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Veltkamp F, Pistorius MCM, Mak-Nienhuis EM, Schreuder MF, Bouts AHM, Mathôt RAA. Saliva monitoring of prednisolone in children with first onset steroid-sensitive nephrotic syndrome: Is it possible? Br J Clin Pharmacol 2024; 90:1677-1687. [PMID: 38599658 DOI: 10.1111/bcp.16066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 03/06/2024] [Accepted: 03/15/2024] [Indexed: 04/12/2024] Open
Abstract
AIMS Prednisolone is the cornerstone of treatment for idiopathic nephrotic syndrome in children, but is associated with marked side-effects. Therapeutic drug monitoring using saliva would be a patient-friendly option to monitor prednisolone treatment. To assess the feasibility of saliva monitoring, we described the pharmacokinetics (PK) of unbound prednisolone in plasma and saliva of children with first onset steroid-sensitive nephrotic syndrome (SSNS). METHODS Children (age 2-16 years) with SSNS participating in a randomized, placebo-controlled trial with levamisole were treated with an 18-week tapering schedule of prednisolone. Five serial samples were collected at 4 (saliva) and 8 weeks (saliva and plasma) after first onset. A nonlinear mixed-effects model was used to estimate the PK parameters of unbound prednisolone and the saliva-to-plasma ratio. Monte Carlo simulations were performed to assess the predictive performance of saliva monitoring. RESULTS From 39 children, 109 plasma and 275 saliva samples were available. Estimates (relative squared error) of unbound plasma clearance and volume of distribution were 93 (5%) L h-1 70 kg-1 and 158 (7%) L 70 kg-1, respectively. Typical saliva-to-plasma ratio was 1.30 (8%). Monte Carlo simulations demonstrated that on basis of 4 saliva samples and a single plasma sample unbound plasma area-under-the-concentration-time curve can be predicted within 20% imprecision in 79% of the patients compared to 87% based on 4 plasma samples. CONCLUSION Saliva proved to be a reliable and patient-friendly option to determine prednisolone plasma exposure in children with SSNS. This opens opportunities for further PK and pharmacodynamics studies of prednisolone in a variety of paediatric conditions.
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Affiliation(s)
- Floor Veltkamp
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Marcel C M Pistorius
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Elske M Mak-Nienhuis
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Antonia H M Bouts
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Ron A A Mathôt
- Department of Pharmacy & Clinical Pharmacology, Amsterdam University Medical Centers, location University of Amsterdam, Amsterdam, The Netherlands
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Alenazi SA. Incidence and Pathological Patterns of Nephrotic Syndrome among Infants and Children: A Systematic Review. Cureus 2024; 16:e58331. [PMID: 38752042 PMCID: PMC11095912 DOI: 10.7759/cureus.58331] [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] [Accepted: 04/14/2024] [Indexed: 05/18/2024] Open
Abstract
Nephrotic syndrome (NS) is known to be a prevalent chronic illness in young patients. Periorbital swelling in children with this condition is a recurring symptom, either with or without generalized edema. The current study aimed to examine the incidence and pattern of nephrotic syndrome in infants and children by thoroughly examining the recently available literature. A thorough search of PubMed, SCOPUS, Web of Science, Science Direct, and Google Scholar was conducted, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model, to find pertinent material. The Rayyan software (Qatar Computing Research Institute, Ar-Rayyan, Qatar) was utilized during the whole process. Data from a total of 1418 patients from nine trials were considered in this study. Numerous factors influenced the incidence, mean age, sex dominance, and histological patterns in various sample groups. The current findings conclude that variations in socioeconomic, regional, and genetic factors influence the development and pattern of these diseases. The prevalence of pediatric renal disorders differs throughout countries. Season of occurrence, response to corticosteroid treatment, and histopathologic findings appear to differ amongst the diagnosed cases.
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Affiliation(s)
- Shehab A Alenazi
- Department of Pediatrics, Faculty of Medicine, Northern Border University, Arar, SAU
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Mazo A, Kilduff S, Pereira T, Solomon S, Matloff R, Zolotnitskaya A, Samsonov D. Mycophenolate Mofetil Versus Prednisone for Induction Therapy in Steroid-Sensitive Idiopathic Nephrotic Syndrome in Children: An Observational Study. Kidney Med 2024; 6:100776. [PMID: 38435073 PMCID: PMC10904994 DOI: 10.1016/j.xkme.2023.100776] [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] [Indexed: 03/05/2024] Open
Abstract
Rationale & Objective High-dose steroids are recommended for the induction of idiopathic nephrotic syndrome. The aim of this study was to compare standard induction therapy with Mycophenolate Mofetil (MMF). We hypothesized that MMF could be noninferior to steroids in maintaining steroid-induced remission. The second aim was to reduce steroid-induced side effects. Study Design This was an observational study. Setting & Population Patients 2-11 years with first episode of nephrotic syndrome who entered remission within 2 weeks of standard steroid treatment were eligible for enrollment. Patients in the experimental group completed 12-week induction with MMF, whereas the control group continued a standard 12-week steroid protocol. Exposures MMF and prednisolone were used in the study. Outcomes The primary study outcomes were relapse rate and relapse-free interval during a 52-week follow-up. Analytical Approach Descriptive statistics were used for analysis. Results Ten of 41 eligible patients consented to participate in the MMF group and 8 completed the study. The control group included 31 patients, with 23 patients who completed 52 weeks follow-up. During the induction phase, 3 out of 10 patients (30%) in the MMF group and 1 out of 31 (3%) in the control group (P = 0.04) developed relapse. During the 52 weeks follow-up period, 7 out of 10 patients (70%) in the MMF group and 19 out of 31 (61%) in the control group developed relapse (P = 0.72). The median relapse-free interval was 11 and 19 weeks in MMF and control groups, respectively (P = 0.60). No serious side effects were recorded in either group. Limitations The limitations of the study were low patient numbers receiving MMF and single-center design. Conclusions Our small cohort of patients treated with MMF reported a higher relapse rate during the induction phase. However, by 12 months of follow-up the relapse rate and relapse-free intervals were similar between both groups. All patients tolerated MMF without significant side effects, and those who relapsed remained steroid-sensitive.
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Affiliation(s)
- Alexandra Mazo
- Pediatric Nephrology Division, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York
| | - Stella Kilduff
- Pediatric Nephrology Division, Ann and Roberst H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tanya Pereira
- Pediatric Nephrology Division, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York
| | - Sonia Solomon
- Pediatric Nephrology Division, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York
| | - Robin Matloff
- Pediatric Nephrology Division, Connecticut Children’s, University of Connecticut School of Medicine, Hartford, Connecticut
| | - Anna Zolotnitskaya
- Pediatric Nephrology Division, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Dmitry Samsonov
- Pediatric Nephrology Division, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York
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4
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Veltkamp F, Teela L, Luijten MAJ, van Oers HA, Mak-Nienhuis EM, Haverman L, Bouts AHM. Health-related quality of life of children with first onset steroid-sensitive nephrotic syndrome. Eur J Pediatr 2023; 182:4605-4614. [PMID: 37548700 PMCID: PMC10587200 DOI: 10.1007/s00431-023-05135-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/20/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023]
Abstract
This study assessed HRQoL and emotional and behavioral difficulties (EBD) and associated variables in children with first onset SSNS. While relapsing steroid-sensitive nephrotic syndrome (SSNS) in children is associated with lower health-related quality of life (HRQoL), little is known about first onset. Four weeks after onset, children (2-16 years) and/or their parents who participated in a randomized placebo-controlled trial, completed the Pediatric Quality of Life Inventory 4.0 (PedsQL) and Strengths and Difficulties Questionnaire (SDQ) to measure HRQoL and EBD, respectively. Total and subscale scores and the proportion of children with impaired HRQoL (> 1 SD below the mean of the reference group) or SDQ clinical scores (< 10th and > 90th percentile) were compared to the Dutch general population (reference group). Regression analyses were used to identify associated variables. Compared to the reference group, children 8-18 years reported significantly lower total HRQoL, and physical and emotional functioning. A large proportion (> 45%) of these children had impaired HRQoL. There were no differences in HRQoL between children 2-7 years and the reference group, except for higher scores on social functioning (5-7 years). Similar proportions of SSNS and reference children scored within the clinical range of SDQ subscales. Age, sex, and steroid side-effects were negatively associated with HRQol and/or EBD. Conclusion: This study showed that HRQoL and EBD are affected in children of different ages with first onset SSNS. This calls for more awareness from healthcare providers and routinely monitoring of HRQoL and EBD in daily clinical care to prevent worsening of symptoms. Clinical trial registry: Netherlands Trial Register ( https://trialsearch.who.int/ ; NTR7013), date of registration: 02 June 2018. What is Known: • Health-related quality of life (HRQoL) is lower and emotional and behavioral difficulties (EBD) is more affected in children with frequently-relapsing and steroid-dependent nephrotic syndrome. What is New: • HRQoL and EBD are affected in children with first onset steroid-sensitive nephrotic syndrome compared to a reference group of the Dutch general population. • To what extent HRQoL and EBD are affected depends on the age of the patient.
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Affiliation(s)
- Floor Veltkamp
- Amsterdam University Medical Centers location University of Amsterdam, Emma Children's Hospital, Department of Pediatric Nephrology, Meibergdreef 9, Post box 22660, 1100 DD, Amsterdam, the Netherlands
- Amsterdam Reproduction and Development, Child Development, Amsterdam, The Netherlands
| | - Lorynn Teela
- Amsterdam Reproduction and Development, Child Development, Amsterdam, The Netherlands
- Amsterdam University Medical Centers, location University of Amsterdam, Emma Children's Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Meibergdreef 9, Amsterdam, The Netherlands
| | - Michiel A J Luijten
- Amsterdam Reproduction and Development, Child Development, Amsterdam, The Netherlands
- Amsterdam University Medical Centers, location University of Amsterdam, Emma Children's Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Meibergdreef 9, Amsterdam, The Netherlands
| | - Hedy A van Oers
- Amsterdam Reproduction and Development, Child Development, Amsterdam, The Netherlands
- Amsterdam University Medical Centers, location University of Amsterdam, Emma Children's Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health, Mental Health, Amsterdam, the Netherlands
| | - Elske M Mak-Nienhuis
- Amsterdam University Medical Centers location University of Amsterdam, Emma Children's Hospital, Department of Pediatric Nephrology, Meibergdreef 9, Post box 22660, 1100 DD, Amsterdam, the Netherlands
| | - Lotte Haverman
- Amsterdam Reproduction and Development, Child Development, Amsterdam, The Netherlands
- Amsterdam University Medical Centers, location University of Amsterdam, Emma Children's Hospital, Child and Adolescent Psychiatry & Psychosocial Care, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Public Health, Mental Health, Amsterdam, the Netherlands
| | - Antonia H M Bouts
- Amsterdam University Medical Centers location University of Amsterdam, Emma Children's Hospital, Department of Pediatric Nephrology, Meibergdreef 9, Post box 22660, 1100 DD, Amsterdam, the Netherlands.
- Amsterdam Reproduction and Development, Child Development, Amsterdam, The Netherlands.
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Mbanefo NR, Uwaezuoke SN, Eneh CI, Odimegwu CL, Chikani UN, Muoneke UV, Nwolisa CE, Odo KE, Ogbuka FN, Akwue AT. Can Oral Zinc Supplementation Reduce Relapses in Childhood Steroid-Sensitive Nephrotic Syndrome? A Systematic Review. Int J Nephrol Renovasc Dis 2023; 16:143-153. [PMID: 37101939 PMCID: PMC10124555 DOI: 10.2147/ijnrd.s403699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/31/2023] [Indexed: 04/28/2023] Open
Abstract
Introduction Frequent relapses and steroid dependence are common treatment challenges of steroid-sensitive nephrotic syndrome (SSNS) in children. Acute respiratory infection (ARI) is the most frequently reported trigger of relapse. Given the role of zinc supplementation in preventing ARI, some studies show that this targeted intervention may reduce relapses in childhood SSNS. Aim This systematic review aimed to determine if oral zinc supplementation can significantly reduce relapses in this disease. Methods We searched the PubMed and Google Scholar electronic databases for interventional and observational analytical studies without limiting their year or language of publication. We selected studies with primary data that met our inclusion criteria, screened their titles and abstracts, and removed duplicates. We used a preconceived structured form to extract data items from selected studies and conducted a quality assessment of randomized controlled trials (RCTs) and non-randomized studies with the Cochrane collaboration tool and the Newcastle Ottawa Scale, respectively. We qualitatively synthesized the extracted data to validate the review's objective. Results Eight full-text articles were selected, comprising four RCTs and four observational analytical studies. Two of the RCTs had a high risk of bias in three parameters of the Cochrane collaboration tool, while three non-randomized studies had low methodological quality. A total of 621 pediatric patients with SSNS were investigated in the eight studies: six participants dropped out in one study. Three RCTs indicate that zinc supplementation may lead to sustained remission or reduction in relapse rate. Similarly, three observational analytical studies suggest a significant relationship between reduced serum zinc levels and disease severity. Conclusion Despite the association of zinc deficiency with increased morbidity in SSNS and the reduction of relapse rates with zinc supplementation, there is no robust evidence to recommend its use as a therapeutic adjunct. We recommend more adequately-powered RCTs to strengthen the current evidence.
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Affiliation(s)
- Ngozi R Mbanefo
- Department of Pediatrics, the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, Enugu, Nigeria
| | - Samuel N Uwaezuoke
- Department of Pediatrics, the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, Enugu, Nigeria
| | - Chizoma I Eneh
- Department of Pediatrics, Enugu State University Teaching Hospital Enugu, Enugu, Nigeria
| | - Chioma L Odimegwu
- Department of Pediatrics, the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, Enugu, Nigeria
| | - Ugo N Chikani
- Department of Pediatrics, the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, Enugu, Nigeria
| | - Uzoamaka V Muoneke
- Department of Pediatrics, the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, Enugu, Nigeria
| | - Charles E Nwolisa
- Department of Pediatrics, Federal Medical Centre, Owerri, Imo State, Nigeria
| | - Kenneth E Odo
- Department of Pediatrics, the University of Nigeria Teaching Hospital Ituku-Ozalla Enugu, Enugu, Nigeria
| | - Francis N Ogbuka
- Department of Pediatrics, Enugu State University Teaching Hospital Enugu, Enugu, Nigeria
| | - Anthony T Akwue
- Emergency Department, ASEER Field Hospital, Al Rabwah, Kingdom of Saudi Arabia
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Trautmann A, Boyer O, Hodson E, Bagga A, Gipson DS, Samuel S, Wetzels J, Alhasan K, Banerjee S, Bhimma R, Bonilla-Felix M, Cano F, Christian M, Hahn D, Kang HG, Nakanishi K, Safouh H, Trachtman H, Xu H, Cook W, Vivarelli M, Haffner D. IPNA clinical practice recommendations for the diagnosis and management of children with steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2023; 38:877-919. [PMID: 36269406 PMCID: PMC9589698 DOI: 10.1007/s00467-022-05739-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/03/2022] [Accepted: 08/22/2022] [Indexed: 01/19/2023]
Abstract
Idiopathic nephrotic syndrome is the most frequent pediatric glomerular disease, affecting from 1.15 to 16.9 per 100,000 children per year globally. It is characterized by massive proteinuria, hypoalbuminemia, and/or concomitant edema. Approximately 85-90% of patients attain complete remission of proteinuria within 4-6 weeks of treatment with glucocorticoids, and therefore, have steroid-sensitive nephrotic syndrome (SSNS). Among those patients who are steroid sensitive, 70-80% will have at least one relapse during follow-up, and up to 50% of these patients will experience frequent relapses or become dependent on glucocorticoids to maintain remission. The dose and duration of steroid treatment to prolong time between relapses remains a subject of much debate, and patients continue to experience a high prevalence of steroid-related morbidity. Various steroid-sparing immunosuppressive drugs have been used in clinical practice; however, there is marked practice variation in the selection of these drugs and timing of their introduction during the course of the disease. Therefore, international evidence-based clinical practice recommendations (CPRs) are needed to guide clinical practice and reduce practice variation. The International Pediatric Nephrology Association (IPNA) convened a team of experts including pediatric nephrologists, an adult nephrologist, and a patient representative to develop comprehensive CPRs on the diagnosis and management of SSNS in children. After performing a systematic literature review on 12 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, recommendations were formulated and formally graded at several virtual consensus meetings. New definitions for treatment outcomes to help guide change of therapy and recommendations for important research questions are given.
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Affiliation(s)
- Agnes Trautmann
- grid.7700.00000 0001 2190 4373Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Olivia Boyer
- grid.50550.350000 0001 2175 4109Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Children’s Hospital, APHP, Paris, France
| | - Elisabeth Hodson
- grid.413973.b0000 0000 9690 854XCochrane Kidney and Transplant, Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, Australia
| | - Arvind Bagga
- grid.413618.90000 0004 1767 6103Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Debbie S. Gipson
- grid.214458.e0000000086837370Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI USA
| | - Susan Samuel
- grid.22072.350000 0004 1936 7697Section of Pediatric Nephrology, Department of Pediatrics, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Jack Wetzels
- grid.10417.330000 0004 0444 9382Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Khalid Alhasan
- grid.56302.320000 0004 1773 5396Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sushmita Banerjee
- grid.414710.70000 0004 1801 0469Department of Pediatric Nephrology, Institute of Child Health, Kolkata, India
| | - Rajendra Bhimma
- grid.16463.360000 0001 0723 4123University of KwaZulu-Natal, Durban, South Africa
| | - Melvin Bonilla-Felix
- grid.267034.40000 0001 0153 191XDepartment of Pediatrics, University of Puerto Rico-Medical Sciences Campus, San Juan, Puerto Rico
| | - Francisco Cano
- grid.443909.30000 0004 0385 4466Department of Pediatric Nephrology, Luis Calvo Mackenna Children’s Hospital, University of Chile, Santiago, Chile
| | - Martin Christian
- Children’s Kidney Unit, Nottingham Children’s Hospital, Nottingham, UK
| | - Deirdre Hahn
- grid.413973.b0000 0000 9690 854XDivision of Pediatric Nephrology, Department of Paediatrics, The Children’s Hospital at Westmead, Sydney, Australia
| | - Hee Gyung Kang
- grid.31501.360000 0004 0470 5905Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children’s Hospital & Seoul National University College of Medicine, Seoul, Korea
| | - Koichi Nakanishi
- grid.267625.20000 0001 0685 5104Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hesham Safouh
- grid.7776.10000 0004 0639 9286Pediatric Nephrology Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Howard Trachtman
- grid.214458.e0000000086837370Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI USA
| | - Hong Xu
- grid.411333.70000 0004 0407 2968Department of Nephrology, Children’s Hospital of Fudan University, Shanghai, China
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Somerset, UK
| | - Marina Vivarelli
- grid.414125.70000 0001 0727 6809Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Rome, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover and Center for Rare Diseases, Hannover Medical School, Hannover, Germany.
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Mattoo TK, Sanjad S. Current Understanding of Nephrotic Syndrome in Children. Pediatr Clin North Am 2022; 69:1079-1098. [PMID: 36880923 DOI: 10.1016/j.pcl.2022.08.002] [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] [Indexed: 11/05/2022]
Abstract
Nephrotic syndrome in children is mostly idiopathic in origin. About 90% of patients respond to corticosteroids; 80-90% have at least one relapse and 3-10% become corticosteroid resistant after the initial response. A kidney biopsy is seldom indicated for diagnosis except in patients with atypical presentation or corticosteroid resistance. For those in remission, the risk of relapse is reduced by the administration of daily low dose corticosteroids for 5-7 days at the onset of an upper respiratory infection. Some patients may continue having relapses through adult life. Many country-specific practice guidelines have been published, which are very similar with clinically insignificant differences.
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Affiliation(s)
- Tej K Mattoo
- Department of Pediatrics, Wayne State University School of Medicine, 400 Mack Avenue, Suite 1 East, Detroit, MI 48201, USA.
| | - Sami Sanjad
- American University of Beirut Medical Center, Beirut, Lebanon
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8
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Clinical practice guidelines for nephrotic syndrome: consensus is emerging. Pediatr Nephrol 2022; 37:2975-2984. [PMID: 35763086 DOI: 10.1007/s00467-022-05639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 01/10/2023]
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9
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Zion E, Borovitz Y, Alfandary H, Haskin O, Levi S, Shoham S, Davidovits M, Dagan A. A Clinical Response-Adjusted Steroid Treatment Protocol for Children With Newly Diagnosed Idiopathic Nephrotic Syndrome. Am J Kidney Dis 2022; 80:473-482.e1. [PMID: 35659571 DOI: 10.1053/j.ajkd.2022.04.007] [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] [Received: 09/22/2021] [Accepted: 04/08/2022] [Indexed: 02/02/2023]
Abstract
RATIONALE & OBJECTIVE Prednisone protocols for children with idiopathic nephrotic syndrome (INS) are generally similar in dose and duration, despite wide variations in time to response. We assessed the feasibility of a novel clinical treatment protocol characterized by a shorter duration and lower cumulative dose for children with early clinical response. STUDY DESIGN Nonrandomized pilot clinical trial. SETTING & PARTICIPANTS The study population included 59 children with newly diagnosed INS treated between 2014 and 2019 who responded to treatment within 8 days. INTERVENTION The intervention group (n = 27) was treated with a response-adjusted protocol during which responders received an 8-week course of tapering doses of prednisone. The usual care group (n =32) was treated with the standard protocol (prednisone, 60 mg/m2/24 hours for 6 weeks, followed by 40 mg/m2/48 hours for 4 weeks, followed by a slow taper for a total of 24 weeks). OUTCOME Consent rate, cumulative prednisone dose, the development of frequently relapsing or steroid-dependent nephrotic syndrome (FRNS or SDNS, respectively), relapses per year, treatment with steroid-sparing therapies, and adverse effects of steroid therapy over 3 years of follow-up observation. RESULTS The consent rate was 88%. The mean cumulative steroid dose for the initial treatment was 70 mg/kg and 141 mg/kg (P < 0.001) in the intervention and usual care groups, respectively. None of the patients in the intervention group relapsed while on faster steroid taper down. The occurrence of FRNS and SDNS in the intervention group was not statistically different than in the usual care group, hazard ratios were 0.80 (95% CI, 0.37-1.73) and 0.61 (95% CI, 0.30-1.27), respectively. The proportions of relapse-free patients were similar (P = 0.5), and adverse steroid events did not differ between the groups. LIMITATIONS Lack of randomization and small sample size. CONCLUSIONS These findings demonstrate the feasibility of a shortened duration of steroid dosing for INS when patients demonstrate an initial clinical response to treatment. A larger study is needed to characterize the relative efficacy and toxicity of this novel treatment regimen. FUNDING This study received no funding. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCTO2649413.
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Affiliation(s)
- Elena Zion
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Department A, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.
| | - Yael Borovitz
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Hadas Alfandary
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Orly Haskin
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shelly Levi
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Shoval Shoham
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Miriam Davidovits
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amit Dagan
- Institute of Nephrology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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10
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Hodson E, Hahn D, Craig JC. Prednisone for Steroid-Sensitive Nephrotic Syndrome: Can We Use Lower Doses for the First Presentation in Children? Am J Kidney Dis 2022; 80:433-435. [PMID: 35927137 DOI: 10.1053/j.ajkd.2022.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 05/20/2022] [Indexed: 02/02/2023]
Affiliation(s)
- Elisabeth Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia; Department of Nephrology, The Children's Hospital at Westmead, Sydney, Australia.
| | - Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia; College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Zotta F, Vivarelli M, Emma F. Update on the treatment of steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:303-314. [PMID: 33665752 DOI: 10.1007/s00467-021-04983-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/13/2021] [Accepted: 02/02/2021] [Indexed: 02/07/2023]
Abstract
Steroid-sensitive nephrotic syndrome (SSNS) is a rare condition that develops primarily in preadolescent children after the age of 1 year. Since the 1950s, oral corticosteroids have been the mainstay of treatment of all children presenting with nephrotic syndrome, with most patients responding within 4 weeks to an oral course of prednisone (PDN). However, corticosteroids have important side effects and 60-80 % of patients relapse, developing frequently relapsing or steroid-dependent forms. For these reasons, many patients require second-line steroid-sparing immunosuppressive medications that have considerably improved relapse-free survival, while avoiding many PDN-related toxicities. Since most patients will eventually heal from their disease with a normal kidney function, the morbidity of SSNS is primarily related to side effects of drugs that are used to maintain prolonged remission. Therefore, treatment is essentially based on balancing the use of different drugs to achieve permanent remission with the lowest cumulative number of side effects. Treatment choice is based on the severity of SSNS, on patient age, and on drug tolerability. This review provides an update of currently available therapeutic strategies for SSNS.
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Affiliation(s)
- Federica Zotta
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marina Vivarelli
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesco Emma
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
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12
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Christian MT, Maxted AP. Optimizing the corticosteroid dose in steroid-sensitive nephrotic syndrome. Pediatr Nephrol 2022; 37:37-47. [PMID: 33611671 PMCID: PMC7896825 DOI: 10.1007/s00467-021-04985-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/13/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
The use of corticosteroids in the treatment of steroid-sensitive nephrotic (SSNS) syndrome in children has evolved surprisingly slowly since the ISKDC consensus over 50 years ago. From a move towards longer courses of corticosteroid to treat the first episode in the 1990s and 2000s, more recent large, well-designed randomized controlled trials (RCTs) have unequivocally shown no benefit from an extended course, although doubt remains whether this applies across all age groups. With regard to prevention of relapses, daily ultra-low-dose prednisolone has recently been shown to be more effective than low-dose alternate-day prednisolone. Daily low-dose prednisolone for a week at the time of acute viral infection seems to be effective in the prevention of relapses but the results of a larger RCT are awaited. Recently, corticosteroid dosing to treat relapses has been questioned, with data suggesting lower doses may be as effective. The need for large RCTs to address the question of whether corticosteroid doses can be reduced was the conclusion of the authors of the recent corticosteroid therapy for nephrotic syndrome in children Cochrane update. This review summarizes development in thinking on corticosteroid use in SSNS and makes suggestions for areas that merit further scrutiny.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK.
| | - Andrew P Maxted
- Department of Paediatric Nephrology, Nottingham Children's Hospital, Nottingham, NG7 2UH, UK
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Christian MT, Webb NJA, Woolley RL, Afentou N, Mehta S, Frew E, Brettell EA, Khan AR, Milford DV, Bockenhauer D, Saleem MA, Hall AS, Koziell A, Maxwell H, Hegde S, Finlay ER, Gilbert RD, Jones C, McKeever K, Cook W, Ives N. Daily low-dose prednisolone to prevent relapse of steroid-sensitive nephrotic syndrome in children with an upper respiratory tract infection: PREDNOS2 RCT. Health Technol Assess 2022; 26:1-94. [DOI: 10.3310/wtfc5658] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
Most children with steroid-sensitive nephrotic syndrome have relapses that are triggered by upper respiratory tract infections. Four small trials, mostly in children already taking maintenance corticosteroid in countries of different upper respiratory tract infection epidemiology, showed that giving daily low-dose prednisone/prednisolone for 5–7 days during an upper respiratory tract infection reduces the risk of relapse.
Objectives
To determine if these findings were replicated in a large UK population of children with relapsing steroid-sensitive nephrotic syndrome on different background medication or none.
Design
A randomised double-blind placebo-controlled trial, including a cost-effectiveness analysis.
Setting
A total of 122 UK paediatric departments, of which 91 recruited patients.
Participants
A total of 365 children with relapsing steroid-sensitive nephrotic syndrome (mean age 7.6 ± 3.5 years) were randomised (1 : 1) according to a minimisation algorithm based on background treatment. Eighty children completed 12 months of follow-up without an upper respiratory tract infection. Thirty-two children were withdrawn from the trial (14 prior to an upper respiratory tract infection), leaving a modified intention-to-treat analysis population of 271 children (134 and 137 children in the prednisolone and placebo arms, respectively).
Interventions
At the start of an upper respiratory tract infection, children received 6 days of prednisolone (15 mg/m2) or an equivalent dose of placebo.
Main outcome measures
The primary outcome was the incidence of first upper respiratory tract infection-related relapse following any upper respiratory tract infection over 12 months. The secondary outcomes were the overall rate of relapse, changes in background treatment, cumulative dose of prednisolone, rates of serious adverse events, incidence of corticosteroid adverse effects, change in Achenbach Child Behaviour Checklist score and quality of life. Analysis was by intention-to-treat principle. The cost-effectiveness analysis used trial data and a decision-analytic model to estimate quality-adjusted life-years and costs at 1 year, which were then extrapolated over 16 years.
Results
There were 384 upper respiratory tract infections and 82 upper respiratory tract infection-related relapses in the prednisolone arm, and 407 upper respiratory tract infections and 82 upper respiratory tract infection-related relapses in the placebo arm. The number of patients experiencing an upper respiratory tract infection-related relapse was 56 (42.7%) and 58 (44.3%) in the prednisolone and placebo arms, respectively (adjusted risk difference –0.024, 95% confidence interval –0.14 to 0.09; p = 0.70). There was no evidence that the treatment effect differed when data were analysed according to background treatment. There were no significant differences in secondary outcomes between treatment arms. Giving daily prednisolone at the time of an upper respiratory tract infection was associated with increased quality-adjusted life-years (0.9427 vs. 0.9424) and decreased average costs (£252 vs. £254), when compared with standard care. The cost saving was driven by background therapy and hospitalisations after relapse. The finding was robust to sensitivity analysis.
Limitations
A larger number of children than expected did not have an upper respiratory tract infection and the sample size attrition rate was adjusted accordingly during the trial.
Conclusions
The clinical analysis indicated that giving 6 days of daily low-dose prednisolone at the time of an upper respiratory tract infection does not reduce the risk of relapse of steroid-sensitive nephrotic syndrome in UK children. However, there was an economic benefit from costs associated with background therapy and relapse, and the health-related quality-of-life impact of having a relapse.
Future work
Further work is needed to investigate the clinical and health economic impact of relapses, interethnic differences in treatment response, the effect of different corticosteroid regimens in treating relapses, and the pathogenesis of individual viral infections and their effect on steroid-sensitive nephrotic syndrome.
Trial registration
Current Controlled Trials ISRCTN10900733 and EudraCT 2012-003476-39.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin T Christian
- Department of Paediatric Nephrology, Nottingham Children’s Hospital, Nottingham, UK
| | - Nicholas JA Webb
- Department of Paediatric Nephrology, University of Manchester, Academic Health Science Centre, Royal Manchester Children’s Hospital, Manchester, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Nafsika Afentou
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Samir Mehta
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Adam R Khan
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - David V Milford
- Department of Paediatric Nephrology, Birmingham Children’s Hospital, Birmingham, UK
| | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK
| | - Moin A Saleem
- School of Clinical Sciences, University of Bristol, Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, UK
| | | | - Ania Koziell
- Child Health Clinical Academic Group, King’s College London, Department of Paediatric Nephrology, Evelina London Children’s Hospital, London, UK
| | - Heather Maxwell
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Glasgow, UK
| | - Shivaram Hegde
- Department of Paediatric Nephrology, University Hospital of Wales, Cardiff, UK
| | - Eric R Finlay
- Department of Paediatric Nephrology, Leeds Children’s Hospital, Leeds, UK
| | - Rodney D Gilbert
- Department of Paediatric Nephrology, Southampton Children’s Hospital, Southampton, UK
| | - Caroline Jones
- Department of Paediatric Nephrology, Alder Hey Children’s Hospital, Liverpool, UK
| | - Karl McKeever
- Department of Paediatric Nephrology, Royal Hospital for Sick Children, Belfast, UK
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Taunton, UK
| | - Natalie Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Fribourg M, Cioni M, Ghiggeri G, Cantarelli C, Leventhal JS, Budge K, Bin S, Riella LV, Colucci M, Vivarelli M, Angeletti A, Perin L, Cravedi P. CyTOF-Enabled Analysis Identifies Class-Switched B Cells as the Main Lymphocyte Subset Associated With Disease Relapse in Children With Idiopathic Nephrotic Syndrome. Front Immunol 2021; 12:726428. [PMID: 34621271 PMCID: PMC8490633 DOI: 10.3389/fimmu.2021.726428] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/01/2021] [Indexed: 01/21/2023] Open
Abstract
B cell depleting therapies permit immunosuppressive drug withdrawal and maintain remission in patients with frequently relapsing nephrotic syndrome (FRNS) or steroid–dependent nephrotic syndrome (SDNS), but lack of biomarkers for treatment failure. Post-depletion immune cell reconstitution may identify relapsing patients, but previous characterizations suffered from methodological limitations of flow cytometry. Time-of-flight mass cytometry (CyTOF) is a comprehensive analytic modality that simultaneously quantifies over 40 cellular markers. Herein, we report CyTOF-enabled immune cell comparisons over a 12-month period from 30 children with SDNS receiving B cell depleting therapy who either relapsed (n = 17) or remained stable (n = 13). Anti-CD20 treatment depleted all B cells subsets and CD20 depleting agent choice (rituximab vs ofatumumab) did not affect B cell subset recovery. Despite equal total numbers of B cells, 5 subsets of B cells were significantly higher in relapsing individuals; all identified subsets of B cells were class-switched. T cell subsets (including T follicular helper cells and regulatory T cells) and other major immune compartments were largely unaffected by B cell depletion, and similar between relapsing and stable children. In conclusion, CyTOF analysis of immune cells from anti-CD20 antibody treated patients identifies class-switched B cells as the main subset whose expansion associates with disease relapse. Our findings set the basis for future studies exploring how identified subsets can be used to monitor treatment response and improve our understanding of the pathogenesis of the disease.
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Affiliation(s)
- Miguel Fribourg
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Michela Cioni
- Nephrology, Dialysis and Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
| | - GianMarco Ghiggeri
- Nephrology, Dialysis and Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
| | - Chiara Cantarelli
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Dipartimento di Medicina e Chirurgia Università di Parma, Unitá Operativa (UO) Nefrologia, Azienda Ospedaliera-Universitaria Parma, Parma, Italy
| | - Jeremy S Leventhal
- Division of Nephrology, White Plains Hospital, White Plains, NY, United States
| | - Kelly Budge
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sofia Bin
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Leonardo V Riella
- Center for Transplantation Sciences, Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Area, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Marina Vivarelli
- Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Andrea Angeletti
- Nephrology, Dialysis and Transplantation Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genova, Italy
| | - Laura Perin
- Gabriel Organization for All Renal Research (GOFARR) Laboratory, Children's Hospital Los Angeles, Division of Urology, Saban Research Institute, University of Southern California, Los Angeles, CA, United States
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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15
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 733] [Impact Index Per Article: 244.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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16
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Low-dose versus conventional-dose prednisolone for nephrotic syndrome relapses: a randomized controlled non-inferiority trial. Pediatr Nephrol 2021; 36:3143-3150. [PMID: 33861375 DOI: 10.1007/s00467-021-05048-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/13/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Reduction of steroid exposure in relapses of steroid-sensitive nephrotic syndrome (SSNS) is under-researched. METHODS In this randomized controlled non-inferiority trial, 1-12-year-old children with relapse of SSNS were randomized to receive prednisolone 1 mg/kg/day (low dose) or 2 mg/kg/day (standard dose) until disease remission or day 15, whichever was earlier. Therapy was switched to 2 mg/kg/day in children in low-dose group not in remission by day 15. Primary outcome was days to remission, and secondary outcome being pattern of subsequent relapse(s) over 1 year. Estimating time to remission of 8 ± 2.5 days with standard-dose therapy, non-inferiority margin of 2 days, 90% power, and α-0.05, 60 patients were randomized. RESULTS Of the 60 children (30 in each group) enrolled, 4 (one in low-dose group) failed remission by day 15. Time to remission was comparable between low-dose and standard-dose groups [9.0 ± 2.2 vs. 8.6 ± 2.2 days; mean difference (95% CI) 0.4 (- 0.79 to 1.59) days; p = 0.49], thus establishing non-inferiority of low dose. Median time to subsequent relapse was 86 (IQR 74.8, 97.2) and 150 (IQR 59.0, 240.9) days, in low- versus standard-dose groups, respectively (log rank p = 0.39). In follow-up, proportion of children having relapses, frequency of relapses, proportion with frequent relapse/steroid dependent (FR/SD), and cumulative corticosteroid dose taken were comparable between groups. CONCLUSIONS This study shows that time to achieve remission after treatment of a relapse with low-dose prednisolone is non-inferior to that after treatment with conventional dose in children with SSNS. The proportion of children achieving remission, further course, and pattern of relapses was comparable between both groups.
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17
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Rodriguez-Lopez S, Chanchlani R, Dart AB, Morgan CJ, Lapeyraque AL, Tee JB, Brobbey A, Perinpanayagam MA, Samuel S, Nettel-Aguirre A. Characteristics Associated with Variation in Corticosteroid Exposure in Children with Steroid-Sensitive Nephrotic Syndrome: Results from a Canadian Longitudinal Study. KIDNEY360 2021; 2:1960-1967. [PMID: 35419527 PMCID: PMC8986050 DOI: 10.34067/kid.0002692021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
Background Variation in dose and duration of corticosteroids for childhood-onset steroid-sensitive nephrotic syndrome occurs worldwide, likely reflecting the evolving evidence on optimal dosing and variable severity of the disease observed between patients. We conducted a study to determine the associations between site, physician, and patient factors, and average daily corticosteroid dose and duration of therapy. Methods Data were derived from the Canadian Childhood Nephrotic Syndrome (CHILDNEPH) Project, an observational longitudinal study from 2013 to 2019 of children with nephrotic syndrome involving pediatric nephrologists in 11 sites across Canada. The primary outcome was average daily corticosteroid dose prescribed per episode of proteinuria, reported as mg/m2 prednisone equivalents. Secondary outcome was duration of treatment for each episode of proteinuria in days. Exposure variables were categorized into site-, physician-, and patient-level variables. Results In total, 328 children, median age at enrollment of 4.3 years old (interquartile range [IQR], 3.6), participated and were followed for a median time of 2.62 years (IQR, 2.6). The observed variability in average daily corticosteroid dose and in duration of therapy was mostly attributed to the site where the patient was treated. Accounting for between patient, physician, and site differences, average daily corticosteroid dose decreased with increasing age (beta coefficient, -0.07; 95% confidence interval [95% CI], -0.09 to -0.05], P<0.001). African and Indigenous ethnicity was associated with longer treatment duration compared with White patients (beta coefficient: African, 42.29, 95% CI, 7.85 to 76.73, P=0.02; Indigenous, 29.65, 95% CI, 2.79 to 56.52, P=0.03). Conclusions We found practice variation with respect to corticosteroid prescriptions across 11 Canadian sites, and that variation is mostly explained at the site level. Age and ethnicity are important factors to be considered, because they are significantly associated with the average corticosteroid dose and duration of therapy.
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Affiliation(s)
- Sara Rodriguez-Lopez
- Division of Nephrology, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Canada
| | - Rahul Chanchlani
- Division of Nephrology, Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Canada
| | - Allison B. Dart
- Division of Nephrology, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Canada
| | - Catherine J. Morgan
- Division of Nephrology, Department of Pediatrics, Stollery Children’s Hospital, University of Alberta, Edmonton, Canada
| | - Anne-Laure Lapeyraque
- Division of Nephrology, Pediatric Department, Sainte Justine University Hospital Center, Montreal, Canada
| | - James B. Tee
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Anita Brobbey
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Maneka A. Perinpanayagam
- Section of Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Susan Samuel
- Section of Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Alberto Nettel-Aguirre
- Centre for Health and Social Analytics, National Institute for Applied Statistics Research, University of Wollongong, Wollongong, Australia
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Koirala A, Jefferson JA. Steroid Minimization in Adults with Minimal Change Disease. GLOMERULAR DISEASES 2021; 1:237-249. [PMID: 36751385 PMCID: PMC9677715 DOI: 10.1159/000517626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/30/2021] [Indexed: 11/19/2022]
Abstract
Background Minimal change disease (MCD) causes approximately 10% of nephrotic syndrome in adults. While glucocorticoids (GCs) effectively induce remission in MCD, the disease has a high relapse rate (50-75%), and repeated exposure to GCs is often required. The adverse effects of GCs are well recognized and commonly encountered with the high doses and recurrent courses used in MCD. Summary In this review, we will discuss the standard therapy of MCD in adults and then describe new therapeutic options in induction therapy and treatment of relapses in MCD, minimizing the exposure to GCs. Key Messages Steroid minimization strategies may decrease adverse effects in the treatment of MCD.
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Pasini A, Bertulli C, Casadio L, Corrado C, Edefonti A, Ghiggeri G, Ghio L, Giordano M, La Scola C, Malaventura C, Maringhini S, Mastrangelo AP, Materassi M, Mencarelli F, Messina G, Monti E, Morello W, Puccio G, Romagnani P, Montini G. Childhood Idiopathic Nephrotic Syndrome: Does the Initial Steroid Treatment Modify the Outcome? A Multicentre, Prospective Cohort Study. Front Pediatr 2021; 9:627636. [PMID: 34307246 PMCID: PMC8295604 DOI: 10.3389/fped.2021.627636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/12/2021] [Indexed: 12/02/2022] Open
Abstract
Background: A great majority of children with idiopathic nephrotic syndrome will relapse after successful treatment of the initial episode. The possibility that different steroid dosing regimens at onset, adjusted for risk factors, can reduce the rate of relapse represents an interesting option to investigate. Objectives: To evaluate the effect of the initial steroid regimen, adjusted for time to remission (TTR), on the frequency of relapses and steroid dependence, and to verify the influence of prognostic factors on disease course. Methods: A multicentre, prospective, cohort study. Children with nephrotic syndrome, with TTR ≤ 10 days (Group A), were given a 20-week prednisone regimen (2,828 mg/m2) and those with a TTR >10 days, a 22-week regimen (3,668 mg/m2) (Group B). Previously published retrospective data from the same centers were also evaluated. Main outcomes were: relapse rate, number of frequent relapsers + steroid dependent children and total prednisone dose after induction. Results: 143 children were enrolled. Rate of relapsed subjects (77 vs. 79%) and frequent relapsers + steroid dependent subjects (40 vs. 53%) did not differ between Groups A and B, or between the retrospective and prospective cohorts. The cumulative prednisone dose taken after the induction treatment was similar in both groups and in the retrospective and prospective cohorts. TTR was not associated with relapse risk. Age at onset and total serum protein were significantly lower in relapsing patients. At ROC analysis, the best cut-off was 5.3 years for age at onset and 4.2 g/dL for total serum protein. According to these cut-offs, older children with higher total serum protein had a higher relapse free survival rate (58%) than younger children with lower total serum protein (17%). Conclusions: TTR was not found to be a prognostic factor of relapse; because of this, different steroid regimens, adjusted for TTR, did not modify the relapse rate in any relevant measure. Conversely, younger age and low total serum protein were independent predictors of relapse risk, however this outcome was not modified by higher prednisone regimens. Clinical Trial Registration:https://www.ClinicalTrials.gov/, identifier: NCT01386957 (www.nefrokid.it).
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Affiliation(s)
- Andrea Pasini
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Bertulli
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luca Casadio
- Unità Operativa Complessa of Paediatrics and Neonatology, Local Health Authority of Romagna, Ravenna, Italy
| | - Ciro Corrado
- Pediatric Nephrology Unit, Children's Hospital “G. Di Cristina”, A.R.N.A.S. “Civico”, Palermo, Italy
| | - Alberto Edefonti
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - GianMarco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, Laboratory on Pathophysiology of Uremia, Istituto G. Gaslini, Genoa, Italy
| | - Luciana Ghio
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Giordano
- Nephrology Unit, Giovanni XXIII Children's Hospital, Bari, Italy
| | - Claudio La Scola
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Malaventura
- Section of Pediatrics, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Silvio Maringhini
- Pediatric Nephrology Unit, Children's Hospital “G. Di Cristina”, A.R.N.A.S. “Civico”, Palermo, Italy
| | - Antonio P. Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Materassi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Francesca Mencarelli
- Nephrology and Dialysis Unit, Department of Pediatrics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giovanni Messina
- Nephrology Unit, Giovanni XXIII Children's Hospital, Bari, Italy
| | - Elena Monti
- Specialty School of Paediatrics - Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Paola Romagnani
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Granda Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Maggiore Policlinico, Milan, Italy
- Giuliana and Bernardo Caprotti Chair of Pediatrics, Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy
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Veltkamp F, Rensma LR, Bouts AHM. Incidence and Relapse of Idiopathic Nephrotic Syndrome: Meta-analysis. Pediatrics 2021; 148:peds.2020-029249. [PMID: 34193618 DOI: 10.1542/peds.2020-029249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Idiopathic nephrotic syndrome (INS) in children is a disease with considerable morbidity, yet the incidence and risk for relapse have not been systematically reviewed. OBJECTIVE To estimate the overall pooled weighted incidence and risk for relapse of INS in children. DATA SOURCES Medline and Embase (until December 2020). STUDY SELECTION All studies reporting incidence (per 100 000 children per year) and/or risk for relapse (the proportion of patients who experience ≥1 relapse) of INS in children (age: <18 years) were eligible. DATA EXTRACTION After quality assessment, data were extracted: study (design, localization, and sample size) and patient (age, sex, steroid response, and ethnicity) characteristics, incidence, and risk for relapse. RESULTS After screening, 73 studies were included for analysis (27 incidence, 54 relapse). The overall pooled weighted estimate and corresponding prediction interval (PI) of the incidence was 2.92 (95% PI: 0.00-6.51) per 100 000 children per year. Higher incidences were found in non-Western countries (P < .001). Incidence tended to be lower in white children, but this was not significant. The overall pooled weighted estimate of the risk for relapse was 71.9% (95% PI: 38.8-95.5). Between 1945 and 2011, incidence did not change (P = .39), yet the risk for relapse decreased significantly (P = .024), from 87.4% to 66.2%. LIMITATIONS There was no full-text availability (n = 33), considerable heterogeneity, and limited studies from Africa, Latin America, and Asia. CONCLUSIONS INS has a low incidence with ethnic variation but high risk for relapse. Although corticosteroids have significantly reduced the risk for relapse, it remains unacceptably high, underscoring the need for alternative treatment strategies.
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Affiliation(s)
- Floor Veltkamp
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Leonie R Rensma
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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21
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Schijvens AM, Sinha A, Bagga A, Schreuder MF. Need for uniform definitions in childhood nephrotic syndrome. Nephrol Dial Transplant 2021; 36:941-945. [PMID: 33367868 DOI: 10.1093/ndt/gfaa338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/12/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anne M Schijvens
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
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22
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Williams AE, Gbadegesin RA. Steroid Regimen for Children with Nephrotic Syndrome Relapse. Clin J Am Soc Nephrol 2021; 16:179-181. [PMID: 33478977 PMCID: PMC7863643 DOI: 10.2215/cjn.19201220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Anna Elizabeth Williams
- Division of Nephrology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
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23
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Chin HJ, Chae DW, Kim YC, An WS, Ihm C, Jin DC, Kim SG, Kim YL, Kim YS, Kim YG, Koo HS, Lee JE, Lee KW, Oh J, Park JH, Jiang H, Lee H, Lee SK. Comparison of the Efficacy and Safety of Tacrolimus and Low-Dose Corticosteroid with High-Dose Corticosteroid for Minimal Change Nephrotic Syndrome in Adults. J Am Soc Nephrol 2021; 32:199-210. [PMID: 33168602 PMCID: PMC7894664 DOI: 10.1681/asn.2019050546] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/08/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Tacrolimus is used as a steroid-sparing immunosuppressant in adults with minimal change nephrotic syndrome. However, combined treatment with tacrolimus and low-dose steroid has not been compared with high-dose steroid for induction of clinical remission in a large-scale randomized study. METHODS In this 24-week open-label noninferiority study, we randomized 144 adults with minimal change nephrotic syndrome to receive 0.05 mg/kg twice-daily tacrolimus plus once-daily 0.5 mg/kg prednisolone, or once-daily 1 mg/kg prednisolone alone, for up to 8 weeks or until achieving complete remission. Two weeks after complete remission, we tapered the steroid to a maintenance dose of 5-7.5 mg/d in both groups until 24 weeks after study drug initiation. The primary end point was complete remission within 8 weeks (urine protein: creatinine ratio <0.2 g/g). Secondary end points included time until remission and relapse rates (proteinuria and urine protein: creatinine ratio >3.0 g/g) after complete remission to within 24 weeks of study drug initiation. RESULTS Complete remission within 8 weeks occurred in 53 of 67 patients (79.1%) receiving tacrolimus and low-dose steroid and 53 of 69 patients (76.8%) receiving high-dose steroid; this difference demonstrated noninferiority, with an upper confidence limit below the predefined threshold (20%) in both intent-to-treat (11.6%) and per-protocol (17.0%) analyses. Groups did not significantly differ in time until remission. Significantly fewer patients relapsed on maintenance tacrolimus (3-8 ng/ml) plus tapered steroid versus tapered steroid alone (5.7% versus 22.6%, respectively; P=0.01). There were no clinically relevant safety differences. CONCLUSIONS Combined tacrolimus and low-dose steroid was noninferior to high-dose steroid for complete remission induction in adults with minimal change nephrotic syndrome. Relapse rates were significantly lower with maintenance tacrolimus and steroid compared with steroid alone. No clinically-relevant differences in safety findings were observed.
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Affiliation(s)
- Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Won Suk An
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, South Korea
| | - ChunGyoo Ihm
- Department of Nephrology, Kyunghee University Medical Center, Seoul, South Korea
| | - Dong-Chan Jin
- Department of Internal Medicine, St Vincent Hospital, Suwon, South Korea
| | - Sung Gyun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Soo Kim
- Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, South Korea
| | - Yoon-Goo Kim
- Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ho Seok Koo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, South Korea
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kang Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon, South Korea
| | - Jieun Oh
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Jung Hwan Park
- Department of Internal Medicine, Konkuk University Medical Center, Seoul, South Korea
| | - Hongsi Jiang
- Medical Affairs Asia Oceania, Astellas Pharma Singapore Pte. Ltd., Singapore
| | - Hyuncheol Lee
- Clinical Research, Astellas Pharma Korea Inc., Seoul, South Korea
| | - Sang Koo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
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24
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Ehren R, Benz MR, Brinkkötter PT, Dötsch J, Eberl WR, Gellermann J, Hoyer PF, Jordans I, Kamrath C, Kemper MJ, Latta K, Müller D, Oh J, Tönshoff B, Weber S, Weber LT. Commentary on "Pediatric Idiopathic Steroid-sensitive Nephrotic Syndrome Diagnosis and Therapy - Short version of the updated German Best Practice Guideline (S2e)". Pediatr Nephrol 2021; 36:2961-2966. [PMID: 34091755 PMCID: PMC8445862 DOI: 10.1007/s00467-021-05136-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/12/2021] [Indexed: 12/03/2022]
Affiliation(s)
- Rasmus Ehren
- Pediatric Nephrology, Children’s and Adolescents’ Hospital, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marcus R. Benz
- Pediatric Nephrology, Children’s and Adolescents’ Hospital, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Paul T. Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany ,Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Jörg Dötsch
- Pediatric Nephrology, Children’s and Adolescents’ Hospital, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Wolfgang R. Eberl
- Department of Pediatrics, Städtisches Klinikum Braunschweig, Braunschweig, Germany
| | - Jutta Gellermann
- Pediatric Nephrology, Charité Children’s Hospital, Berlin, Germany
| | - Peter F. Hoyer
- Center for Children and Adolescents, Pediatric Clinic II, University of Duisburg-Essen, Essen, Germany
| | - Isabelle Jordans
- Bundesverband Niere eV (German National Kidney-Patients Association), Mainz, Germany
| | - Clemens Kamrath
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Markus J. Kemper
- Department of Pediatrics, Asklepios Medical School, Hamburg, Germany
| | - Kay Latta
- Clementine Kinderhospital Frankfurt, Frankfurt, Germany
| | - Dominik Müller
- Pediatric Nephrology, Charité Children’s Hospital, Berlin, Germany
| | - Jun Oh
- Division of Pediatric Nephrology, Hepatology and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children’s Hospital, Heidelberg, Germany
| | - Stefanie Weber
- Department of Pediatrics II, University Children’s Hospital, Philipps-University Marburg, Marburg, Germany
| | - Lutz T. Weber
- Pediatric Nephrology, Children’s and Adolescents’ Hospital, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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25
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Ehren R, Benz MR, Brinkkötter PT, Dötsch J, Eberl WR, Gellermann J, Hoyer PF, Jordans I, Kamrath C, Kemper MJ, Latta K, Müller D, Oh J, Tönshoff B, Weber S, Weber LT. Pediatric idiopathic steroid-sensitive nephrotic syndrome: diagnosis and therapy -short version of the updated German best practice guideline (S2e) - AWMF register no. 166-001, 6/2020. Pediatr Nephrol 2021; 36:2971-2985. [PMID: 34091756 PMCID: PMC8445869 DOI: 10.1007/s00467-021-05135-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/26/2021] [Accepted: 05/12/2021] [Indexed: 01/21/2023]
Abstract
Idiopathic nephrotic syndrome is the most frequent glomerular disease in children in most parts of the world. Children with steroid-sensitive nephrotic syndrome (SSNS) generally have a good prognosis regarding the maintenance of normal kidney function even in the case of frequent relapses. The course of SSNS is often complicated by a high rate of relapses and the associated side effects of repeated glucocorticoid (steroid) therapy. The following recommendations for the treatment of SSNS are based on the comprehensive consideration of published evidence by a working group of the German Society for Pediatric Nephrology (GPN) based on the systematic Cochrane reviews on SSNS and the guidelines of the KDIGO working group (Kidney Disease - Improving Global Outcomes).
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Affiliation(s)
- Rasmus Ehren
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany.
| | - Marcus R Benz
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Paul T Brinkkötter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases (CECAD), Cologne, Germany
| | - Jörg Dötsch
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Wolfgang R Eberl
- Department of Pediatrics, Städtisches Klinikum Braunschweig, Braunschweig, Germany
| | - Jutta Gellermann
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Peter F Hoyer
- Center for Children and Adolescents, Pediatric Clinic II, University of Duisburg-Essen, Essen, Germany
| | - Isabelle Jordans
- Bundesverband Niere eV (German National Kidney-Patients Association), Mainz, Germany
| | - Clemens Kamrath
- Division of Pediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Medical School, Hamburg, Germany
| | - Kay Latta
- Clementine Kinderhospital Frankfurt, Frankfurt, Germany
| | - Dominik Müller
- Pediatric Nephrology, Charité Children's Hospital, Berlin, Germany
| | - Jun Oh
- Division of Pediatric Nephrology, Hepatology and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Stefanie Weber
- Department of Pediatrics II, University Children's Hospital, Philipps-University Marburg, Marburg, Germany
| | - Lutz T Weber
- Faculty of Medicine and University Hospital Cologne, Pediatric Nephrology, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
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Schijvens AM, Teeninga N, Dorresteijn EM, Teerenstra S, Webb NJ, Schreuder MF. Steroid treatment for the first episode of childhood nephrotic syndrome: comparison of the 8 and 12 weeks regimen using an individual patient data meta-analysis. Eur J Pediatr 2021; 180:2849-2859. [PMID: 33774744 PMCID: PMC8346453 DOI: 10.1007/s00431-021-04035-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 11/25/2022]
Abstract
Steroids are the cornerstone of the treatment of childhood nephrotic syndrome. The optimal duration for the first episode remains a matter of debate. The aim of this study is to determine whether the 8 weeks International Study of Kidney Disease in Children (ISKDC) regimen is equally effective as the 12 weeks steroid regimen from the German society of pediatric nephrology (Arbeitsgemeinschaft für Pädiatrische Nephrologie [APN]). An individual patient data (IPD) meta-analysis of randomized controlled trials reporting on prednisolone treatment for a first episode of childhood nephrotic syndrome was conducted. European trials aimed at investigating the ISKDC and/or APN steroid regimen were selected. The lead investigators of the selected trials were requested to provide the IPD of the specific treatment groups. Four trials included European cohorts using dosing schedules according to the regimens studied. IPD of two trials were available. A significant difference was found in time to first relapse after cessation of steroid treatment between the 8 and 12 weeks treatment group with a median time to relapse of 29 and 63 days, respectively. Moreover, relapse rate ratios during total follow-up were 51% higher for the 8 weeks regimen. Finally, younger children have a significantly lower time to first relapse and frequently relapsing nephrotic syndrome.Conclusions: The results of this IPD meta-analysis suggest that the 8 weeks steroid regimen for a first episode of steroid-sensitive nephrotic syndrome may not be equally effective as the 12 weeks steroid regimen. Moreover, this study highlights the importance of using uniform definitions to enable accurate comparison and interpretation of trial results.Trial registration: Registration number: CRD42020199244, date of registration 16-08-2020 What is Known: • Steroids are the cornerstone of the treatment of childhood nephrotic syndrome, however the optimal duration for the first episode remains a matter of debate. • Currently, the 8 weeks ISKDC protocol and 12 weeks APN protocol are among the most frequently used protocols in Europe. What is New: • The 8 weeks steroid regimen for a first episode of steroid-sensitive nephrotic syndrome may not be equally effective as the 12 weeks steroid regimen for the treatment of a first episode of nephrotic syndrome. • Younger children have a significantly shorter time to first relapse and time to frequent relapsing nephrotic syndrome.
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Affiliation(s)
- Anne M. Schijvens
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Nijmegen, the Netherlands
| | - Nynke Teeninga
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Nijmegen, the Netherlands
| | - Eiske M. Dorresteijn
- Department of Pediatric Nephrology, Erasmus University Medical Center, Sophia Children’s Hospital, Rotterdam, the Netherlands
| | - Steven Teerenstra
- Department for Health Evidence, section Biostatistics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Nicholas J. Webb
- Department of Paediatric Nephrology, Royal Manchester Children’s Hospital, Manchester, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL UK
| | - Michiel F. Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children’s Hospital, Nijmegen, the Netherlands
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Results of the PROPINE randomized controlled study suggest tapering of prednisone treatment for relapses of steroid sensitive nephrotic syndrome is not necessary in children. Kidney Int 2020; 99:475-483. [PMID: 33152448 DOI: 10.1016/j.kint.2020.09.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/24/2020] [Accepted: 09/03/2020] [Indexed: 01/16/2023]
Abstract
Corticosteroid-related toxicity in children with steroid-sensitive nephrotic syndrome is primarily related to the cumulative dose of prednisone. To optimize treatment of relapses, we conducted the PROPINE study, a multicentric, open-label, randomized, superiority trial. Seventy-eight relapsing children aged 3-17 years who had not received steroid-sparing medications during the previous 12 months were randomized to receive, from day five after remission, either 18 doses of 40 mg/m2 of prednisone on alternate days (short arm), or the same cumulative dose tapered over double the time (long arm). Patients were monitored with an ad-hoc smartphone application, allowing daily reporting. The primary outcome was the six-month relapse rate at which time, 23/40 and 16/38 patients had relapsed in the long and short arms, respectively (no significant difference). Additionally, 40/78 patients were also enrolled in a secondary crossover study and were allocated to the opposite arm. Altogether, at six months, the relapse rate was 32/40 and 28/40 in the long and short arms, respectively (no significant difference). A post-hoc analysis excluding 30 patients treated with low-dose prednisone maintenance therapy failed to show significant differences between the two arms. No differences in adverse events, blood pressure and weight gain were observed. Thus, our data do not support the prescription of prolonged tapering schedules for relapses of steroid-sensitive nephrotic syndrome in children.
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28
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Hahn D, Samuel SM, Willis NS, Craig JC, Hobson EM. Corticosteroid therapy for nephrotic syndrome in children. Cochrane Database Syst Rev 2020; 2020:CD001533. [PMID: 35659203 PMCID: PMC8094227 DOI: 10.1002/14651858.cd001533.pub6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND In nephrotic syndrome protein leaks from blood into the urine through the glomeruli resulting in hypoproteinaemia and generalised oedema. While most children with nephrotic syndrome respond to corticosteroids, 80% experience a relapsing course. Corticosteroids have reduced the death rate to around 3%. However, corticosteroids have well recognised potentially serious adverse effects such as obesity, poor growth, hypertension, diabetes mellitus, osteoporosis, and behavioural disturbances. This is an update of a review first published in 2000 and updated in 2002, 2005, 2007, and 2015. OBJECTIVES The aim of this review was to assess the benefits and harms of different corticosteroid regimens in children with steroid-sensitive nephrotic syndrome (SSNS). The benefits and harms of therapy were studied in two groups of children 1) children in their initial episode of SSNS, and 2) children who experience a relapsing course of SSNS. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 30 May 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) performed in children (one to 18 years) in their initial or subsequent episode of SSNS, comparing different durations, total doses or other dose strategies using any corticosteroid agent. DATA COLLECTION AND ANALYSIS Two authors independently assessed risk of bias and extracted data. Results were expressed as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CI). MAIN RESULTS In this 2020 review update 16 new included studies were identified providing a total of 48 included studies with 3941 randomised participants. Risk of bias methodology was often poorly performed with only 25 studies and 22 studies respectively assessed to be at low risk for random sequence generation and allocation concealment. Only nine studies (19%) were at low risk of bias for performance (blinding of participants and personnel) and 11 studies were at low risk of detection bias (blinding of outcome assessment); nine of these studies were placebo-controlled RCTs. Twenty-two studies (fewer than 50%) were at low risk for attrition bias and 23 studies were at low risk for reporting bias (selective outcome reporting). In seven studies, which evaluated children in their initial episode of SSNS and were at low risk of bias for selection bias, there is little or no difference in the number of children with frequent relapses when comparing two months of prednisone with three months or more (RR 0.99, 95% CI 0.82 to 1.19; 585 participants, 4 studies; I2 = 0%) or when comparing three months with five to seven months of therapy (RR 0.99, 95% CI 0.74 to 1.33; 376 participants, 3 studies; I2 = 35%; high certainty evidence). In analyses of eight studies at low risk of selection bias, there is little or no difference in the number of children with any relapse by 12 to 24 months when comparing two months of prednisone with three months or more (RR 0.91, 95% CI 0.78 to 1.06; 637 participants; 5 studies; I2 = 47%) or when comparing three months with five to seven months of therapy (RR 0.88, 95% CI 0.70 to 1.11; 377 participants, 3 studies; I2 = 53%). Little or no difference was noted in adverse effects between the different treatment durations. Among children with relapsing SSNS, two small studies showed that time to remission did not differ between prednisone doses of 1 mg/kg compared with the conventional dose of 2 mg/kg (MD 0.71 days, 95% CI -0.43 to 1.86; 79 participants) and that the total prednisone dose administered was lower (MD -20.60 mg/kg, 95% CI -25.65 to -15.55; 20 participants). Two studies found little or no difference in the number with relapse at six months when comparing dosing by weight with dosing by surface area (RR 1.03, 95% CI 0.71 to 1.49; 146 participants). One study found a reduced risk of relapse with low daily dosing compared with alternate daily dosing (MD -0.90 number of relapses/year, 95% CI -1.33 to -0.47). Four studies found that in children with frequently relapsing disease, daily prednisone during viral infections compared with alternate-day prednisone or no treatment reduced the risk of relapse. AUTHORS' CONCLUSIONS There are now four well designed studies randomising 823 children which have clearly demonstrated that there is no benefit of prolonging prednisone therapy beyond two to three months in the first episode of SSNS. Small studies in children with relapsing disease have identified no differences in the times to remission using half the conventional induction dose of 2 mg/kg or 60 mg/m2. It is imperative that a much larger study be carried out to confirm these findings. Lower dose prednisone therapy administered daily during an upper respiratory infection or other infection reduces the risk of relapse compared with continuing alternate-day prednisone or no prednisone based on four small studies. The results of a much larger RCT enrolling more than 300 children are awaited to determine the relative efficacies and adverse effects of using alternate-day compared with daily prednisone to prevent relapse in children with intercurrent infections.
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Affiliation(s)
- Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Susan M Samuel
- Department of Pediatrics, University of Calgary, Calgary, Canada
| | - Narelle S Willis
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Elisabeth M Hobson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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Uwaezuoke SN, Ndu IK, Mbanefo NR. Prevalence rates of histopathologic subtypes associated with steroid resistance in childhood nephrotic syndrome in Sub-Saharan Africa: a systematic review. Int J Nephrol Renovasc Dis 2019; 12:167-176. [PMID: 31372025 PMCID: PMC6627175 DOI: 10.2147/ijnrd.s207372] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 05/22/2019] [Indexed: 01/16/2023] Open
Abstract
Introduction The prevalence rates of the common histopathologic subtypes of childhood nephrotic syndrome associated with steroid resistance appear to be changing globally. In Sub Saharan Africa (SSA), the trend is similar over the past few decades. Aim This systematic review aims to determine the current prevalence rates of the histopathologic subtypes associated with childhood steroid-resistant nephrotic syndrome (SRNS) in SSA. Methods A search of the PubMed, Google and African Journals Online databases was conducted from January to December 2018 using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow-chart to identify relevant articles which met the aim of the systematic review. A qualitative synthesis and descriptive analysis of the extracted data were then conducted. The mean values for the prevalence rates of the reported histopathologic subtypes were calculated. A meta-analysis was not done due to few numbers of studies reviewed. The review is registered with PROSPERO, number CRD42018111916. Results In the West African sub-region, the currently reported histopathologic subtypes associated with childhood nephrotic syndrome are focal segmental glomerulosclerosis (FSGS), minimal-change nephropathy (MCN), membrano-proliferative glomerulonephritis (MPGN), membranous nephropathy (MN) and mesangial proliferative glomerulonephritis (MesPGN). The picture is the same in South Africa. More importantly, the predominant histopathologic lesions associated with steroid resistance are FSGS (West Africa) and MCN/FSGS (South Africa), with mean prevalence rates of 57.2% and 36.1% respectively. Conclusion The prevalence of FSGS is currently high in childhood nephrotic syndrome in SSA. This histopathologic subtype remains the commonest lesion associated with SRNS in this part of the globe.
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Affiliation(s)
- Samuel N Uwaezuoke
- Pediatric Nephrology Firm, Department of Pediatrics, College of Medicine, University of Nigeria Nsukka/University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | - Ikenna K Ndu
- Department of Pediatrics, Enugu State University Teaching Hospital, Enugu, Nigeria
| | - Ngozi R Mbanefo
- Pediatric Nephrology Firm, Department of Pediatrics, College of Medicine, University of Nigeria Nsukka/University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
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Veltkamp F, Khan DH, Reefman C, Veissi S, van Oers HA, Levtchenko E, Mathôt RAA, Florquin S, van Wijk JAE, Schreuder MF, Haverman L, Bouts AHM. Prevention of relapses with levamisole as adjuvant therapy in children with a first episode of idiopathic nephrotic syndrome: study protocol for a double blind, randomised placebo-controlled trial (the LEARNS study). BMJ Open 2019; 9:e027011. [PMID: 31375606 PMCID: PMC6688689 DOI: 10.1136/bmjopen-2018-027011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Idiopathic nephrotic syndrome (INS) is characterised by a high relapse rate up to 80% after initial response to standard therapy with corticosteroids. Steroid toxicity is common and causes a great burden of disease that negatively influences the health-related quality of life (HRQoL). Recently, studies have shown that levamisole, an anthelminthic drug, significantly improves relapse-free survival in children with frequent relapses or steroid dependency. Compared with other steroid-sparing drugs, levamisole has relatively few side effects. We hypothesise that adding levamisole to standard therapy with corticosteroids in children with a first episode of INS will prevent relapses, decrease cumulative dosage of steroids used and improve HRQoL. This paper presents the study protocol for the LEARNS study (LEvamisole as Adjuvant therapy to Reduce relapses of Nephrotic Syndrome). METHODS AND ANALYSIS An international, double-blind, placebo-controlled randomised trial will be conducted in 20 participating hospitals in the Netherlands and Belgium. Participants (n=92) with a first episode of INS, aged 2-16 years, who achieve remission after 4 weeks of oral prednisolone will be randomly assigned (1:1) to receive either levamisole 2.5 mg/kg alternate day or placebo added to prednisolone (18-week tapering schedule) for a total of 24 weeks. Follow-up will be until 2 years after first presentation. Additionally, parents and/or children will fill out five HRQoL questionnaires. Primary outcome of the LEARNS study is occurrence of relapses within 12 months after first presentation. Secondary outcomes include time to first relapse, cumulative steroid dose after 2 years, safety parameters and quality of life scores. ETHICS AND DISSEMINATION The trial was approved by the Medical Ethical Committee. Results of the study will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NL6826, 2017-001025-41.
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Affiliation(s)
- Floor Veltkamp
- Paediatric Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Djera H Khan
- Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Christa Reefman
- Paediatric Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Susan Veissi
- Paediatric Nephrology, Radboudumc, Nijmegen, The Netherlands
| | - Hedy A van Oers
- Psychosocial Department, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Elena Levtchenko
- Paediatric Nephrology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Ron A A Mathôt
- Hospital Pharmacy, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sandrine Florquin
- Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Joanna A E van Wijk
- Paediatric Nephrology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Lotte Haverman
- Psychosocial Department, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Antonia H M Bouts
- Paediatric Nephrology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Moorani KN, Hotchandani HM, Zubair AM, Lohana NC, Veerwani NR. Immunosuppressive therapy in children with primary nephrotic syndrome: single center experience, Karachi, Pakistan. BMC Nephrol 2019; 20:239. [PMID: 31269922 PMCID: PMC6607530 DOI: 10.1186/s12882-019-1347-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/18/2019] [Indexed: 01/10/2023] Open
Abstract
Background Majority of children with nephrotic syndrome are steroid sensitive, but treatment of difficult to treat nephrotic (frequent relapsing, steroid dependent and steroid resistant) syndrome is challenging. Low dose steroid, levamisole, cyclophosphamide (CPM), mycophenolate mofetil (MMF) and calcineurin inhibitors (CNIs) are the common options of treatment. Objective of the study was to determine the response to steroid and alternative immunosuppressive agents (ISAs) in children with difficult nephrotic syndrome (DNS). Methods This is a retrospective cohort study of 176 children with DNS, managed over 12 years at The Kidney Center-Postgraduate Training Institute, Karachi- Pakistan from 2005 to 2017. Initial episode was treated with daily oral prednisolone (OP) for 4–8 weeks followed by alternate day OP for 12–24 weeks. Subsequently low dose OP, levamisole (Leva)and cyclophosphamide was used for frequent relapsing (FR)/ steroid dependent (SD). All with initial steroid resistance and non- responders to leva and or cyclophosphamide were biopsied and treated with CNIs and MMF. Data was analyzed using descriptive statistics. Results There were 130(73.86%) children with FR/SD and 46(26.13%) with SRNS. All children with SR (46) and 86 with FR/SD were biopsied. Minimal change disease (60.60%) and focal segmental glomerulosclerosis (FSGS 23%) were the two common lesions. Majority (73.86%) received single OP whereas divided doses were administered in 26.13% cases. Daily OP was used for 4, 6 and 8 weeks in 61.36,28.4 and10.22% respectively. Steroids were tapered over 3 (31.81%),4 (52.27%) and 6 months (15.90%). Levamisole, CPM, cyclosporin (CS) and MMF were used sequentially in 45, 54.23, 50 and 20% respectively. Combination of MMF and CS was used in 11.29% of cases. Levamisole was effective in 80%, CPM induced complete remission (CR, 57.77%) or partial remission (PR, 22.22%), CS induced CR 46.59% and PR 39.77%. MMF showed PR and CR 69 and 12.82% respectively. At last follow up, 46% were maintaining remission while off treatment, whereas 35% are maintaining remission on therapy,10.23% lost- to-follow, 5.68% progressed to chronic kidney disease. Mortality was 2.84% and it was due to infection and uremia. Conclusion Majority had steroid sensitive MCD. Levamisole and cyclophosphamide were effective in maintaining remission in FR/ SD. FSGS was responsible for resistance to steroid and alternative ISAs. Cyclosporin was effective in inducing remission in SRNS. Mortality was less than 3%.
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Affiliation(s)
- Khemchand Netaram Moorani
- Department of Pediatric Nephrology, National Institute of Child Health (NICH), Jinnah Sindh Medical University, Karachi, Pakistan. .,Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan.
| | - Harnam Moolchand Hotchandani
- Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan
| | - Aasia Mohammad Zubair
- Department of Pediatric Nephrology, National Institute of Child Health (NICH), Jinnah Sindh Medical University, Karachi, Pakistan.,Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan
| | - Neelesh Chander Lohana
- Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan
| | - Nanga Ram Veerwani
- Department of Pediatric Nephrology, The Kidney Center Postgraduate Training Institute (TKC-PGTI), Karachi, Sindh, 75500, Pakistan
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Webb NJ, Woolley RL, Lambe T, Frew E, Brettell EA, Barsoum EN, Trompeter RS, Cummins C, Wheatley K, Ives NJ. Sixteen-week versus standard eight-week prednisolone therapy for childhood nephrotic syndrome: the PREDNOS RCT. Health Technol Assess 2019; 23:1-108. [PMID: 31156083 DOI: 10.3310/hta23260] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The optimal corticosteroid regimen for treating the presenting episode of steroid-sensitive nephrotic syndrome (SSNS) remains uncertain. Most UK centres use an 8-week regimen, despite previous systematic reviews indicating that longer regimens reduce the risk of relapse and frequently relapsing nephrotic syndrome (FRNS). OBJECTIVES The primary objective was to determine whether or not an extended 16-week course of prednisolone increases the time to first relapse. The secondary objectives were to compare the relapse rate, FRNS and steroid-dependent nephrotic syndrome (SDNS) rates, requirement for alternative immunosuppressive agents and corticosteroid-related adverse events (AEs), including adverse behaviour and costs. DESIGN Randomised double-blind parallel-group placebo-controlled trial, including a cost-effectiveness analysis. SETTING One hundred and twenty-five UK paediatric departments. PARTICIPANTS Two hundred and thirty-seven children presenting with a first episode of SSNS. Participants aged between 1 and 15 years were randomised (1 : 1) according to a minimisation algorithm to ensure balance of ethnicity (South Asian, white or other) and age (≤ 5 or ≥ 6 years). INTERVENTIONS The control group (n = 118) received standard course (SC) prednisolone therapy: 60 mg/m2/day of prednisolone in weeks 1-4, 40 mg/m2 of prednisolone on alternate days in weeks 5-8 and matching placebo on alternate days in weeks 9-18 (total 2240 mg/m2). The intervention group (n = 119) received extended course (EC) prednisolone therapy: 60 mg/m2/day of prednisolone in weeks 1-4; started at 60 mg/m2 of prednisolone on alternate days in weeks 5-16, tapering by 10 mg/m2 every 2 weeks (total 3150 mg/m2). MAIN OUTCOME MEASURES The primary outcome measure was time to first relapse [Albustix® (Siemens Healthcare Limited, Frimley, UK)-positive proteinuria +++ or greater for 3 consecutive days or the presence of generalised oedema plus +++ proteinuria]. The secondary outcome measures were relapse rate, incidence of FRNS and SDNS, other immunosuppressive therapy use, rates of serious adverse events (SAEs) and AEs and the incidence of behavioural change [using Achenbach Child Behaviour Checklist (ACBC)]. A comprehensive cost-effectiveness analysis was performed. The analysis was by intention to treat. Participants were followed for a minimum of 24 months. RESULTS There was no significant difference in time to first relapse between the SC and EC groups (hazard ratio 0.87, 95% confidence interval 0.65 to 1.17; log-rank p = 0.3). There were also no differences in the incidence of FRNS (SC 50% vs. EC 53%; p = 0.7), SDNS (44% vs. 42%; p = 0.8) or requirement for other immunosuppressive therapy (56% vs. 54%; p = 0.8). The total prednisolone dose received following completion of study medication was 5475 mg vs. 6674 mg (p = 0.07). SAE rates were not significantly different (25% vs. 17%; p = 0.1) and neither were AEs, except poor behaviour (yes/no), which was less frequent with EC treatment. There were no differences in ACBC scores. EC therapy was associated with a mean increase in generic health benefit [0.0162 additional quality-adjusted life-years (QALYs)] and cost savings (£4369 vs. £2696). LIMITATIONS Study drug formulation may have prevented some younger children who were unable to swallow whole or crushed tablets from participating. CONCLUSIONS This trial has not shown any clinical benefit for EC prednisolone therapy in UK children. The cost-effectiveness analysis suggested that EC therapy may be cheaper, with the possibility of a small QALY benefit. FUTURE WORK Studies investigating EC versus SC therapy in younger children and further cost-effectiveness analyses are warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN16645249 and EudraCT 2010-022489-29. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 26. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Nicholas Ja Webb
- Department of Paediatric Nephrology, University of Manchester, Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Manchester, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Tosin Lambe
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | - Emma Frew
- Health Economics Unit, University of Birmingham, Birmingham, UK
| | | | - Emma N Barsoum
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Keith Wheatley
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Benz MR, Ehren R, Tönshoff B, Weber LT. Nephrotisches Syndrom im Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0677-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The Canadian childhood nephrotic syndrome (CHILDNEPH) study: report on mid-study feasibility, recruitment and main measures. BMC Nephrol 2019; 20:159. [PMID: 31088399 PMCID: PMC6515641 DOI: 10.1186/s12882-019-1320-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 03/29/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND To assess reasons for continuing practice variation in the management of childhood nephrotic syndrome despite expert reviews and guidelines, we are conducting a longitudinal cohort study in children with glucocorticoid sensitive nephrotic syndrome. Objectives of this mid-study report are to describe patient and physician recruitment characteristics, glucocorticoid prescriptions, use of second line agents, biopsy practices, and adherence to study protocol. METHODS Children with new onset nephrotic syndrome and providers are being recruited from all 12 pediatric nephrology centres across Canada with > 2½ years follow-up. Data collection points of observation are over a minimum 36 months. Details of prescribed glucocorticoids and of all second line agents used during treatment are being collected. All relapses are being recorded with time to urinary remission of proteinuria. RESULTS To date, 243 patients (57.1% male) from 12 centres were included. Median number of patients per centre was 29 (range 2-45), and median age of cohort was 7.3 (IQR 4.2) at enrollment. Forty-eight physicians were recruited, median 5 (range 2-8) per site. Median number of relapses per patient year of follow-up was 2.1 (IQR 4). Cumulative dose variability of glucocorticoids prescribed per episode of proteinuria and length of treatment was observed between participating centres. CONCLUSION The Canadian pediatric nephrology community established a longitudinal childhood nephrotic syndrome cohort study that confirms ongoing practice variability. The study will help to evaluate its impact on patient outcomes, and facilitate clinical trial implementation in nephrotic syndrome.
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Treating the idiopathic nephrotic syndrome: are steroids the answer? Pediatr Nephrol 2019; 34:777-785. [PMID: 29869116 DOI: 10.1007/s00467-018-3963-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/09/2018] [Accepted: 04/05/2018] [Indexed: 10/14/2022]
Abstract
The use of steroids in idiopathic nephrotic syndrome is the major discovery of the twentieth century in the field of pediatric nephrology. At onset of the twenty-first century, steroids remain the first line of treatment at first flare. All the protocols to treat the first flare are similar by a common sequence including a first phase of daily prednisolone/prednisone at a dose of 60 mg/m2/day for at least 4 weeks followed by an alternate-day regimen for several weeks. It appears that a cumulated dose of 2240 mg/m2 given in 8 weeks at the first flare without tapering sequence is not inferior to increased dose and duration in terms of prevalence of frequent relapsers and the subsequent cumulated dose of steroids at 24 months of follow-up. A higher cumulated dose might only be interesting in patients aged below 4 years although a formal demonstration is still missing. Several retrospective studies are concordant to suggest that intravenous methylprednisolone pulses are useful to reach a full urinary remission in case of oral resistance to 4 weeks of oral prednisone/prednisolone. A majority of patients have multiple relapses after the treatment of the first flare and half meet the definition of steroid dependency. In those patients, long-lasting alternate-day prednisone/prednisolone therapy does not lead to long-lasting remission, opening the question of the best strategy of immunosuppression.
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Five-year outcome of children with idiopathic nephrotic syndrome: the NEPHROVIR population-based cohort study. Pediatr Nephrol 2019; 34:671-678. [PMID: 30552564 DOI: 10.1007/s00467-018-4149-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 09/26/2018] [Accepted: 11/09/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND The optimal therapeutic regimen for children at onset of idiopathic nephrotic syndrome (INS) is still under debate. A better knowledge of the disease's course is necessary to design more appropriate and/or personalized treatment protocols. METHODS We report the 5-year outcome of patients included from December 2007 to May 2010 in the prospective multicentric and multiethnic population-based NEPHROVIR study. Patients were treated at onset according to the French steroid protocol (3990 mg/m2, 18 weeks). Data were collected at 5 years or last follow-up. RESULTS Out of the 188 children with nephrotic syndrome (121 boys, 67 girls; median age 4.1 years), 174 (93%) were steroid-sensitive. Six percent of steroid-sensitive patients required intravenous steroid pulses to get into remission. Relapse-free rate for steroid-sensitive patients was 21% (36/174) at last follow-up (median 72 months). A first relapse occurred in138 steroid sensitive patients (79%) with a median time of 8.3 months (IQ 3.4-11.3). Out of the 138 relapsers, 43 were frequent relapsers. Age at onset below 4 years was the only predictive factor of relapse, while gender, ethnicity, and delay to first remission were not. At 96 months of follow-up, 83% of frequent relapsers were still under steroids and/or immunosuppressive drugs. CONCLUSIONS The treatment of the first flare deserves major improvements in order to reduce the prevalence of relapsers and the subsequent long-lasting exposure to steroids and immunosuppression.
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Korsgaard T, Andersen RF, Joshi S, Hagstrøm S, Rittig S. Childhood onset steroid-sensitive nephrotic syndrome continues into adulthood. Pediatr Nephrol 2019; 34:641-648. [PMID: 30426221 DOI: 10.1007/s00467-018-4119-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/09/2018] [Accepted: 10/15/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Childhood steroid-sensitive nephrotic syndrome (SSNS) has previously been assumed to be a disease of childhood. This has been challenged by few studies reporting that some patients with childhood SSNS may continue to relapse into adulthood. The aim of this study was to investigate the long-term outcome of childhood SSNS presenting data from an unselected well-defined cohort of Danish patients. METHODS We conducted a retrospective study of the clinical outcome from a population of patients consecutively admitted to the pediatric departments in the central and northern region of Denmark from 1998 to 2015. Patients were followed until August 2017. Data were collected from the patient's medical records. RESULTS Long-term outcome was studied in 39 adult patients with childhood onset SSNS. A total of 31% (12/39) had active disease in adulthood. Univariate analysis showed that more severe forms of SSNS (e.g., steroid dependent/frequent relapsing (SD/FR) nephrotic syndrome) in childhood were associated with active disease in adulthood. Comparing adult patients with SD/FR showed a significantly higher number of relapses/patient/year from late childhood and adolescence in the group with active disease vs. non-active disease (1.06 (95%CI: 0.32-1.81) vs. 0.19 (95%CI: 0.06-0.31, p = 0.005). CONCLUSION In general, one third of all patients with SSNS during childhood continue to have active disease during early adulthood, in particular patients with SD/FR continue to suffer from active disease. The present data illustrates that SSNS is not just a disease of childhood but persists in adulthood in a significant number of patients.
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Affiliation(s)
- Trine Korsgaard
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - René Frydensbjerg Andersen
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Shivani Joshi
- Department of Clinical Medicine, Child and Youth Research Laboratory, Aarhus University, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark
| | - Søren Hagstrøm
- Department of Pediatrics, Aalborg University Hospital, Reberbansgade 15, DK-9000, Aalborg, Denmark.,Center for Clinical Research, North Denmark Regional Hospital, Bispensgade 37, DK-9800, Hjoerring, Denmark
| | - Søren Rittig
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
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Schijvens AM, Ter Heine R, de Wildt SN, Schreuder MF. Pharmacology and pharmacogenetics of prednisone and prednisolone in patients with nephrotic syndrome. Pediatr Nephrol 2019; 34:389-403. [PMID: 29549463 PMCID: PMC6349812 DOI: 10.1007/s00467-018-3929-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/19/2018] [Accepted: 02/19/2018] [Indexed: 01/29/2023]
Abstract
Nephrotic syndrome is one of the most common glomerular disorders in childhood. Glucocorticoids have been the cornerstone of the treatment of childhood nephrotic syndrome for several decades, as the majority of children achieves complete remission after prednisone or prednisolone treatment. Currently, treatment guidelines for the first manifestation and relapse of nephrotic syndrome are mostly standardized, while large inter-individual variation is present in the clinical course of disease and side effects of glucocorticoid treatment. This review describes the mechanisms of glucocorticoid action and clinical pharmacokinetics and pharmacodynamics of prednisone and prednisolone in nephrotic syndrome patients. However, these mechanisms do not account for the large inter-individual variability in the response to glucocorticoid treatment. Previous research has shown that genetic factors can have a major influence on the pharmacokinetic and dynamic profile of the individual patient. Therefore, pharmacogenetics may have a promising role in personalized medicine for patients with nephrotic syndrome. Currently, little is known about the impact of genetic polymorphisms on glucocorticoid response and steroid-related toxicities in children with nephrotic syndrome. Although the evidence is limited, the data summarized in this study do suggest a role for pharmacogenetics to improve individualization of glucocorticoid therapy. Therefore, studies in larger cohorts with nephrotic syndrome patients are necessary to draw final conclusions about the influence of genetic polymorphisms on the glucocorticoid response and steroid-related toxicities to ultimately implement pharmacogenetics in clinical practice.
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Affiliation(s)
- Anne M Schijvens
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Saskia N de Wildt
- Department of Pharmacology and Toxicology, Radboud University Medical Center, Nijmegen, The Netherlands
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, 804, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
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Ferrara G, Petrillo MG, Giani T, Marrani E, Filippeschi C, Oranges T, Simonini G, Cimaz R. Clinical Use and Molecular Action of Corticosteroids in the Pediatric Age. Int J Mol Sci 2019; 20:ijms20020444. [PMID: 30669566 PMCID: PMC6359239 DOI: 10.3390/ijms20020444] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 12/19/2022] Open
Abstract
Corticosteroids are the mainstay of therapy for many pediatric disorders and sometimes are life-saving. Both endogenous and synthetic derivatives diffuse across the cell membrane and, by binding to their cognate glucocorticoid receptor, modulate a variety of physiological functions, such as glucose metabolism, immune homeostasis, organ development, and the endocrine system. However, despite their proved and known efficacy, corticosteroids show a lot of side effects, among which growth retardation is of particular concern and specific for pediatric age. The aim of this review is to discuss the mechanism of action of corticosteroids, and how their genomic effects have both beneficial and adverse consequences. We will focus on the use of corticosteroids in different pediatric subspecialties and most common diseases, analyzing the most recent evidence.
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Affiliation(s)
| | - Maria Grazia Petrillo
- Signal Transduction laboratory, NIEHS, NIH, Department of Health and Human Services, Research Triangle Park, Durham, NC 27709, USA.
| | - Teresa Giani
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy.
| | | | - Cesare Filippeschi
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Teresa Oranges
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Gabriele Simonini
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
| | - Rolando Cimaz
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
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Iijima K, Nozu K. Recent Advances in Genetic Aspects and Treatments for Steroid-Sensitive Nephrotic Syndrome in Children. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0183-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Ehren R, Benz MR, Doetsch J, Fichtner A, Gellermann J, Haffner D, Höcker B, Hoyer PF, Kästner B, Kemper MJ, Konrad M, Luntz S, Querfeld U, Sander A, Toenshoff B, Weber LT. Initial treatment of steroid-sensitive idiopathic nephrotic syndrome in children with mycophenolate mofetil versus prednisone: protocol for a randomised, controlled, multicentre trial (INTENT study). BMJ Open 2018; 8:e024882. [PMID: 30309995 PMCID: PMC6252704 DOI: 10.1136/bmjopen-2018-024882] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Idiopathic nephrotic syndrome is the most common glomerular disease in childhood with an incidence of 1.8 cases per 100 000 children in Germany. The treatment of the first episode implies two aspects: induction of remission and sustainment of remission. The recent Kidney Disease Improving Global Outcomes, American Academy of Pediatrics and German guidelines for the initial treatment of the first episode of a nephrotic syndrome recommend a 12-week course of prednisone. Despite being effective, this treatment is associated with pronounced glucocorticoid-associated toxicity due to high-dose prednisone administration over a prolonged period of time. The aim of the INTENT study (Initial treatment of steroid-sensitive idiopathic nephrotic syndrom in children with mycophenolate mofetil versus prednisone: protocol for a randomised, controlled, multicentre trial) is to show that an alternative treatment regimen with mycophenolic acid is not inferior regarding sustainment of remission, but with lower toxicity compared with treatment with glucocorticoids only. METHODS AND DESIGN The study is designed as an open, randomised, controlled, multicentre trial. 340 children with a first episode of steroid-sensitive nephrotic syndrome and who achieved remission by a standard prednisone regimen will be enrolled in the trial and randomised to one of two treatment arms. The standard care group will be treated with prednisone for a total of 12 weeks; in the experimental group the treatment is switched to mycophenolate mofetil, also for a total of 12 weeks in treatment duration. The primary endpoint is the occurrence of a treated relapse within 24 months after completion of initial treatment. ETHICS AND DISSEMINATION Ethics approval for this trial was granted by the ethics committee of the Medical Faculty of the University of Heidelberg (AFmu-554/2014). The study results will be published in accordance with the Consolidated Standards of Reporting Trials statement and the Standard Protocol Items: Recommendations for Interventional Trials guidelines. Our findings will be submitted to major international paediatric nephrology and general paediatric conferences and submitted for publication in a peer-reviewed, open-access journal. TRIAL REGISTRATION NUMBER DRKS0006547; EudraCT2014-001991-76; Pre-result. DATE OF REGISTRATION 30 October 2014; 24 February 2017.
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Affiliation(s)
- Rasmus Ehren
- Department of Pediatrics, University Children’s Hospital Köln, University Hospital Köln, Köln, Germany
| | - Marcus R Benz
- Department of Pediatrics, University Children’s Hospital Köln, University Hospital Köln, Köln, Germany
| | - Jorg Doetsch
- Department of Pediatrics, University Children’s Hospital Köln, University Hospital Köln, Köln, Germany
| | - Alexander Fichtner
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Jutta Gellermann
- Department of Pediatrics, University Children’s Hospital Berlin, University Hospital Berlin Charité, Berlin, Germany
| | - Dieter Haffner
- Department of Pediatrics, University Children’s Hospital Hannover, University Hospital Hannover, Hannover, Germany
| | - Britta Höcker
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Peter F Hoyer
- Department of Pediatrics, University Children’s Hospital Essen, University Hospital Essen, Essen, Germany
| | - Bärbel Kästner
- KKS (Coordination Center for Clinical Trials), University Hospital of Heidelberg, Heidelberg, Germany
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Klinik Nord – Heidberg, Hamburg, Germany
| | - Martin Konrad
- Department of Pediatrics, University Children’s Hospital Münster, University Hospital Münster, Münster, Germany
| | - Steffen Luntz
- KKS (Coordination Center for Clinical Trials), University Hospital of Heidelberg, Heidelberg, Germany
| | - Uwe Querfeld
- Department of Pediatrics, University Children’s Hospital Berlin, University Hospital Berlin Charité, Berlin, Germany
| | - Anja Sander
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Burkhard Toenshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Lutz T Weber
- Department of Pediatrics, University Children’s Hospital Köln, University Hospital Köln, Köln, Germany
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Difficult-to-treat idiopathic nephrotic syndrome: established drugs, open questions and future options. Pediatr Nephrol 2018; 33:1641-1649. [PMID: 28879428 DOI: 10.1007/s00467-017-3780-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 10/18/2022]
Abstract
The idiopathic nephrotic syndrome in childhood can be classified according to the International Study of Kidney Disease in Children (ISKDC) based on the response to steroids. Typically, steroid-sensitive nephrotic syndrome (SSNS) is characterised by minimal changes in disease (MCD) histology, whereas in steroid-resistant nephrotic syndrome (SRNS) focal segmental glomerulosclerosis (FSGS) is the most prevalent lesion. Patients with SSNS may develop frequent relapses and/or steroid dependency, which can be difficult to treat. New studies confirm the value of calcineurin inhibitors (CNIs) and mycophenolic acid in preventing relapses of SSNS. Rituximab also plays an important role, but many questions regarding initial dosing, repetitions of courses, and long-term side effects remain unclear. SRNS, especially when unresponsive to treatment, can lead to chronic kidney disease. In particular, treatment with CNIs has improved the prognosis and recent data indicate that treatment can even be discontinued in many patients with full remission. In CNI-unresponsive SRNS, rituximab is less effective than in SSNS and the role of other biologicals (such as ofatumumab, abatacept, and others) remains unclear. A significant proportion of children with FSGS have genetic causes and most patients do not respond to immunosuppression, although individual patients with partial and even complete response have been documented. Future studies should evaluate treatments leading to long-term remission without maintenance immunosuppression in SSNS; in both genetic and immune-mediated SRNS, novel options to decrease the number of treatment-unresponsive patients seem mandatory, as they are at a high risk of developing end-stage renal disease.
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Hama T, Nakanishi K, Ishikura K, Ito S, Nakamura H, Sako M, Saito-Oba M, Nozu K, Shima Y, Iijima K, Yoshikawa N. Study protocol: high-dose mizoribine with prednisolone therapy in short-term relapsing steroid-sensitive nephrotic syndrome to prevent frequent relapse (JSKDC05 trial). BMC Nephrol 2018; 19:223. [PMID: 30200895 PMCID: PMC6131840 DOI: 10.1186/s12882-018-1033-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/02/2018] [Indexed: 11/21/2022] Open
Abstract
Background Eighty percent of children with steroid-sensitive nephrotic syndrome (SSNS) relapse within 2 years and 40–50% patients show frequently-relapsing nephrotic syndrome (FRNS). Patients showing a relapse within 6 months after initial remission are at high risk of FRNS. Since frequent prednisolone treatment for FRNS induces severe prednisolone side effects, development of a treatment to prevent patients from shifting to FRNS is desirable. Mizoribine is an immunosuppressive drug with fewer side effects than prednisolone. Recent studies reported the efficacy of high-dose mizoribine in children with FRNS. Methods/design We conduct a multicenter, open, randomized controlled trial to investigate the efficacy and safety of standard prednisolone plus high-dose mizoribine therapy in children with SSNS showing a relapse within 6 months after an initial remission. Patients are allocated to either standard prednisolone alone treatment group, or standard prednisolone plus high-dose mizoribine group. For the former group, mizoribine is administered at a dose of 10 mg/kg/day once daily and continued for 2 years. The primary endpoint is the duration to frequent relapse. Discussion The results provide important data on use of high-dose mizoribine to prevent SSNS patients from shifting to FRNS. Since blood concentrations of mizoribine have not been investigated in detail until now, there is a possibility that mizoribine is underestimated in favor of other immunosuppressive drugs. In future, high-dose mizoribine therapy may lead to prevention of relapse in children at high risk of FRNS, and to decreased total dose of prednisolone. Trial registration UMIN000005103, (Prospectively registered 1st March 2011).
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Affiliation(s)
- Taketsugu Hama
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa, 903-0215, Japan.
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Hidefumi Nakamura
- Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Mayumi Sako
- Division of Clinical Trials, Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Mari Saito-Oba
- Department of Medical Statistics, Toho University School of Medicine, Ota-ku, Tokyo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
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Induction prednisone dosing for childhood nephrotic syndrome: how low should we go? Pediatr Nephrol 2018; 33:1539-1545. [PMID: 29789934 DOI: 10.1007/s00467-018-3975-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 04/11/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Historically, children with nephrotic syndrome (NS) across British Columbia (BC), Canada have been cared for without formal standardization of induction prednisone dosing. We hypothesized that local historical practice variation in induction dosing was wide and that children treated with lower doses had worse relapsing outcomes. METHODS This retrospective cohort study included 92 NS patients from BC Children's Hospital (1990-2010). We excluded secondary causes of NS, age < 1 year at diagnosis, steroid resistance, and incomplete induction due to early relapse. We explored cumulative induction dose and defined dosing quartiles. Relapsing outcomes above and below each quartile threshold were compared including total relapses in 2 years, time to first relapse, and proportions developing frequently relapsing NS (FRNS) or starting a steroid-sparing agent (SSA). RESULTS Cumulative prednisone was widely distributed with approximated median, 1st, and 3rd quartile doses of 2500, 2000, and 3000 mg/m2 respectively. Doses ≤ 2000 mg/m2 showed significantly higher relapses (4.2 vs 2.7), shorter time to first relapse (61 vs 175 days), and higher SSA use (36 vs 14%) compared to higher doses. Doses ≤ 2500 mg/m2 also showed significantly more relapses (3.9 vs 2.2), quicker first relapse (79 vs 208 days), and higher FRNS (37 vs 17%) and SSA use (28 vs 11%). Relapsing outcomes lacked statistical difference in ≤ 3000 vs > 3000 mg/m2 doses. CONCLUSIONS Results strongly justify our development of a standardized, province-wide NS clinical pathway to reduce practice variation and minimize under-treatment. The lowest induction prednisone dosing threshold to minimize future relapsing risks is likely between 2000 and 2500 mg/m2. Further prospective studies are warranted.
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Mohammed FZ, Zedan MM, El-Hussiny MAB, Barakat LAELA, El-Eshmawy MAAEM. ABCB1 gene polymorphism in nephrotic syndrome. COMPARATIVE CLINICAL PATHOLOGY 2018; 27:1181-1189. [DOI: 10.1007/s00580-018-2719-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/29/2018] [Indexed: 09/01/2023]
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Noone DG, Iijima K, Parekh R. Idiopathic nephrotic syndrome in children. Lancet 2018; 392:61-74. [PMID: 29910038 DOI: 10.1016/s0140-6736(18)30536-1] [Citation(s) in RCA: 276] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 02/15/2018] [Accepted: 02/23/2018] [Indexed: 12/19/2022]
Abstract
The incidence of idiopathic nephrotic syndrome (NS) is 1·15-16·9 per 100 000 children, varying by ethnicity and region. The cause remains unknown but the pathogenesis of idiopathic NS is thought to involve immune dysregulation, systemic circulating factors, or inherited structural abnormalities of the podocyte. Genetic risk is more commonly described among children with steroid-resistant disease. The mainstay of therapy is prednisone for the vast majority of patients who are steroid responsive; however, the disease can run a frequently relapsing course, necessitating the need for alternative immunosuppressive agents. Infection and venous thromboembolism are the main complications of NS with also increased risk of acute kidney injury. Prognosis in terms of long-term kidney outcome overall is excellent for steroid-responsive disease, and steroid resistance is an important determinant of future risk of chronic or end-stage kidney disease.
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Affiliation(s)
- Damien G Noone
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Rulan Parekh
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; Dalla Lana School of Public Health, and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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Taurine Supplementation Alleviates Puromycin Aminonucleoside Damage by Modulating Endoplasmic Reticulum Stress and Mitochondrial-Related Apoptosis in Rat Kidney. Nutrients 2018; 10:nu10060689. [PMID: 29843457 PMCID: PMC6024760 DOI: 10.3390/nu10060689] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 12/27/2022] Open
Abstract
Taurine (TAU) is a sulfur-containing beta amino acid that is not involved in protein composition and anabolism, conditionally essential in mammals provided through diet. Growing evidence supports a protective role of TAU supply in osmoregulation, calcium flux, and reduction of inflammation and oxidant damage in renal diseases like diabetes. Endoplasmic reticulum (ER) stress, due to abnormal proteostasis, is a contributor to nephrotic syndrome and related renal damage. Here, we investigated the effect of dietary TAU (1.5% in drinking water for 15 days) in an established rat model that mimics human minimal change nephrosis, consisting of a single puromycin aminonucleoside (PAN) injection (intraperitoneally 15 mg/100 g body weight), with sacrifice after eight days. TAU limited proteinuria and podocytes foot processes effacement, and balanced slit diaphragm nephrin and glomerular claudin 1 expressions. In cortical proximal tubules, TAU improved lysosomal density, ER perimeter, restored proper ER-mitochondria tethering and mitochondrial cristae, and decreased inflammation. Remarkably, TAU downregulated glomerular ER stress markers (GRP78, GRP94), pro-apoptotic C/EBP homologous protein, activated caspase 3, tubular caspase1, and mitochondrial chaperone GRP75, but maintained anti-apoptotic HSP25. In conclusion, TAU, by targeting upstream ER stress separate from mitochondria dysfunctions at crucial renal sites, might be a promising dietary supplement in the treatment of the drug-resistant nephrotic syndrome.
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Al Talhi A, Al Saran K, Osman ET, Al Shatri A, Osman M, Mirza K. A randomized study on a 3-month versus a 7-month prednisolone regimen for the initial episode of childhood idiopathic nephrotic syndrome at a large Saudi center. Int J Pediatr Adolesc Med 2018; 5:18-23. [PMID: 30805527 PMCID: PMC6363257 DOI: 10.1016/j.ijpam.2017.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 12/24/2017] [Accepted: 12/31/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES The standard International Study of Kidney Disease in Children (ISKDC) regimen of prednisolone of 2 months duration for the treatment of the initial episode of Idiopathic Nephrotic Syndrome (INS) was associated with a high relapse rate. The long prednisolone protocols were introduced in order to reduce the relapse rate and steroid toxicities. The main objective of this study was to assess the efficacy and safety of a 3 months protocol of prednisolone versus a 7 months protocol for the first episode of idiopathic nephrotic syndrome. DESIGN AND SETTING The study took place in the Pediatric Nephrology Department of King Saud Medical City, Riyadh which is a large referral center all over Saudi Arabia. The study was a randomized control trial using 2 groups. Group A received the 3 months protocol and Group B received the 7 months protocol. PATIENTS AND METHODS All children with a confirmed diagnosis of Idiopathic Nephrotic Syndrome were included. The patients were randomized by simple randomization using sealed envelopes into two groups; group A comprised of 60 children using the daily regimen prednisolone 60 mg/m2 OD X 1 ½ months then 40mg/m2 on alternate day for 1 ½ months (total = 3 months) and group B also comprised of 60 children using the 7 months protocol, Prednisolone 60mg/m2 OD x 1 month then 40mg/m2 EOD x 2 months then 30mg/m2 EOD for 2 months then 20mg/m2 EOD for 2 months. The efficacy and safety of these two prednisolone regimens were recorded. The follow-up period was two years. Statistical analysis was done using the SPSS progress version 16 (Chicago, USA) P < .05 was taken as a significant result. Consort guidelines for randomized controlled trials (RCTs) were followed. The hospital ethical committee approved the study. The parents gave an informed consent. RESULTS Group B protocol was found to be significantly better than the group A protocol in both years of follow-up. The mean time of first relapse was significantly better in group B than in group A (P < .0001). The relapse rate reduced significantly in group B vs group A in both the first year (P = .0031) as well as in the second year (P = .00002). The cumulative dose of steroids was significantly less in group B vs group A both in the first year of follow-up (P = .0039) as well as in the second year (P = .0026). The incidence of frequently relapsers was significantly less (P = .049) in group B as compared to group A. The risk of relapse was better in group B as compared to group A (RR 0.8039; 95% CI 0.6566 to 0.9843 significance (P = .0346). The side effects of corticosteroids were significantly less in group B protocol as compared to group A. CONCLUSION We concluded that the long 7 months protocol was significantly better than the 3 months prednisolone regimen in both efficacy and safety for the initial episode of childhood INS.
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Affiliation(s)
- AbdulHadi Al Talhi
- Department of Pediatric Nephrology King Saud Medical City Riyadh, Saudi Arabia
| | - Khalid Al Saran
- Dept. King Saud Medical City, Al Faisal University Riyadh, Saudi Arabia
| | - ElTayeb Taha Osman
- Department of Pediatric Nephrology King Saud Medical City Riyadh, Saudi Arabia
| | - AbdulAziz Al Shatri
- Department of Pediatric Nephrology King Saud Medical City Riyadh, Saudi Arabia
| | - Mutawakil Osman
- Department of Pediatric Nephrology King Saud Medical City Riyadh, Saudi Arabia
| | - Khalid Mirza
- Department of Pediatric Nephrology King Saud Medical City Riyadh, Saudi Arabia
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Population Pharmacokinetics of Prednisolone in Relation to Clinical Outcome in Children With Nephrotic Syndrome. Ther Drug Monit 2017; 38:534-45. [PMID: 27120177 DOI: 10.1097/ftd.0000000000000308] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The relapse frequency in children with nephrotic syndrome (NS) is highly variable despite standardized prednisolone treatment regimens. Existing evidence on the relationship between prednisolone pharmacokinetics (PK) and clinical response in children with NS is scarce and limited. The aim of this study was to develop a pediatric popPK model for prednisolone based on our previous model based on healthy adults using salivary measurements in children with NS and to correlate clinical outcome with between-subject variability in prednisolone exposure. METHODS The pharmacokinetics of prednisolone in a well-defined, prospective cohort consisting of 104 children with NS while in remission was determined. Pharmacokinetic parameters were analyzed in relation to relapse patterns and side effects. Noninvasive salivary prednisolone measurements were performed using a sparse sampling strategy. A population pharmacokinetic approach was used to derive individual estimates of apparent clearance (CL/F) and apparent volume of distribution (V/F) from the salivary concentration-time curve, followed by calculation of the area under the curve (AUC) of free prednisolone. The individual free serum prednisolone exposure from prednisolone in saliva was derived from the salivary concentration-time curves. Genetic polymorphisms of CYP3A4, CYP3A5, ABCB1, NR1L2, and POR were explored in relation to between-subject variability of CL/F. RESULTS Moderate interindividual variability was found for CL/F (CV, 44.7%). Unexplained random between-subject variability (eta) of CL/F was lower in patients carrying 1 or 2 ABCB1 3435C>T alleles compared to wild type: median -0.04 (interquartile range, -0.17 to 0.21) and 0.00 (-0.11 to 0.16) versus 0.17 (-0.08 to 0.47), P = 0.046. Exposure to free prednisolone was not associated with frequent relapses or adverse effects. CONCLUSIONS This study provides evidence for the possibility of prednisolone drug monitoring through salivary measurements and this may be of particular usefulness in pediatric patients. However, the observed variability in prednisolone exposure, in the therapeutic dose range studied, is not considered to be a major determinant of clinical outcome in children with NS.
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