Hepatitis B surface antigenemia in North American children with membranous glomerulonephropathy. Southwest Pediatric Nephrology Study Group

Hepatitis B-related glomerulonephritis and optimization of treatment

Introduction: Multiple studies have revealed a strong relationship between the development of nephropathy and hepatitis B virus (HBV) infection. The underlying pathogenesis of hepatitis B-related glomerulonephritis (HBV-GN) involves immune complexes, which can be isolated from kidney tissues. Clearance of HBV antigenemia improves renal impairment and proteinuria in HBV-GN patients.Areas covered: In this review, we present our current understanding of the epidemiology, pathogenesis, pathology, diagnosis, and treatment of HBV-GN. We discuss the advantages and disadvantages of oral nucleoside/nucleotide analogs (NAs), and the main pharmaceutical treatment for hepatis B.Expert opinion: Currently, antiviral agents are the main HBV-GN therapeutic agents. Although no randomized controlled clinical trials have compared the efficacy of interferon (IFN) and NA, we suggest IFN treatment for pediatric patients (IFN-α in patients ≥1 year; pegIFN-α in patients ≥3 years) considering treatment duration and absence of resistance. Novel NAs have brought about promising treatment options involving high efficacy viral suppression and low resistance rates. NAs with a high barrier to resistance (e.g. entecavir) are recommended as first-line therapy of HBV-GN. Immunosuppression monotherapy, such as corticosteroids, is of little benefit and potentially harmful to HBV-GN patients due to the possibility of viral reactivation.

WITHDRAWN: The combination of tacrolimus and entecavir improves the remission of HBV-associated glomerulonephritis without enhancing viral replication

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Hepatitis B virus-related glomerulonephritis: not a predominant cause of proteinuria in korean patients with chronic hepatitis B

Background/Aims. Hepatitis B virus (HBV) can form immune complexes which may result in various types of glomerulonephritis (GN). However, proteinuria can occur because of other kidney diseases besides HBV-related GN (HBV-GN). The aim of this study is to elucidate the causes of proteinuria and report on the clinical outcomes of HBV-GN. Methods. We reviewed the medical records of patients positive for serum hepatitis B surface antigen who underwent renal biopsies due to proteinuria at a tertiary medical center in Korea. Results. A total of 55 patients were included. HBV-GN was diagnosed in 20 (36.4%) of the patients by confirming the presence of immune complexes (12 of 13 membranoproliferative glomerulonephritis, 7 of 8 membranous glomerulonephritis, and 1 of 13 immunoglobulin A nephropathy). Twenty-one patients had other types of GN. A total of 13 (65%) HBV-GN patients were treated with antiviral agents for a median of 11 months. However, the degrees of proteinuria were not significantly reduced in the antiviral intervention group when compared to the control group. Conclusions. Proteinuria can be caused by various glomerular diseases and HBV-GN accounts for one-third of total GN cases. Well-designed prospective study is needed to assess whether antiviral therapy against HBV infection may improve the prognosis of HBV-GN.

Membranous glomerulonephritis associated with Mycobacterium shimoidei pulmonary infection

Patient: Male, 83

Final Diagnosis: Membranous glomerulonephritis

Symptoms: Producting cough

Medication: —

Clinical Procedure: —

Specialty: Nephrology

Treatment of hepatitis B virus-associated nephropathy

Epidemiological studies have shown a relationship between hepatitis B virus (HBV) infection and development of proteinuria in some patients (most commonly children), with a predominance for male gender and histological findings of membranous nephropathy on renal biopsy. The presence of immune complexes in the kidney suggests an immune complex basis for the disease, but a direct relation between HBV and membranous nephropathy (or other types of glomerular diseases) remains to be proven. Clearance of HBV antigens, either spontaneous or following antiviral treatments results in improvement in proteinuria. Thus, prompt recognition and specific antiviral treatment are critical in managing patients with HBV and renal involvement. The present review focuses on treatment of HBV with special emphasis given to antiviral therapies, its complications, and dosing in patients with HBV-associated kidney disease.

Treatment of chronic hepatitis B in children

Chronic hepatitis B infection remains a significant health problem worldwide, and acquisition during infancy or childhood causes many of the chronic infections that are responsible for the morbidity associated with this disease. Some children with chronic hepatitis B are candidates for treatment. Two medications are currently licensed for use in children, and it is anticipated that others will be available in the next several years. This article describes rationale for treatment, patient selection and pros and cons of the current and expected therapeutic options.

Management of hepatitis B in children

Children with hepatitis B infection require management by physicians knowledgeable about the natural history of this disorder and experienced in the treatment of children. Selection of appropriate pediatric patients for treatment will prevent some cases of advanced liver disease later in life. New treatments under development for adults may benefit children as well, once they have been rigorously investigated in the pediatric population. Prevention of new HBV infections is an important part of management in children, and working with public health campaigns will hopefully reduce both vertical and horizontal transmission.

Extrahepatic manifestations of chronic hepatitis B

Several extrahepatic manifestations are associated with chronic HBV infection, many with significant morbidity and mortality. The cause of these extrahepatic manifestations is generally believed to be immune mediated. PAN is a rare, but serious, systemic complication of chronic HBV affecting the small- and medium-sized vessels. PAN is seen more frequently in North American and European patients and rarely in Asian patients. PAN ultimately involves multiple organ systems, some with devastating consequences, though the hepatic manifestations are often more mild. The optimal treatment of HBV-associated PAN is thought to include a combination of antiviral and immunosuppressive therapies. HBV-associated GN occurs mainly in children, predominantly males, in HBV endemic areas of the world, but is only occasionally reported in the United States. In children, GN is usually self-limited with only rare progression to renal failure. In adults, the natural disease course of GN may be more relentless, slowly progressing to renal failure. Immunosuppressive therapy in HBV-related GN is not recommended, but antiviral therapy with alpha-interferon has shown promise. The serum-sickness like "arthritis-dermatitis" prodrome is seen in approximately one third of patients acquiring HBV. The joint and skin manifestations are varied, but the syndrome spontaneously resolves at the onset of clinical hepatitis with few significant sequelae. Occasionally, arthritis following the acute prodromal infection may persist; however, joint destruction is rare. The association between HBV and mixed essential cryoglobulinemia remains controversial; but a triad of purpura, arthralgias, and weakness, which can progress to nephritis, pulmonary disease, and generalized vasculitis, has characterized the syndrome. Finally, skin manifestations of HBV infection typically present as palpable purpura. Though papular acrodermatitis of childhood has been reported to be caused by chronic HBV, this association remains controversial.

Hepatitis B-associated nephrotic syndrome in Jamaican children

Between December 1984 and November 1996, 171 children under 12 years old presented to the University Hospital of the West Indies with nephrotic syndrome. Hepatitis B surface antigen (HBsAg) was found in ten (6%) of these children, eight of whom had membranous nephropathy (MN), and one each had mesangial proliferative glomerulonephritis (MesN) and minimal change nephrotic syndrome (MCNS). Only those children with MesN and MCNS were steroid-sensitive. The HBsAg-positive status was identified incidentally on screening. At a mean follow-up of 34 months, seven of ten children had experienced complete or partial remission and three had persistent nephrotic syndrome, although none was in renal failure. Six of the ten had biochemical hepatitis. All the children were still HBsAg-positive. Hepatitis B virus (HBV) is a factor contributory to nephrotic syndrome in Jamaican children. As diagnostic clinical markers for HBV-associated nephropathy are usually absent, all children presenting with nephrotic syndrome should be screened for HBsAg. A policy should be implemented in Jamaica for screening pregnant women and at-risk groups for HBsAg, as well as for immunising susceptible neonates, in order to reduce the incidence of HBV-associated pathology.

Viral hepatitis. From prevention to antivirals

The challenge of viral hepatitis has been acknowledged and confronted in the last decade. Significant progress in prevention of infection with HAV and HBV may eradicate these serious infections from the United States and other parts of the world in the coming decades. Application of prophylactic strategies to children will be a major mechanism in accomplishing this task. The quest for potent antiviral medications continues. The next critically important development will be ways to prevent new HCV infections and to treat the millions of already infected individuals at risk for the serious consequences of this disease. For pediatricians, realizing these goals requires a greater understanding of perinatal HCV transmission, use of vaccines for prevention of viral hepatitis, and identification of HCV-infected children who are likely to benefit from new therapeutic strategies as they become available.

Hepatitis B virus-related nephropathy and lupus nephritis: morphologic similarities of two clinical entities

We compared the clinicopathologic features of 22 patients with hepatitis B virus-related membranous nephropathy, all with detectable glomerular hepatitis B e antigen, and of 26 patients with lupus nephritis class V. Both groups of patients similarly presented with heavy proteinuria or nephrotic syndrome; however, the patients with hepatitis B virus-related membranous nephropathy, who were predominantly male, did not have the extrarenal manifestations and autoantibodies seen in systemic lupus erythematosus. The glomerular lesions in both clinical entities were similar and at times indistinguishable, demonstrating polyclonal immunoglobulins and polytypic complements in similar subepithelial ultrastructural distribution. No morphologic feature, single or combined, carrying a high positive predictive value for the diagnosis of either nephritis was identified. Lesions such as hematoxyphil bodies and fingerprint dense deposits, distinctive of systemic lupus erythematosus, were rarely found. At the time of biopsy, when systemic lupus erythematosus is not clinically suspected, the diagnosis between hepatitis B virus-related membranous nephropathy and lupus nephritis may be difficult or impossible to differentiate, especially in geographic areas where both lupus nephritis and hepatitis B surface antigen carriers are common. This study focused on the use of specific monoclonal antisera to detect glomerular hepatitis B virus antigens, which contribute to the diagnosis of hepatitis B virus-related nephritis.

Membranous nephropathy following perinatal transmission of hepatitis B virus infection--long-term follow-up study

In children with hepatitis B-associated membranous glomerulonephritis, the time of onset of the infection and the duration of the carrier state before diagnosis of the renal disease are always unknown. Moreover, follow-up is usually short. We report the unique observation of a French girl who was infected with hepatitis B virus by her mother who had acute hepatitis during the immediate postpartum period; the girl developed proteinuria at 6 years of age. The onset of the infection in the perinatal period, the mild liver abnormalities, and the absence of nephrotic syndrome did not justify any treatment. Spontaneous seroconversion to anti-HBe antibody positive occurred at 12 years of age. Proteinuria gradually diminished and was absent at 18 years. However, HBs antigenemia persists.

Membranous nephropathy following perinatal transmission of hepatitis B virus infection--long-term follow-up study

In children with hepatitis B-associated membranous glomerulonephritis, the time of onset of the infection and the duration of the carrier state before diagnosis of the renal disease are always unknown. Moreover, follow-up is usually short. We report the unique observation of a French girl who was infected with hepatitis B virus by her mother who had acute hepatitis during the immediate postpartum period; the girl developed proteinuria at 6 years of age. The onset of the infection in the perinatal period, the mild liver abnormalities, and the absence of nephrotic syndrome did not justify any treatment. Spontaneous seroconversion to anti-HBe antibody positive occurred at 12 years of age. Proteinuria gradually diminished and was absent at 18 years. However, HBs antigenemia persists.

Resolution of hepatitis B virus-related membranoproliferative glomerulonephritis after orthotopic liver transplantation

The most well-described renal disease associated with hepatitis B virus (HBV) infection is membranous glomerulonephritis; membranoproliferative glomerulonephritis is described much less frequently. The course of HBV-associated renal disease after liver transplantation has not been described to date. We present a 15-year-old girl with HBV-associated membranoproliferative glomerulonephritis and end-stage liver disease, in whom, after cadaver liver transplantation, clinical and histological resolution of renal disease was observed. Resolution was associated with diminution of circulating HBV surface antigen levels.

Long-term outcome of hepatitis B virus-related glomerulonephritis after therapy with interferon alfa

BACKGROUND & AIMS

Glomerulonephritis is an uncommon complication of chronic hepatitis B virus (HBV) infection in adults. A high percentage of patients seem to have short-term response to interferon therapy with improvement of proteinuria. The aim of this study was to assess the long-term response of patients with HBV-related glomerulonephritis to interferon alfa therapy.

METHODS

All patients with chronic hepatitis B and glomerulonephritis who were treated with interferon alfa at the National Institutes of Health between 1985 and 1993 were assessed.

RESULTS

Of the 15 patients treated, 8 (53%) had a long-term serological response with sustained loss of serum hepatitis B e antigen and HBV DNA. After 1-7 years of follow-up, all 8 responders have normal serum aminotransferase levels and 5 are hepatitis B surface antigen negative. Seven of the responders also showed a gradual but marked improvement in proteinuria. In contrast, the 7 nonresponders continued to have evidence of active renal disease and 1 required long-term dialysis therapy. All 8 responders had membranous glomerulonephritis, whereas 4 of 7 nonresponders had membranoproliferative glomerulonephritis.

CONCLUSIONS

Interferon alfa therapy resulted in long-term remission in liver disease in 8 of 15 patients with chronic hepatitis B and glomerulonephritis. This response was accompanied by significant improvement in markers of renal disease in the majority of patients.

Viral hepatitis in children with renal disease

Specific and sensitive diagnostic tests are now available to identify type A, B, C, D and E hepatitis. Hepatitis A and E which cause only acute, very rarely fulminant, hepatitis are spread largely by the faecal-oral route, having a brief viraemic phase. Hepatitis B, C and D which are transmitted parenterally and via secretions are often associated with chronic viraemia. Patients with chronic renal disease are at particular risk. Impaired immunity due to disease or drugs increases the propensity to develop a chronic carrier state which may progress to cirrhosis and hepatocellular carcinoma. Limited reports indicate that hepatitis C infection may cause cirrhosis more rapidly than hepatitis B. The emergence of mutants to both hepatitis B and C is a cause for concern. Treatment with interferon is of limited efficacy. Screening of blood products for viral markers and prudent handling of potentially infected materials to avoid contamination of damaged skin or mucous membrane are the best strategies to prevent infection. Hepatitis B vaccination of all newborns, young adolescents and those at risk is the most effective means of reducing the carrier frequency.

Changing pattern of glomerular disease at Beijing Children's Hospital

Current clinical experience with glomerular disease at a pediatric referral center in Beijing, China, was reviewed. In 1992, renal disorders accounted for 505 of a total 6,885 (7.3%) pediatric medical discharges. Acute glomerulonephritis accounted for 30% of renal diagnoses, while nephrotic syndrome accounted for 28% and Henoch-Schönlein purpura nephritis accounted for 16% of renal disease. Mortality in children with renal disease was 0.4% (two of 505). All children with acute glomerulonephritis recovered or improved at last follow-up, regardless of the relationship to a streptococcal infection. In children with uncomplicated nephrotic syndrome, 91% had a complete or partial response to corticosteroids. Nephritis developed in 81 of 278 patients with Henoch-Schönlein purpura (29%). Since 1956, a dramatic decrease in the diagnosis of acute glomerulonephritis has occurred at this pediatric hospital. Nephrotic syndrome, in contrast, has increased from 45.3 cases per year in the 1956-to-1965 decade to 146 cases annually in the period from 1986 to 1992. Similarly, Henoch-Schönlein purpura has increased from 45.3 cases annually in the 1956-to-1965 period to 238 cases per year in the past 6 years. The incidence of nephritis in patients with Henoch-Schönlein purpura has remained constant at 29% in the past 36 years. These data should be helpful for individuals and institutions who are planning educational or clinical collaborations with pediatric nephrologists in China.

The clinical course of hepatitis B virus-associated nephropathy

Hepatitis B virus (HBV) infection is recognised as an important cause of nephrotic syndrome in endemic areas. This paper retrospectively examines the natural history and treatment of 70 patients with membranous glomerulonephritis and 1 with mesangiocapillary glomerulonephritis associated with HBV infection. Thirty-seven patients were in complete remission by the end of the study. The average duration of proteinuria in these patients was 30 months. The cumulative probability of remission was 64% at 4 years and 84% at 10 years. Three patients were still nephrotic after more than 90 months of follow-up and 2 others had reached end-stage renal failure. Remission occurred within 6 months of clearing the antigen (HBeAg) in the majority of cases. Steroids alone were given to 10 patients and 2 received steroids and cyclophosphamide, with no beneficial effect. Three patients received interferon-alpha 2b. One cleared the HBeAg from the circulation and had a significant fall in proteinuria, but defaulted from follow-up a month after completing treatment. One had a reduction of proteinuria but remained HBeAg positive. There was no change in the condition of the third. Although the majority of children eventually enter remission, there is a significant morbidity associated with the disease. Steroids and other immunosuppressive therapy are of no benefit. Interferon therapy may be useful, but has not been adequately assessed.

Interferon treatment for hepatitis B-associated membranous glomerulonephritis in two Chinese children

Two Chinese boys, aged 3.5 and 5 years, developed nephrotic syndrome and were chronic carriers of hepatitis B virus surface antigen (HBsAg) and hepatitis B virus e antigen (HBeAg). Renal biopsy showed membranous glomerulonephritis and liver biopsy showed chronic persistent hepatitis. They were given interferon-alpha-2a at a dose of 5 MU/m2 on alternate days for 12 and 16 weeks after 2 years of persistent nephrotic syndrome. Patient 1 showed complete remission and resolution of hepatosplenomegaly, but his serum remained positive for HBsAg, HBeAg and hepatitis B virus DNA. Patient 2 showed only a transient clinical response and seroconversion from HBeAg to anti-HBe status. Although not always successful, interferon treatment should be considered in severe persistent nephrotic states, since there is at present no satisfactory treatment for this form of glomerulonephropathy.

Hepatitis B virus. New and evolving issues

Recent developments in molecular biology have advanced our understanding of the pathogenesis of HBV-induced disease. New data derived from the molecular analysis of clinical material have begun to bridge the gap between bench research and the clinical arena. In this review, we consider topics that have relevance to clinical management and that have not been summarized in the recent literature. The recent advances that have been made in the areas of HBV variants, in vitro cell culture systems, and extrahepatic infection are discussed in greater detail.

Hepatitis B virus-associated glomerulonephritis: electron microscopic studies in 98 children

Ninety-eight children with glomerulonephritis concomitant with hepatitis B surface HBs antigenemia were studied, the antigenemia being first documented at the clinical onset of glomerulopathy. Initial diagnoses, based on examination of the paraffin sections, varied, membrano-proliferative, mesangial, and membranous glomerulonephritis being most frequently considered. However, electron microscopic examination showed that 77 children had a uniform type of glomerulopathy, irrespective of the light microscopic appearance. This type was diagnosed as secondary membranous glomerulonephritis. The clinical course of this nephropathy was relatively indolent and short. Moreover, in many children, elimination of some hepatitis B virus (HBV) antigens from the circulation was also associated with clinical remission of glomerulopathy. The remaining 21 children with HBs antigenemia had various morphological forms of glomerulonephritis, these being similar to their idiopathic counterparts in both morphology and clinical course. The distinct clinical and morphological picture of secondary membranous glomerulonephritis with HBs antigenemia occurring in 77 of 98 children supports the hypothesis that HBsV-associated glomerulonephritis is of the secondary membranous type. Thus, we conclude that in children HBV antigenemia associated with glomerulonephritis other than secondary membranous is coincidental.

Trials and tribulations of multicenter studies. Lessons learned from the experiences of the Southwest Pediatric Nephrology Study Group (SPNSG)

Multicenter studies in Pediatric Nephrology have been acknowledged in recent years as an important mechanism for studying renal disease in children. The purpose of this review is to describe some of the experiences of the Southwest Pediatric Nephrology Study Group (SPNSG) in order to assist others in developing their own multicenter studies. The importance of protocol development, including adequate attention to study design, data management, and data analysis, is emphasized. Mechanisms for facilitating the frequency and productivity of study group meetings that are so essential for the success of multicenter studies, are described in some detail. The need and some of the methods for achieving ongoing collaboration within a climate of critical peer review are also discussed. Controversial issues such as authorship and the question of institutional credit for involvement in multicenter studies are discussed in brief. Finally, some of the features of the SPNSG that have permitted us to maintain a relatively high rate of productivity are described. The two most important of these, ongoing commitment to the group and willingness to collaborate across differences of opinion, are stressed throughout the review.

Membranous nephropathy in 52 hepatitis B surface antigen (HBsAg) carrier children in Taiwan

To elucidate the prognosis and the causative viral antigens of hepatitis B virus (HBV)-associated childhood membranous nephropathy (MN), the clinical course and glomerular HBV antigens were studied in 52 HBsAg carrier children with MN (40 boys, 12 girls). With Fab fragments of monoclonal antibodies, hepatitis Be antigen (HBeAg) was detected in the glomerular deposits in 41 (95%) of 43 cases but HBsAg and hepatitis B core antigen (HBcAg) in none. HBeAg was detected in sera from 43 (93%) of 46 children examined. These results suggest that HBeAg plays an important role in the development of MN in HBsAg carrier children. During the follow-up period (mean, 4 years), complete remission was found in 64% and 92% of the patients followed for one and seven years, respectively; only one child had mild renal function impairment. These findings suggest a favorable outcome of HBsAg-associated childhood MN. The patient's age, disease duration, amount of glomerular deposit, focal sclerosis and disease stage appeared to affect the clinical course. HBsAg seroconversion to HBsAg-negative occurred in seven cases, and all (100%) had quick remission in two years. In patients with persistent HBsAg carriage, serum HBeAg status alone did not correlate with remission rate and remission occurred usually before the HBeAg seroconversion to anti-HBe. These findings, together with the predominant horizontal infection in these children in contrast to the frequent vertical (perinatal) transmission from HBsAg carrier mothers in HBsAg carriers in Taiwan, suggest that factors other than HBeAg per se may also play important roles.

A renal biopsy study of hepatitis B virus-associated nephropathy in Korea

The pathogenic role of the hepatitis B virus (HBV) infection for glomerulonephritis (GN) is not clear. The frequency of HBsAg has been studied in sera of 732 consecutive patients who have glomerular diseases by using radioimmunoassay. The frequency of HBs antigenemia was 11.9%, which was not different from that in the general population of South Korea. Of the 87 HBsAg seropositive patients with GN, 29 cases with membranoproliferative GN (MPGN) and eighteen with membranous nephropathy (MN) were diagnosed as having HBV-associated nephropathy. Eighty-seven and one-half percent of the adults with MPGN and 80% of the children with MN were HBsAg carries. The morphologic findings and laboratory data in cases with HBV-associated MPGN and MN did not differ significantly from those observed in patients with MPGN and MN without circulating HBsAg. Yet mesangial deposits were more frequently noted in patients with HBV-associated MN when compared to others with idiopathic MN. Glomerular deposits of HBsAg were not detected using indirect immunofluorescence technique. Even though HBsAg was not demonstrable within the glomeruli, HBV infection seems to play an important role in the pathogenesis of MPGN in Korean adults and MN in children.

Hepatitis B surface antigen associated nephrotic syndrome

Hepatitis B virus (HBV) has been reported in association with the nephrotic syndrome from different parts of the world, but its role as a cause of the pathological findings of nephrotic syndrome is still controversial. We report seven nephrotic children with positive hepatitis B markers in which members of their families were also positive for the markers but without clinical, renal or hepatic involvement. Four showed haematuria at onset and three developed hypertension later in the course of the disease. Only two were responsive to steroid therapy. Renal biopsy was performed in four, of whom three showed membranous nephropathy and the other showed mesangioproliferative glomerulonephritis. Four patients developed end-stage renal disease. We conclude that in our environment HBV, when detected in children with nephrotic syndrome, should not be considered as a chance finding, but may have a definite role in its pathogenesis. Moreover, the prognosis of HBV-associated nephrotic syndrome appears poor.

Viral hepatitis

Recent research has led to a greater understanding of the mechanisms and management of the various forms of viral hepatitis. The clinician can rapidly arrive at a precise diagnosis using serologic markers to complement epidemiologic data. In addition, effective immunoprophylaxis is possible; thus, disease spread can be minimized.

Overview of pediatric nephropathology

I have given a brief overview of the morphologic basis of renal disease in children. Obviously I have been unable to include all the important and well-done studies of various conditions, which together cover the entire spectrum of pediatric renal disease. It is evident from the many studies that the renal biopsy has been, is, and will be quite helpful in elucidating the histologic pattern and severity of injury in the child with clinical evidence of renal disease. As therapy becomes more effective for renal diseases known to cause progressive renal insufficiency, the impact of the renal biopsy will become even greater. Because of the frequent discordance between clinical laboratory findings and renal histologic severity, an initial or baseline biopsy is often the only way to stage the alterations in renal structure. Present tests of renal function are imperfect and are insensitive parameters of insidious and progressive renal disease. The capacity of the kidney to compensate for nephron loss by hypertrophy and modification of the remaining nephrons can mask progressive renal disease and thus impair our ability to detect meaningful differences in therapeutic results. A repeated biopsy or "second look" allows detailed comparison and study of the effects of various therapeutic regimens on the renal disease process. Continued, detailed clinical-morphologic correlations and studies using improved techniques hopefully will provide us with better profiles or predictors of the type, severity, and pathogenesis of the renal disease in the individual patient. Determination of the histologic pattern by renal biopsy at present remains one of the, if not the, most important and reliable prognostic indicators in the individual patient and allows us a unique look at the host response to the varying types of injuries leading to pediatric renal disease.

Viral hepatitis

Recent research has led to a greater understanding of the mechanisms and management of the various forms of viral hepatitis. The clinician can rapidly arrive at a precise diagnosis using serologic markers to complement epidemiologic data. In addition, effective immunoprophylaxis is possible; thus disease spread can be minimized.

Characteristics of glomerular lesions in hepatitis B virus infection

In an attempt to clarify a participation of hepatitis B virus (HBV) in the development of hepatic glomerulopathy in adults, kidney specimens obtained from 151 patients with liver diseases were studied. Although mesangial proliferation was more severe in patients with chronic hepatitis or liver cirrhosis than in those with acute hepatitis, no significant difference was observed between 82 serum hepatitis B surface antigen (HBsAg)-positive (HBV-related group) and 69 negative patients (HBV-nonrelated group). However, double contours of the glomerular capillary walls were observed more often in the former group (18/82, P less than .01), especially in the HBeAg-positive subgroup (8/24, P less than .001), than in the latter (3/69). In addition, glomerular capillary spike formation or a bubblelike appearance was observed in seven patients of the former group. Of these, all five patients examined were HBeAg-positive in their serum. By electron microscopic studies, subendothelial dense deposits and mesangial interpositions were observed more frequently in the HBV-related group, and subepithelial deposits were found only in the HBeAg-positive subgroup. The immunofluorescence study revealed IgA-dominant mesangial deposition in both HBV-related and nonrelated groups. As for the capillary wall deposits, however, IgG was dominant in 13 of the HBV-related group, but only one of the nonrelated group (P less than .01). Furthermore, one patient in the HBV-related group showed capillary wall-dominant HBeAg combined with IgG deposition.(ABSTRACT TRUNCATED AT 250 WORDS)

Hereditary partial deficiency of the third component of complement associated with minimal change nephrotic syndrome

We describe a 10 year old patient admitted to the Children's Hospital of Buffalo with hypocomplementemia associated with steroid responsive minimal change nephrotic syndrome. The sibling also had a low serum C3 concentration and all family members studied had C3 slow phenotypes. Factor I levels were at the lower limit of normal in the patient and his brother. Functional assays for CH50, total hemolytic C3 and serum concentration of C2, C4-C9 and factors B and H were all within normal limits. This case confirms that a depressed serum complement level can occur in minimal change nephrotic syndrome and indicates that this depression could represent a preexisting inherited rather than an acquired deficiency. The findings are consistent with the presence of a null or hypomorphic C3 slow allele in hypocomplementemic family members. Additional studies are needed to resolve the association between the inherited partial C3 deficiency and minimal change nephrotic syndrome.