Hearing status in children with frequently relapsing and steroid resistant nephrotic syndrome

BACKGROUND

Children with idiopathic nephrotic syndrome (INS) are at risk of hearing impairment due to nephrotoxic drugs and biochemical impairments.

METHODS

Forty children with INS aged 5-16 years [20 patients with frequently relapsing nephrotic syndrome (FRNS)/steroid dependent nephrotic syndrome (SDNS) and 20 with steroid resistant nephrotic syndrome (SRNS)] and 20 normal healthy controls were enrolled in this study. Pure tone audiometry was done using the ALPS AD 2000 audiometer. Sensorineural hearing loss was diagnosed when the bone conduction level was >20 dB and the difference in air to bone gap was ≤15 dB. Based on the air conduction (AC) threshold, deafness was graded into the following categories: mild (26-40 dB), moderate (41-55 dB), moderately severe (56-70 dB), severe (71-91 dB) and profound (>91 dB).

RESULTS

Children with FRNS/SDNS had a higher threshold for hearing at frequencies of 250 and 500 Hz, respectively, than the controls. Of the children in the FRNS/SDNS category, three (15 %) had mild sensorineural hearing impairment. These children had a low serum calcium level (P < 0.03) and received higher cumulative doses of furosemide (P < 0.04). Children with SRNS had a higher threshold for hearing at frequencies of 250, 500, 1,000, and 2,000 Hz, respectively, than the controls. Of the 20 children with SRNS, ten (50 %) had sensoineural hearing impairment (8 mild, 2 moderate). Children with SRNS with a hearing defect had received a higher cumulative dose of furosemide (P < 0.03).

CONCLUSIONS

Children with FRNS/SDNS and SRNS are at risk of sensorineural hearing impairment. The risk factors associated with this impairment were higher cumulative doses of furosemide and hypocalcemia. Larger prospective cohort studies are required to evaluate this association.

Histopathologic and clinical findings of congenital nephrotic syndrome in Iranian children: a study of two centers

INTRODUCTION

Congenital nephrotic syndrome (CNS), an uncommon form of kidney disease, presents during the first year of life and is a diagnostic and therapeutic challenge for the pediatricians as well as pediatric nephrologists. Our study is the first study of Iranian children with CNS in two pediatric nephrology centers in Tehran, Iran.

MATERIALS AND METHODS

We reviewed medical charts of 30 infants diagnosed with CNS from 1990 to 2005.

RESULTS

There were 15 boys and 15 girls with CNS (mean age, 1.7 months). The presentation of the disease was nephrotic syndrome in 96.6% of the patients. Eighty percent of the patients presented within 3 months of life and 16 in the neonatal period. The Finnish type of CNS was seen in 43.3% and diffuse mesangial sclerosis in 50%. Preterm labor and low birth weight was seen in 20%. A family history of nephrotic syndrome in infancy was noted for 8 children (26.7%). Numerous complications of nephrotic syndrome occurred in 73.3%. Seventy percent of the patients had 27 episodes of infections. Sepsis was seen in 43.3% of the children, of which 61.5% were caused by gram-negative bacteria and 38.6% were caused by Staphylococcus aureus. Thrombotic complications and hypertension developed in 6.6% and 23.3% of the patients, respectively. The mortality rate of patients was 86.6%.

CONCLUSIONS

Diffuse mesangial sclerosis is an important cause of CNS. The outcome of our patients was poor and most of our patients died before reaching the age of 5 years old.

Mycophenolate mofetil for treatment of idiopathic nephrotic syndrome in children

INTRODUCTION

Management of frequently relapsing steroid-responsive or steroid-resistant idiopathic nephrotic syndrome (NS) in children has been a clinical challenge for pediatric nephrologists. In addition, adverse effects of long-term corticosteroids and cyclosporine administration emerge seeking a safe and effective treatment. The purpose of this study was to evaluate the safety and efficacy of mycophenolate mofetil (MMF) in these patients.

MATERIALS AND METHODS

This study reviewed the outcomes of children with frequently relapsing or steroid-resistant idiopathic NS who were treated with MMF.

RESULTS

A total of 36 patients (23 boys and 13 girls) were included. Their mean age at the time of diagnosis of NS was 61.94 ± 43.9 months. Of the children, 91.6% of those who had frequent relapses and 8.3% of those with steroid-resistant NS responded to MMF significantly (P < .001), with no significant association between age and gender with response to MMF. The treatment was well tolerated with no significant complications.

CONCLUSIONS

In children with frequently relapsing NS, MMF was a safe and useful drug for maintaining remission, while it was of low value in children with steroid-resistant NS.

[Correlation between Chinese medicine syndromes and the NPHS1 gene and NPHS2 gene polymorphism as well as corticosteroid sensitivity in patients with minimal change disease]

OBJECTIVE

To explore the correlation between Chinese medicine (CM) syndromes and the NPHS1 gene and NPHS2 gene polymorphism as well as corticosteroid sensitivity in patients with minimal change disease (MCD).

METHODS

A total of 94 MCD patients were recruited, including 58 steroid-sensitive nephritic syndrome (SSNS) patients and 36 steroid-resistant nephritic syndrome (SRNS) patients. Genomic DNA was obtained from peripheral blood lymphocytes and sequence analysis of single nucleotide polymorphisms (SNPs) in the genes was performed.

RESULTS

(1) The SNPs of G349A-3 in NPHS1 gene was found in MCD, but the SNPs of G686A-5 and C695T-5 in NPHS2 gene were not discovered in MCD. (2) When comparing the frequency of genotype AA and allele A in NPHS1 gene (G349A-3), genotype AA and allele A were higher in the SRNS group than in the SSNS group (P < 0.05). (3) When compared with the SRNS group, qi yang deficiency syndrome had a higher incidence in the SSNS group, and yin deficiency syndrome and qi-yin deficiency syndrome had a less incidence in the SSNS, but with no statistical difference (P > 0.05). The rheumatism syndrome had a higher incidence in the SSNS group (P < 0.05). The blood stasis syndrome had a lower incidence in the SSNS with statistical difference (P < 0.05). (4) There was no statistical difference in the correlation between GG, AA, GA and CM syndromes (P > 0.05).

CONCLUSIONS

Homozygous mutations of AA and allele A in NPHS1 gene were correlated to SRNS patients of MCD. Rheumatism syndrome patients were prone to be sensitive to corticosteroids, while patients of blood stasis syndrome were prone to be insensitive to corticosteroids. We didn't discover the correlation between NPHS1 gene polymorphism and CM syndrome distribution.

Integrin α3 mutations with kidney, lung, and skin disease

Integrin α(3) is a transmembrane integrin receptor subunit that mediates signals between the cells and their microenvironment. We identified three patients with homozygous mutations in the integrin α(3) gene that were associated with disrupted basement-membrane structures and compromised barrier functions in kidney, lung, and skin. The patients had a multiorgan disorder that included congenital nephrotic syndrome, interstitial lung disease, and epidermolysis bullosa. The renal and respiratory features predominated, and the lung involvement accounted for the lethal course of the disease. Although skin fragility was mild, it provided clues to the diagnosis.

Proteomic profiling identifies haptoglobin as a potential serum biomarker for steroid-resistant nephrotic syndrome

BACKGROUND

Long-term outcomes for patients with adult idiopathic nephrotic syndrome correlate closely with steroid responsiveness. The aim of this prospective study was to evaluate the difference in serum proteomes between steroid-sensitive nephrotic syndrome (SSNS) and steroid-resistant nephrotic syndrome (SRNS) patients and identify potential biomarkers for the prediction of SRNS.

METHODS

We performed a gel-based proteomic study of serum obtained from SRNS and SSNS patients and healthy controls at the time of presentation (n = 6 for each group). Proteins from the serum samples were separated using 2-D electrophoresis, digested in-gel and subjected to MALDI-TOF-MS/MS analysis. Further validation was performed utilizing Western blot and ELISA. The sensitivities and specificities of the candidate proteins for predicting SRNS were determined using receiver operating characteristic curves.

RESULTS

Thirteen differentially expressed proteins were identified as haptoglobin (Hp) with different isoelectric points and molecular weights. Western blot and ELISA analysis of samples from 146 subjects (healthy controls = 52, SSNS = 54, SRNS = 40) showed a markedly increased level of Hp in the serum, but not urine, of SRNS compared to SSNS patients. The optimal serum cutoff level of Hp was set at ≥1,279 µg/ml using the receiver operating characteristic curve. The sensitivity and specificity for predicting SRNS were 85.0 and 96.3%, respectively.

CONCLUSIONS

This study provides a novel overview of the difference in serum proteomes of SSNS and SRNS patients. Serum Hp may be a useful predictive biomarker for steroid therapy efficacy in the treatment of idiopathic nephrotic syndrome.

Rituximab treatment for adult patients with focal segmental glomerulosclerosis

We present two cases with steroid-resistant nephrotic syndrome (SRNS) and two cases with steroid-dependent nephrotic syndrome (SDNS) due to focal segmental glomerulonephritis (FSGS) who were treated with a single dose of rituximab (375 mg/m(2)). Although the two cases with SRNS showed no response, the two cases with SDNS achieved complete remission. The patients in whom the peripheral B-cell counts subsequently increased after the administration of rituximab demonstrated a relapse. Rituximab may be an effective treatment agent for SDNS with FSGS and the peripheral B-cell count may be a useful marker in such patients for preventing disease relapse.

[Congenital syphillis presenting congenital nephrotic syndrome in two children and related data review]

OBJECTIVE

To study the clinical features of congenital syphillis presenting congenital nephrotic syndrome (CNS) in children.

METHODS

Two cases diagnosed as congenital syphillis presenting CNS in our hospital were retrospectively analyzed and related data reviewed.

RESULTS

The two children had edema, gross proteinuria, haematuria, hepatosplenomegaly, abdominal distention and anaema. Rapid plasmin regain (RPR) and treponema palidum hemagglutination assay (TPHA) were all positive. One chiild was also had renal biopsy and showed membraous nephropathy. Adequate penicillin therapy got satisfatory effects without steroid treatment.

CONCLUSION

For children with early occurrence of proteinuria, edema accompanied by anaema, and hepatosplenomegaly, we should conside the possibility of syphillis nephropathy, which should be treated with enough dosage of penicillin in instead of steroid. Early diagnosis and treatmen could get complete recovery of CNS.

NPHS2 mutations in Indian children with sporadic early steroid resistant nephrotic syndrome

We examined the frequency and spectrum of podocin NPHS2 mutations in Indian children with sporadic steroid resistant nephrotic syndrome (SRNS). Of 25 children screened, only one (4%) had a pathogenic mutation resulting in a stop codon. The allele and genotype frequencies of the four known single nucleotide polymorphisms detected in the cohort were similar to that of controls. This finding emphasizes the need to screen for mutations in other genes involved in the pathogenesis of SRNS.

[Idiopathic steroid-resistant nephrotic syndrome in child : study of 20 cases]

BACKGROUND

Idiopathic steroid-resistant nephrotic syndrome (ISRNS) is rare and represents a significant therapeutic dilemma for paediatricians and paediatric nephrologists.

AIM

To analyze characteristics of the ISRNS in the child.

METHODS

Retrospective study of 20 cases of ISRNS enrolled in paediatric department of nephrology in Sahloul hospital (Tunisia) between June 1993 and December 2007 (14 years period).

RESULTS

There were eight girls and 12 boys (mean age: 5.8± 3.7 years) originating from the center or the south of Tunisia. Eight of them had a minimal-change disease (MCD), 11 a focal and segmental glomerulosclerosis (FSGS) and one a mesangioproliferative glomerulonephritis (MePGN). In this group, no family form could be identified. All patients were treated by cyclosporine associated with low dose of steroid. We noted a complete remission (CR) in nine cases, partial remission (PR) in three cases and no response to cyclosporine in eight cases. Among patients with CR, six presented MCD and three a FSGS. In this group, we observed relapse of nephrotic syndrome in six cases. End stage renal disease (ESRD) was noted in 10 patients of which five not responded to cyclosporine, two initially having presented a RC and three having since the beginning a PR. Among them, two only could be grafted; one relapses on transplant was observed with a single patient initially presenting a secondarily transformed MePGN in FSGS.

CONCLUSION

Our study confirms the clinical, histological and evolutive heterogeneity of idiopathic steroid-resistant nephrotic syndrome. Although there is any therapeutic consensus in this domain, cyclosporine remains indicated in first intention in sporadic forms of ISRNS. On the other hand, renal transplantation constitutes the only therapeutic alternate in genetic forms that constantly evolve at ESRD.

ACE I/D gene polymorphism can't predict the steroid responsiveness in Asian children with idiopathic nephrotic syndrome: a meta-analysis

Background

The results from the published studies on the association between angiotensin-converting enzyme (ACE) insertion/deletion (I/D) gene polymorphism and the treatment response to steroid in Asian children with idiopathic nephrotic syndrome (INS) is still conflicting. This meta-analysis was performed to evaluate the relation between ACE I/D gene polymorphism and treatment response to steroid in Asian children and to explore whether ACE D allele or DD genotype could become a predictive marker for steroid responsiveness.

Methodology/Principal Findings

Association studies were identified from the databases of PubMed, Embase, Cochrane Library and CBM-disc (China Biological Medicine Database) as of September 1, 2010, and eligible investigations were synthesized using meta-analysis method. Five investigations were identified for the analysis of association between ACE I/D gene polymorphism and steroid-resistant nephrotic syndrome (SRNS) risk in Asian children and seven studies were included to explore the relationship between ACE I/D gene polymorphism and steroid-sensitive nephrotic syndrome (SSNS) susceptibility. Five investigations were recruited to explore the difference of ACE I/D gene distribution between SRNS and SSNS. There was no a markedly association between D allele or DD genotype and SRNS susceptibility or SSNS risk, and the gene distribution differences of ACE between SRNS and SSNS were not statistically significant. II genotype might play a positive role against SRNS onset but not for SSNS (OR = 0.51, P = 0.02; OR = 0.95, P = 0.85; respectively), however, the result for the association of II genotype with SRNS risk was not stable.

Conclusions/Significance

Our results indicate that D allele or DD homozygous can't become a significant genetic molecular marker to predict the treatment response to steroid in Asian children with INS.

Congenital nephrotic syndrome

The aim of this case is to present a case of a two month old female with congenital nephritic syndrome, which is very rare. On admission, the baby showed marked edema and distended abdomen. She was diagnosed and treated with daily albumin infusions, antibiotics, diuretic, gamma globulin replacement, ACEI and NSAIDs. Parents were informed about the nature of the disease, prognosis, and advised for further medical care in a more advanced kidney transplantation centre. This was the first treatment of this condition in the Pediatric Clinic in Kosovo and it presented a challenge for us.

[Congenital nephrotic syndrome of the Finnish type--key to the mechanisms of proteinuria]

Congenital nephrotic syndrome of the Finnish type is a serious renal disease belonging to the Finnish disease heritage. It appears as substantial proteinuria, hypoproteinemia and edema in a newborn. Kidney transplantation is the only effective treatment. The cause of the disease is a mutation in the gene encoding the nephrin protein. Nephrin is produced by the epithelial cell (podocyte) of the glomerulus. It is expressed in the slit membrane connecting the pedicles of the podocyte. This finding has revolutionized the concept of glomerular filtration and set off active research on the pathogenetic mechanisms of proteinuria.

Update on congenital nephrotic syndromes and the contribution of US

The clinical classification of nephrotic syndrome (NS) is based on age at presentation. However, this classification is arbitrary because the majority of early onset NS has a genetic origin and has a widespread age of onset (from fetal life to several years). The aims of this review are to illustrate the knowledge accumulated on congenital nephrotic syndrome (CNS) in terms of genetics, classification, findings at histology and US-based on a review of the literature.

[Long-term outcome of children treated with the ISKDC regimen for the first episode of INS]

We retrospectively analyzed the long-term outcome of 82 children (SRNS group, 10; SDNS group, 35; IRNS group, 37) who were initially treated with the ISKDC regimen at the Saitama Children's Medical Center. The ISKDC regimen consisted of PSL 60 mg/m2/day for 4 weeks, followed by 40 mg/m2 on alternate days for another 4 weeks. The aims of our study were to identify factors at onset that could predict the relapse pattern after using the initial ISKDC regimen, and to assess the prognosis and renal histology after long-term CsA therapy in 31 children. All of six asymptomatic children without edema and identified by chance proteinuria on a urinary screening program had an extremely favorable clinical course. Initial remission time of 9 or more days and the time interval from the initial therapy to the first relapse were significant predictors of steroid dependency. The sensitivity and specificity of these findings were 100% and 90%, respectively, with a positive predictive value of 95% and a negative predictive value of 100%. In addition, after the introduction of CsA therapy, termination of steroid therapy was achieved in 56% of patients with SRNS, and 64% of SDNS, respectively. However, after CsA therapy was tapered or stopped, most patients (21/20: 95%) developed relapses of NS. Of these, 76% (16/21) returned to SDNS, resulting in the reintroduction of CsA. Ten of 22 patients taking CsA (mean duration 31.3 months) had chronic nephrotoxicity. In conclusion, the initial ISKDC regimen is useful for the early prediction of whether or not the patient will develop SDNS. When pediatric nephrologists introduce CsA therapy in children with SDNS, an alternative strategy after long-term use of the agent should be considered.

[Cinacalcet in the treatment of secondary hyperparathyreoidism in a child with chronic kidney disease--case report]

The medical history and treatment of 2.5 years old girl with chronic kidney disease and heavy hyperparathyreoidism was presented in this case report. This girl was treated by peritoneal dialysis (APD) due to chronic kidney disease and congenital nephrotic syndrome. The secondary paraidothyreoidism was a reason of the epiphysial of the upper end of the femur, which appeared despite of the treatment by the Vitamin D3 (Calciphediol and Alphacalcidol) and phosphate binding drugs like Calcium Carbonate and Sevelamer. The primary laboratory tests were: Ca 9.32 mg/dl, Ca jon. 1.21 mmol/l, PO4 7.29 mg/dl, BE +4.9 mmol/l, ALP 1425 U/l, PTH 3774 pg/ml, Albumins 3.23 g/l, Hgb 8.2 g/l. The treatment of cinacalcet (Mimpara, 30 mg, Amgen) in dose of 15 mg was started because of lack of the standard therapy results. The laboratory tests were controlled after 2 weeks and then every week to 5th and every 2 weeks to the end. This therapy was finished after 30 weeks and only the standard therapy of hyperphosphatemia was continued. The laboratory tests 3 month after stopped the treatment were: Ca 10.5 mg/dl, Ca jon. 1.36 mmol/l, PO4 4.0 mg/dl, BE +4.9 mmol/l, ALP 312 U/l, PTH 134 pg/ml, Albumins 3.23 g/l, Hgb 9.9 g/l. There were any adverse events observed during the treatment.

CONCLUSION

It seems, the cinacalcet may be an alternate treatment to paraidectomy in children with chronic kidney disease and heavy secondary hyperparathyreoidism.

A milder variant of Pierson syndrome

Congenital nephrotic syndrome (CNS) comprises a heterogeneous group of conditions having in common the disruption of normal glomerular permselectivity, and it carries a poor prognosis, with most patients progressing to end-stage renal disease. Recently, mutations in the LAMB2 gene encoding laminin beta2 were described as the cause of Pierson syndrome, which is characterized by CNS and a complex ocular maldevelopment with microcoria as the most prominent clinical features. Most affected children exhibit early onset of chronic renal failure, neurodevelopmental deficits, and blindness. We report on a patient with CNS, high-grade myopia, and minor structural eye anomalies, including remnants of pupillary membranes, but no microcoria. The patient had not developed renal failure by the age of 16 months, and he showed no neurodevelopmental deficits. He was identified to be homozygous for a novel LAMB2 missense mutation. This observation, together with two recent reports on milder variants of Pierson syndrome, corroborates the concept that the clinical expression of Pierson syndrome is more variable than initially described, and that milder phenotypes may be related to hypomorphic LAMB2 alleles.

[Comparison of cyclophosphamide and cyclosporine in the treatment of steroid-resistant idiopathic nephrotic syndrome in children]

OBJECTIVE

To compare the therapeutic outcome of cyclophosphamide(CTX) and cyclosporine A (CsA) in the treatment of steroid-resistant idiopathic nephrotic syndrome (SRNS) in children.

METHODS

Thirty-seven children with SRNS were analysed in a retrospective study from Jan 2001 to Dec. 2006. There was initial renal histology of minimal change (MCD) in 28 children, focal segmental glomerulosclerosis (FSGS) in 7 and mesangial proliferative glomerulonephritis (MsPGN) in the other 2. These patients were divided into 2 groups: one group received the induction therapy consisting of intravenous CTX and prednisolone, and the another group were treated with CsA [initial dose 3-5mg/(kg d)] and prednisolone.

RESULTS

(1) Thirty children received CTX, while 21 received CsA, and the total efficacy was 40.0% and 85.7% respectively after the 12 month follow-up. Children with MCD receiving CsA had a better response than those treated with CTX (93.8% vs 36.3%, P<0.05). Children with FSGS receiving CsA did not show a significant difference compared with those treated with CTX (75.0% vs 50.0%, P>0.05). (2) There were no significant associations between age, pathology, clinic type and therapeutic outcome in the 2 groups(P>0.05). (3)The rate of liver functional impairment, leukocytopenia, vomiting and nausea was 10%, 16.7% and 33.3%, respectively in children receiving CTX. The rate of hypertrichosis, gingival hyperplasia and hypertension was 71.4%, 23.8% and 9.5% respectively in children receiving CsA. Two children had central adverse effect. Two patients with FSGS progressed into end-stage renal failure.

CONCLUSION

For children with MCD, CsA combining prednisolone could result in a higher remission rate than intravenous CTX combining prednisolone.

C1q nephropathy in a 2-year-old boy presenting with steroid resistant nephrotic syndrome

We experienced a case of a 2-year-old boy, who presented with steroid resistant nephrotic syndrome, which developed insidiously. Renal biopsy revealed that he had focal and segmental glomerulosclerosis on light microscopy, dominant mesangial deposition of C1q by immunofluorescent staining, and electron dense deposits on electron microscopy, which are all compatible with C1q nephropathy. He had no clinical sign of any collagen diseases, including systemic lupus erythematodes. So, the diagnosis of C1q nephropathy was made. An intensive treatment by a combination of cyclosporine, prednisolone and methylprednisolone pulse therapy was successful in achieving remission and disappearance of proteinuria in this patient. Although he developed hypertension requiring calcium blocker and angiotensin converting enzyme inhibitor, his renal function stayed within normal limit for 3 years after the initiation of the treatment. The growth was well preserved during the 3 years of treatment with almost unchanged SD scores for height. He has delay in speech, which may not be associated with the etiology of his nephropathy, based on the absence of such association in the previous reports. C1q nephropathy is still a controversial clinical entity, so accumulation of the cases may help further understand the pathogenesis and clinical manifestation of C1q nephropathy.