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Mahajan V, Siddiqui A, Tahlan A, D 'Cruz S, Jaiswal S. Spectrum of Anemia in Indian children with Nephrotic Syndrome: a prospective observational study. Eur J Pediatr 2023; 182:4723-4729. [PMID: 37572146 DOI: 10.1007/s00431-023-05150-6] [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: 04/28/2023] [Revised: 06/30/2023] [Accepted: 08/05/2023] [Indexed: 08/14/2023]
Abstract
We aimed to estimate the prevalence of anemia in children with nephrotic syndrome (NS), determine its etiology, and correlate severity with disease duration and response to steroids. This was a prospective cohort study carried from 15th July 2019-14th July 2021 at the pediatric nephrology clinic, of a teaching hospital in India. We screened children aged 3 months-18 years with NS for eligibility. We excluded those suffering from chronic kidney disease and, on haematinics. All children underwent investigations for evaluation of nephrotic syndrome and anemia. To define the clinical phenotype of nephrotic syndrome, the patients were classified as infrequent relapsers, frequent relapsers, steroid dependent and steroid resistant NS as per ISPN guidelines. Children were followed up at least for a period of one year to define their response to steroids. A total of 125 children were finally analysed for all treatment outcomes. Of 125, 37 (30%) children presented with the first episode of NS. Remaining 88 were follow up cases of NS. Of 125 children, 41 (33%) were found to be anemic as per the WHO criteria. Iron deficiency anemia was found in 21 (51%) children. Steroid resistance was twice more prevalent in the anemic group compared to the non-anemic group, 7.3% vs 4.8% respectively, however this difference was not statistically significant, p = 0.65. Anemic group had a trend of higher no. of children receiving antihypertensives compared to non-anemics (38 (93%) vs. 67 (80%), p = 0.07. CONCLUSION Iron deficiency anemia was the commonest cause of anemia and, anemia and need for anti-hypertensives to attain BP control and adequate proteinuria often coexisted in children suffering from nephrotic syndrome. WHAT IS KNOWN • Anemia is a significant complication in children suffering from nephrotic syndrome. • Cause of anemia in nephrotic syndrome is multifactorial. WHAT IS NEW • Iron deficiency anemia was the most common cause of anemia in Indian children with nephrotic syndrome. • Anemia and need for anti-hypertensives to attain adequate BP control and proteinuria often coexisted in children with nephrotic syndrome.
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Affiliation(s)
- Vidushi Mahajan
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India.
| | - Anam Siddiqui
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India
| | - Anita Tahlan
- Department of Pathology and Hematology, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Sanjay D 'Cruz
- Department of General Medicine (Nephrology), Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Shivani Jaiswal
- Department of Biochemistry, Government Medical College and Hospital, Sector 32, Chandigarh, India
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Sannamwong N, Buranakarl C, Sutayatram S, Trisiriroj M, Dissayabutra T. The first study on urinary loss of iron and transferrin in association with proteinuria in dogs with chronic kidney disease. Vet World 2023; 16:154-160. [PMID: 36855344 PMCID: PMC9967729 DOI: 10.14202/vetworld.2023.154-160] [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] [Received: 09/05/2022] [Accepted: 12/09/2022] [Indexed: 01/27/2023] Open
Abstract
Background and Aim Anemia is an important factor in surviving chronic kidney disease (CKD). Anemia in CKD is associated with various factors, such as inadequate production of erythropoietin and the availability of iron and its binding protein. Reduced total iron-binding capacity (TIBC) and iron concentrations may be related to their urinary loss along with proteinuria. This study aimed to determine the urinary loss of iron and transferrin (TF) in relation to the degree of proteinuria. Materials and Methods The study was performed on 37 dogs with CKD. Dogs were divided according to the severity of proteinuria into two groups based on the mean of urinary protein-creatinine (UPC) ratio into UPC ratio <4 and UPC ratio >4. The hematocrit (HCT), blood chemistries, plasma iron, plasma TF, UPC ratio, urinary iron per creatinine ratio (U-Iron/CR), and urinary TF per creatinine ratio (U-TF/CR) were evaluated. Results Anemia was associated with the severity of renal impairment as demonstrated by reduction of HCT when staging of CKD was higher. Dogs with UPC ratio >4 had higher urinary loss of both U-Iron/CR (p < 0.01) and U-TF/CR (p < 0.001) with lower plasma TIBC (p < 0.001). The UPC ratio was positively correlated with both U-Iron/CR (r = 0.710, p < 0.001) and U-TF/CR (r = 0.730, p < 0.001) but negatively with TIBC (r = -0.462, p < 0.01). Conclusion Proteinuria was associated with urinary loss of both iron and TF which may contribute to anemia in CKD.
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Affiliation(s)
- Nawat Sannamwong
- Residency Program in Internal Medicine, Faculty of Veterinary Science, Chulalongkorn University, Bangkok 10330, Thailand,The Small Animal Teaching Hospital, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Chollada Buranakarl
- Department of Physiology, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, 10330, Thailand,Corresponding author: Chollada Buranakarl, e-mail: Co-authors: NS: , SS: , MT: , TD:
| | - Saikaew Sutayatram
- Department of Physiology, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Monkon Trisiriroj
- The Small Animal Teaching Hospital, Faculty of Veterinary Science, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Thasinas Dissayabutra
- STAR Unit of Renal Biochemistry and Stone Disease, Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
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Zhao C, Tang J, Li X, Yan Z, Zhao L, Lang W, Yuan C, Zhou C. Beneficial effects of procyanidin B2 on adriamycin-induced nephrotic syndrome mice: the multi-action mechanism for ameliorating glomerular permselectivity injury. Food Funct 2022; 13:8436-8464. [PMID: 35861207 DOI: 10.1039/d1fo03616e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Despite considerable advances in prevention, diagnosis, and therapy, nephrotic syndrome (NS) remains a significant cause of high morbidity and mortality globally. As a result, there is an urgent need to identify novel effective preventative and therapeutic agents for NS. NS is implicated in glomerular permselectivity injury, which can be attributed to oxidative distress, inflammation, lipid nephrotoxicity, podocyte apoptosis, autophagy dysfunction, and slit diaphragm (SLD) dysfunction. In addition to its well-documented antioxidant potency, procyanidin B2 (PB2) may exhibit pleiotropic effects by targeting various canonical signaling events, such as NF-κB, PPARs, PI3K/Akt, mTOR, and the caspase family. As a result, PB2 may be a promising therapeutic target against NS. To test this hypothesis, we established an Adriamycin (ADR)-induced NS mouse model to evaluate the pleiotropic renoprotective effects of PB2 on NS. Here, we demonstrated that PB2 improves podocyte injury via inhibition of NOX4/ROS and Hsp90/NF-κB to exhibit antioxidant and anti-inflammatory potency, respectively. We also show that PB2 indirectly activates the PI3K/Akt axis by regulating SLD protein levels, resulting in normalized podocyte apoptosis and autophagy function. Further, loss of albumin (ALB) induces lipid nephrotoxicity, which we found to be alleviated by PB2 via activation of PPARα/β-mediated lipid homeostasis and the cholesterol efflux axis. Interestingly, our results also suggested that PB2 reduces electrolyte abnormalities and edema. In addition, PB2 may contribute protective effects against trace element dys-homeostasis, which, through alleviating serum ALB loss, leads to a protective effect on glomerular permselectivity injury. Taken together, our results reveal that the identified mechanisms of PB2 on NS are multifactorial and involve inhibition of oxidative distress and inflammatory responses, as well as improvements in podocyte apoptosis and autophagy dysfunction, amelioration of lipid nephrotoxicity, and modulation of electrolyte abnormalities and edema. Thus, we provide a theoretical basis for the clinical application of PB2 against NS.
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Affiliation(s)
- Chuanping Zhao
- Key Laboratory of Pharmaceutical Quality Control of Hebei Province, College of Pharmaceutical Sciences, Institute of Life Science and Green Development, Hebei University, 180 WuSi Road, Lianchi District, Baoding, 071002, China.
| | - Jiamei Tang
- Key Laboratory of Pharmaceutical Quality Control of Hebei Province, College of Pharmaceutical Sciences, Institute of Life Science and Green Development, Hebei University, 180 WuSi Road, Lianchi District, Baoding, 071002, China.
| | - Xiaoya Li
- Key Laboratory of Pharmaceutical Quality Control of Hebei Province, College of Pharmaceutical Sciences, Institute of Life Science and Green Development, Hebei University, 180 WuSi Road, Lianchi District, Baoding, 071002, China.
| | - Zihan Yan
- Key Laboratory of Pharmaceutical Quality Control of Hebei Province, College of Pharmaceutical Sciences, Institute of Life Science and Green Development, Hebei University, 180 WuSi Road, Lianchi District, Baoding, 071002, China.
| | - Liangliang Zhao
- Department of Monitoring and Analysis, Baoding Environmental Monitoring Center of Hebei Province, 224 Dongfeng Road, Lianchi District, Baoding, 071000, China
| | - Wenbo Lang
- Department of Monitoring and Analysis, Baoding Environmental Monitoring Center of Hebei Province, 224 Dongfeng Road, Lianchi District, Baoding, 071000, China
| | - Chunmao Yuan
- State Key Laboratory of Functions and Applications of Medicinal Plants, Guizhou Medical University, Guiyang 550014, China
| | - Chengyan Zhou
- Key Laboratory of Pharmaceutical Quality Control of Hebei Province, College of Pharmaceutical Sciences, Institute of Life Science and Green Development, Hebei University, 180 WuSi Road, Lianchi District, Baoding, 071002, China.
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Anderson S. Congenital Nephrotic Syndrome of the Finnish Type in a Dominican Newborn: An Overview and Case Report. Neonatal Netw 2022; 41:83-88. [PMID: 35260424 DOI: 10.1891/11-t-745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 12/30/2022]
Abstract
Congenital nephrotic syndrome of the Finnish type (CNS-FT) is a rare genetic condition that causes massive proteinuria, hypoproteinemia, hypercholesterolemia, and edema that progresses to end-stage renal disease. Symptoms may manifest in utero as fetal hydrops or during the first few days to months of life. This article shares the case of a Dominican infant who presented with CNS-FT. It provides a comprehensive overview of CNS-FT including the underlying genetic cause, prenatal and postnatal diagnostic testing options, and treatment recommendations. It walks the reader through the diagnostic and initial and longer-term management of this infant and provides patient outcome at 10 months of age.
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Drüeke TB, Massy ZA. Role of proteinuria in the anemia of chronic kidney disease. Kidney Int 2021; 100:1160-1162. [PMID: 34802554 DOI: 10.1016/j.kint.2021.09.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
The most important contributors to the anemia of patients with chronic kidney disease are insufficient erythropoietin production and erythropoietin hyporesponsiveness, decreased red blood cell half-life, iron deficiency, and inflammation. However, in contrast to the role of kidney failure, that of proteinuria and nephrotic syndrome is less clear. Bissinger et al. now provide evidence in mouse models and patients with chronic kidney disease that heavy proteinuria alters erythrocyte metabolism and increases erythrocyte death.
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Affiliation(s)
- Tilman B Drüeke
- Inserm U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), and Paris Saclay University, Villejuif, France.
| | - Ziad A Massy
- Inserm U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Versailles Saint-Quentin-en-Yvelines University (Paris-Ile-de-France-Ouest University, UVSQ), and Paris Saclay University, Villejuif, France; Department of Nephrology, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Boulogne-Billancourt/Paris, France
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Acharya R, Upadhyay K. An Unusual Occurrence of Erythrocytosis in a Child with Nephrotic Syndrome and Advanced Chronic Kidney Disease. Pediatr Rep 2021; 13:463-469. [PMID: 34449692 PMCID: PMC8396269 DOI: 10.3390/pediatric13030053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/21/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Anemia is common in patients with nephrotic syndrome (NS) for various reasons. Furthermore, anemia can occur in patients with chronic kidney disease (CKD) predominantly owing to inappropriately low erythropoietin (EPO) production relative to the degree of anemia. However, erythrocytosis is uncommon in patients with NS and advanced CKD who are not treated with exogenous erythropoietin stimulating agents, and when present, will necessitate exploration of the other etiologies. Case summary: Here, we describe an 8-year-old girl with erythrocytosis in association with NS and advanced CKD. The patient was found to have erythrocytosis during the evaluation for hypertensive urgency. She also had nephrotic range proteinuria without edema. Serum hemoglobin and hematocrit were 17 gm/dL and 51%, respectively, despite hydration. Renal function test showed an estimated glomerular filtration rate of 30 mL/min/1.73 m2. There was mild iron deficiency anemia with serum iron saturation of 18%. Serum EPO level was normal. Urine EPO was not measured. Renal biopsy showed evidence of focal segmental glomerulosclerosis. Genetic testing for NS showed mutations in podocyte genes: NUP93, INF2, KANK1, and ACTN4. Gene sequence analysis of genes associated with erythrocytosis showed no variants in any of these genes. She required chronic dialysis ten months later and, subsequently, a renal transplantation 14 months after the initial presentation. Conclusion: Since the serum EPO level was normal, an increased sensitivity to EPO is the most probable mechanism of erythrocytosis. The unusual association of erythrocytosis in patients with NS and advanced CKD needs to be studied further in larger studies.
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Affiliation(s)
- Ratna Acharya
- Division of General Pediatrics, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA;
| | - Kiran Upadhyay
- Division of Pediatric Nephrology, Department of Pediatrics, University of Florida, Gainesville, FL 32610, USA
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7
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Iron deficiency in proteinuric children with nephrotic syndrome: A cross-sectional pilot study. Arch Pediatr 2021; 28:485-487. [PMID: 34226064 DOI: 10.1016/j.arcped.2021.05.005] [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: 11/03/2020] [Revised: 02/23/2021] [Accepted: 05/16/2021] [Indexed: 11/21/2022]
Abstract
Massive proteinuria in nephrotic syndrome causes depletion of various proteins. Iron deficiency can occur due to urinary loss of iron, transferrin, and soluble transferrin receptors. We conducted this cross-sectional study of 52 children with proteinuric nephrotic syndrome, aged 1-12 years (mean 7.1±2.7 years). Hemoglobin (Hb), RBC indices (MCV, MCH, MCHC), percentage of hypochromic RBCs (Hypo-He), reticulocyte hemoglobin content (Ret-He), and serum ferritin were examined. Seven (13%) patients had iron deficiency anemia and another 10 (19%) exhibited iron deficiency. A higher proportion of children with steroid-resistant disease had anemia than did steroid-sensitive children (P=0.076). Thus, children with nephrotic syndrome may have iron deficiency (32.7%), which needs to be screened.
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8
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Maier JI, Rogg M, Helmstädter M, Sammarco A, Walz G, Werner M, Schell C. A Novel Model for Nephrotic Syndrome Reveals Associated Dysbiosis of the Gut Microbiome and Extramedullary Hematopoiesis. Cells 2021; 10:cells10061509. [PMID: 34203913 PMCID: PMC8232754 DOI: 10.3390/cells10061509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/10/2021] [Accepted: 06/10/2021] [Indexed: 12/15/2022] Open
Abstract
Glomerular kidney disease causing nephrotic syndrome is a complex systemic disorder and is associated with significant morbidity in affected patient populations. Despite its clinical relevance, well-established models are largely missing to further elucidate the implications of uncontrolled urinary protein loss. To overcome this limitation, we generated a novel, inducible, podocyte-specific transgenic mouse model (Epb41l5fl/fl*Nphs1-rtTA-3G*tetOCre), developing nephrotic syndrome in adult mice. Animals were comprehensively characterized, including microbiome analysis and multiplexed immunofluorescence imaging. Induced knockout mice developed a phenotype consistent with focal segmental glomerular sclerosis (FSGS). Although these mice showed hallmark features of severe nephrotic syndrome (including proteinuria, hypoalbuminemia and dyslipidemia), they did not exhibit overt chronic kidney disease (CKD) phenotypes. Analysis of the gut microbiome demonstrated distinct dysbiosis and highly significant enrichment of the Alistipes genus. Moreover, Epb41l5-deficient mice developed marked organ pathologies, including extramedullary hematopoiesis of the spleen. Multiplex immunofluorescence imaging demonstrated red pulp macrophage proliferation and mTOR activation as driving factors of hematopoietic niche expansion. Thus, this novel mouse model for adult-onset nephrotic syndrome reveals the significant impact of proteinuria on extra-renal manifestations, demonstrating the versatility of this model for nephrotic syndrome-related research.
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Affiliation(s)
- Jasmin I. Maier
- Institute of Surgical Pathology, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany; (J.I.M.); (M.R.); (A.S.); (M.W.)
| | - Manuel Rogg
- Institute of Surgical Pathology, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany; (J.I.M.); (M.R.); (A.S.); (M.W.)
| | - Martin Helmstädter
- Department of Medicine IV, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany; (M.H.); (G.W.)
| | - Alena Sammarco
- Institute of Surgical Pathology, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany; (J.I.M.); (M.R.); (A.S.); (M.W.)
| | - Gerd Walz
- Department of Medicine IV, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany; (M.H.); (G.W.)
| | - Martin Werner
- Institute of Surgical Pathology, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany; (J.I.M.); (M.R.); (A.S.); (M.W.)
| | - Christoph Schell
- Institute of Surgical Pathology, Faculty of Medicine, Medical Center-University of Freiburg, 79106 Freiburg, Germany; (J.I.M.); (M.R.); (A.S.); (M.W.)
- Correspondence:
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Mei H, Wu N, Huang X, Cui Z, Xu J, Yang X, Zeng F, Wang K. Possible mechanisms by which silkworm faeces extract ameliorates adenine-induced renal anaemia in rats. JOURNAL OF ETHNOPHARMACOLOGY 2021; 266:113448. [PMID: 33022342 DOI: 10.1016/j.jep.2020.113448] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/15/2020] [Accepted: 09/30/2020] [Indexed: 06/11/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Silkworm faeces are the dry faeces of the insect Bombyx mori (Linnaeus) and have historically been used in traditional Chinese medicine to treat blood deficiency and rheumatic pain. Silkworm faeces extract (SFE) is derived from silkworm faeces. AIM OF THE STUDY Clinical observations of patients in the Department of Nephrology have shown that SFE effectively improves renal anaemia. However, the molecular mechanism remains unclear. This article mainly explores the regulatory effects of SFE on erythropoietin (EPO) and hepcidin to identify the molecular mechanism of SFE. MATERIALS AND METHODS A rat model of renal anaemia was established by feeding rats food containing 0.75% adenine. SFE was orally administered to the rats, while recombinant human erythropoietin (rhEPO) was used as a positive control drug. Haematological parameters and inflammation levels were compared between rats from each group, and pathological kidney sections from each rat were observed. The serum EPO and hepcidin levels were detected using enzyme-linked immunosorbent assay (ELISA) kits, while Western blot analyses were performed to detect the levels of proteins involved in the EPO-related hypoxia-inducible factor 2α (HIF-2α)/prolyl hydroxylase 2 (PHD2) signalling pathway and hepcidin-related BMP6/SMAD4 and interleukin-6 (IL-6)/STAT3 signalling pathways. RESULTS SFE significantly ameliorated haematological parameters, renal function, and inflammation levels in the rats. A mechanistic study showed that SFE promoted EPO expression by upregulating HIF-2α expression and inhibiting the expression of NF-κB and GATA2 both in vivo and in vitro. In particular, SFE inhibited PHD2 expression, resulting in a decrease in the enzymatic reaction of HIF-2α to increase EPO expression. Furthermore, SFE inhibited hepcidin expression by blocking the BMP6/SMAD4 and IL-6/STAT3 pathways. CONCLUSIONS SFE regulated iron metabolism by inhibiting hepcidin and simultaneously promoted EPO synthesis to improve renal anaemia in rats.
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Affiliation(s)
- Hao Mei
- Hubei Key Laboratory of Nature Medicinal Chemistry and Resource Evaluation, Tongji Medical College of Huazhong University of Science and Technology, No. 13, Hongkong Road, 430030, Wuhan, China
| | - Niuniu Wu
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiao Huang
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zheng Cui
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jingya Xu
- Hubei Key Laboratory of Nature Medicinal Chemistry and Resource Evaluation, Tongji Medical College of Huazhong University of Science and Technology, No. 13, Hongkong Road, 430030, Wuhan, China
| | - Xiawen Yang
- Hubei Key Laboratory of Nature Medicinal Chemistry and Resource Evaluation, Tongji Medical College of Huazhong University of Science and Technology, No. 13, Hongkong Road, 430030, Wuhan, China
| | - Fang Zeng
- Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Kaiping Wang
- Hubei Key Laboratory of Nature Medicinal Chemistry and Resource Evaluation, Tongji Medical College of Huazhong University of Science and Technology, No. 13, Hongkong Road, 430030, Wuhan, China.
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Hampson KJ, Gay ML, Band ME. Pediatric Nephrotic Syndrome: Pharmacologic and Nutrition Management. Nutr Clin Pract 2021; 36:331-343. [PMID: 33469930 DOI: 10.1002/ncp.10622] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/10/2020] [Accepted: 11/21/2020] [Indexed: 12/16/2022] Open
Abstract
Nephrotic syndrome is a common kidney disease during childhood that is characterized by alterations in glomerular filtration and leads to protein, fluid, and nutrient loss in the urine. Most patients experience peripheral, gravity-dependent edema; however, serious cases exhibit anasarca and ascites. Many long-term complications of the disease exist due to the underlying pathology and the therapies used for treatment, including metabolic bone disease, micronutrient deficiencies, and hyperlipidemia. Pharmacologic and nutrition interventions are key to appropriate management. Fluid and sodium restriction in combination with corticosteroids, albumin, and diuretics are used to manage edema. Steroid-sparing therapies like alkylating agents and calcineurin inhibitors and dietary modification to eliminate dairy and gluten may be warranted in patients with frequent relapses or steroid-refractory disease. Nutrition clinicians should familiarize themselves with the nuances of treating this disease to optimize care for children with nephrotic syndrome.
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Affiliation(s)
- Kyle J Hampson
- Division of Pharmacy Practice, Arnold and Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Brooklyn, New York, USA.,Division of Pharmacotherapy Services, The Brooklyn Hospital Center, Brooklyn, New York, USA
| | - Morgan L Gay
- Department of Pediatric Nephrology, Connecticut Children's, Hartford, Connecticut, USA
| | - Molly E Band
- Department of Pediatric Urology, Yale New Haven Hospital, New Haven, Connecticut, USA
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Boyer O, Schaefer F, Haffner D, Bockenhauer D, Hölttä T, Bérody S, Webb H, Heselden M, Lipska-Zie˛tkiewicz BS, Ozaltin F, Levtchenko E, Vivarelli M. Management of congenital nephrotic syndrome: consensus recommendations of the ERKNet-ESPN Working Group. Nat Rev Nephrol 2021; 17:277-289. [PMID: 33514942 PMCID: PMC8128706 DOI: 10.1038/s41581-020-00384-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 01/30/2023]
Abstract
Congenital nephrotic syndrome (CNS) is a heterogeneous group of disorders characterized by nephrotic-range proteinuria, hypoalbuminaemia and oedema, which manifest in utero or during the first 3 months of life. The main cause of CNS is genetic defects in podocytes; however, it can also be caused, in rare cases, by congenital infections or maternal allo-immune disease. Management of CNS is very challenging because patients are prone to severe complications, such as haemodynamic compromise, infections, thromboses, impaired growth and kidney failure. In this consensus statement, experts from the European Reference Network for Kidney Diseases (ERKNet) and the European Society for Paediatric Nephrology (ESPN) summarize the current evidence and present recommendations for the management of CNS, including the use of renin-angiotensin system inhibitors, diuretics, anticoagulation and infection prophylaxis. Therapeutic management should be adapted to the clinical severity of the condition with the aim of maintaining intravascular euvolaemia and adequate nutrition, while preventing complications and preserving central and peripheral vessels. We do not recommend performing routine early nephrectomies but suggest that they are considered in patients with severe complications despite optimal conservative treatment, and before transplantation in patients with persisting nephrotic syndrome and/or a WT1-dominant pathogenic variant.
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Affiliation(s)
- Olivia Boyer
- grid.412134.10000 0004 0593 9113Department of Pediatric Nephrology, Reference center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France ,grid.508487.60000 0004 7885 7602Laboratory of Hereditary Kidney Diseases, Imagine Institute, INSERM U1163, Paris Descartes University, Paris, France
| | - Franz Schaefer
- grid.7700.00000 0001 2190 4373Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Dieter Haffner
- grid.10423.340000 0000 9529 9877Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Hannover, Germany ,grid.10423.340000 0000 9529 9877Center for Congenital Kidney Diseases, Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Detlef Bockenhauer
- grid.424537.30000 0004 5902 9895UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tuula Hölttä
- grid.15485.3d0000 0000 9950 5666Department of Pediatric Nephrology and Transplantation, The New Children’s Hospital, HUS Helsinki University Hospital, Helsinki, Finland
| | - Sandra Bérody
- grid.412134.10000 0004 0593 9113Department of Pediatric Nephrology, Reference center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France
| | - Hazel Webb
- grid.424537.30000 0004 5902 9895UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Beata S. Lipska-Zie˛tkiewicz
- grid.11451.300000 0001 0531 3426Clinical Genetics Unit, Department of Biology and Medical Genetics, Medical University of Gdańsk, Gdańsk, Poland ,grid.11451.300000 0001 0531 3426Centre for Rare Diseases, Medical University of Gdańsk, Gdańsk, Poland
| | - Fatih Ozaltin
- grid.14442.370000 0001 2342 7339Department of Pediatric Nephrology and Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elena Levtchenko
- grid.5596.f0000 0001 0668 7884Division of Pediatric Nephrology, Department of Pediatrics, University Hospitals Leuven; Department of Development & Regeneration, University of Leuven, Leuven, Belgium
| | - Marina Vivarelli
- grid.414125.70000 0001 0727 6809Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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Abstract
Podocytopathies are kidney diseases in which direct or indirect podocyte injury drives proteinuria or nephrotic syndrome. In children and young adults, genetic variants in >50 podocyte-expressed genes, syndromal non-podocyte-specific genes and phenocopies with other underlying genetic abnormalities cause podocytopathies associated with steroid-resistant nephrotic syndrome or severe proteinuria. A variety of genetic variants likely contribute to disease development. Among genes with non-Mendelian inheritance, variants in APOL1 have the largest effect size. In addition to genetic variants, environmental triggers such as immune-related, infection-related, toxic and haemodynamic factors and obesity are also important causes of podocyte injury and frequently combine to cause various degrees of proteinuria in children and adults. Typical manifestations on kidney biopsy are minimal change lesions and focal segmental glomerulosclerosis lesions. Standard treatment for primary podocytopathies manifesting with focal segmental glomerulosclerosis lesions includes glucocorticoids and other immunosuppressive drugs; individuals not responding with a resolution of proteinuria have a poor renal prognosis. Renin-angiotensin system antagonists help to control proteinuria and slow the progression of fibrosis. Symptomatic management may include the use of diuretics, statins, infection prophylaxis and anticoagulation. This Primer discusses a shift in paradigm from patient stratification based on kidney biopsy findings towards personalized management based on clinical, morphological and genetic data as well as pathophysiological understanding.
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Lim AKH, Kansal A, Kanellis J. Factors associated with anaemia in kidney transplant recipients in the first year after transplantation: a cross-sectional study. BMC Nephrol 2018; 19:252. [PMID: 30290796 PMCID: PMC6173839 DOI: 10.1186/s12882-018-1054-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 09/24/2018] [Indexed: 11/13/2022] Open
Abstract
Background Anaemia after kidney transplantation may reduce quality of life, graft or patient survival. We aimed to determine the prevalence and risk factors for anaemia in the initial 12 months after transplantation. Methods We conducted a cross-sectional study at 6 and 12 months after transplantation. Anaemia was defined by World Health Organization criteria taking into consideration erythropoietin use. Logistic regression was used to determine the association between demographic, clinical and pharmacological risk factors for the main outcome of moderate-severe anaemia. Results A total of 336 transplant recipients were included and the prevalence of moderate-severe anaemia was 27.4% at 6 months and 15.2% at 12 months. Lower kidney function, female gender, transferrin saturation below 10% and proteinuria were associated with moderate-severe anaemia at both time points. Recent intravenous immunoglobulin treatment was associated with anaemia at 6 months. Recent infection and acute rejection were also associated with anaemia 12 months. Around 20% of patients had at least one blood transfusion but they were uncommon beyond 3 months. Conclusions Anaemia remains highly prevalent requiring treatment with erythropoietin and transfusions. Most identifiable risk factors relate to clinical problems rather than pharmacological management, while markers of iron-deficiency remain difficult to interpret in this setting. Electronic supplementary material The online version of this article (10.1186/s12882-018-1054-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andy K H Lim
- Department of Nephrology, Monash Health, Clayton, Victoria, 3168, Australia. .,Department of Medicine, Monash University, Clayton, Victoria, 3168, Australia.
| | - Arushi Kansal
- Department of Nephrology, Monash Health, Clayton, Victoria, 3168, Australia
| | - John Kanellis
- Department of Nephrology, Monash Health, Clayton, Victoria, 3168, Australia.,Department of Medicine, Monash University, Clayton, Victoria, 3168, Australia
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Fan J, Fu R, Ren F, He J, Wang S, Gou M. A case report of CRB2 mutation identified in a Chinese boy with focal segmental glomerulosclerosis. Medicine (Baltimore) 2018; 97:e12362. [PMID: 30212996 PMCID: PMC6156060 DOI: 10.1097/md.0000000000012362] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
RATIONALE Focal segmental glomerulosclerosis (FSGS) is a common disease resulting in end-stage renal disease. The incidence of FSGS is increasing in Western countries. The clinical manifestations include proteinuria, hypoproteinemia, oedema, and hypertension. Single-gene heritable mutations are considered to be the source of FSGS pathogenicity according to recent in-depth studies on the pathogenesis. Here, we first reported the case of a Chinese boy whose histology presented with FSGS caused by a compound heterozygous mutation. PATIENT CONCERNS A 7-year-old Chinese boy was repeatedly admitted to our hospital for fever, cough, and proteinuria since he was 1.6 years old. DIAGNOSES FSGS was identified by renal biopsy. Whole exome sequencing (WES) showed that a novel mutation of crumbs homolog 2 (CRB2) was identified in a Chinese boy with FSGS. INTERVENTIONS Patient was treated with low-dose corticosteroid and mycophenolate mofetil for maintenance therapy. OUTCOMES At last follow-up, protein (+∼++) was observed in his urinalysis. LESSONS We identified a novel mutation of CRB2 in a Chinese boy with FSGS that had never been described in a previous report. These findings suggested that mutations in recessive disease genes are more frequent among early-onset disease.
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