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Robinson CH, Aman N, Banh T, Brooke J, Chanchlani R, Dhillon V, Langlois V, Levin L, Licht C, McKay A, Noone D, Parikh A, Pearl R, Radhakrishnan S, Rowley V, Teoh CW, Vasilevska-Ristovska J, Parekh RS. Impact of childhood nephrotic syndrome on obesity and growth: a prospective cohort study. Pediatr Nephrol 2024; 39:2667-2677. [PMID: 38637343 DOI: 10.1007/s00467-024-06370-0] [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] [Received: 01/24/2024] [Revised: 03/22/2024] [Accepted: 04/03/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND Children with nephrotic syndrome are at risk of obesity and growth impairment from repeated steroid treatment. However, incidence and risk factors for obesity and short stature remain uncertain, which is a barrier to preventative care. Our aim was to determine risk, timing, and predictors of obesity and short stature among children with nephrotic syndrome. METHODS We evaluated obesity and longitudinal growth among children (1-18 years) enrolled in Insight into Nephrotic Syndrome: Investigating Genes, Health, and Therapeutics. We included children with nephrotic syndrome diagnosed between 1996-2019 from the Greater Toronto Area, Canada, excluding congenital or secondary nephrotic syndrome. Primary outcomes were obesity (body mass index Z-score ≥ + 2) and short stature (height Z-score ≤ -2). We evaluated prevalence of obesity and short stature at enrolment (< 1-year from diagnosis) and incidence during follow-up. Cox proportional hazards models determined the association between nephrotic syndrome classification and new-onset obesity and short stature. RESULTS We included 531 children with nephrotic syndrome (30% frequently relapsing by 1-year). At enrolment, obesity prevalence was 23.5%, 51.8% were overweight, and 4.9% had short stature. Cumulative incidence of new-onset obesity and short stature over median 4.1-year follow-up was 17.7% and 3.3% respectively. Children with frequently relapsing or steroid dependent nephrotic syndrome within 1-year of diagnosis were at increased risk of new-onset short stature (unadjusted hazard ratio 3.99, 95%CI 1.26-12.62) but not obesity (adjusted hazard ratio 1.56, 95%CI 0.95-2.56). Children with ≥ 7 and ≥ 15 total relapses were more likely to develop obesity and short stature, respectively. CONCLUSIONS Obesity is common among children with nephrotic syndrome early after diagnosis. Although short stature was uncommon overall, children with frequently relapsing or steroid dependent disease are at increased risk of developing short stature. Effective relapse prevention may reduce steroid toxicity and the risk of developing obesity or short stature.
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Affiliation(s)
- Cal H Robinson
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nowrin Aman
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Tonny Banh
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Josefina Brooke
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rahul Chanchlani
- Division of Nephrology, Department of Pediatrics, McMaster Children's Hospital, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Vaneet Dhillon
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Valerie Langlois
- Division of Nephrology, Department of Paediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Leo Levin
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada
- Program in Cell Biology, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ashlene McKay
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Damien Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Alisha Parikh
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rachel Pearl
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada
- Division of Nephrology, William Osler Health Systems, 20 Lynch Street, Brampton, Ontario, L6W 2Z8, Canada
| | - Seetha Radhakrishnan
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada
| | - Veronique Rowley
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada
| | | | - Rulan S Parekh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.
- Department of Paediatrics, The University of Toronto, Toronto, Ontario, Canada.
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
- Department of Medicine, Women's College Hospital and University of Toronto, 76 Grenville St, Toronto, Ontario, M5S 1B2, Canada.
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2
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Sun Y, Li Z, Sun J, Zhang S, Wang R, Chen B. The efficacy and safety of rituximab with or without glucocorticoid in inducing remission of MCD with different clinical presentations in adults: a retrospective study. Clin Kidney J 2024; 17:sfae139. [PMID: 38854425 PMCID: PMC11161702 DOI: 10.1093/ckj/sfae139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Indexed: 06/11/2024] Open
Abstract
Background To investigate the efficacy and safety of rituximab (RTX) with or without glucocorticoid (GC) in inducing remission of minimal change disease (MCD) in adults. Methods Twenty-one adult MCD patients were included in the study. The patients were assigned to the following three groups according to their background before RTX treatment: an RTX single drug direct induction treatment group (Group A; n = 9), a short-term, low-dose GC combined with RTX induction treatment group (Group B; n = 4), and a short-term, adequate-dose GC-induced remission and RTX maintenance treatment group (Group C; n = 8). The primary endpoints were the time to induction of remission and the rate of clinical remission at 12 months. Results All patients achieved clinical remission, with 19 (90.48%) achieving complete remission (CR), and the median remission time was 4 (2.5, 12) weeks. Eight (88.89%) patients in Group A achieved CR, and the median remission time was 3 (2.25, 14) weeks. In Group B, three (75.00%) patients achieved CR, with a median remission time of 4 (4, 10) weeks. In Group C, eight (100.00%) patients achieved CR, and the median remission time was 3.5 (2, 4) weeks. Conclusions In MCD patients without acute kidney injury, adequate RTX alone or short-term combined treatment with low-dose GCs can effectively induce and maintain MCD remission. Adequate short-term GCs combined with RTX maintenance may be an effective alternative for MCD patients in context of acute kidney injury. There is a need to investigate different induction therapy regimens for the remission of MCD patients with different backgrounds.
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Affiliation(s)
- Yujiao Sun
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhuo Li
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Jing Sun
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Shasha Zhang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Bing Chen
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Liao CY, Chung CH, Wei KY, Tseng MF, Lin FH, Tsao CH, Chien WC, Chu P, Wu CC. Do patients with nephrotic syndrome have an increased risk of osteoporosis? A nationwide population-based retrospective cohort study in Taiwan. BMJ Open 2024; 14:e080858. [PMID: 38719315 PMCID: PMC11086532 DOI: 10.1136/bmjopen-2023-080858] [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: 10/14/2023] [Accepted: 04/03/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVES To evaluate whether nephrotic syndrome (NS) and further corticosteroid (CS) use increase the risk of osteoporosis in Asian population during the period January 2000-December 2010. DESIGN Nationwide population-based retrospective cohort study. SETTING All healthcare facilities in Taiwan. PARTICIPANTS A total of 28 772 individuals were enrolled. INTERVENTIONS 26 614 individuals with newly diagnosed NS between 2000 and 2010 were identified and included in out study. 26 614 individuals with no NS diagnosis prior to the index date were age matched as controls. Diagnosis of osteoporosis prior to the diagnosis of NS or the same index date was identified, age, sex and NS-associated comorbidities were adjusted. PRIMARY OUTCOME MEASURE To identify risk differences in developing osteoporosis among patients with a medical history of NS. RESULTS After adjusting for covariates, osteoporosis risk was found to be 3.279 times greater in the NS cohort than in the non-NS cohort, when measured over 11 years after NS diagnosis. Stratification revealed that age older than 18 years, congestive heart failure, hyperlipidaemia, chronic kidney disease, liver cirrhosis and NS-related disease including diabetes mellitus, hepatitis B infection, hepatitis C infection, lymphoma and hypothyroidism, increased the risk of osteoporosis in the NS cohort, compared with the non-NS cohort. Additionally, osteoporosis risk was significantly higher in NS patients with CS use (adjusted HR (aHR)=3.397). The risk of osteoporosis in NS patients was positively associated with risk of hip and vertebral fracture (aHR=2.130 and 2.268, respectively). A significant association exists between NS and subsequent risk for osteoporosis. CONCLUSION NS patients, particularly those treated with CS, should be evaluated for subsequent risk of osteoporosis.
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Affiliation(s)
- Chen-Yi Liao
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Hsiang Chung
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Kuang-Yu Wei
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Min-Feng Tseng
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Zuoying Branch Of Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan
| | - Fu-Huang Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Chang-Huei Tsao
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Microbiology & Immunology, National Defense Medical Center, Taipei City, Taiwan
| | - Wu-Chien Chien
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Pauling Chu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Chao Wu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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4
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Aldakheel DA, Alamir A, Almarshad KK, Alsafwani ZA, Alshaer RA, Alzulfah AT, Al Rasheed SA. Retrospective Cross-Sectional Study Reviewing the Effectiveness of Mycophenolate Mofetil on Saudi Children With Nephrotic Syndrome. Cureus 2023; 15:e49679. [PMID: 38161837 PMCID: PMC10755642 DOI: 10.7759/cureus.49679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 01/03/2024] Open
Abstract
Background Idiopathic nephrotic syndrome (INS) is the most common form of nephrotic syndrome (NS) in children. It is often associated with minimal change disease (MCD). Corticosteroid therapy is the initial treatment, but many patients experience relapses, leading to steroid-dependent nephrotic syndrome (SDNS) or frequently relapsing steroid-sensitive nephrotic syndrome (FR-SSNS). To avoid prolonged steroid use, mycophenolate mofetil (MMF) is used as an immunosuppressive alternative. MMF is safe and effective for treating SDNS and FR-SSNS in children, with studies showing reduced relapse rates. The current study aims to evaluate MMF's effectiveness and safety in Saudi children with NS and identify factors that affect its efficacy. Methods A retrospective cross-sectional study was conducted at King Abdullah Specialized Children's Hospital (KASCH) in Riyadh, Saudi Arabia. The study included children aged one to 14 years diagnosed with NS who received MMF therapy. Data were collected from medical records from 2000 to 2020. Ethical considerations were followed, and statistical analysis was performed using IBM SPSS Statistics for Windows, version 25 (released 2017; IBM Corp., Armonk, New York, United States). Baseline characteristics and responsiveness to MMF were examined. Results In our study, 45 participants (25 males, 20 females) with NS were treated with MMF. Most participants were steroid-dependent (84.44%) and had frequent relapses. MMF was effective in 84.4% of cases, with a significant reduction in relapse; the mean number of relapses decreased from 3.5 before MMF to 1.6 after MMF (p-value = 0.00002). Moreover, 40% of the participants were completely free of relapse after the introduction of MMF. The average duration of the MMF therapy was 45 months. Post-MMF side effects were rare but documented. Gastrointestinal symptoms were extremely rare. Elevated liver enzyme levels were reported in 8.88% (four cases) of the participants. Leukopenia, a more common adverse effect, was reported in 26.66% of cases during the MMF therapy. The average daily dose of steroid was reduced from 12.5 mg/day pre MMF to 2 mg/day post MMF with a p-value of 0.00229. Conclusion Our study evaluated the use of MMF in 45 participants with NS. We found that MMF was effective in 84.4% of cases, leading to a significant reduction in the number of relapses. Post-MMF side effects were relatively rare, except for leukopenia that was reported in 26.66%. In addition, the average rate of reduction of steroid exposure before and after MMF was significant. These findings suggest that MMF is a promising treatment option for children with NS and an alternative therapy to long-term steroid use, due to its safety and effectiveness, although close monitoring for potential side effects is essential.
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Affiliation(s)
- Deemah A Aldakheel
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulrahman Alamir
- Pediatric Nephrology, King Abdullah Specialized Children's Hospital, Riyadh, SAU
| | - Khawla K Almarshad
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Zahra A Alsafwani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Roa A Alshaer
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdullah T Alzulfah
- Pediatric Nephrology, King Abdullah Specialized Children's Hospital, Riyadh, SAU
| | - Soud A Al Rasheed
- Division of Nephrology, Department of Paediatrics, Ministry of National Guard - Health Affairs, King Abdulaziz Medical City, Riyadh, SAU
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5
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Barry A, McNulty MT, Jia X, Gupta Y, Debiec H, Luo Y, Nagano C, Horinouchi T, Jung S, Colucci M, Ahram DF, Mitrotti A, Sinha A, Teeninga N, Jin G, Shril S, Caridi G, Bodria M, Lim TY, Westland R, Zanoni F, Marasa M, Turudic D, Giordano M, Gesualdo L, Magistroni R, Pisani I, Fiaccadori E, Reiterova J, Maringhini S, Morello W, Montini G, Weng PL, Scolari F, Saraga M, Tasic V, Santoro D, van Wijk JAE, Milošević D, Kawai Y, Kiryluk K, Pollak MR, Gharavi A, Lin F, Simœs E Silva AC, Loos RJF, Kenny EE, Schreuder MF, Zurowska A, Dossier C, Ariceta G, Drozynska-Duklas M, Hogan J, Jankauskiene A, Hildebrandt F, Prikhodina L, Song K, Bagga A, Cheong H, Ghiggeri GM, Vachvanichsanong P, Nozu K, Lee D, Vivarelli M, Raychaudhuri S, Tokunaga K, Sanna-Cherchi S, Ronco P, Iijima K, Sampson MG. Multi-population genome-wide association study implicates immune and non-immune factors in pediatric steroid-sensitive nephrotic syndrome. Nat Commun 2023; 14:2481. [PMID: 37120605 PMCID: PMC10148875 DOI: 10.1038/s41467-023-37985-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 04/10/2023] [Indexed: 05/01/2023] Open
Abstract
Pediatric steroid-sensitive nephrotic syndrome (pSSNS) is the most common childhood glomerular disease. Previous genome-wide association studies (GWAS) identified a risk locus in the HLA Class II region and three additional independent risk loci. But the genetic architecture of pSSNS, and its genetically driven pathobiology, is largely unknown. Here, we conduct a multi-population GWAS meta-analysis in 38,463 participants (2440 cases). We then conduct conditional analyses and population specific GWAS. We discover twelve significant associations-eight from the multi-population meta-analysis (four novel), two from the multi-population conditional analysis (one novel), and two additional novel loci from the European meta-analysis. Fine-mapping implicates specific amino acid haplotypes in HLA-DQA1 and HLA-DQB1 driving the HLA Class II risk locus. Non-HLA loci colocalize with eQTLs of monocytes and numerous T-cell subsets in independent datasets. Colocalization with kidney eQTLs is lacking but overlap with kidney cell open chromatin suggests an uncharacterized disease mechanism in kidney cells. A polygenic risk score (PRS) associates with earlier disease onset. Altogether, these discoveries expand our knowledge of pSSNS genetic architecture across populations and provide cell-specific insights into its molecular drivers. Evaluating these associations in additional cohorts will refine our understanding of population specificity, heterogeneity, and clinical and molecular associations.
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Affiliation(s)
- Alexandra Barry
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Michelle T McNulty
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Xiaoyuan Jia
- Genome Medical Science Project (Toyama), National Center for Global Health and Medicine (NCGM), Tokyo, Japan
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yask Gupta
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Hanna Debiec
- Sorbonne Université, UPMC Paris 06, Institut National de la Santé et de la Recherde Médicale, Unité Mixte de Rechereche, S 1155, Paris, France
| | - Yang Luo
- Kennedy Institute of Rheumatology, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, United Kingdom
- Center for Data Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Divisions of Genetics and Rheumatology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - China Nagano
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Seulgi Jung
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Dina F Ahram
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Adele Mitrotti
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Aditi Sinha
- Department of Pediatrics, AIIMS, New Delhi, India
| | - Nynke Teeninga
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gina Jin
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Shirlee Shril
- Department of Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Gianluca Caridi
- Laboratory on Molecular Nephrology, IRCCS Instituto Giannina Gaslini, Genoa, Italy
| | - Monica Bodria
- Department of Nephrology and Renal Transplantation, IRCCS Instituto Giannina Gaslini, Genoa, Italy
| | - Tze Y Lim
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Rik Westland
- Department of Pediatric Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - Francesca Zanoni
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
- Division of Transplantation, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Maddalena Marasa
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Daniel Turudic
- Department of Pediatric Nephrology, Dialysis and Transplantation, Clinical Hospital Hospital Center Zagreb, University of Zagreb Medical School, Zagreb, Croatia
| | - Mario Giordano
- Division of Nephrology and Pediatric Dialysis, Bari Polyclinic Giovanni XXIII Children's Hospital, Bari, Italy
| | - Loreto Gesualdo
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - Riccardo Magistroni
- Department of Nephrology, Dialysis and Transplant Unit, University Hospital of Modena, Modena, Italy
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Isabella Pisani
- Unità Operativa Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- Unità Operativa Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Jana Reiterova
- Department of Nephrology, Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | | | - William Morello
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milano, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Patricia L Weng
- Department of Pediatric Nephrology, UCLA Medical Center and UCLA Medical Center-Santa Monica, Los Angeles, CA, USA
| | - Francesco Scolari
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Division of Nephrology and Dialysis, University of Brescia and ASST Spedali Civili of Brescia, Brescia, Italy
| | - Marijan Saraga
- Department of Pediatrics, University of Split, Split, Croatia
| | - Velibor Tasic
- Department of Pediatric Nephrology, University Children's Hospital, Skopje, Macedonia
| | - Domenica Santoro
- Division of Nephrology and Dialysis Unit, University of Messina, Sicily, Italy
| | - Joanna A E van Wijk
- Department of Pediatric Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - Danko Milošević
- Department of Pediatric Nephrology, Dialysis and Transplantation, Clinical Hospital Hospital Center Zagreb, University of Zagreb Medical School, Zagreb, Croatia
- Croatian Academy of Medical Sciences, Praska 2/III p.p. 27, 10000, Zagreb, Croatia
| | - Yosuke Kawai
- Genome Medical Science Project (Toyama), National Center for Global Health and Medicine (NCGM), Tokyo, Japan
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Martin R Pollak
- Division of Nephrology, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Pediatric, Division of Pediatric Nephrology, Columbia University Irving Medical Center New York-Presbyterian Morgan Stanley Children's Hospital in New York, New York, NY, USA
| | - Ali Gharavi
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Fangmin Lin
- Department of Pediatric, Division of Pediatric Nephrology, Columbia University Irving Medical Center New York-Presbyterian Morgan Stanley Children's Hospital in New York, New York, NY, USA
| | - Ana Cristina Simœs E Silva
- Department of Pediatrics, Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Ruth J F Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eimear E Kenny
- Institute for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Genomic Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of General Internal Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aleksandra Zurowska
- Department of Pediatrics, Nephrology and Hypertension, Medical University Gdansk, Gdansk, Poland
| | - Claire Dossier
- AP-HP, Pediatric Nephrology Department, Hôpital Robert-Debré, Paris, France
| | - Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | - Julien Hogan
- AP-HP, Pediatric Nephrology Department, Hôpital Robert-Debré, Paris, France
| | - Augustina Jankauskiene
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Friedhelm Hildebrandt
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Larisa Prikhodina
- Research and Clinical Institute for Pediatrics, Pirogov Russian National Research Medical University, Taldomskava St, 2, Moscow, Russia
| | - Kyuyoung Song
- Department of Biochemistry and Molecular Biology, University of Ulsan College of Medicine, Songpa-gu, Seoul, Korea
| | - Arvind Bagga
- Department of Pediatrics, AIIMS, New Delhi, India
| | - Hae Cheong
- Department of Pediatrics, Hallym University Sacred Heart Hospital, 22, Gwanpyeong-ro 170 beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, Korea
| | - Gian Marco Ghiggeri
- Department of Nephrology and Renal Transplantation, IRCCS Instituto Giannina Gaslini, Genoa, Italy
| | - Prayong Vachvanichsanong
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat-Yai, Songkhla, 90110, Thailand
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Dongwon Lee
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Marina Vivarelli
- Division of Nephrology, and Dialysis, Department of Pediatric Subspecialities, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Soumya Raychaudhuri
- Center for Data Sciences, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Divisions of Genetics and Rheumatology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, MA, USA
- Centre for Genetics and Genomics Versus Arthritis, University of Manchester, Manchester, UK
| | - Katsushi Tokunaga
- Genome Medical Science Project (Toyama), National Center for Global Health and Medicine (NCGM), Tokyo, Japan
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Simone Sanna-Cherchi
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Pierre Ronco
- Sorbonne Université, UPMC Paris 06, Institut National de la Santé et de la Recherde Médicale, Unité Mixte de Rechereche, S 1155, Paris, France
- Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | - Kazumoto Iijima
- Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Matthew G Sampson
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA.
- Kidney Disease Initiative & Medical and Population Genetics Program, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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6
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Liu S, Bush WS, Miskimen K, Gonzalez-Vicente A, Bailey JNC, Konidari I, McCauley JL, Sedor JR, O'Toole JF, Crawford DC. T-cell receptor diversity in minimal change disease in the NEPTUNE study. Pediatr Nephrol 2023; 38:1115-1126. [PMID: 35943576 PMCID: PMC10037226 DOI: 10.1007/s00467-022-05696-x] [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: 02/21/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Minimal change disease (MCD) is the major cause of childhood idiopathic nephrotic syndrome, which is characterized by massive proteinuria and debilitating edema. Proteinuria in MCD is typically rapidly reversible with corticosteroid therapy, but relapses are common, and children often have many adverse events from the repeated courses of immunosuppressive therapy. The pathobiology of MCD remains poorly understood. Prior clinical observations suggest that abnormal T-cell function may play a central role in MCD pathogenesis. Based on these observations, we hypothesized that T-cell responses to specific exposures or antigens lead to a clonal expansion of T-cell subsets, a restriction in the T-cell repertoire, and an elaboration of specific circulating factors that trigger disease onset and relapses. METHODS To test these hypotheses, we sequenced T-cell receptors in fourteen MCD, four focal segmental glomerulosclerosis (FSGS), and four membranous nephropathy (MN) patients with clinical data and blood samples drawn during active disease and during remission collected by the Nephrotic Syndrome Study Network (NEPTUNE). We calculated several T-cell receptor diversity metrics to assess possible differences between active disease and remission states in paired samples. RESULTS Median productive clonality did not differ between MCD active disease (0.0083; range: 0.0042, 0.0397) and remission (0.0088; range: 0.0038, 0.0369). We did not identify dominant clonotypes in MCD active disease, and few clonotypes were shared with FSGS and MN patients. CONCLUSIONS While these data do not support an obvious role of the adaptive immune system T-cells in MCD pathogenesis, further study is warranted given the limited sample size. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Shiying Liu
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
| | - William S Bush
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Kristy Miskimen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, USA
| | - Agustin Gonzalez-Vicente
- Glickman Urological and Kidney Disease and Lerner Research Institutes, Cleveland Clinic, Cleveland, OH, USA
| | - Jessica N Cooke Bailey
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA
| | - Ioanna Konidari
- John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Jacob L McCauley
- John P. Hussman Institute for Human Genomics, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - John R Sedor
- Glickman Urological and Kidney Disease and Lerner Research Institutes, Cleveland Clinic, Cleveland, OH, USA
| | - John F O'Toole
- Glickman Urological and Kidney Disease and Lerner Research Institutes, Cleveland Clinic, Cleveland, OH, USA
| | - Dana C Crawford
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA.
- Cleveland Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, USA.
- Department of Genetics and Genome Sciences, Case Western Reserve University, Cleveland, OH, USA.
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7
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Kogon AJ, Ballester LS, Zee J, Walker N, Zaritsky JJ, Atkinson MA, Sethna CB, Hoofnagle AN, Leonard MB, Denburg MR. Vitamin D supplementation in children and young adults with persistent proteinuria secondary to glomerular disease. Pediatr Nephrol 2023; 38:749-756. [PMID: 35852656 PMCID: PMC11305009 DOI: 10.1007/s00467-022-05660-9] [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: 10/20/2021] [Revised: 06/04/2022] [Accepted: 06/06/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Vitamin D deficiency is common in glomerular disease. Supplementation may be ineffective due to ongoing urinary losses of vitamin D binding protein. We sought to determine if daily cholecalciferol supplementation would increase vitamin D concentrations in children with glomerular disease and persistent proteinuria, without adverse effects. METHODS Eighteen participants at least 5 years of age with primary glomerular disease and urine protein:creatinine ratio ≥ 0.5 were enrolled from four pediatric nephrology practices to receive cholecalciferol supplementation: 4,000 IU or 2,000 IU per day for serum 25 hydroxyvitamin vitamin D (25OHD) concentrations < 20 ng/mL and 20 ng/mL to < 30 ng/mL, respectively. Measures of vitamin D and mineral metabolism were obtained at baseline and weeks 6 and 12. Multivariable generalized estimating equation (GEE) regression estimated mean percent changes in serum 25OHD concentration. RESULTS Median baseline 25OHD was 12.8 ng/mL (IQR 9.3, 18.9) and increased to 27.8 ng/mL (20.5, 36.0) at week 6 (p < 0.001) without further significant increase at week 12. A total of 31% of participants had a level ≥ 30 ng/mL at week 12. Supplementation was stopped in two participants at week 6 for mildly elevated calcium and phosphorus, respectively, with subsequent declines in 25OHD of > 20 ng/mL. In the adjusted GEE model, 25OHD was 102% (95% CI: 64, 141) and 96% (95% CI: 51, 140) higher versus baseline at weeks 6 and 12, respectively (p < 0.001). CONCLUSION Cholecalciferol supplementation in vitamin D deficient children with glomerular disease and persistent proteinuria safely increases 25OHD concentration. Ideal dosing to fully replete 25OHD concentrations in this population remains unknown. CLINICAL TRIAL NCT01835639. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Amy J Kogon
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, USA.
| | - Lance S Ballester
- Biostatistics and Data Management Core, The Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Pennsylvania, PA, USA
| | - Natalie Walker
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, USA
| | - Joshua J Zaritsky
- Division of Pediatric Nephrology, Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE, USA
| | - Meredith A Atkinson
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Andrew N Hoofnagle
- Departments of Laboratory Medicine and Medicine, Kidney Research Institute, University of Washington, Seattle, DC, USA
| | - Mary B Leonard
- Department of Pediatrics, Stanford School of Medicine, Palo Alto, CA, USA
| | - Michelle R Denburg
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania and The Children's Hospital of Philadelphia, Pennsylvania, PA, USA
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8
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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: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Olivia Boyer
- Department 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
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Debbie S Gipson
- Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Susan Samuel
- Section of Pediatric Nephrology, Department of Pediatrics, Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Canada
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Khalid Alhasan
- Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sushmita Banerjee
- Department of Pediatric Nephrology, Institute of Child Health, Kolkata, India
| | | | - Melvin Bonilla-Felix
- Department of Pediatrics, University of Puerto Rico-Medical Sciences Campus, San Juan, Puerto Rico
| | - Francisco Cano
- Department 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
- Division of Pediatric Nephrology, Department of Paediatrics, The Children's Hospital at Westmead, Sydney, Australia
| | - Hee Gyung Kang
- Division of Pediatric Nephrology, Department of Pediatrics, Seoul National University Children's Hospital & Seoul National University College of Medicine, Seoul, Korea
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Hesham Safouh
- Pediatric Nephrology Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Howard Trachtman
- Department of Pediatrics, Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Wendy Cook
- Nephrotic Syndrome Trust (NeST), Somerset, UK
| | - Marina Vivarelli
- Division 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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9
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Goodwin Davies AJ, Xiao R, Razzaghi H, Bailey LC, Utidjian L, Gluck C, Eckrich D, Dixon BP, Deakyne Davies SJ, Flynn JT, Ranade D, Smoyer WE, Kitzmiller M, Dharnidharka VR, Magnusen B, Mitsnefes M, Somers M, Claes DJ, Burrows EK, Luna IY, Furth SL, Forrest CB, Denburg MR. Skeletal Outcomes in Children and Young Adults with Glomerular Disease. J Am Soc Nephrol 2022; 33:2233-2246. [PMID: 36171052 PMCID: PMC9731624 DOI: 10.1681/asn.2021101372] [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: 10/24/2021] [Accepted: 08/10/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Children with glomerular disease have unique risk factors for compromised bone health. Studies addressing skeletal complications in this population are lacking. METHODS This retrospective cohort study utilized data from PEDSnet, a national network of pediatric health systems with standardized electronic health record data for more than 6.5 million patients from 2009 to 2021. Incidence rates (per 10,000 person-years) of fracture, slipped capital femoral epiphysis (SCFE), and avascular necrosis/osteonecrosis (AVN) in 4598 children and young adults with glomerular disease were compared with those among 553,624 general pediatric patients using Poisson regression analysis. The glomerular disease cohort was identified using a published computable phenotype. Inclusion criteria for the general pediatric cohort were two or more primary care visits 1 year or more apart between 1 and 21 years of age, one visit or more every 18 months if followed >3 years, and no chronic progressive conditions defined by the Pediatric Medical Complexity Algorithm. Fracture, SCFE, and AVN were identified using SNOMED-CT diagnosis codes; fracture required an associated x-ray or splinting/casting procedure within 48 hours. RESULTS We found a higher risk of fracture for the glomerular disease cohort compared with the general pediatric cohort in girls only (incidence rate ratio [IRR], 1.6; 95% CI, 1.3 to 1.9). Hip/femur and vertebral fracture risk were increased in the glomerular disease cohort: adjusted IRR was 2.2 (95% CI, 1.3 to 3.7) and 5 (95% CI, 3.2 to 7.6), respectively. For SCFE, the adjusted IRR was 3.4 (95% CI, 1.9 to 5.9). For AVN, the adjusted IRR was 56.2 (95% CI, 40.7 to 77.5). CONCLUSIONS Children and young adults with glomerular disease have significantly higher burden of skeletal complications than the general pediatric population.
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Affiliation(s)
- Amy J Goodwin Davies
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hanieh Razzaghi
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - L Charles Bailey
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Levon Utidjian
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caroline Gluck
- Division of Nephrology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Daniel Eckrich
- Division of Nephrology, Nemours/Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Bradley P Dixon
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
- Children's Hospital Colorado, Aurora, Colorado
| | | | - Joseph T Flynn
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Hospital, Seattle, Washington
| | | | - William E Smoyer
- Department of Pediatrics, The Ohio State University, Columbus, Ohio
- Nationwide Children's Hospital, Columbus, Ohio
| | | | - Vikas R Dharnidharka
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
- St. Louis Children's Hospital, St. Louis, Missouri
| | | | - Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Michael Somers
- Boston Children's Hospital, Harvard University, Boston, Massachusetts
| | - Donna J Claes
- Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Evanette K Burrows
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ingrid Y Luna
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Susan L Furth
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher B Forrest
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michelle R Denburg
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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10
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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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11
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Cébron C, Godron-Dubrasquet A, Aladjidi N, Roussey G, Boyer O, Avramescu M, Baudouin V, Terzic J, Allain-Launay E, Rieux-Laucat F, Decramer S, Simon T, Harambat J. Benign and malignant proliferation in idiopathic nephrotic syndrome: a French cohort study. Pediatr Nephrol 2022; 37:1837-1843. [PMID: 35006357 DOI: 10.1007/s00467-021-05386-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 11/03/2021] [Accepted: 11/25/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND There seems to be a possible link between nephrotic syndrome (NS) and lymphoproliferative syndrome, but it remains poorly understood. METHODS This multicentric and retrospective study focuses on children, who developed idiopathic NS and malignant or benign proliferation between 2000 and 2021. RESULTS Eleven patients were included, with a median age of 4 years. Only one had a steroid-resistant nephrotic syndrome (SRNS). The maintenance therapy before the proliferation was in majority tacrolimus or mycophenolate mofetil (MMF), but three patients did not receive treatments. The proliferation was mainly a Hodgkin's lymphoma (45%) or a lymphoproliferative disease (36%), in a median time after the NS of two years. Viruses were found in seven cases (EBV in five cases and HHV-8 in two). CONCLUSION The association between proliferative syndrome and idiopathic NS may not be fortuitous, possibly with a common lymphocytic disturbance. Genetic analyses could improve the comprehension of these manifestations in the future. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Clara Cébron
- Department of Pediatric Internal Medicine, Rheumatology and Nephrology, Centre De Référence Des Maladies Rénales Rares du Sud-Ouest, SoRare, Toulouse University Hospital, Toulouse, France
- Pediatric Department, Grenoble University Hospital, Grenoble, France
| | - Astrid Godron-Dubrasquet
- Department of Pediatrics, Pediatric Nephrology Unit, Centre De Référence Des Maladies Rénales Rares du Sud-Ouest, SoRare, Bordeaux University Hospital, Bordeaux, France
| | - Nathalie Aladjidi
- Department of Pediatrics, Pediatric Oncology Hematology Unit, Bordeaux University Hospital, Bordeaux, France
| | | | - Olivia Boyer
- Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France
| | - Marina Avramescu
- Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France
| | - Veronique Baudouin
- Department of Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
| | - Joelle Terzic
- Department of Pediatric Nephrology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Frédéric Rieux-Laucat
- Imagine Institute, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, INSERM, UMR 1163, Université de Paris, Paris, France
| | - Stéphane Decramer
- Department of Pediatric Internal Medicine, Rheumatology and Nephrology, Centre De Référence Des Maladies Rénales Rares du Sud-Ouest, SoRare, Toulouse University Hospital, Toulouse, France
- Centre De Référence Des Maladies Rénales Rares du Sud-Ouest, SoRare, Membre du réseau européen ERKNet, Toulouse, France
- INSERM U1048, Institute of Cardiovascular and Metabolic Diseases, Toulouse, France
| | - Thomas Simon
- Department of Pediatric Internal Medicine, Rheumatology and Nephrology, Centre De Référence Des Maladies Rénales Rares du Sud-Ouest, SoRare, Toulouse University Hospital, Toulouse, France.
- Centre De Référence Des Maladies Rénales Rares du Sud-Ouest, SoRare, Membre du réseau européen ERKNet, Toulouse, France.
| | - Jérôme Harambat
- Department of Pediatrics, Pediatric Nephrology Unit, Centre De Référence Des Maladies Rénales Rares du Sud-Ouest, SoRare, Bordeaux University Hospital, Bordeaux, France
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12
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Lin J, Sun J. Rituximab May Have Positive Effect on Refractory Nephrotic Syndrome: A Meta-Analysis of Randomized Trials. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3008597. [PMID: 35813445 PMCID: PMC9262522 DOI: 10.1155/2022/3008597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 06/11/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022]
Abstract
Purpose This study was aimed at demonstrating the role of rituximab (RTX) on the influence of nephrotic syndrome (NS) and on urinary protein which was not significant. Methods The clinical randomized controlled trials were performed by eight databases. Meanwhile, the confidence interval (CI) of either relative risk or mean difference was set to 95%. Besides, the heterogeneity of the research results is tested by I 2. Results A total of 1658 references were found using the search method. This meta-analysis will be done by the ultimately eight different studies. Each study is described as random controlled trial. According to these eight studies, the remission of test group and control group was quite higher (OR: 1.60; 95% Cl: 1.17, 2.20; P < 0.01) than the control group, serum albumin (SMD: 4.19; 95% Cl: 1.49, 6.89; P < 0.01), and urine protein (SMD: 0.79; 95% Cl: -0.64, 2.22; P = 0.28). Despite the fact that the remission rate's funnel plot was asymmetrically distributed, Egger's test and Begg's test revealed no probable publish bias. Conclusion The results of this study suggest that rituximab (RTX) may be effective in RNS, as evidenced by remission rates and serum albumin. However, the effect on urinary protein was not significant. The clear evidence is missing in this literature. Therefore, large sample, multicenter, low risk of bias clinical studies, as well as basic medical research, is needed.
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Affiliation(s)
- Jingjing Lin
- Nephrology Department, First People's Hospital of Linping District, Hangzhou, China
| | - Jia Sun
- Nephrology Department, First People's Hospital of Linping District, Hangzhou, China
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13
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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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14
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Tang X, Shen Q, Rao J, Chen J, Fang X, Zhang Z, Grewal M, Mattoo T, Xu H. Duration of initial prednisolone therapy for first episode of childhood nephrotic syndrome based on time to response. Front Pediatr 2022; 10:1043285. [PMID: 36405821 PMCID: PMC9666732 DOI: 10.3389/fped.2022.1043285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/13/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The duration of initial corticosteroid therapy in newly diagnosed Idiopathic nephrotic syndrome (INS) is about 3 months. Our study was designed to test the feasibility of a shorter duration of corticosteroid therapy in newly diagnosed INS who show a quicker response. METHODS Patients who responded within 10 days (Group A) received 8 weeks of corticosteroid therapy as compared to 12-14 weeks of standard therapy in those who responded between >10 days to 28 days (Group B), and follow up for 52 weeks. The primary endpoint is time to first relapse after treatment completion. (NCT03878914, March 18, 2019). RESULTS A total of 33 children with INS were enrolled and the follow-up data were analyzed. The clinical and laboratory characteristics of patients in both groups were similar. No significant difference was found in time to first relapse [65(14.5, 159) days for Group A vs. 28(17, 61.5) days for Group B, P = 0.371], the incidence of frequently relapsing nephrotic syndrome [6/18 (33.3%) vs. 5/10(50%), P = 0.644] or requirement for alternative immunosuppressant [4/18 (22.2%) vs. 1/10 (10%), P = 0.769]. Group A received similar corticosteroid dose compare with Group B (3511 ± 2421 mg/m2 vs. 4117 ± 2556 mg/m2, P = 0.524). Frequency and severity of corticosteroid-related complications was similar in both groups. CONCLUSIONS The time to first relapse and the number of relapses per patient were comparable between the two groups. However, more patients in Group A relapsed and the mean total dose of prednisolone for the study period was very similar between the two groups.
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Affiliation(s)
- Xiaoshan Tang
- Department of Nephrology, Shanghai Kidney Development and Pediatric Kidney Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Shanghai Kidney Development and Pediatric Kidney Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jia Rao
- Department of Nephrology, Shanghai Kidney Development and Pediatric Kidney Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Jing Chen
- Department of Nephrology, Shanghai Kidney Development and Pediatric Kidney Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaoyan Fang
- Department of Nephrology, Shanghai Kidney Development and Pediatric Kidney Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Zhiqing Zhang
- Department of Nephrology, Shanghai Kidney Development and Pediatric Kidney Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
| | - Manpreet Grewal
- Division of Pediatric Nephrology, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, United States
| | - Tej Mattoo
- Division of Pediatric Nephrology, Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, United States
| | - Hong Xu
- Department of Nephrology, Shanghai Kidney Development and Pediatric Kidney Disease Research Center, National Children's Medical Center, Children's Hospital of Fudan University, Shanghai, China
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15
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Latief M, Shafi O, Hassan Z, Abbas F, Farooq S. Levamisole in steroid-dependent nephrotic syndrome in children: A case series. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2022. [DOI: 10.4103/mjdrdypu.mjdrdypu_211_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Parikh RV, Tan TC, Fan D, Law D, Salyer AS, Yankulin L, Wojcicki JM, Zheng S, Ordonez JD, Chertow GM, Khoshniat-Rad F, Yang J, Go AS. Population-based identification and temporal trend of children with primary nephrotic syndrome: The Kaiser Permanente nephrotic syndrome study. PLoS One 2021; 16:e0257674. [PMID: 34648518 PMCID: PMC8516311 DOI: 10.1371/journal.pone.0257674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Limited population-based data exist about children with primary nephrotic syndrome (NS). METHODS We identified a cohort of children with primary NS receiving care in Kaiser Permanente Northern California, an integrated healthcare delivery system caring for >750,000 children. We identified all children <18 years between 1996 and 2012 who had nephrotic range proteinuria (urine ACR>3500 mg/g, urine PCR>3.5 mg/mg, 24-hour urine protein>3500 mg or urine dipstick>300 mg/dL) in laboratory databases or a diagnosis of NS in electronic health records. Nephrologists reviewed health records for clinical presentation and laboratory and biopsy results to confirm primary NS. RESULTS Among 365 cases of confirmed NS, 179 had confirmed primary NS attributed to presumed minimal change disease (MCD) (72%), focal segmental glomerulosclerosis (FSGS) (23%) or membranous nephropathy (MN) (5%). The overall incidence of primary NS was 1.47 (95% Confidence Interval:1.27-1.70) per 100,000 person-years. Biopsy data were available in 40% of cases. Median age for patients with primary NS was 6.9 (interquartile range:3.7 to 12.9) years, 43% were female and 26% were white, 13% black, 17% Asian/Pacific Islander, and 32% Hispanic. CONCLUSION This population-based identification of children with primary NS leveraging electronic health records can provide a unique approach and platform for describing the natural history of NS and identifying determinants of outcomes in children with primary NS.
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MESH Headings
- Adolescent
- Biopsy
- Child
- Child, Preschool
- Cohort Studies
- Female
- Glomerulonephritis, Membranous/diagnosis
- Glomerulonephritis, Membranous/epidemiology
- Glomerulonephritis, Membranous/pathology
- Glomerulosclerosis, Focal Segmental/diagnosis
- Glomerulosclerosis, Focal Segmental/epidemiology
- Glomerulosclerosis, Focal Segmental/pathology
- Humans
- Male
- Nephrosis, Lipoid/diagnosis
- Nephrosis, Lipoid/epidemiology
- Nephrosis, Lipoid/pathology
- Nephrotic Syndrome/diagnosis
- Nephrotic Syndrome/epidemiology
- Nephrotic Syndrome/pathology
- Proteinuria/diagnosis
- Proteinuria/epidemiology
- Proteinuria/pathology
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Affiliation(s)
- Rishi V. Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Thida C. Tan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Dongjie Fan
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - David Law
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, CA, United States of America
| | - Anne S. Salyer
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, CA, United States of America
| | - Leonid Yankulin
- Department of Nephrology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, United States of America
| | - Janet M. Wojcicki
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States of America
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
| | - Sijie Zheng
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, CA, United States of America
| | - Juan D. Ordonez
- Department of Nephrology, Kaiser Permanente Oakland Medical Center, Oakland, CA, United States of America
| | - Glenn M. Chertow
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
- Departments of Medicine (Nephrology) and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Farzien Khoshniat-Rad
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Jingrong Yang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, United States of America
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA, United States of America
- Departments of Medicine (Nephrology) and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, United States of America
- Department of Health System Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States of America
- * E-mail:
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17
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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: 748] [Impact Index Per Article: 249.3] [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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18
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Ravani P, Colucci M, Bruschi M, Vivarelli M, Cioni M, DiDonato A, Cravedi P, Lugani F, Antonini F, Prunotto M, Emma F, Angeletti A, Ghiggeri GM. Human or Chimeric Monoclonal Anti-CD20 Antibodies for Children with Nephrotic Syndrome: A Superiority Randomized Trial. J Am Soc Nephrol 2021; 32:2652-2663. [PMID: 34544820 PMCID: PMC8722811 DOI: 10.1681/asn.2021040561] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/20/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The chimeric anti-CD20 monoclonal antibody rituximab is effective in steroid-dependent and calcineurin inhibitor-dependent forms of nephrotic syndrome, but many patients relapse at 1 year. Because ofatumumab, a fully human anti-CD20 monoclonal antibody, has a more extended binding site and higher affinity to CD20 compared with rituximab, it might offer superior efficacy in these patients. METHODS We designed a single-center randomized clinical trial to compare the long-term efficacy of ofatumumab versus rituximab in children and young adults with nephrotic syndrome maintained in remission with prednisone and calcineurin inhibitors. We randomized 140 children and young adults (aged 2-24 years) to receive intravenous ofatumumab (1.50 mg/1.73 m2) or rituximab (375 mg/m2). After infusions, oral drugs were tapered and withdrawn within 60 days. The primary outcome was relapse at 1 year, which was analyzed following the intent-to-treat principle. The secondary endpoint was relapse within 24 months from infusion, on the basis of urine dipstick and confirmed by a urine protein-to-creatinine ratio <200. RESULTS At 12 months, 37 of 70 (53%) participants who received ofatumumab experienced relapse versus 36 of 70 (51%) who received rituximab (odds ratio [OR], 1.06; 95% confidence interval [95% CI], 0.55 to 2.06). At 24 months, 53 of 70 (76%) participants who received ofatumumab experienced relapse, versus 46 of 70 (66%) who received rituximab (OR, 1.6; 95% CI, 0.8 to 3.3). The two groups exhibited comparable B cell subpopulation reconstitution and did not differ in adverse events. CONCLUSIONS A single dose of ofatumumab was not superior to a single dose of rituximab in maintaining remission in children with steroid-dependent and calcineurin inhibitor-dependent nephrotic syndrome. CLINICAL TRIAL REGISTRATION NUMBERS ClinicalTrials.gov (NCT02394119) and https://www.clinicaltrialsregister.eu/ctr-search/search (2015-000624-28).
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Affiliation(s)
- Pietro Ravani
- Division of Nephrology, University of Calgary, Calgary, Alberta, Canada
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Division, Bambino Gesù Children's Hospital Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Maurizio Bruschi
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Marina Vivarelli
- Division of Nephrology, Bambino Gesù Children's Hospital Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Michela Cioni
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Armando DiDonato
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Francesca Lugani
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Francesca Antonini
- Core Facilities, Istituto di Ricovero e Cura a Carattere Scientifico Istituto G. Gaslini, Genoa, Italy
| | - Marco Prunotto
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Switzerland
| | - Francesco Emma
- Division of Nephrology, Bambino Gesù Children's Hospital Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Andrea Angeletti
- Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
| | - Gian Marco Ghiggeri
- Laboratory on Molecular Nephrology, Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy,Division of Nephrology, Dialysis, Transplantation, Istituto Giannina Gaslini Istituto di Ricovero e Cura a Carattere Scientifico, Genoa, Italy
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19
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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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20
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Meuleman MS, Guilmin-Crépon S, Hummel A, Daugas E, Dumas A, Leye F, Dantal J, Rigothier C, Provot F, Chauveau D, Burtey S, Hertig A, Dahan K, Durrbach A, Dossier C, Karras A, Guerrot D, Esnault V, Rémy P, Massy ZA, Tostivint I, Morin MP, Zaoui P, Fritz O, Le Quintrec M, Wynckel A, Bourmaud A, Boyer O, Sahali D, Alberti C, Audard V, Mellerio H. Long-term health-related quality of life outcomes of adults with pediatric onset of frequently relapsing or steroid-dependent nephrotic syndrome. J Nephrol 2021; 35:1123-1134. [PMID: 34224090 DOI: 10.1007/s40620-021-01111-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Long-term psychosocial outcomes and health-related quality of life (HRQOL) in adults with pediatric onset of frequently relapsing or steroid-dependent idiopathic nephrotic syndrome (FRNS or SDNS) remain to be determined. METHODS In this prospective cohort study, 59 adults with pediatric onset of FRNS/SDNS and persistent active glomerular disease in adulthood completed the GEDEPAC-2 questionnaire exploring 11 well-being domains. Data were compared to the French general population (FGP) with standardized incidence ratio ([SIR]; adjusted for period, age, gender). Regression models were performed to identify predictive factors of psychosocial well-being. RESULTS In 82% of cases, the questionnaire was completed while the participants (n = 59; 47 men; median age = 32 years; median number of relapses = 13) were in complete remission (under specific therapy in 76% of cases). Participants had higher educational degree than in the FGP (SIR = 6.3; p < 0.01) and more frequently a managerial occupation (SIR = 3.1; p < 0.01). Social integration was acceptable with regard to marital status and experience of sexual intercourse, but experiences of discrimination were far more frequent (SIR = 12.5; p < 0.01). The SF-12 mental component summary (MCS) score was altered (Z-score = - 0.6; p < 0.01) and mean multidimensional fatigue inventory (MFI-20) global fatigue score appeared high (12). Transfer from pediatric to adult healthcare was followed by a period of discontinued care for 33% of participants. Multivariate analysis revealed a close relationship between MFI-20, physical health, and MCS. CONCLUSIONS This study shows that pediatric onset FRNS and SDNS may have a long-term negative impact on mental HRQOL and highlights the impact of fatigue, which is often not adequately considered in routine care.
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Affiliation(s)
- Marie-Sophie Meuleman
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare "Syndrome Néphrotique Idiopathique", Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", 51 Avenue du Marechal-de-Lattre-de-Tassigny, Créteil Cedex, 94010, Creteil, France. .,Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Université Paris Est Créteil, Equipe 21, Creteil, France.
| | - Sophie Guilmin-Crépon
- Université de Paris, ECEVE UMR 1123, INSERM, 75010, Paris, France.,Unité d'Épidémiologie Clinique, CIC 1426, AP-HP.Nord, Hôpital Universitaire Robert Debré, Inserm, 75019, Paris, France
| | - Aurélie Hummel
- Service de Néphrologie, AP-HP, Hôpital Necker, Paris, France
| | - Eric Daugas
- Service de Néphrologie, AP-HP, Hôpital Bichat, Université de Paris, INSERM U1149, Paris, France
| | - Agnès Dumas
- Université de Paris, ECEVE UMR 1123, INSERM, 75010, Paris, France
| | - Fallou Leye
- Unité d'Épidémiologie Clinique, CIC 1426, AP-HP.Nord, Hôpital Universitaire Robert Debré, Inserm, 75019, Paris, France
| | - Jacques Dantal
- Service de Néphrologie Immunologie Clinique Transplantation, Centre de Recherche en Transplantation et Immunologie (CRTI), Centre Hospitalier Universitaire (CHU) de Nantes, Nantes, France
| | - Claire Rigothier
- Service de Néphrologie Transplantation, Dialyse et Aphérèses, CHU de Bordeaux, Bordeaux, France
| | - François Provot
- Service de Néphrologie, Hôpital Huriez, CHU de Lille, Lille, France
| | - Dominique Chauveau
- Service de Néphrologie et Transplantation d'Organes, Hôpital de Rangueil et Centre de Référence Maladies Rénales Rares, CHU de Toulouse, Toulouse, France
| | - Stéphane Burtey
- APHM, INSERM, INRAe, C2VN, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, Aix Marseille University, Marseille, France
| | - Alexandre Hertig
- Service de Néphrologie et Transplantation Rénale, AP-HP, Hôpital Tenon, Paris, France
| | - Karine Dahan
- Service de Néphrologie et Dialyse, AP-HP, Hôpital Tenon, Paris, France
| | - Antoine Durrbach
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare "Syndrome Néphrotique Idiopathique", Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", 51 Avenue du Marechal-de-Lattre-de-Tassigny, Créteil Cedex, 94010, Creteil, France
| | - Claire Dossier
- Service de Néphrologie Pédiatrique, AP-HP, Hôpital Robert Debré, Paris, France
| | - Alexandre Karras
- Service de Néphrologie, AP-HP, Hôpital Européen Georges Pompidou, Université de Paris, Paris, France
| | | | - Vincent Esnault
- Service de Néphrologie, Hôpital Pasteur, CHU de Nice, Nice, France
| | - Philippe Rémy
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare "Syndrome Néphrotique Idiopathique", Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", 51 Avenue du Marechal-de-Lattre-de-Tassigny, Créteil Cedex, 94010, Creteil, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Université Paris Est Créteil, Equipe 21, Creteil, France
| | - Ziad A Massy
- Service de Néphrologie, AP-HP, Hôpital Ambroise Paré, Boulogne-Billancourt, France.,INSERM U1018 CESP, UVSQ, UPS Villejuif, Villejuif, France
| | - Isabelle Tostivint
- Service de Néphrologie et Transplantation, AP-HP, Hôpital Pitié Salpêtrière, Paris, France
| | - Marie-Pascale Morin
- Service de Néphrologie, Hôpital de Pontchaillou, CHU de Rennes, Rennes, France
| | - Philippe Zaoui
- Service de Néphrologie, Hémodialyse, Aphérèse et Transplantation Rénale, CHU de Grenoble Alpes, Université Grenoble-Alpes, Grenoble, France
| | - Olivier Fritz
- Service de Néphrologie, Centre Hospitalier (CH) La Rochelle, La Rochelle, France
| | - Moglie Le Quintrec
- Service de Néphrologie Dialyse et Transplantation Rénale, Hôpital Lapeyronie, CHU de Montpellier, Montpellier, France
| | | | - Aurélie Bourmaud
- Université de Paris, ECEVE UMR 1123, INSERM, 75010, Paris, France.,Unité d'Épidémiologie Clinique, CIC 1426, AP-HP.Nord, Hôpital Universitaire Robert Debré, Inserm, 75019, Paris, France
| | - Olivia Boyer
- Service de Néphrologie Pédiatrique, Centre de Référence Maladie Rare "Syndrome Néphrotique Idiopathique", Institut Imagine, AP-HP, Hôpital Necker-Enfants Malades, Université de Paris, Paris, France
| | - Dil Sahali
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare "Syndrome Néphrotique Idiopathique", Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", 51 Avenue du Marechal-de-Lattre-de-Tassigny, Créteil Cedex, 94010, Creteil, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Université Paris Est Créteil, Equipe 21, Creteil, France
| | - Corinne Alberti
- Université de Paris, ECEVE UMR 1123, INSERM, 75010, Paris, France.,Unité d'Épidémiologie Clinique, CIC 1426, AP-HP.Nord, Hôpital Universitaire Robert Debré, Inserm, 75019, Paris, France
| | - Vincent Audard
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare "Syndrome Néphrotique Idiopathique", Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", 51 Avenue du Marechal-de-Lattre-de-Tassigny, Créteil Cedex, 94010, Creteil, France.,Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Université Paris Est Créteil, Equipe 21, Creteil, France
| | - Hélène Mellerio
- Université de Paris, ECEVE UMR 1123, INSERM, 75010, Paris, France.,Service de médecine d'adolescent, Plateforme de Transition AD'venir, AP-HP, Hôpital Robert Debré, Paris, France.,Groupe Français de Recherche en Médecine et Santé de l'Adolescent, Paris, France
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21
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Marchel DM, Gipson DS. Adult survivors of idiopathic childhood onset nephrotic syndrome. Pediatr Nephrol 2021; 36:1731-1737. [PMID: 33155129 DOI: 10.1007/s00467-020-04773-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/12/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
Like many pediatric chronic health conditions, idiopathic childhood onset nephrotic syndrome (iCONS) and late effects of iCONS medical management may continue to impact the affected population in adulthood. Approximately 15% of adult survivors of steroid-sensitive iCONS continue to relapse. Long-term kidney health is associated with steroid response patterns as well as pathology findings of FSGS, tubulointerstitial fibrosis, tubular atrophy, and global glomerulosclerosis. Long-term cardiovascular disease burden is largely unknown in adult survivors, but risk factors starting in childhood, including hypertension, dyslipidemia, and obesity, are common in iCONS. Reproductive health concerns, including azo-/oligospermia and successful pregnancies, are largely related to prior exposure to cytotoxic therapies. Additional investigations are needed to complete the assessment and initiate the mitigation of the late effects of treatment-sensitive and treatment-resistant iCONS.
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Affiliation(s)
- Dorota M Marchel
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.
| | - Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
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22
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Lin L, Wang W, Wu Y, Xie J, Li X, Pan X, Zhang W, Xu J, Cai Y, Ren H, Chen N. Consolidation Treatment and Long-Term Prognosis of Rituximab in Minimal Change Disease and Focal Segmental Glomerular Sclerosis. DRUG DESIGN DEVELOPMENT AND THERAPY 2021; 15:1945-1953. [PMID: 34007154 PMCID: PMC8121273 DOI: 10.2147/dddt.s302257] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 04/13/2021] [Indexed: 12/16/2022]
Abstract
Purpose There is currently a lack of studies investigating long-term prognosis and the necessity of further rituximab (RTX) consolidation treatment for minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). The aim of this study was to evaluate the efficacy of RTX for these diseases and to investigate whether a consolidation treatment can lower risks of relapse and reinforce long-term remission. Patients and Methods A retrospective study was conducted. The relapse and remission of 70 patients treated with 1 course of RTX treatment (4 infusions of 375 mg/m2) over a median follow-up time of 27 months (12–60 months) were analyzed. The rates of patients that were able to achieve non-relapse for a duration of 24 months between RTX consolidation therapy and non-consolidation therapy were compared. Results There were 67 cases (95.71%) of remission and 3 cases (4.29%) of non-remission. The average number of relapses decreased from 3.7±2.5 times before the treatment to 0.8±1.8 times after treatment (P <0.001). The average avannual number of relapses decreased from 1.3±1.2 times/year to 0.2±0.3 times/year (P <0.001). The results from the Cox proportional-hazards model showed that the risk of relapse in patients who received RTX non-consolidation treatment was significantly higher than those with consolidation treatment (odds ratios (OR) 20.9, 95% confidence intervals (CI) OR 5.7–75.7, p<0.001). The 24-month relapse-free rate was also significantly higher in patients with consolidation therapy compared with non-consolidation therapy (86.36% vs 25%, p<0.001). No adverse events were recorded. Conclusion RTX is highly effective in treating MCD and FSGS, and RTX consolidation therapy may be recommended to reinforce long-term remissions.
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Affiliation(s)
- Li Lin
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Weiming Wang
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - YiFan Wu
- Biomedical and Health Informatics, University of Washington, Seattle, WA, USA
| | - JingYuan Xie
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Xiao Li
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - XiaoXia Pan
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Wen Zhang
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Jing Xu
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - YiKai Cai
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Hong Ren
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
| | - Nan Chen
- Department of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, People's Republic of China
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23
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Jensen NB, Justesen SD, Larsen A, Ernst E, Pedersen LH. A systematic overview of the spermatotoxic and genotoxic effects of methotrexate, ganciclovir and mycophenolate mofetil. Acta Obstet Gynecol Scand 2021; 100:1557-1580. [PMID: 33755191 DOI: 10.1111/aogs.14151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/23/2021] [Accepted: 03/14/2021] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Immunosuppressant drugs are increasingly being used in the reproductive years. Theoretically, such medications could affect fetal health either through changes in the sperm DNA or through fetal exposure caused by a presence in the seminal fluid. This systematic overview summarizes existing literature on the spermatotoxic and genotoxic potentials of methotrexate (MTX), a drug widely used to treat rheumatic and dermatologic diseases, and mycophenolate mofetil (MMF), which alone or supplemented with ganciclovir (GCV) may be crucial for the survival of organ transplants. MATERIAL AND METHODS The systematic overview was performed in accordance with the PRISMA guidelines: A systematic literature search of the MEDLINE and Embase databases was done using a combination of relevant terms to search for studies on spermatotoxic or genotoxic changes related to treatment with MTX, GCV or MMF. The search was restricted to English language literature, and to in vivo animal studies (mammalian species) and clinical human studies. RESULTS A total of 102 studies were identified, hereof 25 human and 77 animal studies. For MTX, human studies of immunosuppressive dosages show transient effect on sperm quality parameters, which return to reference values within 3 months. No human studies have investigated the sperm DNA damaging effect of MTX, but in other organs the genotoxic effects of immunosuppressive doses of MTX are fluctuating. In animals, immunosuppressive and cytotoxic doses of MTX adversely affect sperm quality parameters and show widespread genotoxic damages in various organs. Cytotoxic doses transiently change the DNA material in all cell stages of spermatogenesis in rodents. For GCV and MMF, data are limited and the results are indeterminate, for which reason spermatotoxic and genotoxic potentials cannot be excluded. CONCLUSIONS Data from human and animal studies indicate transient spermatotoxic and genotoxic potentials of immunosuppressive and cytotoxic doses of MTX. There are a limited number of studies investigating GCV and MMF.
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Affiliation(s)
| | | | - Agnete Larsen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Erik Ernst
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Laboratory for Reproduction, Institute of Anatomy, Aarhus University, Aarhus, Denmark
| | - Lars H Pedersen
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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24
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Prevalence and predictors of ocular complications among children undergoing nephrotic syndrome treatment in a resource-limited setting. BMC Ophthalmol 2021; 21:55. [PMID: 33482766 PMCID: PMC7821477 DOI: 10.1186/s12886-021-01817-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 01/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Nephrotic syndrome is the most common glomerulopathy among children aged 2–18 years and high dose corticosteroids are the backbone of its management. Potentially blinding ocular complications often result from nephrotic syndrome and/or its treatment. We conducted a study to determine the prevalence and predictors of ocular complications among children undergoing nephrotic syndrome treatment at Mulago National Referral Hospital. Methods This was a cross-sectional study conducted for three [3] months at the pediatric renal unit of Mulago National Referral Hospital (MNRH). Data from a consecutive sample of 100 children was collected using a semi-structured questionnaire, entered into Epi-data 4.4.2 and exported to STATA 14 for analysis at univariate, bivariate and multivariate levels. A robust Poisson regression model was used to identify predictors of ocular complications. Results Out of 100 patients examined, 80(80%) had ocular complications. The median age was 10 (IQR: 7–12) and 52 (52%) were girls. The most frequent complications were hypertrichosis and refractive errors in 71% (95%CI 61.1–79.6) and 56% (95%CI 45.7–65.9) of the patients respectively. Age above 10 years was the predictor for ocular complications with a RR = 1.37 (95%CI:1.14–1.64) p = 0.001. Conclusions We found a high prevalence of ocular complications among children with nephrotic syndrome in this tertiary hospital. The predictor of ocular complications was age greater than 10 years. We recommend that all children with nephrotic syndrome undergo a baseline ocular examination prior to commencement of treatment and be reviewed periodically by an ophthalmologist. Supplementary Information The online version contains supplementary material available at 10.1186/s12886-021-01817-6.
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Malek F, Shomali A, Mirmohammadkhani M, Mansori K, Pahlevan D. Effects of Chlorine Gas Exposure and Associated Factors on Spirometric Parameters in Detergent Industry Workers: a Four-Year Cross-Sectional Study. TANAFFOS 2021; 20:43-50. [PMID: 34394369 PMCID: PMC8355941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study aimed to determine the effects of chlorine gas exposure and the associated factors on spirometric parameters among detergent industry workers in Semnan, Iran. MATERIALS AND METHODS This four-year cross-sectional study was concocted on 100 workers of two detergent factories in Semnan, Iran. Two questionnaires were used for data collection. The first questionnaire included demographic and occupational information, and the second questionnaire included spirometric parameters, such as forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC ratio, peak expiratory flow (PEF), and PEF 25-75%. The spirometric parameters were measured over four consecutive years by a trained technician. Next, to determine the effects of chlorine gas exposure and its associated factors on spirometric parameters, a generalized estimating equation (GEE) model was used. The correlation structure of GEE was considered to be autoregressive 1 (AR-1). Analyses were performed in STATA version 14. RESULTS All spirometric parameters showed a decreasing trend during 2012-2015. The GEE model showed a significant association between chlorine gas exposure and all spirometric parameters; the beta-coefficients for the effect of exposure (year) on FVC, FEV1, FEV1/FVC ratio, PEF, and PEF 25-75% were -4.51, -6.46, -4.27, -6.09, and -10.29, respectively. Also, this model demonstrated a significant association between smoking and FEV1, PEF, and PEF 25-75%; the beta-coefficients for the effect of smoking on these parameters were -5.64, -8.88, and -5.75, respectively. Additionally, the GGE model showed a significant association between the body mass index (BMI) and FVC and FEV1 (P<0.05); the beta-coefficients for the effect of BMI on these two parameters were - 0.59 and -0.48, respectively. CONCLUSION The spirometric parameters showed a decreasing trend over time among detergent industry workers; this decline was more remarkable among individuals with a history of smoking. Therefore, it seems necessary to implement screening programs and periodic active examinations for these workers.
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Affiliation(s)
- Farhad Malek
- Department of Internal Medicine, Kosar Hospital, Semnan University of Medical Sciences, Semnan, Iran
| | - Amir Shomali
- Department of Internal Medicine, Kosar Hospital, Semnan University of Medical Sciences, Semnan, Iran
| | - Majid Mirmohammadkhani
- Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran,,Department of Epidemiology and Biostatistics, Semnan University of Medical Sciences, Semnan, Iran
| | - Kamyar Mansori
- Department of Biostatistics and Epidemiology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Daryoush Pahlevan
- Department of Community Medicine, School of Medicine, Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran.,Correspondence to: Pahlevan D, Address: Department of Community Medicine, School of Medicine, Social Determinants of Health Research Center, Semnan University of Medical Sciences, Semnan, Iran Email address:
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Lodeweyckx N, Wouters K, Ledeganck KJ, Trouet D. Biopsy or Biomarker? Children With Minimal Change Disease Have a Distinct Profile of Urinary Epidermal Growth Factor. Front Pediatr 2021; 9:727954. [PMID: 34900856 PMCID: PMC8657767 DOI: 10.3389/fped.2021.727954] [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: 06/20/2021] [Accepted: 10/05/2021] [Indexed: 02/02/2023] Open
Abstract
Background: In this study, the profile of urinary EGF excretion (uEGF/uCreat) was mapped in children presenting with prolonged proteinuria or with nephrotic syndrome refractory to or dependent of steroids. We investigated whether uEGF/uCreat could be linked to the underlying biopsy result, taking into account its response to immunosuppressive medication and to ACE inhibition, as well as genetic predisposition. Methods: Ninety-eight pediatric patients with initial presentation of nephrotic syndrome or prolonged proteinuria were included in this study, along with 49 healthy controls and 20 pediatric Alport patients. All patients had a normal kidney function and were normotensive during the course of the study, whether or not under ACE inhibition. In repeated urine samples, uEGF was measured and concentration was normalized by urine creatinine. In order to compare diagnosis on kidney biopsy, genetic predisposition and response of uEGF/uCreat to immunosuppression and to ACE inhibition, uEGF/uCreat is studied in a linear mixed effects model. Results: Patients with Minimal Change Disease (MCD) showed a significantly different profile of uEGF/uCreat in comparison to healthy children, as well as compared to patients with Focal Segmental Glomerulosclerosis (FSGS) or another glomerulopathy on kidney biopsy. The response of uEGF/uCreat to ACE inhibition was absent in minimal change disease and contrasted with an impressive beneficial effect of ACE inhibition on uEGF/uCreat in FSGS and other proteinuric glomerulopathies. Absence of a genetic predisposition was also associated with a significantly lower uEGF/uCreat. Conclusions: Despite preserved kidney function, children with a proteinuric or nephrotic glomerular disease on kidney biopsy show a significantly lower uEGF/uCreat, indicative of early tubulo-interstitial damage, which appears reversible under ACE inhibition in any underlying glomerulopathy except in minimal change disease. In view of the distinct profile of uEGF/uCreat in minimal change disease compared to other glomerulopathies, and the link between genetic predisposition and uEGF/uCreat, our study suggests that uEGF/uCreat can be a helpful tool to decide on the need for a renal biopsy in order to differentiate minimal change disease from other proteinuric glomerular diseases.
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Affiliation(s)
- Niels Lodeweyckx
- Department of Pediatric Nephrology, Antwerp University Hospital, Edegem, Belgium
| | - Kristien Wouters
- Clinical Trial Center (CTC), Clinical Research Center (CRC) Antwerp, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Kristien J Ledeganck
- Laboratory of Experimental Medicine and Pediatrics and Member of the Infla-Med Centre of Excellence, University of Antwerp, Edegem, Belgium
| | - Dominique Trouet
- Department of Pediatric Nephrology, Antwerp University Hospital, Edegem, Belgium.,Laboratory of Experimental Medicine and Pediatrics and Member of the Infla-Med Centre of Excellence, University of Antwerp, Edegem, Belgium
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27
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Gao X, Wang Y, Xu Z, Deng H, Yang H, Zhong F. Systematic Review and Meta-Analysis of Rituximab for Steroid-Dependent or Frequently Relapsing Nephrotic Syndrome in Children. Front Pediatr 2021; 9:626323. [PMID: 34368023 PMCID: PMC8339375 DOI: 10.3389/fped.2021.626323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 06/16/2021] [Indexed: 11/20/2022] Open
Abstract
Objective: To explore the effectiveness and safety of rituximab (RTX) for steroid-dependent or frequently relapsing nephrotic syndrome via a systematic review and meta-analysis. Methods: All the literature about RTX therapy for childhood nephrotic syndrome (NS) on PubMed, Web of Science, Cochrane Library, EMBASE, and Chinese biomedical literature database published before November 1, 2019, were conducted and selected according to the preset criteria. The Cochrane bias risk assessment tool was used to evaluate the quality of the literature included. The outcome data were analyzed by RevMan 5.3 software. Results: There were six RCT studies that met the inclusion criteria with a moderate quality after evaluation. At the end of the treatment, the relapse rate of NS in the RTX group reduced significantly when compared with that in the control group [odds ratio (OR) = 0.11, 95% confidence interval (CI) (0.03, 0.43), p = 0.001]. The number of patients in the RTX group used less steroid or/and calcineurin inhibitors significantly than that in the control group [OR = 0.05, 95% CI (0.01, 0.28), p = 0.0007]. For children who were steroid-dependent, RTX treatment significantly reduced the dosage of the steroid, compared with that in control [standardized mean difference (SMD) = -1.49, 95% CI (-2.00, -0.99), p < 0.00001]. There was no significant reduction in protein excretion between the two groups [SMD = -0.33, 95% CI (-0.71, 0.04), p = 0.08]. Fewer serious adverse reactions of RTX in the six studies were reported and most adverse events were mild. Conclusion: RTX is effective and safe for children with steroid-dependent or frequently relapsing nephrotic syndrome. Systematic Review Registration: Identifier: CRD 42020150933. https://www.crd.york.ac.uk/prospero/. This review has been registered to the PROSPERO on 27 Feb 2020.
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Affiliation(s)
- Xia Gao
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Yan Wang
- Graduate School, Ningxia Medical University, Yinchuan, China.,Neonatology Department, Northwest Women and Children's Hospital, Xi'an, China
| | - Zichuan Xu
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huiying Deng
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huabin Yang
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Fu Zhong
- Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou, China
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28
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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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29
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Time to Relapse and Its Predictors among Children with Nephrotic Syndrome in Comprehensive Specialized Hospitals, Tigray, Ethiopia, 2019. Int J Pediatr 2020; 2020:8818953. [PMID: 33299427 PMCID: PMC7704192 DOI: 10.1155/2020/8818953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/16/2020] [Accepted: 10/29/2020] [Indexed: 01/19/2023] Open
Abstract
Background Relapse in children with nephrotic syndrome leads to a variety of complications due to prolonged treatment and potential dependency on steroids. However, there is no study conducted to determine the incidence and predictive factors of relapse for nephrotic syndrome in Ethiopia, especially in children. Thus, this study aimed to assess the incidence of relapse and its predictors among children with nephrotic syndrome in Ethiopia. Methods A retrospective study was conducted by reviewing all charts of children with an initial diagnosis of the nephrotic syndrome in tertiary hospitals from 2011 to 2018. Charts of children with a diagnosis of steroid-resistant cases were excluded. The extraction tool was used for data collection, Epi-data manager V-4.4.2 for data entry, and Stata V-14 for cleaning and analysis. Kaplan-Meier curve, log-rank test, life table, and crude hazard ratios were used to describe the data and adjusted hazard ratios with 95% CI and P value for analysis. Median relapse time, incidence rate of relapse, and cumulative relapse probabilities at a certain time interval were computed. Bivariable and multivariate analyses were performed using the Cox proportional hazard regression to identify the factors associated with relapse. Any variable at P < 0.25 in the bivariable analysis was transferred to multivariate analysis. Then, the adjusted hazard ratio with 95% CI and P ≤ 0.05 was used to report the association and to test the statistical significance, respectively. Finally, texts, tables, and graphs were used to present the results. Results and Conclusion. Majority, 64.5% (40/66), of relapses were recorded in the first 12 months of follow-up. The incidence rate of relapse was 42.6 per 1000 child-month-observations with an overall 1454 child-month-observations and the median relapse time of 16 months. Having undernutrition [AHR = 3.44; 95% CI 1.78-6.65], elevated triglyceride [AHR = 3.37; 95% CI 1.04-10.90], decreased serum albumin level [AHR = 3.51; 95% CI 1.81-6.80], and rural residence [AHR = 4.00; 95% CI 1.49-10.76] increased the hazard of relapse. Conclusion and Recommendation. Relapse was higher in the first year of the follow-up period. Undernutrition, hypoalbuminemia, hypertriglyceridemia, and being from rural areas were independent predictors of relapse. A focused evaluation of those predictors during the initial diagnosis of the disease is compulsory.
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30
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Lin YH, Huang CY, Ke CC, Wang YY, Lai TH, Liu HC, Ku WC, Chan CC, Lin YH. ACTN4 Mediates SEPT14 Mutation-Induced Sperm Head Defects. Biomedicines 2020; 8:biomedicines8110518. [PMID: 33228246 PMCID: PMC7699536 DOI: 10.3390/biomedicines8110518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/13/2020] [Accepted: 11/17/2020] [Indexed: 12/22/2022] Open
Abstract
Septins (SEPTs) are highly conserved GTP-binding proteins and the fourth component of the cytoskeleton. Polymerized SEPTs participate in the modulation of various cellular processes, such as cytokinesis, cell polarity, and membrane dynamics, through their interactions with microtubules, actin, and other cellular components. The main objective of this study was to dissect the molecular pathological mechanism of SEPT14 mutation-induced sperm head defects. To identify SEPT14 interactors, co-immunoprecipitation (co-IP) and nano-liquid chromatography-mass spectrometry/mass spectrometry were applied. Immunostaining showed that SEPT14 was significantly localized to the manchette structure. The SEPT14 interactors were identified and classified as (1) SEPT-, (2) microtubule-, (3) actin-, and (4) sperm structure-related proteins. One interactor, ACTN4, an actin-holding protein, was selected for further study. Co-IP experiments showed that SEPT14 interacts with ACTN4 in a male germ cell line. SEPT14 also co-localized with ACTN4 in the perinuclear and manchette regions of the sperm head in early elongating spermatids. In the cell model, mutated SEPT14 disturbed the localization pattern of ACTN4. In a clinical aspect, sperm with mutant SEPT14, SEPT14A123T (p.Ala123Thr), and SEPT14I333T (p.Ile333Thr), have mislocalized and fragmented ACTN4 signals. Sperm head defects in donors with SEPT14 mutations are caused by disruption of the functions of ACTN4 and actin during sperm head formation.
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Affiliation(s)
- Yu-Hua Lin
- Department of Chemistry, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Division of Urology, Department of Surgery, Cardinal Tien Hospital, New Taipei City 231, Taiwan
| | - Chia-Yen Huang
- Department of Biological Science and Technology, National Chiao Tung University, Hsinchu 300, Taiwan;
- Gynecologic Cancer Center, Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei 106, Taiwan
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan; (T.-H.L.); (W.-C.K.)
| | - Chih-Chun Ke
- PhD Program in Nutrition & Food Science, Fu Jen Catholic University, New Taipei City 242, Taiwan;
- Department of Urology, En Chu Kong Hospital, New Taipei City 237, Taiwan
| | - Ya-Yun Wang
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242, Taiwan; (Y.-Y.W.); (H.-C.L.)
| | - Tsung-Hsuan Lai
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan; (T.-H.L.); (W.-C.K.)
- Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei 106, Taiwan
| | - Hsuan-Che Liu
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242, Taiwan; (Y.-Y.W.); (H.-C.L.)
| | - Wei-Chi Ku
- School of Medicine, Fu Jen Catholic University, New Taipei City 242, Taiwan; (T.-H.L.); (W.-C.K.)
| | - Chying-Chyuan Chan
- Department of Obstetrics and Gynecology, Taipei City Hospital, Renai Branch, Taipei 106, Taiwan;
| | - Ying-Hung Lin
- Graduate Institute of Biomedical and Pharmaceutical Science, Fu Jen Catholic University, New Taipei City 242, Taiwan; (Y.-Y.W.); (H.-C.L.)
- Correspondence:
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Abstract
Podocytopathies are kidney diseases in which direct or indirect podocyte injury drives proteinuria or nephrotic syndrome. In children and young adults, genetic variants in >50 podocyte-expressed genes, syndromal non-podocyte-specific genes and phenocopies with other underlying genetic abnormalities cause podocytopathies associated with steroid-resistant nephrotic syndrome or severe proteinuria. A variety of genetic variants likely contribute to disease development. Among genes with non-Mendelian inheritance, variants in APOL1 have the largest effect size. In addition to genetic variants, environmental triggers such as immune-related, infection-related, toxic and haemodynamic factors and obesity are also important causes of podocyte injury and frequently combine to cause various degrees of proteinuria in children and adults. Typical manifestations on kidney biopsy are minimal change lesions and focal segmental glomerulosclerosis lesions. Standard treatment for primary podocytopathies manifesting with focal segmental glomerulosclerosis lesions includes glucocorticoids and other immunosuppressive drugs; individuals not responding with a resolution of proteinuria have a poor renal prognosis. Renin-angiotensin system antagonists help to control proteinuria and slow the progression of fibrosis. Symptomatic management may include the use of diuretics, statins, infection prophylaxis and anticoagulation. This Primer discusses a shift in paradigm from patient stratification based on kidney biopsy findings towards personalized management based on clinical, morphological and genetic data as well as pathophysiological understanding.
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32
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Kari JA, Alhasan KA, Albanna AS, Safdar OY, Shalaby MA, Böckenhauer D, El-Desoky SM. Rituximab versus cyclophosphamide as first steroid-sparing agent in childhood frequently relapsing and steroid-dependent nephrotic syndrome. Pediatr Nephrol 2020; 35:1445-1453. [PMID: 32337638 DOI: 10.1007/s00467-020-04570-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 03/20/2020] [Accepted: 04/06/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Approximately 50% of children with steroid-sensitive nephrotic syndrome (SSNS) will suffer from frequent relapses or steroid dependency, prompting the use of so-called steroid-sparing drugs. In this pilot study, we compare the efficacy and safety of rituximab to oral cyclophosphamide as first-line steroid-sparing medications. METHODS A prospective open-label non-randomized study of children with frequent relapsing or steroid-dependant SSNS. Exclusion criteria were steroid-resistant disease, prescription of immunosuppressive agents other than prednisolone or levamisole, evidence of impaired kidney function, leucopenia, or active infection. The recruited children were allocated either to the oral cyclophosphamide (3 mg/kg/day for 8 weeks) or intravenous rituximab treatment (two doses of 375 mg/m2/dose, 2 weeks apart) and were monitored for relapses and side effects for 12 months. RESULTS Forty-six subjects were included from two centers; 27 received cyclophosphamide and 19 received rituximab. One-year relapse-free survival was reached in 17 (58.6%) patients treated with cyclophosphamide compared to 16 (84.2%) with rituximab (adjusted HR 0.36; 95% CI 0.09-1.45; p = 0.151). The mean interval to relapse was 6.9 months in the cyclophosphamide group (N = 10) and 6.3 months in the rituximab group (N = 3). Both treatments were associated with a significant (p < 0.001) reduction in prescribed dose of oral alternate-day steroid from 1.02 to 0.36 mg/kg (cyclophosphamide) and 0.86 to 0.08 mg/kg (rituximab). Importantly, a significantly (p = 0.003) higher percentage of patients achieved complete withdrawal of steroid within 3 months of commencing study treatment in the rituximab (73.7%) versus cyclophosphamide (29.6%) group. Transient leucopenia was the most frequent adverse effect observed in the cyclophosphamide group (18.5%) and one patient (3.4%) had acute hepatotoxicity besides severe leucopenia and neutropenia in the 7th week of treatment with complete recovery with the withdrawal of cyclophosphamide and maintenance of remission. A minor infusion-related reaction in the form of a generalized macular skin rash was observed in one patient (5%) in the rituximab group. CONCLUSIONS Rituximab is non-inferior to cyclophosphamide and safe as a first-line steroid-sparing agent in children with SSNS. A larger multicenter study is required to assess superiority over cyclophosphamide. Graphical abstract.
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Affiliation(s)
- Jameela A Kari
- Faculty of Medicine, King Abduaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia. .,Paediatric Nephrology Center of Excellence, Department of Pediatrics, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia.
| | - Khalid A Alhasan
- Pediatrics Department, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia
| | - Amr S Albanna
- King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Kingdom of Saudi Arabia
| | - Osama Y Safdar
- Faculty of Medicine, King Abduaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia.,Paediatric Nephrology Center of Excellence, Department of Pediatrics, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia
| | - Mohamed A Shalaby
- Faculty of Medicine, King Abduaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia.,Paediatric Nephrology Center of Excellence, Department of Pediatrics, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia
| | - Detlef Böckenhauer
- Department of Renal Medicine, University College London, London, UK.,Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sherif M El-Desoky
- Faculty of Medicine, King Abduaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia.,Paediatric Nephrology Center of Excellence, Department of Pediatrics, King Abdulaziz University, PO Box 80215, Jeddah, 21589, Kingdom of Saudi Arabia
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Lee JM, Kronbichler A, Shin JI, Oh J. Review on long-term non-renal complications of childhood nephrotic syndrome. Acta Paediatr 2020; 109:460-470. [PMID: 31561270 DOI: 10.1111/apa.15035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 08/15/2019] [Accepted: 09/25/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nephrotic syndrome (NS) is the most common glomerular childhood disease. A body of literature has described the long-term renal prognosis of childhood-onset idiopathic NS. However, the nonrenal outcomes have not been studied as much. AIM We aimed to discuss the long-term non-renal outcomes of childhood NS, highlighting studies with a follow-up period of more than 10 years. RESULTS We reviewed the literature and found that a number of immunosuppressive agents have stopped inflammation, stabilised the podocyte cytoskeleton and reduce proteinuria. However, prolonged treatment has frequently been associated with a high risk of renal and non-renal complications in patients with a complicated disease course, defined as frequent relapses or steroid dependency. Non-renal complications may include impaired longitudinal growth and pubertal development, undesirable fertility outcomes, ocular complications, bone mineral diseases and potential malignancies. CONCLUSION This review discusses and summarises the non-renal outcomes of idiopathic childhood NS.
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Affiliation(s)
- Jiwon M. Lee
- Department of Pediatrics Chungnam National University Hospital and College of Medicine Daejeon Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension) Medical University Innsbruck Innsbruck Austria
| | - Jae Il Shin
- Department of Pediatrics Yonsei University College of Medicine Seoul Korea
- Division of Pediatric Nephrology Severance Children's Hospital Seoul Korea
- Institute of Kidney Disease Research Yonsei University College of Medicine Seoul Korea
| | - Jun Oh
- Department of Pediatrics University Hamburg‐Eppendorf Hamburg Germany
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Narla D, Swiatecka-Urban A. Therapeutic Response to Corticosteroids Remains a Valid Approach to Initial Management of Children With Idiopathic Nephrotic Syndrome. Front Pediatr 2020; 8:533. [PMID: 32984227 PMCID: PMC7492527 DOI: 10.3389/fped.2020.00533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/27/2020] [Indexed: 11/13/2022] Open
Abstract
Complete remission of idiopathic nephrotic syndrome (INS) in response to corticosteroids has been widely adopted as an indicator of satisfactory long-term outcomes in pediatric patients. The approach was based on the results of studies conducted in the 1960s and 1970s. The studies found that corticosteroid-responsive minimal change disease (MCD) was the most frequent diagnosis in INS patients. In more recent years, studies have reported increased frequency of focal segmental glomerulosclerosis (FSGS) and primary corticosteroid resistance without a corresponding increase of FSGS. It became unclear whether withholding kidney biopsy before treatment with corticosteroids is still the best management practice. We performed a retrospective chart review at the UPMC Children's Hospital of Pittsburgh and identified patients who were referred for evaluation of edema or proteinuria between 2002 and 2014. We identified 114 pediatric patients with INS who were treated initially with a corticosteroid (prednisone or prednisolone) 2 mg/kg (max 60 mg)/day for 4-6 weeks followed by 2 mg/kg (max 60 mg) every other day for 4-6 weeks and had not received a corticosteroid-sparing agent before completing at least 8 weeks of the initial therapy. Corticosteroid resistance in pediatric INS patients was independently associated with the black race, older age at presentation (>8 years), and female sex. The majority of blacks who were resistant to corticosteroids had a tissue diagnosis of MCD. Among the whites who were steroid-resistant, MCD and FSGS were diagnosed in similar proportions of cases. Thus, the tissue diagnosis in could not predict the response to corticosteroids. Nineteen percent of whites with FSGS were steroid-sensitive and none of the blacks with FSGS responded to corticosteroids. These data suggest that the histologic diagnosis of FSGS could not rule out response to corticosteroids, at least, in the white patient population. In summary, our data demonstrate that at this time, the therapeutic response to corticosteroids continues to be a valid approach for the initial evaluation and therapy of children diagnosed with INS at our center. Future studies should evaluate the mechanisms of changing characteristics of pediatric INS. The specific role of patient demographics, ethnicity, as well as genetic and environmental factors could be evaluated by a prospective, multicenter study.
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Affiliation(s)
- Deepti Narla
- Department of Nephrology, Children's Hospital of Pittsburgh of UMPC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Agnieszka Swiatecka-Urban
- Department of Nephrology, Children's Hospital of Pittsburgh of UMPC, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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35
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Gipson DS, Trachtman H, Waldo A, Gibson KL, Eddy S, Dell KM, Srivastava T, Lemley KV, Greenbaum LA, Hingorani S, Meyers KE, Kaskel FJ, Reidy KJ, Sethna CB, Tran CL, Wang CS, Tuttle KR, Oh G, Neu AM, Brown E, Lin JJ, Yee JL, Roth TM, Troost JP, Gillespie BW, Sampson MG, Kretzler M, Ju W. Urinary Epidermal Growth Factor as a Marker of Disease Progression in Children With Nephrotic Syndrome. Kidney Int Rep 2019; 5:414-425. [PMID: 32280839 PMCID: PMC7136430 DOI: 10.1016/j.ekir.2019.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 11/18/2019] [Accepted: 11/25/2019] [Indexed: 12/21/2022] Open
Abstract
Introduction Childhood-onset nephrotic syndrome has a variable clinical course. Improved predictive markers of long-term outcomes in children with nephrotic syndrome are needed. This study tests the association between baseline urinary epidermal growth factor (uEGF) excretion and longitudinal kidney function in children with nephrotic syndrome. Methods The study evaluated 191 participants younger than 18 years enrolled in the Nephrotic Syndrome Study Network, including 118 with their first clinically indicated kidney biopsy (68 minimal change disease; 50 focal segmental glomerulosclerosis) and 73 with incident nephrotic syndrome without a biopsy. uEGF was measured at baseline for all participants and normalized by the urine creatinine (Cr) concentration. Renal epidermal growth factor (EGF) mRNA was measured in the tubular compartment microdissected from kidney biopsy cores from a subset of patients. Linear mixed models were used to test if baseline uEGF/Cr and EGF mRNA expression were associated with change in estimated glomerular filtration rate (eGFR) over time. Results Higher uEGF/Cr at baseline was associated with slower eGFR decline during follow-up (median follow-up = 30 months). Halving of uEGF/Cr was associated with a decrease in eGFR slope of 2.0 ml/min per 1.73 m2 per year (P < 0.001) adjusted for age, race, diagnosis, baseline eGFR and proteinuria, and APOL1 genotype. In the biopsied subgroup, uEGF/Cr was correlated with EGF mRNA expression (r = 0.74; P < 0.001), but uEGF/Cr was retained over mRNA expression as the stronger predictor of eGFR slope after multivariable adjustment (decrease in eGFR slope of 1.7 ml/min per 1.73 m2 per year per log2 decrease in uEGF/Cr; P < 0.001). Conclusion uEGF/Cr may be a useful noninvasive biomarker that can assist in predicting the long-term course of kidney function in children with incident nephrotic syndrome.
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Affiliation(s)
- Debbie S Gipson
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Howard Trachtman
- Division of Nephrology, Department of Pediatrics, New York University Langone Health, New York, New York, USA
| | - Anne Waldo
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sean Eddy
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Katherine M Dell
- Department of Pediatrics, Case Western Reserve University, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Tarak Srivastava
- Section of Nephrology, Children's Mercy Hospital and University of Missouri at Kansas City, Kansas City, Missouri, USA
| | - Kevin V Lemley
- Division of Nephrology, Children's Hospital-LA, Los Angeles, California, USA
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sangeeta Hingorani
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA.,Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kevin E Meyers
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Frederick J Kaskel
- Division of Nephrology, Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, New York, New York, USA
| | - Kimberly J Reidy
- Division of Nephrology, Department of Pediatrics, Albert Einstein College of Medicine and Montefiore Medical Center, New York, New York, USA
| | - Christine B Sethna
- Pediatric Nephrology, Cohen Children's Medical Center of New York, Zucker School of Medicine, Hofstra University, Hempstead, New York, USA
| | - Cheryl L Tran
- Department of Pediatrics, Mayo Clinic, Rochester, Minnesota, USA
| | - Chia-Shi Wang
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Katherine R Tuttle
- Providence St. Joseph Health, Providence Medical Research Center, Spokane, Washington, USA.,Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Gia Oh
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Alicia M Neu
- Division of Pediatric Nephrology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Brown
- Division of Nephrology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jen-Jar Lin
- Division of Pediatric Nephrology, Brenner Children's Hospital, Wake Forest University Baptist Health, Winston-Salem, North Carolina, USA
| | - Jennifer Lai Yee
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Therese M Roth
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan P Troost
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Brenda W Gillespie
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew G Sampson
- Division of Nephrology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Matthias Kretzler
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Wenjun Ju
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
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36
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Abstract
PURPOSE OF REVIEW To summarize the literature regarding alterations in bone health in patients with glomerular kidney disease and highlight areas in need of additional investigation. RECENT FINDINGS There is mounting evidence that children and adults with glomerular conditions, with or without compromised kidney function, comprise a distinct subgroup of patients with unique risk factors for altered bone health. Patients with glomerular kidney disease are exposed to both disease-related and treatment-related factors that affect bone structure and function. In addition to chronic kidney disease-related risk factors for impaired bone health, high rates of exposure to osteotoxic medications, varying degrees of systemic inflammation, and altered vitamin D metabolism may contribute to compromised bone health in individuals with glomerular disease. Further study is needed to better understand these risk factors and the complex interaction between the immune system and bone cells in glomerular disease.
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Affiliation(s)
- Dorey A Glenn
- UNC Kidney Center, Universirty of North Carolina at Chapel Hill, 7024 Burnett Womack Building, Chapell Hill, NC, 27599-7155, USA
| | - Michelle R Denburg
- The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Nagano C, Sako M, Kamei K, Ishikura K, Nakamura H, Nakanishi K, Omori T, Nozu K, Iijima K. Study protocol: multicenter double-blind, randomized, placebo-controlled trial of rituximab for the treatment of childhood-onset early-stage uncomplicated frequently relapsing or steroid-dependent nephrotic syndrome (JSKDC10 trial). BMC Nephrol 2019; 20:293. [PMID: 31375087 PMCID: PMC6679488 DOI: 10.1186/s12882-019-1470-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 07/19/2019] [Indexed: 11/25/2022] Open
Abstract
Background Eighty percent of children with idiopathic nephrotic syndrome respond well to steroid therapy, but up to 50% of patients with steroid-sensitive nephrotic syndrome exhibit frequently relapsing (FRNS) or steroid-dependent nephrotic syndrome (SDNS). Several studies identified the chimeric anti-CD20 monoclonal antibody rituximab as an effective treatment for patients with complicated FRNS/SDNS. Recent studies suggested that rituximab could also be a first-line treatment for early-stage uncomplicated FRNS/SDNS, although further studies are required to confirm its efficacy and safety. Methods/design We are conducting a multicenter, double-blind, randomized placebo controlled trial to investigate the efficacy and safety of rituximab for the treatment of childhood-onset early-stage uncomplicated FRNS/SDNS. Patients will be allocated to receive two 375 mg/m2 doses (maximum dose: 500 mg) of either rituximab or placebo. Investigators are permitted to request the disclosure of a subject’s allocation code if he or she exhibits treatment failure. Additionally, if placebo-treated subjects display early relapse (a sign of treatment failure), they have the option to receive rituximab in an unblinded phase. The primary endpoint is relapse-free survival during the observation period. Discussion The results will provide important data on the use of rituximab for patients with uncomplicated FRNS/SDNS. In the future, rituximab treatment will enable most patients with uncomplicated FRNS/SDNS to discontinue or reduce steroid therapy without relapse, and it is possible that rituximab could represent an immunosuppressive therapy for these diseases. Trial registration This trial was prospectively registered to the JMACCT Clinical Trials Registry on September 6, 2018 (Trial ID: JMA-IIA00380).
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Affiliation(s)
- China Nagano
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Mayumi Sako
- Division for Clinical Trials, Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Hidefumi Nakamura
- Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Takashi Omori
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
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38
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Mühlig AK, Lee JY, Kemper MJ, Kronbichler A, Yang JW, Lee JM, Shin JI, Oh J. Levamisole in Children with Idiopathic Nephrotic Syndrome: Clinical Efficacy and Pathophysiological Aspects. J Clin Med 2019; 8:E860. [PMID: 31208104 PMCID: PMC6617114 DOI: 10.3390/jcm8060860] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 06/11/2019] [Accepted: 06/12/2019] [Indexed: 12/28/2022] Open
Abstract
Steroid sensitive nephrotic syndrome is one of the most common pediatric glomerular diseases. Unfortunately, it follows a relapsing and remitting course in the majority of cases, with 50% of all cases relapsing once or even more often. Most children with idiopathic nephrotic syndrome respond initially to steroid therapy, nevertheless repeated courses for patients with relapses induce significant steroid toxicity. Patients with frequent relapses or steroid dependency thus require alternative treatment, such as cyclophosphamide, cyclosporine, tacrolimus, mycophenolate mofetil, levamisole, or rituximab. To reduce the relapse rate, several drugs have been used. Among these, levamisole has been considered the least toxic and least expensive therapy. Several randomized controlled trials (RCT) showed that levamisole is effective in reducing the relapse risk in steroid sensitive forms of nephrotic syndrome with a low frequency of side effects. Levamisole is a synthetic imidazothiazole derivative with immune-modulatory properties. In this article, we review recent data from randomized trials and observational studies to assess the efficacy of levamisole in frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome.
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Affiliation(s)
- Anne K Mühlig
- Department of Pediatrics, University Hamburg-Eppendorf, 20246 Hamburg, Germany.
| | - Jun Young Lee
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kangwon 26426, Korea.
| | - Markus J Kemper
- Department of Pediatrics, Asklepios Klink Nord-Heidberg, 22417 Hamburg, Germany.
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck 6020, Austria.
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Kangwon 26426, Korea.
| | - Jiwon M Lee
- Department of Pediatric Nephrology, Chungnam National University Hospital, Daejeon 35015, Korea.
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
- Division of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
| | - Jun Oh
- Department of Pediatrics, University Hamburg-Eppendorf, 20246 Hamburg, Germany.
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39
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Xia ZK, Gao YF, Rong LP, Dang XQ, Shen Q, Jiang XY, Yi ZW, Xu H. Usefulness of mizoribine administration in children with frequently relapsing nephrotic syndrome, and the relationship between pharmacokinetic parameters and efficacy: a multicenter prospective cohort study in China. World J Pediatr 2019; 15:262-269. [PMID: 30864060 DOI: 10.1007/s12519-019-00241-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/14/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Mizoribine (MZR) is an immunosuppressant used to treat adult nephropathy. There is little experience with the drug in treating Chinese children with frequently relapsing nephrotic syndrome (FRNS). We investigated the efficacy and safety for treating MZR with FRNS. Furthermore, the relationship between efficacy and serum concentration was investigated. METHODS A prospective multicenter observational 12-month study was performed for evaluating the usefulness of MZR with FRNS. Serum MZR concentration was measured, and the relationships between pharmacokinetic parameters (Cmax, AUC), number of relapses, and urinary protein were evaluated. RESULTS Eighty-two pediatric patients from four hospitals were treated with MZR and prednisone. MZR treatment significantly reduced the number of relapses and steroid doses. A correlation between pharmacokinetic parameters and relapses was observed, which fits well with the sigmoidal Emax model. Even in the relationship between pharmacokinetic parameters and urinary proteins, it was recognized that there was a threshold in the pharmacokinetic parameters for the therapeutic effect similar to the results obtained with the sigmoidal Emax model. Eleven patients (13.4%) experienced mild adverse events. CONCLUSIONS MZR therapy was effective in reducing the number of relapses and steroid doses. No severe adverse reactions were observed. Therapeutically effective serum concentrations were estimated to be Cmax ≥ about 2 μg/mL or AUC ≥ about 10 μg h/mL. MZR and steroid treatment were effective and safe for pediatric FRNS.
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Affiliation(s)
- Zheng-Kun Xia
- Department of Pediatrics, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China.
| | - Yuan-Fu Gao
- Department of Pediatrics, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210002, China
| | - Li-Ping Rong
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China
| | - Xi-Qiang Dang
- Department of Pediatric Nephrology, Children's Medical Center, Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Qian Shen
- Department of Nephrology and Rheumatology, Children's Hospital of Fudan University, Shanghai 201102, China
| | - Xiao-Yun Jiang
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou 510080, China
| | - Zhu-Wen Yi
- Department of Pediatric Nephrology, Children's Medical Center, Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Hong Xu
- Department of Nephrology and Rheumatology, Children's Hospital of Fudan University, Shanghai 201102, China
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Efficacy of low-dose daily versus alternate-day prednisolone in frequently relapsing nephrotic syndrome: an open-label randomized controlled trial. Pediatr Nephrol 2019; 34:829-835. [PMID: 30194663 DOI: 10.1007/s00467-018-4071-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/22/2018] [Accepted: 08/24/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND While patients with frequently relapsing nephrotic syndrome (FRNS) are initially treated with long-term alternate-day prednisolone, relapses and adverse effects are common. In an open-label randomized controlled trial, we compared the efficacy of therapy with low-dose daily to standard alternate-day prednisolone in reducing relapse rates over 12-month follow-up. METHODS Consecutive patients, aged 2-18 years, with FRNS were included. Following therapy of relapse, prednisolone was tapered to 0.75 mg/kg on alternate days. Stratifying for steroid dependence, patients were randomly assigned to prednisolone at 0.2-0.3 mg/kg daily or 0.5-0.7 mg/kg alternate day for 12 months. Relapses were treated with daily prednisolone, followed by return to intervention. Primary outcome was the incidence of relapses. Proportion with therapy failure (≥ 2 relapses in any 6 months or significant steroid toxicity) and sustained remission, cumulative prednisolone intake and adverse events were evaluated. RESULTS Patients receiving daily prednisolone (n = 30) showed significantly fewer relapses than those on alternate-day therapy (n = 31) (0.55 relapses/person-year versus 1.94 relapses/person-year; incidence rate ratio 0.28; 95% CI 0.15, 0.52). Daily therapy was associated with higher rates of sustained remission at 6 months (73.3 versus 48.4%) and 1 year (60 versus 31.6%; log rank p = 0.013), lower rates of treatment failure at 6 months (3.3 versus 32.8%) and 1 year (6.7 versus 57.4%; p < 0.0001), and lower prednisolone use (0.27 ± 0.07 versus 0.39 ± 0.19 mg/kg/day; p = 0.003). Three and two patients need to receive the study intervention to enable sustained remission and prevent treatment failure, respectively. CONCLUSIONS In patients with FRNS, daily administration of low-dose prednisolone is more effective than standard-dose alternate day therapy in lowering relapse rates, sustaining remission, and enabling steroid sparing.
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Ahn YH, Kim SH, Han KH, Choi HJ, Cho H, Lee JW, Shin JI, Cho MH, Lee JH, Park YS, Ha IS, Cheong HI, Kim SY, Lee SJ, Kang HG. Efficacy and safety of rituximab in childhood-onset, difficult-to-treat nephrotic syndrome: A multicenter open-label trial in Korea. Medicine (Baltimore) 2018; 97:e13157. [PMID: 30431588 PMCID: PMC6257685 DOI: 10.1097/md.0000000000013157] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The anti-CD20 monoclonal antibody rituximab (RTX) has been proposed as a rescue therapy for difficult-to-treat nephrotic syndrome (NS). We conducted a clinical trial to evaluate the efficacy and safety of RTX in children with difficult-to-treat NS dependent on or resistant to steroids and calcineurin inhibitors (CNIs). METHODS A multicenter open-label trial was performed at 8 major pediatric nephrology centers in Korea. The investigation consisted of a randomized controlled trial for steroid- and CNI-dependent NS (DDNS; randomization into the RTX group and the control group, at a ratio of 2:1) and a single-arm study of steroid and CNI-resistant NS (DRNS). DDNS patients in the RTX group and DRNS patients received a single dose of intravenous RTX (375 mg/m of body surface area) for B-cell depletion. A second RTX dose was administered at week 2 if the first dose failed to achieve depletion of CD19(+) cells. The primary endpoint was rate of maintaining remission at 6 months after treatment for DDNS and rate of remission achievement for DRNS. RESULTS Sixty-one children with DDNS were enrolled while in remission and randomized to the control group (21 patients) or the RTX group (40 patients). At 6 months after treatment, the remission rates were 74.3% in the RTX group and 31.3% in the control group (P = .003). The mean duration of remission maintenance was significantly higher in the RTX group than in the control group (9.0 vs 2.9 months, P = .004). Of the 23 patients with DRNS enrolled in the single-arm study and treated with RTX, 9 (39.1%) achieved partial or complete remission within 6 months. Depletion of B cells occurred in all patients with RTX therapy. Thirty patients (50.8% of 59 patients analyzed) experienced mild and transient infusion reaction during RTX administration, and most adverse events were mild. CONCLUSIONS RTX administration was safe and effective in patients with difficult-to-treat NS. One or 2 doses of RTX may be sufficient to deplete B cells and achieve better control of pediatric NS.
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Affiliation(s)
- Yo Han Ahn
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam
| | - Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan
| | - Kyoung Hee Han
- Department of Pediatrics, Jeju National University School of Medicine, Jeju
| | - Hyun Jin Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Heeyeon Cho
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Jung Won Lee
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Severance Children's Hospital, Seoul
| | - Min Hyun Cho
- Department of Pediatrics, Kyungpook National University, School of Medicine, Daegu
| | - Joo Hoon Lee
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Seo Park
- Department of Pediatrics, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
| | - Su Young Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan
| | - Seung Joo Lee
- Department of Pediatrics, Ewha Womans University School of Medicine, Seoul
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul
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Cortazar FB, Rosenthal J, Laliberte K, Niles JL. Continuous B-cell depletion in frequently relapsing, steroid-dependent and steroid-resistant nephrotic syndrome. Clin Kidney J 2018; 12:224-231. [PMID: 30976400 PMCID: PMC6452201 DOI: 10.1093/ckj/sfy067] [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: 01/29/2018] [Indexed: 12/21/2022] Open
Abstract
Background Patients with frequently relapsing (FR), steroid-dependent (SD) and steroid-resistant (SR) nephrotic syndrome are a therapeutic challenge with limited treatment options. Here, we retrospectively analyze the efficacy and safety of rituximab-induced continuous B-cell depletion in these populations. Methods Patients were included if they were at least 18 years of age and had FR, SD or SR minimal change disease (MCD) or primary focal segmental glomerulosclerosis (FSGS) and were treated with a strategy of continuous B-cell depletion. Partial remission (PR) was defined as a urinary protein:creatinine ratio (UPCR) of ≤3.5 g/g and a 50% reduction in the UPCR from baseline. Complete remission (CR) was defined as a UPCR ≤0.3 g/g. Results We identified 20 patients with MCD (n = 13) or FSGS (n = 7) who fulfilled the inclusion criteria. All patients had either SD (n = 12), SR (n = 7) or FR (n = 1) disease. Patients received a median of nine rituximab doses [interquartile range (IQR) 7.5, 11] and were treated for a median time of 28 months (IQR 23, 41). Prednisone was weaned from a median of 60 mg daily (IQR 40, 60) at rituximab initiation to 4.5 mg daily (IQR 0, 5.5) by 12 months. All patients achieved PR. CR occurred in 11 of 13 patients with FR or SD disease, but only 1 of 7 patients with SR disease (logrank P = 0.01). Four relapses occurred, all in patients with SR disease. Three serious infections occurred over 70.3 patient-years. Conclusion Continuous B-cell depletion is a therapeutic option in the management of complicated nephrotic syndrome. Additional studies are needed to clarify the utility of this strategy.
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Affiliation(s)
- Frank B Cortazar
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Jillian Rosenthal
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Karen Laliberte
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - John L Niles
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
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Abstract
BACKGROUND Calcineurin inhibitors (CNIs) are commonly given to transplant recipients of kidneys and other solid organs and to patients with immune disorders, such as steroid-resistant nephrotic syndrome, steroid-dependent nephrotic syndrome, and frequent relapse nephrotic syndrome. Although CNIs remain the most effective available immunosuppressant agent, there is clinical concern regarding possible long-term nephrotoxicity. This concern is especially significant in children who have a longer life expectancy and greater growth rate. DATA SOURCES In this review, we analyzed the literatures to identify original articles that examined use of CNIs in children who received organ transplantation and nephropathy to assess the available evidence of their nephrotoxicity. PubMed, Elsevier, and Tompson ISI Web of Knowledge were searched for identifying relevant papers. RESULTS Clinical research supports the presence of CNI-related nephrotoxicity. However, some researchers have questioned the prevalence and seriousness of chronic CNIs nephrotoxicity, especially because the pathological lesions typically associated with long-term CNI use are nonspecific. Many researchers have focused on early markers of CNI nephrotoxicity, and the methods that may help prevent and manage nephrotoxicity. CONCLUSIONS Future research should focus on investigating early markers of CNI nephrotoxicity and strategies for improved immunosuppressant therapy, and developing alternative treatments. CNI-mediated nephrotoxicity should always be taken seriously in clinic.
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Affiliation(s)
- Fei Liu
- Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Jian-Hua Mao
- Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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Abstract
PURPOSE OF REVIEW This review summarizes recent findings on musculoskeletal health in three chronic renal conditions of childhood: chronic kidney disease stages 2-5D, nephrotic syndrome, and urolithiasis. Findings with important clinical implications warranting further investigation are highlighted. RECENT FINDINGS Recent cohort studies have demonstrated a high burden of fracture and progressive deficits of cortical bone in children with chronic kidney disease. Lower cortical density is associated with incident fracture and may be an important therapeutic target. Parathyroid hormone and calcium are independent correlates of cortical density, and modifiable factors for fracture include parathyroid hormone and phosphate binder use. Children with nephrotic syndrome, even with normal renal function, have evidence of abnormal bone metabolism and structure, and vitamin D deficiency may be an important modifiable risk factor in this population. Urolithiasis has been associated with reduced bone mineral density and is increasingly common in children and adolescents. Population-based data found a significantly increased risk of fracture in adolescent males and young women. SUMMARY Recent findings substantiate concern regarding the particular vulnerability of the growing skeleton to chronic renal disease. Studies are needed to determine how to optimize assessment and management of bone health in children with these conditions, particularly in terms of calcium and vitamin D requirements, with the goal of improving childhood bone accrual for lifelong fracture prevention.
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Downie ML, Gallibois C, Parekh RS, Noone DG. Nephrotic syndrome in infants and children: pathophysiology and management. Paediatr Int Child Health 2017; 37:248-258. [PMID: 28914167 DOI: 10.1080/20469047.2017.1374003] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Nephrotic syndrome is defined by nephrotic-range proteinuria (≥40 mg/m2/hour or urine protein/creatinine ratio ≥200 mg/mL or 3+ protein on urine dipstick), hypoalbuminaemia (<25 g/L) and oedema. This review focuses on the classification, epidemiology, pathophysiology, management strategies and prognosis of idiopathic nephrotic syndrome of childhood, and includes a brief overview of the congenital forms.
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Affiliation(s)
- Mallory L Downie
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada
| | - Claire Gallibois
- d Department of Medicine , Royal College of Surgeons in Ireland , Dublin , Ireland
| | - Rulan S Parekh
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada.,d Department of Medicine , Royal College of Surgeons in Ireland , Dublin , Ireland.,e Child Health Evaluative Sciences, Research Institute , The Hospital for Sick Children , Toronto , Canada.,f Division of Nephrology , University Health Network , Toronto , Canada.,g Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Damien G Noone
- a Department of Paediatrics , Univeristy of Toronto , Toronto , Canada.,b Division of Nephrology , The Hospital for Sick Children , Toronto , Canada.,c Department of Paediatrics , University of Toronto , Toronto , Canada
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Kim JH, Park E, Hyun HS, Cho MH, Ahn YH, Choi HJ, Kang HG, Ha IS, Cheong HI. Long-term repeated rituximab treatment for childhood steroid-dependent nephrotic syndrome. Kidney Res Clin Pract 2017; 36:257-263. [PMID: 28904877 PMCID: PMC5592893 DOI: 10.23876/j.krcp.2017.36.3.257] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 06/30/2017] [Accepted: 07/18/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Rituximab (RTX) can be used as a rescue therapy for steroid-dependent nephrotic syndrome (SDNS). However, the efficacy and safety of long-term, repeated use of RTX are not established. This study was conducted to assess the efficacy and safety of long-term, repeated RTX treatment in children. METHODS Eighteen consecutive child patients with SDNS who were treated with three or more cycles of RTX for one year or longer were recruited, and their medical records were retrospectively reviewed. RESULTS The patients were followed for 4.7 ± 1.9 years and received 5.2 ± 2.3 cycles of RTX over 2.8 ± 1.1 years. Approximately 70% of the additional RTX cycles were administered due to recovery of B-cells without relapse. The relapse rate decreased from 3.4 ± 2.0 per year initially to 0.4 ± 0.8 per year at the third year after RTX treatment. Approximately 10% of the RTX infusions were accompanied by mild infusion reactions. Eight patients showed sustained remission without any oral medication after the last cycle of RTX, while 10 patients had one or more episodes of relapse after the last cycle of RTX. The relapse rate in the latter group decreased from 2.8 ± 1.5 per year before RTX treatment to 1.3 ± 0.8 per year after cessation of RTX treatment. No significant differences in clinical parameters were found between the two groups. CONCLUSION This retrospective study showed that pre-emptive and long-term, repeated RTX treatment is relatively effective and safe in children with SDNS. However, well-designed prospective studies are needed to confirm these findings.
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Affiliation(s)
- Ji Hyun Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Eujin Park
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Hye Sun Hyun
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Myung Hyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Yo Han Ahn
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Hyun Jin Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.,Research Coordination Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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Schijvens AM, Dorresteijn EM, Roeleveld N, Ter Heine R, van Wijk JAE, Bouts AHM, Keijzer-Veen MG, van de Kar NCAJ, van den Heuvel LPWJ, Schreuder MF. REducing STEroids in Relapsing Nephrotic syndrome: the RESTERN study- protocol of a national, double-blind, randomised, placebo-controlled, non-inferiority intervention study. BMJ Open 2017; 7:e018148. [PMID: 28963315 PMCID: PMC5623563 DOI: 10.1136/bmjopen-2017-018148] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Oral corticosteroids are the first-line treatment for idiopathic childhood nephrotic syndrome. Most children experience several relapses, needing repeated courses of corticosteroid therapy. This exposes them to side effects and long-term complications. For most patients, long-term prognosis is for complete resolution of the disease over time and maintenance of normal kidney function. Therefore, it is vital to focus on minimising adverse events of the disease and its therapy. Unfortunately, no randomised controlled trials are available to determine the optimal corticosteroid treatment of an infrequent relapse of nephrotic syndrome. Recent studies show that treatment schedules for the first episode can safely be shortened to 2 months. The hypothesis of the REducing STEroids in Relapsing Nephrotic syndrome (RESTERN) study is that a 4-week reduction of alternate-day steroids after inducing remission is effective and safe, reduces steroid exposure by 35% on average and is therefore preferable. METHODS AND ANALYSIS The RESTERN study is a nationwide, double-blind, randomised, placebo-controlled, non-inferiority intervention study. Children aged 1-18 years with a relapse of steroid-sensitive nephrotic syndrome are eligible for this study. Study subjects (n=144) will be randomly assigned to either current standard therapy in the Netherlands or a reduced prednisolone schedule. The primary outcome of the RESTERN study is the time to first relapse after the final prednisolone dose. The secondary outcomes are the number or relapses, progression to frequent relapsing or steroid dependent nephrotic syndrome and the cumulative dosage of prednisolone during the study period. ETHICS AND DISSEMINATION This non-inferiority trial will be performed in accordance with the Declaration of Helsinki and has been approved by the medical ethical committee of Arnhem-Nijmegen and the Dutch Competent Authority (Central Committee on Research Involving Human Subjects, CCMO). After completion of this study, results will be published in national and international peer-reviewed scientific journals. Papers will be published according to CCMO guidelines. The final report will be made available to trial participants. TRIAL REGISTRATION NUMBER NTR5670, EudraCT no 2016-002430-76.
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Affiliation(s)
- A M Schijvens
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - E M Dorresteijn
- Department of Pediatric Nephrology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - N Roeleveld
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - R Ter Heine
- Department of Pharmacy, Radboudumc, Nijmegen, The Netherlands
| | - J A E van Wijk
- Department of Pediatric Nephrology, VU University Medical Center, Amsterdam, The Netherlands
| | - A H M Bouts
- Department of Pediatric Nephrology, Emma Children's Hospital, Academic Medical Center, Amsterdam, The Netherlands
| | - M G Keijzer-Veen
- Department of Pediatric Nephrology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - N C A J van de Kar
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - L P W J van den Heuvel
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
- Department of Growth and Regeneration, University Hospital Leuven, Leuven, Belgium
| | - M F Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
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Alsaidi S, Wagner D, Grisaru S, Midgley J, Hamiwka L, Wade A, Nettel-Aguirre A, Samuel S. Glomerular Filtration Rate Trends During Follow-up in Children With Steroid-Sensitive Nephrotic Syndrome. Can J Kidney Health Dis 2017; 4:2054358117709496. [PMID: 28607687 PMCID: PMC5453627 DOI: 10.1177/2054358117709496] [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: 07/24/2016] [Accepted: 03/19/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Overall prognosis of children with steroid-sensitive nephrotic syndrome (SSNS) is regarded as generally favorable. However, only a few recent studies have evaluated changes in kidney function and blood pressure over time in children with SSNS. OBJECTIVES We describe clinical features of SSNS patients and characterize changes in calculated estimated glomerular filtration rate (eGFR) and use of antihypertensive medications during follow-up. DESIGN This is a retrospective cohort study. SETTING This study was conducted in a Canadian pediatric nephrology center. PATIENTS This study included patients aged 1 to 18 years with SSNS. MEASUREMENTS eGFR was calculated from recorded serum creatinine and height measurements using the modified Schwartz equation. METHODS eGFR was calculated at yearly intervals, and the trend of eGFR was assessed using linear mixed effects model. Patients were also evaluated for use of antihypertensive medications during follow-up. RESULTS Seventy-eight patients-median age, 3.2 years (interquartile range [IQR], 2.65) and median follow-up of 4.37 (IQR, 5.6)-were evaluated. Sixty-three (80.8%) had at least 1 relapse. Twenty-two (28.2%) and 20 (25.6%) were steroid dependent and frequently relapsing, respectively. Forty-three patients (55.1%) received at least 1 steroid-sparing agent, and of these, 18 (41.8%) received a calcineurin inhibitor. One patient had eGFR ≤90 mL/min/1.73 m2 during observation. eGFR remained unchanged over the follow-up period in this cohort of patients. Four patients (5.1%) were on antihypertensive medications at the end of follow-up. LIMITATIONS Patients who had frequent relapses had more measurements available for serum creatinine and height, creating a sampling bias. The number of eGFR measurements was overall small, making it difficult to ascertain eGFR trend. CONCLUSION eGFR remained unchanged over time in this cohort, and a small proportion of patients required antihypertensive therapy at the end of follow-up. Our study highlights the needs for carefully constructed long-term observational studies of children with nephrotic syndrome.
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Affiliation(s)
- Sulaiman Alsaidi
- Division of Pediatric Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Daniel Wagner
- Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Silviu Grisaru
- Division of Pediatric Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Julian Midgley
- Division of Pediatric Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Lorraine Hamiwka
- Division of Pediatric Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Andrew Wade
- Division of Pediatric Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Alberto Nettel-Aguirre
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Susan Samuel
- Division of Pediatric Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Alberta, Canada
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Rituximab for Steroid-Dependent or Frequently Relapsing Idiopathic Nephrotic Syndrome in Adults: A Retrospective, Multicenter Study in Spain. BioDrugs 2017; 31:239-249. [DOI: 10.1007/s40259-017-0221-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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