Childhood nephrotic syndrome: clinical associations and response to therapy

Influenza vaccination among children with idiopathic nephrotic syndrome: an investigation of practices

Background

Annual influenza vaccination is recommended for all children with idiopathic nephrotic syndrome (INS) in France. Consequently, the Social Security automatically sends prescriptions to all patients suffering from a chronic disease. The aim of this study was to evaluate the follow-up to these recommendations.

Methods

We conducted a monocentric retrospective investigation of practices. We included all children with steroid-sensitive INS in remission who attended our clinics from January 1st 2015 to January 1st 2017, resided in France and had a valid phone number. Data were collected from May 2017 to June 2017 through a phone interview and review of clinical charts.

Results

75 patients met the inclusion criteria. The parents of 57 children could be reached by phone and agreed to participate to the survey. 35/57 (61.4%) declared having received a prescription during the 2016–2017 campaign. Only 14 children (24.6%) were vaccinated. 17/43 (39.5%) parents of unvaccinated children had concerns about the safety of the vaccine, 16/43 (37.2%) were not aware of the recommendations, 5/43 (11.6%) had been recommended by their physician not to vaccinate their child, 3/43 (7%) forgot to have them vaccinated and 2/43 (4.6%) reported no reason. 13/43 (30%) unvaccinated children presented a relapse during the flu season - 2/13 during an influenza-like illness - whereas 1/14 (7%) immunized children presented a relapse during the six months of post-vaccination follow-up. Relapse rates were not increased in vaccinated children compared to unvaccinated children (p = 0.15), nor in the 6 months following vaccination compared to the 6 months prior (1/14 vs 5/14, p = 0.20).

Conclusions

1) < 2/3 patients were properly prescribed the recommended yearly influenza vaccination at our center 2) only 1/4 were vaccinated and most of their parents were misinformed. Physicians must be aware of this and should make every effort to better inform their patients on the risks of flu illness and the benefits and safety of the vaccination.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1240-2) contains supplementary material, which is available to authorized users.

The immune system in minimal change nephrotic syndrome

Numerous examples of abnormal immune responsiveness have been described in minimal change nephrotic syndrome (MCNS). The of MCNS with allergy and with certain genetic markers of immune responsiveness, as well as the excellent response of proteinuria to immunomodulatory agents, has suggested a causal relationship between the immunological and renal abnormalities. However, the nature of this relationship is uncertain. Before it can be clarified, the basic mechanism(s) involved in disturbed immunity in patients with MCNS must be better characterized. Studies of humoral and cellular immune function support the hypothesis that immune regulation is abnormal. However, conclusive evidence of participation by a defined immunoregulatory system in the events leading to immune dysfunction has not been obtained. Thus, considerable work remains to be done in determining the nature and cause of abnormal immunity in MCNS prior to investigating its potential role in the pathogenesis of proteinuria.

Identification of the lymphokine soluble immune response suppressor in urine of nephrotic children

Patients with minimal change nephrotic syndrome (MCNS) frequently have suppressed in vivo and in vitro immune responsiveness of uncertain etiology. Because increased suppressor cell activity has been associated with this disease, urines from MCNS patients were screened for activity of the lymphokine soluble immune response suppressor (SIRS), a product of concanavalin A- or interferon-activated suppressor T cells. Urines from untreated MCNS patients suppressed polyclonal plaque-forming cell responses of cultured splenocytes. This suppressive activity was identified as human SIRS by the following functional and physical criteria: molecular weight estimated by gel filtration; kinetics of suppression; inhibition of suppression by catalase, levamisole, and 2-mercaptoethanol; abrogation of activity by acid or protease treatment; elution pattern on high performance liquid chromatography; and cross-reactivity with monoclonal antimurine SIRS antibodies. Suppressive activity disappeared from urine after initiation of treatment but before remission of symptoms. Urines were tested from 11 patients with MCNS, all of whom excreted SIRS. In addition, two nephrotic patients with acute glomerulonephritis and three nephrotic patients with membranoproliferative disease excreted SIRS, but other nephrotics and all nonnephrotic patients did not. These results indicate that excretion of SIRS occurs in certain cases of nephrotic syndrome and that the presence of SIRS in the urine is not accounted for solely by the presence of proteinuria or nephrosis. Serum from four nephrotic patients also contained SIRS, whereas neither serum nor urine from six normal subjects contained SIRS activity. The systemic presence of SIRS in these four patients, and the identification of SIRS in urines from a larger group of patients, suggest a possible role for SIRS in the suppressed immune responses often found in nephrotic syndrome.

Immunosuppressive treatment in the prevention of renal failure in primary glomerular diseases

Despite the relative paucity of well controlled studies, there is reason for cautious optimism with respect to favorably influencing the course of certain primary glomerular diseases with pharmacologic therapy. Particularly promising in this regard is the role of corticosteroids in membranous nephropathy, anticoagulant and antithrombotic agents in membranoproliferative glomerulonephritis and high-dose "pulse" steroids, "quadruple therapy" or plasma exchange with immunosuppression in idiopathic crescentic glomerulonephritis. Further controlled trials are urgently needed in the various forms of mesangial proliferative glomerulonephritis, including Berger's disease, in focal and segmental glomerulosclerosis and membranous nephropathy in which reduced GFR or steroid resistance has been demonstrated. It seems quite clear that even a temporary delay in the onset of ESRD, if such can be obtained with a minimum of lasting side effects, is a reasonable goal of therapy considering the expense of maintenance dialysis and transplantation.