Infections in Children With Nephrotic Syndrome: Twenty Years of Experience

Prevalence and associated factors of infection in children with nephrotic syndrome aged 2-18 years in the northwest and east Amhara region, Ethiopia: a multi-center cross-sectional retrospective study

BACKGROUND

Infection is the most common complication of pediatric patients with nephrotic syndrome. The factors associated with infection in nephrotic syndrome are lacking. The objective of the study was to identify the prevalence and associated factors among children with nephrotic syndrome aged 2 to 18 years.

METHODS

We conducted a hospital-based retrospective cross-sectional study. The data collector installed an Epi5 collector electronic data-collecting tool from Google Play. Then, we exported the data to Stata version 15.1 for analysis. The mean, standard deviation, frequency, and percentage were used for descriptive statistics. The logistic regression model was used to identify the factors associated with infection.

RESULTS

In this study, the prevalence of infection among nephrotic syndrome children is 39.8% (95%CI: 30.7, 49.7). The types of infection identified were pneumonia, urinary tract infection, diarrheal disease, cutaneous fungal infection, intestinal parasitic infection, and sepsis. The presence of hematuria increased the odds of infection by 5-times. On the other hand, low level of serum albumin increased the odds of infection by 7%. Being a rural resident increased the odds of infection by 3.3-times as compared to urban.

CONCLUSIONS

Serum albumin level, presence of hematuria, and rural residence were significantly associated with infection. We recommended a longitudinal incidence study on large sample size at multicenter to strengthen this finding.

Diagnostic value of serum CRP, PCT and IL-6 in children with nephrotic syndrome complicated by infection: a single center retrospective study

OBJECTIVE

The purpose was to look into the diagnostic value of serum CRP, PCT and IL-6 in children with nephrotic syndrome co-infection.

METHODS

One hundred and forty-nine children with nephrotic syndrome who met the inclusion and exclusion criteria were included in this study. The children were divided into three groups: bacterial infection group, non-bacterial infection group, and non-infection group. The diagnostic value was analyzed and compared using the ROC curve.

RESULTS

There was no statistically significant difference in the Leukocyte counts among three groups. The mean results of serum CRP, PCT and IL-6 were significantly higher in the bacterial infection group compared to those in the non-infection group (p < 0.05). AUC of CRP, PCT, IL-6 in bacterial infection were 0.791, 0.859, 0.783. The following combinations CRP + PCT + IL-6, IL-6 + PCT, CRP + PCT significantly increased the efficiency of bacterial infection diagnosis, the AUCs were 0.881, 0.884, and 0.884, respectively. AUC of PCT in non-bacterial infection was 0.663. The combinations of these three clinical indicators performed no better than PCT in ROC analysis.

CONCLUSION

Normal CRP or IL-6 levels do not rule out the diagnosis of bacterial infection in children on long-term glucocorticoid therapy. The appropriate combination of two or three indicators can improve the diagnostic value.

IMPACT

This study evaluated the diagnostic value of the serum concentrations of CRP, PCT and IL-6 and assessed whether the value of their combined application is better than when used alone for diagnosing primary nephrotic syndrome complicated by infection. The elevation in leukocyte count cannot be used to diagnose children with nephrotic syndromes on long-term glucocorticoid treatment who have bacterial infections. Normal CRP or IL-6 levels do not rule out the diagnosis of bacterial infection in children on long-term glucocorticoid therapy. The appropriate combination of two or three indicators can improve diagnostic value, sensitivity, and specificity.

Diagnosis of bacterial infection in children with relapse of nephrotic syndrome: a personalized decision-analytic nomogram and decision curve analysis

BACKGROUND

Infections associated with nephrotic relapses (NR) are often managed according to physician preferences. A validated prediction tool will aid clinical decision-making and help in rationalizing antibiotic prescriptions. Our objective was to develop a biomarker-based prediction model and a regression nomogram for the prediction of the probability of infection in children with NR. We also aimed to perform a decision curve analysis (DCA).

METHODS

This cross-sectional study included children (1-18 years) with NR. The outcome of interest was the presence of bacterial infection as diagnosed using standard clinical definitions. Total leucocyte count (TLC), absolute neutrophil count (ANC), quantitative C-reactive protein (qCRP), and procalcitonin (PCT) were the biomarker predictors. Logistic regression was used to identify the best biomarker model, followed by discrimination and calibration testing. Subsequently, a probability nomogram was constructed and DCA was done to determine the clinical utility and net benefits.

RESULTS

We included 150 relapse episodes. A bacterial infection was diagnosed in 35%. Multivariate analysis showed the ANC + qCRP model to be the best predictive model. This model displayed excellent discrimination (AUC: 0.83), and calibration (optimism-adjusted intercept: 0.015, slope: 0.926). A prediction nomogram and web-application was developed. The superiority of the model was also confirmed by DCA in the probability threshold range of 15-60%.

CONCLUSIONS

An ANC-based and qCRP-based internally validated nomogram can be used for the prediction of probability of infection in non-critically ill children with NR. Decision curves from this study will aid in the decision-making of empirical antibiotic therapy, incorporating threshold probabilities as a surrogate of physician preference. A higher resolution version of the Graphical abstract is available as Supplementary information.

The Clinical Spectrum and Occurrence of Major Infections in Hospitalized Children With Nephrotic Syndrome

Background Nephrotic syndrome (NS) is one of the most common renal ailments in the pediatric population. The management of NS with major infections remains a challenge to pediatricians and pediatric nephrologists, as it is associated with increased morbidity and mortality. In this study, we aimed to know the clinical spectrum and occurrence of major infections in hospitalized children with NS. Methods This prospective, observational study was conducted over a period of two years among hospitalized NS children from one year to 18 years. The clinical spectrum and hospital course were studied in detail, and the data generated were analyzed to obtain valid results. Results A total of 101 hospitalizations of 66 children were assessed for the occurrence of infective complications. The incidence rate of infective complications among the hospitalized nephrotics was 29.7%. Urinary tract infection (UTI) was the commonest infective complication, followed by spontaneous bacterial peritonitis (SBP). Other infective complications observed were pneumonia, enteric fever, methicillin-resistant Staphylococcus aureus (MRSA) sepsis, tuberculosis, and varicella. Conclusion Infective complications are quite common among NS patients, where appropriate identification and prompt treatment could reduce morbidity and mortality.

Epidemiology and outcomes of pneumococcal sepsis in children with nephrotic syndrome in a developing country

BACKGROUND

Pneumococcal infections are common in children with nephrotic syndrome. Knowledge of the commonly available serotypes and antibiotic susceptibility will help in prevention and appropriate management of pneumococcal sepsis, especially in resource-limited countries.

METHODS

Demographic, clinical, and laboratory data on children with nephrotic syndrome and pneumococcal infections were extracted from the electronic medical records.

RESULTS

Sixty-three isolates of pneumococci obtained from 60 children with nephrotic syndrome, over a period of 14 years, were included in the study. This represented 18% of all pneumococcal infections occurring in children during the same period. Commonly available vaccines covered up to 58% of all the serotypes causing infection. Severe disease, with shock, intensive care admission and/or meningitis, was observed in 38% children and mortality was observed in 10%. Resistance to commonly used antibiotics was not observed, except for erythromycin.

CONCLUSIONS

Pneumococcal sepsis was observed to be common in children with nephrotic syndrome and results in significant morbidity and mortality. Commonly used antibiotics were observed to be effective in management of the infections.

Risk Factors for Poor Prognosis of Severe Infection in Children With Idiopathic Nephrotic Syndrome: A Double-Center, Retrospective Study

Background: Infection is the most common complication of Idiopathic Nephrotic Syndrome (INS) and the main cause of INS recurrence, severe infection and even leading to mortality. The purpose of this study was to investigate the risk factors of severe infection in INS children and the clinical parameters influencing prognosis. Methods: Totally 147 children with INS and concomitant infections were enrolled and classified into the severe infection group (SIG) and Non-severe infection group (Non-SIG). The clinical characteristics and auxiliary examination results were compared between the two groups, and the early-warning parameters for severe infection and risk factors for poor prognosis were evaluated. Results: There were 49 patients in the SIG, 98 patients in the Non-SIG. In the SIG, the most common severe infections disease included severe pneumonia (63.6%), severe sepsis (30.6%), septic shock (4.1%). In SIG, Gram-positive bacteria (GPB) were more common, as was respiratory syncytial virus (RSV), and the three most common strains were Pseudomonas aeruginosa, Staphylococcus aureus (SA) and Staphylococcus epidermidis. There were more steroid-resistant nephrotic syndrome and combination of steroids and immunosuppressants in SIG, compared with the Non-SIG (P = 0.000). Patients in the SIG has lower complement 3 (C3, ≤ 0.55 g/L,) and absolute lymphocyte count (ALC, ≤ 1.5 × 10⁹/L) (P = 0.004). Logistic regression analysis revealed that the independent risk factors for severe infections were the combined use of immunosuppressants [95% confidence interval (CI):1.569-463.541, P = 0.023], steroid resistance (95% CI: 4.845-2,071.880, P = 0.003), C-reactive protein (CRP) ≥8 mg/L (95% CI: 43.581-959, 935.668, P = 0.001), and infections caused by GPB (95% CI: 27.126-2,118, 452.938, P = 0.002), influenza (95% CI: 2.494-1, 932.221, P = 0.012) and RSV (95% CI: 5.011-24 963.819, P = 0.007). The patients in the SIG were classified into the survival group (N = 39) and the mortality group (N = 5). Logistic regression analysis showed that white blood cell count (WBC) >15 × 10⁹/L (95% CI: 1.046-2.844, P = 0.033) was an independent risk factor of poor prognosis for these patients. Conclusions: Resistance to steroids, combined with steroids and IS agents, and GPB infections (especially SA) are high-risk factors for severe infection in children with INS. We should monitor CRP ≥ 8 mg/L, C3 ≤ 0.55 g/L and ALC ≤ 1.5 × 10⁹/L to avoid developing severe infection. Accompanied by an increase in ANC, WBC significantly increased, suggesting a fatal infection.

Vaccination of immune compromised children-an overview for physicians

Immune compromised children are threatened by a higher risk of infections; some of these are preventable by vaccination. Primary care physicians play a fundamental role in optimising vaccination status. In this narrative review, we present the evidence on vaccine safety and immunogenicity in immune compromised children and discuss in which conditions live-attenuated vaccines can possibly be used. Vaccination schedules differ in some of these conditions, including the use of vaccines with higher antigenic contents (e.g. high-dose hepatitis B vaccine), additional vaccine doses (e.g. 2-dose schedule meningococcal vaccine), more frequent booster doses (e.g. life-long pneumococcal vaccine booster), supplementary vaccines (e.g. meningococcal B vaccine) and use of vaccines beyond the age of usual recommendation (e.g. Haemophilus influenza type b vaccine after 5 years of age). Serological monitoring is a useful tool for customizing vaccination schedule in immune compromised children, confirming adequate vaccine response and documenting seroprotection (especially against measles and varicella). Finally, verification of vaccination status of all household members can prevent them being vector of transmission of an infection to the immune compromised children. Conclusion: Intensified information strategies are needed to improve trust, rectify perceived risks and improve vaccine acceptability; primary physicians can play a critical role in the latter. What is Known: • Physician's awareness is key to success, since it repeatedly correlates with higher vaccination rates What is New: • The vaccination status of immunocompromised children is rarely up-to-date • Knowing the latest vaccine recommendations is challenging, as they differ for each medical condition and change periodically • This review summarises the vaccine recommendations for children with compromised immune systems and highlights how paediatricians play a key role in coordinating their application.