Forms of nephrotic syndrome more likely to progress to renal impairment

Membranoproliferative glomerulonephritis in childhood: factors affecting prognosis

Membranoproliferative glomerulonephritis (MPGN) is a distinctive form of chronic glomerulonephritis. We present the results of our 96 paediatric patients with MPGN, reporting the survival and factors affecting prognosis in these patients. There were 64 boys and 32 girls with an age range of 2-17 (mean 10.6 +/- 3.7) years. All patients initially received oral corticosteroid therapy; remission was achieved in 22.9%. The unresponsive 77.1% either received cyclophosphamide and/or pulse methylprednisolone; 25.4% and 50.0% of these patients entered complete remission, respectively. The overall 1-year renal survivals of the MPGN patients were 90.1%, 5-year and 10-year survival rates were 81.9% and 61%, respectively. At multivariate analysis the factors affecting renal prognosis were haematuria at presentation (p < 0.05, risk factor 3.52), urinary protein/creatinine ratio (p < 0.05, risk factor 1.06 per 1 unit) and low haemoglobin values (p < 0.05, risk factor 1.43 for each 1 g/dl decrement). We suggest that more aggressive immunosuppression therapy should be instituted in patients unresponsive to steroids and that the aforementioned risk factors are higher for the development of renal failure.

Evaluation of hematuria, proteinuria, and hypertension in adolescents

Signs or symptoms of renal disease in adolescents deserve prompt attention and appropriate evaluation. Adolescents are susceptible to a variety of urinary tract disorders. The key issue in the evaluation of hematuria or proteinuria in adolescents is the existence of concomitant signs of renal disease. For isolated hematuria or proteinuria, demonstration of persistence and a reasoned evaluation are in order. Hypertension in adolescents must be carefully documented and, when present, considered seriously. The fact that most teens with persistent elevated blood pressures have essential hypertension is still a great concern because for most of these adolescents the hypertension will be lifelong and, if left untreated, can be associated with significant morbidity and mortality in the adult years.

Applying decision analysis to management of adolescent idiopathic nephrotic syndrome

Due to the concern that adolescents presenting with nephrotic syndrome are less likely to have minimal change disease than younger children, pediatric nephrologists have tended toward renal biopsy-tailored treatment rather than corticosteroid use in this population. The need for biopsy prior to treatment of nephrotic syndrome in adults has been challenged. A similar challenge to the clinical need for this procedure in adolescents with idiopathic nephrotic syndrome is raised here. The principles of medical decision analysis were applied and calculations were made with the Decision Maker computer program. The life expectancy of an adolescent who receives biopsy-tailored treatment was found to be no different from that of an adolescent who receives empiric corticosteroid treatment. We conclude that renal biopsy is not mandatory for the clinical management of adolescents with idiopathic nephrotic syndrome. Prognostically, a response, or lack thereof, to empiric corticosteroid therapy may be just as informative as a histological diagnosis.

Renal histology in polycystic kidney disease with incipient and advanced renal failure

Renal specimens were obtained at surgery or postmortem from patients with autosomal dominant polycystic kidney disease (ADPKD). Patients had either serum creatinine (SCr) below 350 mumol/liter (N = 12) or terminal renal failure (N = 50). Specimens were examined by two independent observers using a carefully validated score system. Mean glomerular diameters were similar in ADPKD patients with early renal failure (176 +/- 38 microns) and in victims of traffic accidents (177 +/- 23 microns), while they were significantly greater in diabetics with comparable renal function (205 +/- 16 microns). Glomerular diameters in ADPKD patients with terminal renal failure (191 +/- 45 microns) and with early renal failure were not significantly different. On average, 29% of glomeruli (17 to 62) were globally sclerosed in early renal failure, and 49% (19 to 93) in terminal renal failure. The proportion of glomeruli with segmental sclerosis was less than 4% in both groups. Marked vascular sclerosis, interstitial fibrosis, and tubular atrophy were present in early renal failure, and even more so in terminal renal failure. Interstitial infiltrates were scarce and consisted mainly of CD4 positive lymphocytes and CD68 positive macrophages. Immunestaining with monoclonal renin antibodies showed an increased juxtaglomerular index and expression of renin by arterioles adjacent to cysts, as well as by cyst wall epithelia. The data show more severe vascular and interstitial, but not glomerular, changes in ADPKD with advanced as compared to early renal failure.

Long-term follow-up in children with steroid-resistant nephrotic syndrome

A prospective study was performed in order to evaluate the efficacy of oral cyclophosphamide and chlorambucil in inducing a remission in children with steroid-resistant primary nephrotic syndrome (NS). Out of 215 children with steroid-resistant primary NS, 164 had been followed from one to 10 years. The children had a mean age of 8.2 years, with a range from one to 16 years. Steroid resistance was more common in children over six years of age compared with the other age groups. Hematuria was seen in 68 of the 164 children (41%); hypertension in 41 (25%); and hyperlipidemia in 112 (68%). Hypocomplementemia was noted in 24 of the 65 (37%) children in whom complement concentrations were determined. Renal biopsy was performed in 117 of the children. Pathologic changes consisted of minimal change nephrotic syndrome (MCNS) in 14 children (12%), membranoproliferative glomerulonephritis (MPGN) in 45 (38%), focal segmental glomerulosclerosis (FSGS) in 20 (25%), mesangial proliferation (MP) in 23 (20%), and membranous glomerulonephritis in six children (5%). Cyclophosphamide (2 mg/kg/day) was given to 164 patients, with complete remission and partial remission rates of 20.7% (34 of 164 children) and 24.4% (40 of 164 children), respectively. In this group, sustained remission and sustained partial remission rates were found in 20% (32 children) and 13% (21 children), respectively. Chlorambucil was given to 40 children with steroid- and cyclophosphamide-resistant nephrotic syndrome, with total remission and partial remission rates of 20% (eight children), and 12.5% (five children), respectively. These rates did not change during the follow-up. Thus, cyclophosphamide is valuable in the treatment of children with steroid-resistant NS with a variety of histologic changes.

Glomerulonephritis with end-stage liver disease in childhood

Renal biopsies were done perioperatively in 18 children receiving liver grafts. All specimens showed glomerulonephritis, which was mesangial-proliferative in 15 and mesangio-capillary in 3. Of the 16 children who were alive four or more months after transplantation, only 1 showed progressive deterioration of renal function; 1 other had a subnormal but static glomerular filtration rate. In all 6 children who had proteinuria before operation, the urine became normal.

Severe hypertension after liver transplantation in alpha 1 antitrypsin deficiency

Five children with alpha 1 antitrypsin deficiency and terminal liver disease received liver grafts; all five became hypertensive and four developed hypertensive encephalopathy. There was evidence of renal disease preoperatively and renal biopsy specimens showed variable glomerulonephritic histology with IgA nephropathy in one, mesangial-proliferative changes in two, and mesangio-capillary glomerulonephritis type I in two. Four hypertensive episodes were preceded by a fall in creatinine clearance. The association of glomerulonephritis with alpha 1 antitrypsin deficiency in children is more common than has been recognised. Affected patients are prone to severe hypertension of probable renal origin after liver transplantation and the renal lesion may affect long term prognosis.

Glomerular hypertrophy in minimal change disease predicts subsequent progression to focal glomerular sclerosis

The study sought a diagnostic clue to identify the group of pediatric patients with apparent minimal change disease who subsequently develop focal glomerular sclerosis (FGS). Review of all renal biopsy material at our institutions identified 42 pediatric patients who met the standard criteria for minimal change disease (MCD) on initial biopsies. Of those, 10 deteriorated clinically and on rebiopsy showed focal glomerular sclerosis (FGS). The initial renal biopsies of these 10 patients were analyzed morphometrically to determine the mean glomerular tuft area (GA). The results were compared to those of the remaining 32 patients whose subsequent benign clinical course was consistent with MCD, and to randomly selected, age-matched autopsy controls without renal disease (CONT, N = 10). The mean age was comparable among the three groups studied. Separate groups of adult (N = 12) and pediatric (N = 18) patients with initial biopsies with FGS were also studied. The initial biopsy of pediatric patients who subsequently showed FGS (rebiopsy performed on average 3.3 years later) had an average GA of 13.5 x 10(-3) mm2, 76% larger than glomeruli from children with MCD (7.7 x 10(-3) mm2, P less than 0.0005) and 62% larger than CONT (8.4 x 10(-3) mm2, P less than 0.005). Patients with FGS on initial biopsy, whether adult or pediatric, also had significantly larger GA than the age-matched MCD or CONT groups. Evaluation of GA in all the 42 pediatric biopsies with initial MCD further showed that in 23 patients GA was equal to or smaller than the CONT average.(ABSTRACT TRUNCATED AT 250 WORDS)