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Delbet JD, Parmentier C, Ulinski T. Tolvaptan therapy to treat severe hyponatremia in pediatric nephrotic syndrome. Pediatr Nephrol 2020; 35:1347-1350. [PMID: 32232633 DOI: 10.1007/s00467-020-04530-6] [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: 02/09/2020] [Revised: 02/24/2020] [Accepted: 03/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Tolvaptan is a selective oral vasopressin V2-receptor antagonist. Some data have implicated stimulation of arginine vasopressin (AVP) as an important factor in oedema formation in a rodent model of nephrotic syndrome (NS) and adult NS patients. We report case of pediatric NS with severe hyponatremia efficiently treated by tolvaptan. CASE/DIAGNOSIS - TREATMENT A 22-month-old girl presented first with NS. She remained nephrotic after a 30-day course of oral steroids. Tacrolimus was inefficient and there was no response to plasma exchanges (15 sessions on a daily basis). She had severe oedema and ascites. Thus, in addition to immunosuppressive therapy, she received diuretics, furosemide 5 mg/kg/day, and amiloride 1 mg/kg/day, and required water restriction. She was hypertensive and was treated with a full dose of calcium inhibitor (amlodipine 0.5 mg/kg/day). After2 months of treatment, serum sodium reached 116 mmol/L and urinary osmolarity 547 mosmol/L, suggesting an inappropriate AVP secretion. Tolvaptan was introduced at 0.3 mg/kg/day and progressively increased to 3 mg/kg/day on day 4, leading to a partial correction of serum sodium (130 mmol/l) and a urinary osmolarity decrease to 90 mosmol/L. Tolvaptan was then continued at the dose of 3 mg/kg/day with unchanged serum sodium, without hypernatremia or dehydration. Her weight decreased from 14.8 k to 14 k, but oedema still persisted. CONCLUSION Tolvaptan was very efficient in this case of hyponatremia associated with steroid-resistant NS. Tolvaptan should be considered in the management of therapy-resistant hyponatremia in patients with NS.
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Affiliation(s)
- Jean-Daniel Delbet
- Pediatric Nephrology Unit, Trousseau Hospital, APHP.6, DMU Origyne, Paris, France. .,Sorbonne Université, Paris, France. .,Department of Pediatric Nephrology, Armand Trousseau Hospital, 26 Avenue du Docteur Arnold Netter, 75012, Paris, France.
| | - Cyrielle Parmentier
- Pediatric Nephrology Unit, Trousseau Hospital, APHP.6, DMU Origyne, Paris, France.,Sorbonne Université, Paris, France
| | - Tim Ulinski
- Pediatric Nephrology Unit, Trousseau Hospital, APHP.6, DMU Origyne, Paris, France.,Sorbonne Université, Paris, France
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Pasini A, Benetti E, Conti G, Ghio L, Lepore M, Massella L, Molino D, Peruzzi L, Emma F, Fede C, Trivelli A, Maringhini S, Materassi M, Messina G, Montini G, Murer L, Pecoraro C, Pennesi M. The Italian Society for Pediatric Nephrology (SINePe) consensus document on the management of nephrotic syndrome in children: Part I - Diagnosis and treatment of the first episode and the first relapse. Ital J Pediatr 2017; 43:41. [PMID: 28427453 PMCID: PMC5399429 DOI: 10.1186/s13052-017-0356-x] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/07/2017] [Indexed: 02/07/2023] Open
Abstract
This consensus document is aimed at providing an updated, multidisciplinary overview on the diagnosis and treatment of pediatric nephrotic syndrome (NS) at first presentation. It is the first consensus document of its kind to be produced by all the pediatric nephrology centres in Italy, in line with what is already present in other countries such as France, Germany and the USA. It is based on the current knowledge surrounding the symptomatic and steroid treatment of NS, with a view to providing the basis for a separate consensus document on the treatment of relapses. NS is one of the most common pediatric glomerular diseases, with an incidence of around 2-7 cases per 100000 children per year. Corticosteroids are the mainstay of treatment, but the optimal therapeutic regimen for managing childhood idiopathic NS is still under debate. In Italy, shared treatment guidelines were lacking and, consequently, the choice of steroid regimen was based on the clinical expertise of each individual unit. On the basis of the 2015 Cochrane systematic review, KDIGO Guidelines and more recent data from the literature, this working group, with the contribution of all the pediatric nephrology centres in Italy and on the behalf of the Italian Society of Pediatric Nephrology, has produced a shared steroid protocol that will be useful for National Health System hospitals and pediatricians. Investigations at initial presentation and the principal causes of NS to be screened are suggested. In the early phase of the disease, symptomatic treatment is also important as many severe complications can occur which are either directly related to the pathophysiology of the underlying NS or to the steroid treatment itself. To date, very few studies have been published on the prophylaxis and treatment of these early complications, while recommendations are either lacking or conflicting. This consensus provides indications for the prevention, early recognition and treatment of these complications (management of edema and hypovolemia, therapy and prophylaxis of infections and thromboembolic events). Finally, recommendations about the clinical definition of steroid resistance and its initial diagnostic management, as well as indications for renal biopsy are provided.
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Affiliation(s)
- Andrea Pasini
- Nephrology and Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria, Policlinico Sant’Orsola-Malpighi, Bologna, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Pediatrics, University Hospital of Padua, Padua, Italy
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit with Dialysis, AOU G. Martino, Messina, Italy
| | - Luciana Ghio
- Pediatric Nephrology and Dialysis Unit, Fondazione Ca’ Granda, IRCCS Ospedale Maggiore, Policlinico Milano, Milan, Italy
| | - Marta Lepore
- Pediatric Nephrology and Dialysis Unit, Fondazione Ca’ Granda, IRCCS Ospedale Maggiore, Policlinico Milano, Milan, Italy
| | - Laura Massella
- Nephrology and Dialysis Unit, Pediatric Subspecialties Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | | | - Licia Peruzzi
- City of the Health and the Science of Turin Health Agency, Regina Margherita Children’s Hospital, Turin, Italy
| | - Francesco Emma
- Nephrology and Dialysis Unit, Pediatric Subspecialties Department, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Carmelo Fede
- Pediatric Nephrology and Rheumatology Unit with Dialysis, AOU G. Martino, Messina, Italy
| | - Antonella Trivelli
- Division of Nephrology, Dialysis, Transplantation, and Laboratory on Pathophysiology of Uremia, Istituto G. Gaslini, Genoa, Italy
| | - Silvio Maringhini
- Pediatric Nephrology Unit, Children’s Hospital ‘G. Di Cristina’, A.R.N.A.S. ‘Civico’, Palermo, Italy
| | - Marco Materassi
- Nephrology and Dialysis Unit, Meyer Children’s Hospital, Florence, Italy
| | - Giovanni Messina
- Nephrology Unit, Giovanni XXIII Children’s Hospital, Bari, Italy
| | - Giovanni Montini
- Pediatric Nephrology and Dialysis Unit, Fondazione Ca’ Granda, IRCCS Ospedale Maggiore, Policlinico Milano, Milan, Italy
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Pediatrics, University Hospital of Padua, Padua, Italy
| | | | - Marco Pennesi
- Institute of Maternal and Child Health IRCCS “Burlo Garofolo”, Department of Pediatrics, Trieste, Italy
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Translational Research for Pediatric Lower Urinary Tract Dysfunction. Int Neurourol J 2016; 20:S105-111. [PMID: 27915476 PMCID: PMC5169095 DOI: 10.5213/inj.1632726.363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 10/17/2016] [Indexed: 02/07/2023] Open
Abstract
This review provides a comprehensive view of translational research aimed at elucidating the pathophysiology of pediatric lower urinary tract dysfunction (LUTD). A web search was conducted according to combinations of keywords, and the significance of each article was defined by the author. The dramatic evolution of the mass analysis method of genomes, transcripts, and proteins has enabled a comprehensive analysis of molecular events underlying diseases, and these methodologies have also been applied to pediatric LUTD. In genetic analyses of syndromes underlying daytime incontinence, urofacial (Ochoa) syndrome may be creating a prototype of a new research approach. Nocturnal enuresis has long been studied genetically, and several candidate loci have been reported. However, the pursuit for enuresis genes has been abandoned partly because genetic association and enuresis phenotype (bladder or renal type) could not be linked. Enuresis associated with diabetes insipidus has provided new insights into the etiology of the diseases. A chronobiological approach may shed new light on this area. Posterior urethral valves and neurogenic bladders have attracted the interest of pediatric urologists to the smooth muscle biology of the bladder. Bladder exstrophy and cloacal anomalies are rare but major anomalies caused by defective urorectal development and have recently been studied from a genetic standpoint. Translational studies for pediatric LUTD may be extended to adult bladder disease, or to application of precision medicine for diseased children.
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Teoh CW, Robinson LA, Noone D. Perspectives on edema in childhood nephrotic syndrome. Am J Physiol Renal Physiol 2015; 309:F575-82. [PMID: 26290369 DOI: 10.1152/ajprenal.00229.2015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/11/2015] [Indexed: 12/21/2022] Open
Abstract
There have been two major theories surrounding the development of edema in nephrotic syndrome (NS), namely, the under- and overfill hypotheses. Edema is one of the cardinal features of NS and remains one of the principal reasons for admission of children to the hospital. Recently, the discovery that proteases in the glomerular filtrate of patients with NS are activating the epithelial sodium channel (ENaC), resulting in intrarenal salt retention and thereby contributing to edema, might suggest that targeting ENaC with amiloride might be a suitable strategy to manage the edema of NS. Other potential agents, particularly urearetics and aquaretics, might also prove useful in NS. Recent evidence also suggests that there may be other areas involved in salt storage, especially the skin, and it will be intriguing to study the implications of this in NS.
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Affiliation(s)
- Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lisa A Robinson
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Damien Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Ellis D. Pathophysiology, Evaluation, and Management of Edema in Childhood Nephrotic Syndrome. Front Pediatr 2015; 3:111. [PMID: 26793696 PMCID: PMC4707228 DOI: 10.3389/fped.2015.00111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/07/2015] [Indexed: 01/22/2023] Open
Abstract
Generalized edema is a major presenting clinical feature of children with nephrotic syndrome (NS) exemplified by such primary conditions as minimal change disease (MCD). In these children with classical NS and marked proteinuria and hypoalbuminemia, the ensuing tendency to hypovolemia triggers compensatory physiological mechanisms, which enhance renal sodium (Na(+)) and water retention; this is known as the "underfill hypothesis." Edema can also occur in secondary forms of NS and several other glomerulonephritides, in which the degree of proteinuria and hypoalbuminemia, are variable. In contrast to MCD, in these latter conditions, the predominant mechanism of edema formation is "primary" or "pathophysiological," Na(+) and water retention; this is known as the "overfill hypothesis." A major clinical challenge in children with these disorders is to distinguish the predominant mechanism of edema formation, identify other potential contributing factors, and prevent the deleterious effects of diuretic regimens in those with unsuspected reduced effective circulatory volume (i.e., underfill). This article reviews the Starling forces that become altered in NS so as to tip the balance of fluid movement in favor of edema formation. An understanding of these pathomechanisms then serves to formulate a more rational approach to prevention, evaluation, and management of such edema.
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Affiliation(s)
- Demetrius Ellis
- Division of Pediatric Nephrology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
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