyclophosphamide at 6 months (2 studies, 83 children: RR 0.54, 95% CI 0.34 to 0.88), but not at 12 to 24 months (2 studies, 83 children: RR 0.99, 95% CI 0.76 to 1.29) and may result in fewer infections (2 studies, 83 children: RR 0.14, 95% CI 0.03 to 0.72) (low certainty evidence). Cyclophosphamide compared to chlorambucil may make little or no difference in the risk of relapse after 12 months (1 study, 50 children: RR 1.31, 95% CI 0.80 to 2.13) (low certainty evidence). AUTHORS' CONCLUSIONS New studies incorporated in this review indicate that rituximab is a valuable additional agent for managing children with steroid-dependent nephrotic syndrome. However, the treatment effect is temporary, and many children will require additional courses of rituximab. The long-term adverse effects of this treatment are not known. Comparative studies of CNIs, MMF, levamisole and alkylating agents have demonstrated little or no differences in efficacy but, because of insufficient power; clinically important differences in treatment effects have not been completely excluded.
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Affiliation(s)
- Nicholas G Larkins
- Princess Margaret HospitalDepartment of NephrologyRoberts RdSubiacoWAAustralia6008
| | - 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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Esezobor CI, Solarin AU, Olagunju AT. Significant Burden and Psychological Distress Among Caregivers of Children With Nephrotic Syndrome: A Cross-Sectional Study. Can J Kidney Health Dis 2020; 7:2054358119898016. [PMID: 31949915 PMCID: PMC6950537 DOI: 10.1177/2054358119898016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/12/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Childhood nephrotic syndrome (NS) follows a chronic course in most children.
However, little is known about the psychosocial burden of NS on the
caregivers despite evidence that caregiver burden or impairment in their
well-being may alter the outcome of chronic childhood illnesses. Objectives: To determine the frequency and predictors of significant caregiver burden and
psychological distress among caregivers of children with NS. Design: A cross-sectional study. Setting: Two pediatric nephrology clinics in Lagos, Nigeria. Patients: We included primary caregivers of children with idiopathic NS for at least 6
months. Measurements: The primary outcomes were psychological distress and significant caregiver
burden among caregivers. Methods: We interviewed caregivers using the 12-item General Health Questionnaire
(GHQ-12) and the 6-item Zarit Burden Interview (ZBI-6). The GHQ-12 scores ≥
3 and ZBI-6 scores ≥ 6 indicated psychological distress and significant
caregiver burden, respectively. Results: The caregivers were mostly mothers (77.9%) and married (92.4%), whereas the
children (n = 172) were mainly male (65.1%). Most of the children (n = 152;
88.4%) had steroid-sensitive NS including 24 (14%) children with frequent
relapses or steroid dependence and 20 (11.6%) with steroid-resistant NS. Of
the 172 caregivers, 53 (30.8%) and 30 (17.4%) reported psychological
distress and significant burden, respectively. Caregivers of children in
relapse had adjusted an odds ratio (aOR) with 95% confidence interval (CI)
of 2.45 (1.05-5.67) and 3.30 (1.22-8.92) of psychological distress and
significant caregiver burden, respectively. Furthermore, caregivers of male
children and those who needed help paying for health care had an aOR of 4.61
(1.34-15.68) and 3.06 (1.06-8.87) of significant caregiver burden,
respectively. Limitations: The study was limited by its cross-sectional design and the use of generic
rather than disease-specific instruments. Conclusion: One in every 6 caregivers of children with idiopathic NS reported significant
caregiver burden, and it was associated with psychological distress. Our
findings underscore the need for psychosocial support for caregivers of
children with NS, especially those with identifiable vulnerability.
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Affiliation(s)
- Christopher I Esezobor
- Department of Paediatrics, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Mushin, Nigeria
| | - Adaobi U Solarin
- Department of Paediatrics and Child Health, Lagos State University College of Medicine, Ikeja, Nigeria
| | - Andrew T Olagunju
- Department of Psychiatry, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Mushin, Nigeria
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15
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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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16
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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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17
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Mühlig AK, Lee JY, Kemper MJ, Kronbichler A, Yang JW, Lee JM, Shin JI, Oh J. Levamisole in Children with Idiopathic Nephrotic Syndrome: Clinical Efficacy and Pathophysiological Aspects. J Clin Med 2019; 8:E860. [PMID: 31208104 PMCID: PMC6617114 DOI: 10.3390/jcm8060860] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 12/28/2022] Open
Abstract
Steroid sensitive nephrotic syndrome is one of the most common pediatric glomerular diseases. Unfortunately, it follows a relapsing and remitting course in the majority of cases, with 50% of all cases relapsing once or even more often. Most children with idiopathic nephrotic syndrome respond initially to steroid therapy, nevertheless repeated courses for patients with relapses induce significant steroid toxicity. Patients with frequent relapses or steroid dependency thus require alternative treatment, such as cyclophosphamide, cyclosporine, tacrolimus, mycophenolate mofetil, levamisole, or rituximab. To reduce the relapse rate, several drugs have been used. Among these, levamisole has been considered the least toxic and least expensive therapy. Several randomized controlled trials (RCT) showed that levamisole is effective in reducing the relapse risk in steroid sensitive forms of nephrotic syndrome with a low frequency of side effects. Levamisole is a synthetic imidazothiazole derivative with immune-modulatory properties. In this article, we review recent data from randomized trials and observational studies to assess the efficacy of levamisole in frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome.
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Affiliation(s)
- Anne K Mühlig
- Department of Pediatrics, University Hamburg-Eppendorf, 20246 Hamburg, Germany.
| | - Jun Young Lee
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kangwon 26426, Korea.
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Klink Nord-Heidberg, 22417 Hamburg, Germany.
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck 6020, Austria.
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kangwon 26426, Korea.
| | - Jiwon M Lee
- Department of Pediatric Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea.
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
- Division of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
| | - Jun Oh
- Department of Pediatrics, University Hamburg-Eppendorf, 20246 Hamburg, Germany.
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18
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Bakkum L, Willemen AM, Zoetebier L, Bouts AH. A longitudinal study on the effects of psychological stress on proteinuria in childhood steroid-sensitive nephrotic syndrome. J Psychosom Res 2019; 121:8-13. [PMID: 30739735 PMCID: PMC6543065 DOI: 10.1016/j.jpsychores.2019.01.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Steroid-sensitive nephrotic syndrome (SSNS) in children is often complicated by one or more relapses, as manifested by the appearance of proteinuria. Besides health-related triggers, psychological stress might be related to relapse. This longitudinal study examined the link between perceived stress, emotional valence (feeling happy vs. unhappy) and daily reported proteinuria, and investigated the temporal relation between stressful events and proteinuria. METHOD Sixteen children (4-13 years) diagnosed with SSNS were included. Patients kept an online diary for an average of 124 days, wherein they reported proteinuria (n = 1985 urine samples), perceived stress, emotional valence, medication use and health complaints. Stressful days were determined at the start of the study. Using multilevel analysis, the following associations were tested: (1) the relation between perceived stress, emotional valence and proteinuria, and (2) the temporal relation between stressful days and proteinuria. RESULTS Appearance of proteinuria was reported in 410/1985 urine samples. Perceived stress and not emotional valence significantly predicted proteinuria (95% CI [0.11, 0.27]), even five days later. There was a significant temporal association between stressful days and proteinuria (95% CI [0.22, 1.14]). The effect sizes of these associations were small, f = 0.04 and f = 0.12, respectively. CONCLUSIONS Our findings suggest that psychological stress may trigger proteinuria in children with SSNS. Future research in larger samples is needed to support our findings.
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Affiliation(s)
- Lianne Bakkum
- Department of Public Health and Primary Care, Primary Care Unit, University of Cambridge, Cambridge, United Kingdom; Department of Clinical Child and Family Studies and Amsterdam Public Health, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Agnes Maresa Willemen
- Department of Clinical Child and Family Studies and Amsterdam Public Health, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Antonia H Bouts
- Department of Pediatric Nephrology, Emma Children's Hospital, AMC, Amsterdam, The Netherlands
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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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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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Boyer O, Baudouin V, Bérard E, Dossier C, Audard V, Guigonis V, Vrillon I. [Idiopathic nephrotic syndrome]. Arch Pediatr 2017; 24:1338-1343. [PMID: 29169714 DOI: 10.1016/j.arcped.2017.09.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 08/02/2017] [Accepted: 09/15/2017] [Indexed: 10/18/2022]
Abstract
Nephrotic syndrome (NS) is defined by massive proteinuria and hypoalbuminemia, with resulting hyperlipidemia and edema. The most common cause of NS in children is idiopathic nephrotic syndrome (INS), also called nephrosis. Its annual incidence has been estimated to 1-4 per 100,000 children and varies with age, race, and geography. Many agents or conditions have been reported to be associated with INS such as infectious diseases, drugs, allergy, vaccinations, and malignancies. The disease may occur during the 1st year of life, but it usually starts between the ages of 2 and 7 years. INS is characterized by a sudden onset, edema being the major presenting symptom, but may rarely be discovered during a routine urine analysis. The disease may also be revealed by a complication such as hypovolemia, infection (pneumonia and peritonitis due to Streptococcus pneumoniae), deep-vein or arterial thromboses, and pulmonary embolism. Renal biopsy is usually not indicated in a child aged 1-10 years with typical symptoms and a complete remission with corticosteroids. Conversely, it is indicated in children under 1 year in case of macroscopic hematuria, hypertension, low C3 levels, persistent renal failure, or steroid resistance. Steroid therapy is applied in all children whatever the histopathology. Initial prednisone therapy in France consists of 60mg/m2 administered daily for 4 weeks (maximum dose, 60mg/day), followed by alternate-day prednisone with tapering doses. Eight-five to 90 % patients are steroid-responsive and may relapse, but the majority still responds to steroids over the subsequent courses. Only 1-3 % of patients who are initially steroid-sensitive subsequently become steroid-resistant. Children with primary or secondary steroid-resistance are at risk of end-stage kidney disease. Symptomatic treatment includes salt restriction, fluid restriction when natremia is less than 125 meq/L, reduction of saturated fat and carbohydrates, calcium and vitamin D supplements, anticoagulation, and vaccination. Albumin infusions are only indicated in case of complications. Diuretics should be restricted to cases of severe edema, after hypovolemia has been corrected.
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Affiliation(s)
- O Boyer
- Service de néphrologie pédiatrique, centre de référence syndrome néphrotique idiopathique de l'enfant et de l'adulte, hôpital Necker-Enfants-Malades, institut Imagine, université Paris-Descartes, Assistance publique-Hôpitaux de Paris, 75015 Paris, France.
| | - V Baudouin
- Service de néphrologie pédiatrique, centre de référence syndrome néphrotique idiopathique de l'enfant et de l'adulte, hôpital Robert-Debré, institut Imagine, université Paris-Diderot, Assistance publique-Hôpitaux de Paris, 75019 Paris, France
| | - E Bérard
- Service de néphrologie pédiatrique, CHU de Nice, Archet 2, 06200 Nice, France
| | - C Dossier
- Service de néphrologie pédiatrique, centre de référence syndrome néphrotique idiopathique de l'enfant et de l'adulte, hôpital Robert-Debré, institut Imagine, université Paris-Diderot, Assistance publique-Hôpitaux de Paris, 75019 Paris, France
| | - V Audard
- Service de néphrologie et transplantation, centre de référence syndrome néphrotique idiopathique de l'enfant et de l'adulte, hôpital Henri-Mondor, Inserm U955, université Paris-Est-Créteil, 94010 Créteil, France
| | - V Guigonis
- Département de pédiatrie, hôpital Mère-Enfant, 87000 Limoges, France
| | - I Vrillon
- Service de pédiatrie, hôpital d'enfants, CHRU de Nancy, 54511 Vandœuvre-lès-Nancy, France
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Franke I, Aydin M, Llamas Lopez CE, Kurylowicz L, Ganschow R, Lentze M, Born M. The incidence of the nephrotic syndrome in childhood in Germany. Clin Exp Nephrol 2017. [PMID: 28643120 DOI: 10.1007/s10157-017-1433-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The incidence of childhood nephrotic syndrome (NS) in Germany is not well known. METHODS An ESPED-based nationwide collection of epidemiological data of children in 2005 and 2006. RESULT The mean age of NS at onset was 5.5 ± 3.7 years. The gender ratio of boys to girls was 1.8:1. The average length of stay was 15.5 ± 11.2 days, with younger children remaining significantly longer in hospital. Steroid-resistance was more common in children ≥8 years (p = 0.023). Focal-segmental glomerulosclerosis (FSGS) was more common in children >10 years (p = 0.029). The ratio of males to females with FSGS was 1:1.9, thus the FSGS risk for girls at onset was 3.3-times greater. Considering the available data, the incidence of NS in Germany is 1.2/100,000 in the population <18 years, of which 1.0/100,000 are steroid-sensitive. CONCLUSION Compared with international data, which primarily focused on regional and small populations, this is the largest study about the incidence of the childhood NS.
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Affiliation(s)
- Ingo Franke
- Department of General Paediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Malik Aydin
- Department of General Paediatrics, University Children's Hospital Bonn, Bonn, Germany. .,Centre of Biomedical Education and Research, Helios University Children's Hospital Wuppertal, University of Witten/Herdecke, Witten, Germany. .,Helios University Children's Hospital Wuppertal, University of Witten/Herdecke, Heusnerstr. 40, 42283, Wuppertal, Germany.
| | | | - Lisa Kurylowicz
- Department of General Paediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Rainer Ganschow
- Department of General Paediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Michael Lentze
- Department of General Paediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Mark Born
- Department of Radiology, Paediatric Radiology, University of Bonn, Bonn, Germany
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Alharthi AA. Patterns of Childhood Steroid-Sensitive and Steroid-Resistant Nephrotic Syndrome in Saudi Children. Clin Pediatr (Phila) 2017; 56:177-183. [PMID: 27130200 DOI: 10.1177/0009922816645521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nephrotic syndrome (NS) is one of the most common causes of chronic kidney disease in children. Mostly, NS is controlled by steroids. In spite of this, 10% to 20% of the patients have steroid resistant NS (SRNS), and the rest have steroid sensitive NS (SSNS). Eighty-seven children with NS (66 SSNS; 21SRNS) were retrospectively studied within the past 10 years in Taif region of Saudi Arabia. Regarding outcome, 66 (76%) patient responded to the steroid therapy, while 21 (24%) patients characterize as SRNS. Out of 66 SSNS, 25 children revealed complete remission, 26 were diagnosed as steroid dependent, and 15 were identified as frequent relapses. Among 21 SRNS biopsied patients, focal segmental glomerulosclerosis was the most common histological patterns of NS followed by the membranoproliferative glomerulonephritis pattern, which is significantly different from other studies performed in the Kingdom of Saudi Arabia. Out of 21 SRNS patients, 13 developed chronic kidney disease, 4 got end-stage renal disease, and 4 patients died.
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Affiliation(s)
- Abdulla A Alharthi
- 1 Taif University, Taif, Kingdom of Saudi Arabia.,2 Alhada Armed Forces Hospital, Taif, Kingdom of Saudi Arabia
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Kang HG, Seo H, Lim JH, Kim JI, Han KH, Park HW, Koo JW, Kim KH, Kim JH, Cheong HI, Ha IS. Markers of disease and steroid responsiveness in paediatric idiopathic nephrotic syndrome: Whole-transcriptome sequencing of peripheral blood mononuclear cells. J Int Med Res 2017. [PMID: 28639503 PMCID: PMC5536413 DOI: 10.1177/0300060516652762] [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] [Indexed: 12/13/2022] Open
Abstract
Objective To identify markers of disease and steroid responsiveness in paediatric idiopathic nephrotic syndrome. Methods Whole-transcriptome sequencing was performed of peripheral blood mononuclear cells (PBMCs) from patients with NS. Differentially expressed genes (DEGs) were identified in patients with active NS vs those in remission, and those with steroid-sensitive NS (SSNS) vs steroid-resistant NS (SRNS). Results A total of 1065 DEGs were identified in patients with NS (n = 10) vs those in remission (n = 9). These DEGs correlated with cytokine and/or immune system signalling and the extracellular matrix. Comparisons between SSNS (n = 6) and SRNS (n = 4) identified 1890 DEGs. These markers of steroid responsiveness were enriched with genes related to the cell cycle, targets of microRNAs, and genes related to cytokines. Conclusions Meaningful DEGs were identified. Additional studies with larger numbers of patients will provide more comprehensive data.
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Affiliation(s)
- Hee Gyung Kang
- 1 Department of Paediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,2 Research Coordination Centre for Rare Diseases, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heewon Seo
- 3 Seoul National University Biomedical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea.,4 Systems Biomedical Informatics Research Centre, Seoul National University, Seoul, Republic of Korea
| | - Jae Hyun Lim
- 3 Seoul National University Biomedical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea.,4 Systems Biomedical Informatics Research Centre, Seoul National University, Seoul, Republic of Korea
| | - Jong Il Kim
- 5 Genomic Medicine Institute, Seoul National University, Seoul, Republic of Korea
| | - Kyoung Hee Han
- 6 Department of Paediatrics, Jeju University Hospital, Jeju, Korea
| | - Hye Won Park
- 7 Department of Paediatrics, Seoul National University Bundang Hospital, Gyeonggi-do, Republic of Korea
| | - Ja Wook Koo
- 8 Department of Paediatrics, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Kee Hyuck Kim
- 9 Department of Paediatrics, National Health Insurance Corporation Ilsan Hospital, Gyeonggi-do, Republic of Korea
| | - Ju Han Kim
- 3 Seoul National University Biomedical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea.,4 Systems Biomedical Informatics Research Centre, Seoul National University, Seoul, Republic of Korea
| | - Hae Il Cheong
- 1 Department of Paediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,2 Research Coordination Centre for Rare Diseases, Seoul National University Hospital, Seoul, Republic of Korea.,10 Kidney Research Institute, Medical Research Centre, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Il-Soo Ha
- 1 Department of Paediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,10 Kidney Research Institute, Medical Research Centre, Seoul National University College of Medicine, Seoul, Republic of Korea
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25
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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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26
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Banh TH, Hussain-Shamsy N, Patel V, Vasilevska-Ristovska J, Borges K, Sibbald C, Lipszyc D, Brooke J, Geary D, Langlois V, Reddon M, Pearl R, Levin L, Piekut M, Licht CP, Radhakrishnan S, Aitken-Menezes K, Harvey E, Hebert D, Piscione TD, Parekh RS. Ethnic Differences in Incidence and Outcomes of Childhood Nephrotic Syndrome. Clin J Am Soc Nephrol 2016; 11:1760-1768. [PMID: 27445165 PMCID: PMC5053779 DOI: 10.2215/cjn.00380116] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/31/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Ethnic differences in outcomes among children with nephrotic syndrome are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a longitudinal study at a single regional pediatric center comparing ethnic differences in incidence from 2001 to 2011 census data and longitudinal outcomes, including relapse rates, time to first relapse, frequently relapsing disease, and use of cyclophosphamide. Among 711 children, 24% were European, 33% were South Asian, 10% were East/Southeast Asian, and 33% were of other origins. RESULTS Over 10 years, the overall incidence increased from 1.99/100,000 to 4.71/100,000 among children ages 1-18 years old. In 2011, South Asians had a higher incidence rate ratio of 6.61 (95% confidence interval, 3.16 to 15.1) compared with Europeans. East/Southeast Asians had a similar incidence rate ratio (0.76; 95% confidence interval, 0.13 to 2.94) to Europeans. We determined outcomes in 455 children from the three largest ethnic groups with steroid-sensitive disease over a median of 4 years. South Asian and East/Southeast Asian children had significantly lower odds of frequently relapsing disease at 12 months (South Asian: adjusted odds ratio; 0.55; 95% confidence interval, 0.39 to 0.77; East/Southeast Asian: adjusted odds ratio; 0.42; 95% confidence interval, 0.34 to 0.51), fewer subsequent relapses (South Asian: adjusted odds ratio; 0.64; 95% confidence interval, 0.50 to 0.81; East/Southeast Asian: adjusted odds ratio; 0.47; 95% confidence interval, 0.24 to 0.91), lower risk of a first relapse (South Asian: adjusted hazard ratio, 0.74; 95% confidence interval, 0.67 to 0.83; East/Southeast Asian: adjusted hazard ratio, 0.65; 95% CI, 0.63 to 0.68), and lower use of cyclophosphamide (South Asian: adjusted hazard ratio, 0.82; 95% confidence interval, 0.53 to 1.28; East/Southeast Asian: adjusted hazard ratio, 0.54; 95% confidence interval, 0.41 to 0.71) compared with European children. CONCLUSIONS Despite the higher incidence among South Asians, South and East/Southeast Asian children have significantly less complicated clinical outcomes compared with Europeans.
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Affiliation(s)
| | | | - Viral Patel
- Child Health Evaluative Sciences, Research Institute
| | | | | | | | | | | | - Denis Geary
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Valerie Langlois
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | | | - Rachel Pearl
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Leo Levin
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | | | - Christoph P.B. Licht
- Division of Nephrology, and
- Program in Cell Biology, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Elizabeth Harvey
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Diane Hebert
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Tino D. Piscione
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Rulan S. Parekh
- Child Health Evaluative Sciences, Research Institute
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada; and
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Larkins N, Kim S, Craig J, Hodson E. Steroid-sensitive nephrotic syndrome: an evidence-based update of immunosuppressive treatment in children. Arch Dis Child 2016; 101:404-8. [PMID: 26289063 DOI: 10.1136/archdischild-2015-308924] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/28/2015] [Indexed: 01/08/2023]
Abstract
Nephrotic syndrome is one of the most common paediatric glomerular diseases, with an incidence of around two per 100,000 children per year. Corticosteroids are the mainstay of treatment, with 85%-90% of children going into remission with an 8-week course of treatment. Unfortunately, nephrotic syndrome follows a relapsing and remitting course in the majority, with 90% relapsing at least once. About half will progress to frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS). Different initial steroid regimens have been evaluated since the first trials in Europe and America in the 1960s. Most trials have been designed to evaluate the optimal duration of the initial therapy, rather than different cumulative doses of corticosteroid, or the management of relapses. Until recently, these data suggested that an initial treatment duration of up to 6 months reduced the number of children developing a relapse, without evidence of increased steroid toxicity. Recently, three large, well-designed randomised control trials were published, which demonstrated no significant reduction in risk of relapse or of developing FRNS by extended treatment compared with 2 or 3 months. While there are few trial data to guide the treatment of individual relapses in steroid-sensitive nephrotic syndrome (SSNS), there is some evidence that a short course of corticosteroid therapy during upper respiratory tract infection may prevent relapse. In patients with FRNS or SDNS who continue to relapse despite low-dose alternate-day steroids a number of non-corticosteroid, steroid-sparing immunosuppressive agents (cyclophosphamide, ciclosporin, tacrolimus, mycophenolate mofetil, levamisole, rituximab) have been shown to reduce the risk of relapse and of FRNS. However, there are limited head-to-head data to inform which agent should be preferred. In this article, we review recent data from randomised trials to update paediatricians on the current evidence supporting interventions in SSNS.
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Affiliation(s)
- Nicholas Larkins
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Siah Kim
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia Discipline of Paediatrics and Child Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan Craig
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Elisabeth Hodson
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, New South Wales, Australia Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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Kang HG, Cheong HI. Nephrotic syndrome: what's new, what's hot? KOREAN JOURNAL OF PEDIATRICS 2015; 58:275-82. [PMID: 26388891 PMCID: PMC4573440 DOI: 10.3345/kjp.2015.58.8.275] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/18/2015] [Indexed: 12/17/2022]
Abstract
While the incidence of nephrotic syndrome (NS) is decreasing in Korea, the morbidity of difficult-to-treat NS is significant. Efforts to minimize treatment toxicity showed that prolonged treatment after an initial treatment for 2-3 months with glucocorticosteroids was not effective in reducing frequent relapses. For steroid-dependent NS, rituximab, a monoclonal antibody against the CD20 antigen on B cells, was proven to be as effective, and short-term daily low-dose steroids during upper respiratory infections reduced relapses. Steroid resistance or congenital NS are indications for genetic study and renal biopsy, since the list of genes involved in NS is lengthening.
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Affiliation(s)
- Hee Gyung Kang
- Department of Pediatrics, Research Coordination Center for Rare Diseases, Seoul National University Children's Hospital, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Research Coordination Center for Rare Diseases, Seoul National University Children's Hospital, Seoul, Korea
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29
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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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