IPNA clinical practice recommendations for the diagnosis and management of children with steroid-sensitive nephrotic syndrome

The efficacy and safety of rituximab monotherapy in the new onset pediatric idiopathic nephrotic syndrome: a randomized controlled clinical trial

BACKGROUND

Nephrotic syndrome (NS) is a common form of glomerular disease in children, characterized by a high propensity for relapse. Prolonged use of glucocorticoids (GCs) can result in various side effects. Rituximab (RTX) may be considered as an initial treatment option for primary nephrotic syndrome in pediatric patients.

METHODS

We conducted a prospective, single-center, randomized controlled trial (RCT) to evaluate whether the initial use of RTX monotherapy is superior to GC therapy in treating pediatric idiopathic NS and to assess its safety. The primary outcome and secondary outcomes were compared between the two groups.

RESULTS

A total of 24 pediatric patients were included in the study, comprising 19 males and 5 females. After six weeks of treatment, the complete remission (CR) rate in the GC group was significantly higher than that in the RTX group (100% vs 33.3%). Compared with the RTX group, the GC group had a shorter time to first remission (14.25 d vs. 9.5 d). During the follow-up period, none of the patients in the RTX group who achieved CR experienced relapse, with the longest relapse-free duration being 79 weeks. In the GC group, nine patients experienced relapse with the longest relapse-free period being 94 weeks. No serious adverse events occurred in either group. The cumulative steroid dosage was not statistically different between the 2 groups (p = 0.41).

CONCLUSION

Although the CR rate of children with idiopathic NS treated with RTX alone is significantly lower, the relapse rate among responders to RTX is also lower than that of the GC treatment.

A "Trial within a Cohort" platform for pediatric clinical trials on idiopathic nephrotic syndrome: scope, objectives, and design of the retrospective-prospective cohort PIN'SNP

BACKGROUND

Idiopathic nephrotic syndrome (INS) in children is the most common glomerular disease and is characterized by recurrent relapses. There is no community consensus on the treatment of relapsing forms of nephrotic syndrome in children, unlike that for the initial presentation. To date, available treatments only enable relapsing patients to be maintained in remission, rather than modifying the course of the disease; therefore, more therapeutic trials are needed. The Société de Néphrologie Pédiatrique (SNP) decided to implement within its French centers a national coordinated long-term clinical research program for children treated for INS based on a Trials within Cohorts (TwiCs) model. The aim of this paper is to describe the PIN'SNP cohort and research program as well as the TwiCs design adapted to INS research in the French regulatory system.

METHODS

This retrospective-prospective, multicenter research program will rely on a dynamic prospective cohort of children followed for an INS, known as the PIN'SNP cohort (i) to identify cases treated within SNP centers, (ii) to describe their clinical and epidemiological characteristics, and (iii) to provide a platform to nest prospective trials, and thus facilitate inclusion of patients in these future trials.

CONCLUSIONS

The PIN'SNP cohort is the first French national pediatric platform dedicated to the implementation of randomized nested trials along with longitudinal and observational studies on INS in children. The adaptation of the TwiCs design to inform all eligible patients/parents to each nested trial will facilitate methodological robustness and ethical acceptability and reinforce communication between investigators and participants.

TRIAL REGISTRATION

number NCT04207580.

Clinical applicability of 2023 International Pediatric Nephrology Association recommended limited therapeutic drug monitoring formulae to assess mycophenolic acid exposure

BACKGROUND

The 2023 IPNA guidelines recommended a 12-h mycophenolic acid (MPA) area under the curve (AUC) estimation for managing pediatric nephrotic syndrome and MPA AUC > 50 mg * h/L for an optimal therapeutic response to mycophenolate mofetil (MMF). The IPNA guidelines endorsed two limited AUC formulae based on three-point MPA measurements to predict 12-h MPA AUC. The relative performance of these two limited AUC formulae has not been tested.

METHODS

We analyzed 156 MPA AUCs from 122 stable kidney transplant recipients to predict the 12-h AUC (10 MPA measurements analyzed with trapezoid rule) using the IPNA-recommended three-point Formula 1 and Formula 2.

RESULTS

Three-point Formula 1 and Formula 2 classified 69% and 60% limited MPA AUCs as > 50 mg * h/L (difference 8.90%, p = 0.10). Three-point Formula 1 and Formula 2 demonstrated a similar association with 12-h AUC (R2 0.72 vs. 0.71) and exhibited identical areas under ROC (AUROC) for predicting 12-h AUC > 50 mg * h/L (AUROC 0.82, 95% CI 0.75, 0.88 vs. 0.80, 95% CI 0.73, 0.86; p = 0.53). Fixed MMF dose and MPA C0 level showed a relatively weaker association (R2 0.16 and 0.43) with 12-h AUC. Four-point MPA formulae improved the prediction of 12-h AUC compared to the three-point formulae. Among all C0 thresholds, C0 > 3.5 mg/L demonstrated the best prediction of 12-h AUC > 50 mg * h/L (AUROC 0.74, 95% CI 0.66, 0.80).

CONCLUSIONS

IPNA recommended limited AUC formulae perform equivalently and improve upon MMF dose and C0 level to predict 12-h MPA AUC.

Tacrolimus or Mycophenolate Mofetil for Frequently Relapsing or Steroid-Dependent Nephrotic Syndrome: A Randomized Clinical Trial

Importance

Both tacrolimus (TAC) and mycophenolate mofetil (MMF) are recommended for children with frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS). However, their comparative effectiveness and safety have not been evaluated through randomized clinical trials.

Objective

To compare the effectiveness and safety of TAC and MMF in children with FRNS or SDNS.

Design, Setting, and Participants

In this multicenter, open-label randomized clinical trial conducted at 12 pediatric nephrology centers across China, 270 children aged 2 to 18 years with FRNS or SDNS were allocated at a 1:1 ratio to treatment with either TAC or MMF. The study was conducted from November 2019 to July 2023, and data analysis was completed from July 2023 to March 2024.

Intervention

Patients received either TAC (0.025-0.050 mg/kg, orally twice daily) or MMF (10-15 mg/kg, orally twice daily) for 1 year, along with a tapering regimen of steroids.

Main Outcomes and Measures

The primary end point was 1-year relapse-free survival. Relapse frequency, cumulative steroid dosage, and safety profiles were also evaluated.

Results

A total of 292 patients from 12 care centers were assessed for eligibility, and 270 patients were randomized to receive either TAC (n = 135) or MMF (n = 135). Among 270 patients, median (IQR) age was 6.91 (4.25-9.96) years, and 70 patients (25.9%) were female. Compared with MMF, the 1-year relapse-free survival rate in the TAC group was 1.86-fold higher (hazard ratio [HR], 2.86; 95% CI, 1.79-4.76; P < .001) in the intention-to-treat analysis. This difference was also significant after adjusting for the per-protocol analysis (HR, 2.78; 95% CI, 1.72-4.55; P < .001). The mean (SD) time to first relapse was significantly longer in the TAC group (323.99 [98.33] days) compared to the MMF group (263.21 [132.84] days). Furthermore, the TAC group showed a lower annual relapse rate than the MMF group (17.78% vs 41.48%) and required a significantly lower mean (SD) cumulative steroid dose (0.22 [0.10] mg/kg/day vs 0.34 [0.22] mg/kg/day). The safety profile was similar in both groups.

Conclusions and Relevance

In this randomized clinical trial, compared with MMF, a 1-year course of TAC therapy significantly extended the period of relapse-free survival in children with FRNS or SDNS.

Trial Registration

ClinicalTrials.gov Identifier: NCT04048161.

Risk factors and retreatment for relapse in childhood primary nephrotic syndrome treated with rituximab

BACKGROUND

The effectiveness of rituximab (RTX) for steroid-dependent/frequently relapsing nephrotic syndrome (SDNS/FRNS) in children is well documented. However, there are insufficient data on relapse risk factors. Additionally, the retreat regimen for relapsed children requires further investigation.

METHODS

We administered single dose RTX (375 mg/m2, maximum 500 mg) to children with SDNS/FRNS between May 2020 and December 2022. An additional single dose of RTX was administered when B-cell depletion (CD19 + B cells < 1%) was incomplete or B-cell recovery (CD19 + B cells ≥ 1%) occurred. Primary and secondary outcomes were the first and second relapse, respectively.

RESULTS

Eighty-nine patients were included and the observation period was 12.2-43.2 months. Thirty-three patients (37.1%) relapsed after RTX treatment. Multivariate analysis showed that previous steroid-resistant nephrotic syndrome (SRNS) history and low NK-cell percentage at initial RTX treatment were independent risk factors for first relapse. In the relapse group, 26 patients (78.8%) continued RTX treatment upon B-cell recovery. During mean follow-up period of (15.4 ± 8.1) months, 15 patients (45.5%) experienced a second relapse. Compared with non-continued RTX treatment group, the continued RTX treatment group had a lower relapse rate (34.6% (9/26) versus 85.7% (6/7); P = 0.047) and fewer relapses (0.0 (0.0, 0.6) versus 1.8 (0.9, 2.7) times/year; P = 0.004). Multivariate analysis showed that continued RTX treatment was the protective factor for second relapse.

CONCLUSION

Previous SRNS history and low NK-cell percentage at initial RTX treatment may be associated with higher risk of relapse. Despite the possibility of relapse during RTX treatment, continued RTX treatment is effective in reducing relapse.

Executive summary of the KDIGO 2025 Clinical Practice Guideline for the Management of Nephrotic Syndrome in Children

The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Management of Glomerular Diseases was last updated and published in 2021. KDIGO continues to be committed to the nephrology community to provide periodic updates, based on new developments for each of the glomerular diseases. For children with nephrotic syndrome, the updated guideline now contains a treatment algorithm on when to perform a kidney biopsy and/or genetic testing and which immunosuppressive therapy to use in children with a complete response to glucocorticoids (steroid sensitive), who subsequently become infrequent or frequent relapsers or even steroid dependent. If a glucocorticoid-sparing agent must be considered after failure of an initial glucocorticoid therapy to induce remission, the choice among a calcineurin inhibitor, oral cyclophosphamide, levamisole, mycophenolate mofetil, and rituximab is a decision that requires consideration of patient-related issues such as resources, adherence, adverse effects, and patient preferences. Herein, an executive summary of the most important changes in the KDIGO 2025 Clinical Practice Guideline for the Management of Nephrotic Syndrome in Children is provided as a quick reference.

Nutritional management of pediatric nephrotic syndrome regarding oxidative stress and antioxidant balance

Pediatric nephrotic syndrome remains a complex clinical entity, with incompletely elucidated pathogenetic mechanisms, in which oxidative stress appears to have a substantial etiopathogenic role. Recent evidence supports the involvement of redox imbalance in podocyte damage, impaired glomerular function, and systemic decline. All this suggests that antioxidant interventions can favorably modulate the course of the disease. This narrative review aims to synthesize the most relevant data from the current literature on the interaction between oxidative stress and nephrotic syndrome in children, with a focus on the therapeutic potential of antioxidants. The analysis focuses on the molecular mechanisms by which oxidative stress contributes to the progression of renal dysfunction, the role of oxidative biomarkers in disease monitoring, and the ability of antioxidants to reduce the need for immunosuppressants and corticosteroids, thus contributing to the decrease in associated morbidity. The translational perspectives of antioxidant therapy are also discussed, in the context of the urgent need for effective adjuvant strategies with a safety profile superior to conventional therapies. By integrating these data, the paper supports the valorization of antioxidant interventions as an emerging direction in the management of pediatric nephrotic syndrome and substantiates the need for controlled clinical trials, with rigorous design, in this field.

Emerging pharmacotherapies for the treatment of childhood nephrotic syndrome

INTRODUCTION

Childhood nephrotic syndrome (NS) is a relatively rare condition but an important cause of morbidity. It is classified based on histopathology and response to corticosteroid therapy.

AREAS COVERED

Children with steroid-sensitive disease have a favorable long-term prognosis with maintenance of normal kidney function. However, nearly half of these patients have persistent disease activity requiring chronic corticosteroid therapy or exposure to second-line immunosuppressive agents. The identification of anti-nephrin antibodies in many patients with steroid-sensitive disease suggests immunotherapy to reduce pathogenic antibody formation may represent a qualitative advance in treatment. Children with steroid-resistant disease are likely to have focal segmental glomerulosclerosis (FSGS). There are no approved treatments for this condition. FSGS is a heterogeneous entity, and improvements in care will likely depend on molecular classification of subtypes based on the underlying disease mechanism. This approach will enable selection of treatments that match the cause of NS in each child for precision medicine therapy.

EXPERT OPINION

Children with NS today benefit from therapeutic options not previously available, but clinical decisions still rely on steroid responsiveness at disease onset. Continued advancement in treating NS requires collaboration between basic scientists and nephrologists and the organization of a clinical trial framework to evaluate novel therapies.

Association of COVID-19 vaccination with relapsed nephrotic syndrome and new onset nephrotic syndrome in children

BACKGROUND

Several case reports describe new onset or relapsed nephrotic syndrome (NS) after COVID-19 mRNA vaccination. However, there have been no systematic studies in children.

METHODS

In this single-center, retrospective cohort study, we used our electronic health record registry to identify patients with NS who received ≥ 1 dose of COVID-19 vaccine from 12/2020 to 12/2022. For each patient, we determined number of relapses in the 180 days pre- and 60 days post-vaccination. Conditional logistic regression was used to assess risk of relapse after vaccination. Linear regression was used to estimate the mean difference between individual-level post- and pre-vaccine relapse rates.

RESULTS

Ninety-five patients with relapsing NS were included (median age 12 years, 43% female). Their clinical phenotype was as follows: 33% infrequent relapsing, 52% frequently relapsing (FR)/steroid-dependent (SD)/secondarily steroid responsive (SSR), and 16% steroid-resistant. Twenty-five patients (26%) relapsed in the pre-vaccine period, 17 (18%) had ≥ 1 relapse post-vaccination, and 78 (82%) had no relapse documented after COVID-19 vaccination. There was no significant difference in the risk of relapse after versus before vaccination (odds ratio 0.43, p = 0.08), and no significant difference in relapse rates after versus before vaccination (mean difference 0.08 per 100 patient-days, p = 0.39), overall or by phenotype. Of post-vaccine relapses, 94% occurred among the FR/SD/SSR group. Five patients met criteria for new onset NS presenting ≤ 60 days after receipt of the COVID-19 vaccine.

CONCLUSIONS

In a systematic pre/post comparison of individual-level relapse frequency, we found no significant difference in risk or rates of relapse after COVID-19 vaccination in children with NS.

Post-varicella vaccination uveitis in a child with nephrotic syndrome receiving immunosuppressive treatment: a case report

Patients with nephrotic syndrome are at heightened risk of infections due to the underlying disease pathophysiology and the effects of immunosuppressive therapies. Varicella-zoster virus (VZV) infection can cause severe complications in immunocompromised individuals. Concerns about the safety of live attenuated vaccines in this population persist. Emerging vaccination strategies incorporate pre-vaccination risk stratification algorithms based on immunological criteria. We present a case of a five-year-old male with corticosteroid-dependent nephrotic syndrome, in complete remission on mycophenolate mofetil therapy, who received the varicella vaccine after meeting immunocompetence criteria. Fourteen days post-vaccination, he developed scant vesicular lesions, with VZV DNA detected by PCR via swab. By day 16 post-vaccination, he presented with left-eye panuveitis. VZV DNA was also detected in the blood by PCR. Differentiation of VZV vaccine strains from wild-type strains was not possible. Additionally, molecular testing for VZV in the aqueous humor was not performed. However, given the temporal association with varicella vaccination, the detection of VZV in the blood and cutaneous lesions, and most importantly, the immunosuppression of the patient, post-vaccination ocular varicella was assumed even without an epidemiological history of varicella exposure. This case highlights the importance of a thorough immunocompetence assessment before administering live vaccines to immunosuppressed patients, as well as close post-vaccine monitoring and a high index of suspicion for complications to optimize vaccine safety in this vulnerable group. Patients with nephrotic syndrome require vaccination strategies tailored to their individual risk.

Long-Term Impact of Interdisciplinary Collaboration on Oral Health in Children with Nephrotic Syndrome: A 12-Year Retrospective Study

Objectives: Children with nephrotic syndrome (NS) are prone to oral health issues due to immunosuppression and systemic inflammation, which may exacerbate their renal condition. The objective of this study was to evaluate the impact of a 12-year interdisciplinary collaboration between pediatric dentists and nephrologists on oral health in children with NS. Methods: A retrospective analysis of 80 NS patients-40 assessed in 2012 and 40 in 2024-was conducted using caries indices (dmft/DMFT), Plaque Index, and Gingival Index. Statistical tests assessed differences between groups (p < 0.05). Results: The prevalence of active caries significantly decreased (50% vs. 78%; p = 0.011), with fewer decayed permanent teeth (0.96 ± 1.56 vs. 2.66 ± 2.51; p = 0.003) and improved oral hygiene (good hygiene in 52.5% vs. 30%; p = 0.041) in the 2024 group. Gingivitis was less severe compared to 2012. Conclusions: Long-term interdisciplinary care significantly improved oral health in children with NS. These improvements may contribute to reduced systemic inflammation and better overall disease control. Integrating dental care into NS management is recommended to support long-term outcomes.

Single (375 mg/m2) vs. double dose of rituximab along with mycophenolate mofetil for children with steroid-dependent/frequently relapsing nephrotic syndrome: a multicentre open-label randomized controlled trial

BACKGROUND

Optimal dosing of rituximab when given with mycophenolate mofetil (MMF) for frequently relapsing nephrotic syndrome/steroid-dependent nephrotic syndrome (FRNS/SDNS) remains uncertain.

METHODS

This was a prospective, non-inferiority, open-label randomized controlled multicentre study. Children (2-18 years old) with difficult FRNS/SDNS were randomized to group A (rituximab 375 mg/m2 once) or group B (rituximab 375 mg/m2 twice; 7-14 days apart) followed by continuous MMF and 3 months of tapered steroids. Primary outcome at an 18-month follow-up was time to first relapse. Secondary outcomes included post rituximab time to CD19 repopulation, sustained remission and significant adverse events (SAEs).

RESULTS

Ninety-six children (median age 8.6 years; IQR 6.4 to 11.3 years, 72% male) were randomized, 48 per arm. CD19 depletion (< 1%) was achieved in both groups. Three from single dose and two from double dose arm were lost to follow-up or withdrew. After 18 months, although non-inferiority could not be demonstrated, there was no difference in primary outcome either by intention-to-treat or per-protocol analysis. The restricted mean time to first relapse was 14.5 months (95% CI 13.1-15.9) in group A and 14.8 months (95% CI 13.5-16.1) in group B (p = 0.69). Relapse rate was similar between group A (19/45; 42%) and group B (16/46; 35%) (p = 0.53, hazard ratio 0.86 (95% CI 0.46-1.6)). Secondary outcomes were also similar between the groups.

CONCLUSIONS

Among children with FRNS/SDNS although non-inferiority could not be demonstrated, no statistically significant difference in outcome was found between 375 and 750 mg/m2 rituximab when accompanied with MMF.

Changes in polyunsaturated fatty acids are linked to metabolic syndrome in children with steroid-sensitive nephrotic syndrome-a clinical observation

OBJECTIVE

Alterations in lipid metabolic pathways constitute a pivotal characteristic of Steroid-Sensitive Nephrotic Syndrome (SSNS). Despite the significance, there has been scant exploration into the influence of polyunsaturated fatty acids (PUFAs) on metabolic syndrome (MetS) in children with SSNS. This study endeavors to elucidate the association between PUFAs and MetS in this specific pediatric population.

METHODS

This study enrolled a total of 185 children aged 0-7 years with SSNS between May 2023 and May 2024. Based on international guidelines for MetS, patients were classified into a MetS group (n = 73) and a non-MetS group (n = 112). A healthy control group (n = 82) was also established. Surveys, anthropometric measurements, and blood samples were used to assess lipid profiles, glucose, insulin, and Hemoglobin A1C (HbA1C). The concentrations of serum PUFAs were quantitatively analyzed utilizing gas chromatography-mass spectrometry (GC-MS) techniques.

RESULTS

The MetS group exhibited significantly elevated levels of fasting blood glucose, triglyceride (TG), low-density lipoprotein (LDL) cholesterol, HbA1C, insulin, the ratio of TG to high-density lipoprotein (HDL) cholesterol, and the ratio of total cholesterol to HDL cholesterol compared to the non-MetS group. Significant differences were observed among healthy controls, MetS group, and non-MetS group in terms of ω-3 alpha-linolenic acid (ALA), ω-3 docosahexaenoic acid (DHA), ω-6 arachidonic acid, and ω-6 to ω-3 ratio.

CONCLUSIONS

High ω-6 arachidonic acid, ω-6/ω-3 ratio and low ω-3 ALA and ω-3 DHA were associated with elevated TG levels. An elevation in TG concentrations among pediatric patients with SSNS may have been implicated to MetS.

Short-term outcome of levamisole in frequently relapsing nephrotic syndrome: a single-center prospective cohort study

Introduction

This study aims to describe the outcome of levamisole (LEVA) treatment in children with frequently relapsing nephrotic syndrome (FRNS).

Methods

This prospective cohort study was conducted at the Department of Pediatric Nephrology, Sindh Institute of Urology and Transplantation from 1 January 2019 to 31 December 2020. Children aged 1-18 years diagnosed with FRNS were included. LEVA was started with a dose of 2-2.5 mg/kg every other day for 2 years along with low-dose prednisolone in the first year.

Results

A total of 70 children with FRNS were enrolled in the study. The median age was 7.5 [interquartile range (IQR) 5.0-9.6 years] with a slight predominance of boys (42, 60%). The mean number of relapses and cumulative dose of steroids significantly decreased after 2 years of LEVA therapy and during the 1-year follow-up. LEVA non-response was observed in half of the studied participants (28, 46%). The responders and non-responders were comparable in terms of cumulative dose of steroids and number of relapses in the year prior to starting LEVA [5,242 ± 1,738 versus 4,910 ± 1,469 (p-value = 0.52) and 5.4 ± 2.4 versus 5.2 ± 2.1 (p-value = 0.85)].

Conclusion

LEVA therapy resulted in a substantial reduction in the frequency of relapses and cumulative dosage, indicating its potential as an alternative option for children with relapsing disease.

Time to remission in childhood steroid sensitive nephrotic syndrome: a change in perspective

Time to remission (TTR) has been largely considered one of the predictive factors for the risk of relapse and steroid dependency in childhood steroid-sensitive nephrotic syndrome, yet conflicting opinions exist. However, the factors influencing TTR have never been studied. We performed a post-hoc analysis of the prospective pediatric cohort enrolled in a previous multicenter study (ClinicalTrials.gov Id: NCT01386957) to evaluate the possible influence of some clinical and laboratory parameters at INS onset on the timing of TTR. A total of 136 children were evaluated. In simple linear regression models, TTR was directly correlated with serum uric acid, urea, potassium, and urinary protein levels at onset. TTR showed a non-linear inverse correlation with age at onset. A multiple linear regression model of TTR showed that hyperuricemia (p = 0.0000007), non linear age (p = 0.0006) and proteinuria (especially in binary form) (p = 0.02) were significant predictors of TTR, and that there was a significant positive interaction between uricemia and proteinuria as predictors of TTR (p = 0.004). Conclusions: In our analysis, TTR appears to be associated to a nephrotic status at clinical diagnosis characterized by more severe proteinuria and hyperuricemia. Moreover, younger age at onset, notably associated with prognosis, is also associated with a longer TTR. What is Known: • Corticosteroids are the first-line treatment in childhood nephrotic syndrome. • Over the years, time to remission has been considered a potential predictive factor for the risk of relapse and steroid dependency in childhood nephrotic syndrome, with conflicting results. What is New: • Clinical and laboratory parameters at nephrotic syndrome onset are associated with prolonged time to remission in children.

Different profiles of fatty acids between leukocytes and whole blood in children with idiopathic nephrotic syndrome

Idiopathic nephrotic syndrome (INS) is the most common pediatric glomerular disease, characterized by proteinuria, hypoalbuminemia and edema and caused by an immune dysregulation of T and B cells. Fatty acids (FA) are involved in immune response, with omega-6 prevailing in pro-inflammatory states and omega-3 promoting anti-inflammatory effects. While previous studies of INS assessed FA profile in blood or serum, which may be influenced by many systemic and dietary factors, the intracellular FA metabolism in white blood cells of children with INS, critical to immune cell activation, remains still unexplored. This pilot study compares the FA profile within leukocytes (endo-leukocyte, EL) and whole blood in 35 children with INS and 34 matched controls. INS patients were stratified by steroid sensitivity vs. steroid resistance and by remission vs. proteinuric state. EL FA profiles were analyzed via gas chromatography and dietary habits were evaluated by the Kid Med questionnaire. While blood FA profile of patients demonstrated both elevated omega-6 and omega-3 levels (P-value < 0.005), EL show an inflammatory dominance, with increased omega-6 (P-value < 0.005), but similar omega-3 levels, compared to controls. Furthermore, EL profiles showed reduced saturated FA and palmitic acid but elevated oleic acid levels (P-value < 0.005), possibly indicating a compensatory anti-inflammatory response. This study suggests that EL FA profile may provide unique insights into intracellular mechanisms of inflammation in INS, complementing data arising from blood FA analysis. Despite some limitations, including the small sample size, the study of FA inside the cellular population directly involved in INS underscores its potential in increasing diagnostic precision of FA anomalies in the course of nephrotic syndrome. This new approach may also represent the prerequisite for a clearcut evaluation of the effectiveness of pharmacologic and dietary therapies, like the supplementation with omega 3 metabolites and a diet rich in omega-3.

Differences in kidney prognosis between congenital and infantile nephrotic syndrome

BACKGROUND

More than half of patients with congenital nephrotic syndrome (CNS) or infantile nephrotic syndrome (infantile NS) have a monogenic aetiology. This study aimed to clarify differences in the clinical course, genetic background, and genotype-phenotype correlation between CNS and infantile NS.

METHODS

We enrolled patients who were diagnosed with CNS or infantile NS and referred to our hospital for genetic analysis and investigated the clinical characteristics and genetic background of patients with identified causative genes.

RESULTS

Among 74 patients enrolled, disease-causing genetic variants were detected in 50 patients. The median age for developing kidney failure in the genetic CNS (n = 33) and genetic infantile NS (n = 17) groups with monogenic variants was 13.2 and 19.0 months, respectively (P = 0.13). The age at developing kidney failure was significantly earlier in CNS patients with genes other than NPHS1 than in CNS patients with NPHS1 variants (1.0 vs. 31.0 months; P < 0.001). In patients with pathogenic variants other than NPHS1, there was a significant difference in the age at developing kidney failure between CNS and infantile NS patients (1.0 vs. 15.0 months; P < 0.001). Of patients with NPHS1 variants, no infants with NS had any truncating variants or developed kidney failure during follow-up.

CONCLUSIONS

The onset of CNS or infantile NS affects the kidney prognosis in patients with genetic nephrotic syndrome. Among patients with pathogenic variants in the same gene, patients with infantile NS may have a milder genotype and better prognosis than those with CNS.

Amino acid variants in the HLA-DQA1 and HLA-DQB1 molecules explain the major association of variants with relapse status in pediatric patients with steroid-sensitive nephrotic syndrome

BACKGROUND

Management of patients with steroid-sensitive nephrotic syndrome (SSNS) is challenging because of frequent relapses. Causal variants in the human leukocyte antigen (HLA) class II region that are associated with relapse remain undetermined.

METHODS

We collected a cohort of East Asian individuals comprising 206 pediatric patients with SSNS and 435 healthy controls from Southwest China. Ninety children with steroid-sensitive nephrotic syndrome without relapse (SSNSWR) and 116 children with steroid-dependent and/or frequent relapse nephrotic syndrome (SDNS/FRNS) were genotyped using Sanger sequencing. We then measured the transcriptional level, allele expression imbalance (AEI) and functional proteins of HLA-DQA1 and HLA-DQB1 in different stages of SDNS/FRNS.

RESULTS

rs1464545187 in ANKRD36 was associated with an approximately 1.69-fold greater risk for SSNSWR (P = 0.04; 95% confidence interval [CI], 1.05-2.72). Clustered risk variants in HLA-DQA1 and HLA-DQB1 were significantly associated with SDNS/FRNS (rs1047989: P = 2.26E-07, odds ratio [OR] = 2.25, 1.65-3.05; rs9273471: P = 5.45E-05, OR = 1.84, 1.37-2.46; HLA-DQB1*06:02: P = 0.017, OR = 0.19, 0.04-0.77). The genotype distributions of rs1047989, 2:171713702, rs1049123, rs9273471, and HLA-DQB1*06:02 in patients with SSNS were significantly different from those in healthy controls. rs1047989 (HLA-DQA1) was significantly associated with a greater number of infections at relapse in SDNS/FRNS patients (P = 0.045, OR = 6.79, 95% CI: 1.29-168.52). Flow cytometry showed that the proportion of cells expressing HLA-DQA1+/DQB1+ (HLA-DQA1+, P = 0.0046; HLA-DQB1+, P = 0.0045) was lowest in the relapse stage. In addition, the mRNA levels of HLA-DQA1 and HLA-DQB1 were significantly greater in the relapse group than in the remission group (HLA-DQA1, P = 0.03; HLA-DQB1, P = 0.002). No significant AEIs were detected in the different stages of SDNS/FRNS. The rs1047989 variant is likely to affect the structure and stability of HLA-DQA1.

CONCLUSION

rs1464545187 is a risk locus for SSNSWR but not SDNS/FRNS in Chinese children. Functional variations in HLA-DQA1 and HLA-DQB1 are implicated in regulating the immune response of SSNS patients, which may explain the typical triggering of SDNS/FRNS onset by infections.

Is Childhood IgA Nephropathy Different From Adult IgA Nephropathy? A Narrative Review

Purpose of the review

Immunoglobulin A (IgA) nephropathy (IgAN) is the most common primary glomerular kidney disease. Children and adults are presumed to have the same disease and are treated similarly. However, there are differences between childhood IgAN and adult IgAN that may require unique treatment considerations, even after transition to adult nephrology services. A narrative review was conducted to compare childhood and adult IgAN and to describe the distinct characteristics of childhood IgAN. Reframing childhood IgAN can inform guideline recommendations unique to childhood IgAN, the development of targeted therapies, and clinical trial design.

Sources of information

Medline and Embase were searched for reports on children and adults with IgAN published between January 2013 and December 2023 (updated May 2024). The search was not restricted by age group, outcomes reported, language, or study design. Randomized controlled trials (RCTs), observational studies, review articles, and nephrology conference abstracts were included. A total of 3104 reports were retrieved. Forty-seven reports (37 primary studies and 10 reviews) were included in the review. Two RCTs and 35 observational studies included a total of 45 085 participants (9223 children and 35 862 adults).

Method

Data were extracted for primary IgAN and not for IgA vasculitis-associated nephritis. Findings were described with no statistical comparisons due to variations in interventions and outcome definitions.

Key findings

Gross hematuria was the obvious clinical difference between childhood IgAN and adult (60-88% vs 15-20%). Nephrotic syndrome was more common in children, approaching up to 44%, while <18% of adults had nephrotic syndrome. Children were biopsied sooner (6 vs 15 months) and had more inflammatory kidney lesions (mesangial hypercellularity: 41-82% vs 38-64%; endocapillary hypercellularity: 39-58% vs 17-34%). Chronic kidney lesions were more prevalent in adults (segmental sclerosis: 62-77% vs 8-51%; interstitial fibrosis/tubular atrophy: 34-37% vs 1-18%). The use of immunosuppressive therapy was higher in children (46-84% vs 35-56%). Children were started on immunosuppressive therapy sooner than adults. Adults were more likely to be optimized with renin-angiotensin system inhibitors (87-94% vs 49-75%). Children had better kidney function than adults at diagnosis (estimated glomerular filtration rate of 90-128 vs 50-88 ml/min/1.73 m2), and children also had better kidney survival, with kidney failure of 3.1% vs 13.4% at 5 years. Children had more risk alleles for IgAN and higher levels of mannose-binding lectin than adults.

Limitations

Most studies were retrospective and observational, with limited data on children and disease mechanisms. Data were not pooled for analysis because of important differences in definitions and measurements of baseline characteristics and outcomes. Data from countries with established urine screening programs were different compared to countries without urine screening programs. Some observed differences may be due to practice variation and delayed diagnosis in adults (lead-time bias). Well-designed prospective studies and standardized measures for kidney function assessment and outcomes can reduce heterogeneity and improve results from reviews.

Conclusion

Inherent differences between childhood IgAN and adult IgAN may be due to distinct disease mechanisms. Approaching childhood IgAN as a separate condition could lead to the discovery of targeted therapies and improve management during childhood and after the transition to adult care.

Navigating Genetic Testing in Nephrology: Options and Decision-Making Strategies

Technological advances such as next-generation sequencing (NGS) have enabled high-throughput assessment of the human genome, supporting the usage of genetic testing as a first-line tool across clinical medicine. Although individually rare, genetic causes account for end-stage renal disease in 10% to 15% of adults and 70% of children, and in many of these individuals, genetic testing can identify a specific etiology and meaningfully impact management. However, with numerous options for genetic testing available, nephrologists may feel uncomfortable integrating genetics into their clinical practice. Here, we aim to demystify the process of genetic test selection and highlight the opportunities for interdisciplinary collaboration between nephrologists and genetics professionals, thereby supporting precision medicine for patients with kidney disease. We first detail the various clinical genetic testing modalities, highlighting their technical advantages and limitations, and then discuss indications for their usage. Next, we provide a generalized workflow for genetic test selection among individuals with kidney disease and illustrate how this workflow can be applied to genetic test selection across diverse clinical contexts. We then discuss key areas related to the usage of genetic testing in clinical nephrology that merit further research and approaches to investigate them.

Comparative Efficacy of Nonsteroid Immunosuppressive Medications in Childhood Nephrotic Syndrome

Importance

Cyclophosphamide and calcineurin inhibitors are the most used nonsteroid immunosuppressive medications globally for children with various chronic inflammatory conditions. Their comparative effectiveness remains uncertain, leading to worldwide practice variation. Nephrotic syndrome is the most common kidney disease managed by pediatricians globally and suboptimal treatment is associated with high morbidity.

Objective

To evaluate the comparative effectiveness of cyclophosphamide vs calcineurin inhibitors (tacrolimus or cyclosporine) for childhood nephrotic syndrome relapse prevention.

Design, Setting, and Participants

Using target trial emulation methods, the study team emulated a pragmatic, open-label clinical trial using available data from the Insight Into Nephrotic Syndrome: Investigating Genes, Health, and Therapeutics (INSIGHT) study. INSIGHT is a multicenter, prospective cohort study in the Greater Toronto Area, Canada. Participants included children (1 to 18 years) with steroid-sensitive nephrotic syndrome diagnosed between 1996 and 2019 from the Greater Toronto Area, who initiated cyclophosphamide or a calcineurin inhibitor treatment. Data analysis was performed in 2024.

Exposures

Incident cyclophosphamide or calcineurin inhibitor treatment. Randomization was emulated by overlap weighting of propensity scores for treatment assignment.

Main Outcomes

The primary outcome was time to relapse, analyzed by weighted Kaplan-Meier and Cox proportional hazards models. Secondary outcomes included relapse rates, subsequent immunosuppression, kidney function, hypertension, adverse events, and quality of life.

Results

Of 578 children (median age at diagnosis, 3.7 [IQR, 2.8-6.0] years; 371 male [64%] and 207 female [36%]), 252 initiated cyclophosphamide, 131 initiated calcineurin inhibitors, and 87 sequentially initiated both medications. Baseline characteristics were well balanced after propensity score weighting. During median 5.5-year (quarter 1 to quarter 3, 2.5-9.2) follow-up, there was no significant difference in time to relapse between calcineurin inhibitor vs cyclophosphamide treatment (hazard ratio [HR], 1.25; 95% CI, 0.84-1.87). Relapses were more common after calcineurin inhibitor treatment than cyclophosphamide (85% vs 73%) in the weighted cohorts, but not statistically significant. There were also no significant differences in subsequent relapse rates, nonsteroid immunosuppression use, or kidney function between medications. Calcineurin inhibitor treatment was associated with more hospitalizations (HR, 1.83; 95% CI, 1.14-2.92) and intravenous albumin use (HR, 2.81; 95% CI, 1.65-4.81).

Conclusions and Relevance

In this study, there was no evidence of difference in time to relapse after cyclophosphamide and calcineurin inhibitor treatment in children with nephrotic syndrome. Cyclophosphamide treatment is shorter in duration and more accessible globally than calcineurin inhibitors.

IPNA clinical practice recommendations for the diagnosis and management of children with IgA nephropathy and IgA vasculitis nephritis

IgA nephropathy and IgA vasculitis with nephritis, albeit rare, represent two relatively frequent glomerular conditions in childhood. Compared to adults, pediatric IgA nephropathy has a more acute presentation, most frequently with synpharyngitic macrohematuria and histologically with more intense inflammation and less intense chronic damage. Management of these conditions is controversial and supported by little high-quality evidence. The paucity of evidence is due to the disease heterogeneity, its inter-ethnic variability, and the difficulty of extrapolating data from adult studies due to the peculiarities of the condition in children. IgA vasculitis with nephritis is a kidney manifestation of a systemic disorder, typical of the pediatric age, in which both the diagnosis of kidney involvement and its management are poorly defined, and an interdisciplinary approach is crucial. Both conditions can have a profound and long-lasting impact on kidney function and the global health of affected children. The International Pediatric Nephrology Association has therefore convened a diverse international group of experts from different disciplines to provide guidance on the recommended management of these conditions in children and to establish common definitions and define priorities for future high-quality, evidence-based collaborative studies for the benefit of children.

To biopsy or not to biopsy a teenager with idiopathic nephrotic syndrome? Biopsy first

Kidney biopsy plays a crucial role in the diagnosis and management of several glomerular diseases. While it is generally considered a routine and safe procedure in children, it should be conducted with the primary objective of addressing the following question: do the prognosis and treatments vary based on the findings of kidney biopsy? In children presenting with idiopathic nephrotic syndrome (INS), guidelines suggest to consider kidney biopsy for individuals older than 12 years, primarily due to the possible increased incidence of different glomerulonephritis compared to younger patients, who predominantly manifest with minimal change disease. However, these guidelines also advocate for uniform therapeutic strategies, typically steroids, irrespective of the age or histological findings. Whether the age of more than 12 years may be a recommendation for performing kidney biopsy at presentation of INS is debatable. Instead, kidney biopsy could be reserved for steroid-resistant cases. On the other hand, when kidney biopsy is performed in INS, particularly in focal segmental glomerulosclerosis, histology may reveal additional lesions, that are strongly associated with a poorer response to treatment and worse clinical outcomes. Therefore, current guidelines on treatments of nephrotic syndrome may appear overly restrictive, despite the relevant findings provided by kidney biopsy. Therefore, in the present manuscript, which is part of a pro-con debate on the management of nephrotic syndrome in adolescents, we emphasize the potential role of performing a kidney biopsy before initiating corticosteroid treatment.

Steroid pulse therapy in idiopathic nephrotic syndrome in the era of modern immunosuppressive treatment-still up to date?

BACKGROUND

Intravenous steroid pulses (SP) are successfully used for the treatment of patients with idiopathic nephrotic syndrome (INS) resistant to oral prednisone.

METHODS

We performed a retrospective analysis of all patients in the three pediatric nephrology centers of the Paris region from 2002 to 2022 who were resistant to a 30-day course of oral prednisone and who received SP for their first INS flare and analyzed their disease course over 4 years.

RESULTS

Forty-seven patients (17 girls), median age 3.4 years, were analyzed. Of them, 68% reached remission within 7 days of SP. No significant short-term side effects were noted. Half of the patients started immunosuppressive treatment immediately after their first remission and 62% of them relapsed at least once, whereas all the patients who did not receive immunosuppressive treatment since their first remission relapsed. Among the SP-sensitive patients, 75% needed calcineurin inhibitor (CNI) or B-cell depletion during their disease course to achieve stable remission. Forty-two percent of the whole cohort received B-cell-depleting agents. Among the 15 SP-resistant patients, all received CNI. Twelve/fifteen patients reached remission. After 4 years, 68% among the SP-sensitive patients and 87% of SP-resistant patients still had an active disease.

CONCLUSIONS

SP are helpful to obtain rapid remission in pediatric INS patients resistant to oral steroids. However, as most SP-sensitive patients need immunosuppressive drugs, mainly CNI and B-cell-depleting agents it could be interesting to discuss the possibility to start CNI directly after the 30-day course of prednisone instead of SP.

To biopsy or not to biopsy a teenager with typical idiopathic nephrotic syndrome? Start steroids first

It is well known that minimal change disease (MCD) and focal segmental glomerulosclerosis are the most common histopathology findings in children with idiopathic nephrotic syndrome. Moreover, several studies demonstrated that MCD is associated with high steroid-responsiveness and a low incidence of kidney failure, suggesting that routine kidney biopsy is not warranted. Over time, the indications for performing a kidney biopsy have become increasingly stringent, aiming to limit unnecessary invasive procedures in the paediatric population. The most recent guidelines state that a kidney biopsy is not usually necessary at disease onset. Still, it should be performed in case of atypical features suggestive of systemic diseases or glomerulonephritis and in case of steroid-resistance, to assess the different differential diagnoses, regardless of patient age. Moreover, it has been shown that the best prognostic marker in childhood nephrotic syndrome is response to treatment and that kidney histology is not accurate in predicting prognosis. Furthermore, a kidney biopsy is not necessary to predict the relapsing course. Notably, kidney biopsy is an invasive procedure and may lead to significant complications. Finally, novel non-invasive biomarkers have been validated or are in the process of being approved to guide differential diagnoses and thus limit the need for kidney biopsies in patients with typical nephrotic syndrome. In the following sections, we aim to explain why initiating steroid treatment as the initial approach in teenagers with typical nephrotic syndrome is a reasonable strategy. Additionally, we explore how kidney biopsy indications may be alleviated in this population.

The Role of Cytokines and Chemokines as Biomarkers of Disease Activity in Idiopathic Nephrotic Syndrome in Children

(1) This study investigates the association of plasma concentrations of various cytokines and chemokines with the disease activity of idiopathic nephrotic syndrome (INS) in children in Slovenia. (2) In a prospective single-center study lasting 18 months, we took sequential plasma samples from children with INS at disease onset or relapse (prior to corticosteroid (CS) therapy), at remission, and after discontinuation of CS therapy. The Olink®Target 48 Cytokine Panel was applied to analyze 45 analytes in the plasma samples, adhering to the manufacturer's protocol. We performed a statistical analysis with a paired samples analysis with a t-test as well as with a non-parametric Wilcoxon correction test. (3) We included 18 pediatric patients with INS in the study. We demonstrated statistically significant differences in the concentrations of CSF1, IL4, FLT3LG, CCL19, and MMP12 in the patients at disease onset or relapse compared to those in remission, differences in the concentrations of CSF1 and IL17F in the patients at disease onset or relapse compared to those in remission after CS treatment, and differences in the concentrations of CCL19, MMP12, and CCL13 in the patients in remission compared to those in remission after CS treatment. (4) The findings support potential roles of certain cytokines and chemokines, especially CSF1, CCL19, and MMP12, in influencing the disease activity of INS.

Kinetic-pharmacodynamic model to predict post-rituximab B-cell repletion as a predictor of relapse in pediatric idiopathic nephrotic syndrome

Purpose

Rituximab has proven efficacy in children with idiopathic nephrotic syndrome (INS). However, vast majority of children inevitably experience relapse with B-cell repletion, necessitating repeat course of rituximab, which may increase the risk of adverse effects. The timing of additional dosing and optional dosing regimen of rituximab in pediatric patients with INS have yet to be determined. This study aimed to identify factors that influence disease relapse and B-cell repletion to provide tailored treatment.

Methods

LASSO and random survival forest were performed on 143 children to screen covariates which were then included in Cox regression model to determine the biomarkers of relapse and establish a nomogram. A kinetic-pharmacodynamic (K-PD) model was developed in 59 children to characterize the time course of CD19+ B-cell after rituximab treatment. Monte Carlo simulation was conducted to explore a mini-dose regimen with larger intervals.

Results

Nomogram contained 7 predictors of relapse including neutrophil-to-lymphocyte ratio, duration of B-cell depletion, duration of disease, urine immunoglobulin G to creatinine ratio, urine transferrin, duration of maintenance immunosuppressant and hemoglobin. As a direct PD indicator, each 1-month increase of duration of B-cell depletion decreased risk of relapse by 21.4% (HR = 0.786; 95% CI: 0.635-0.972; p = 0.026). The K-PD model predicted t1/2 (CV%) of rituximab and CD19+ B-cell to be 11.6 days (17%) and 173.3 days (22%), respectively. Immunoglobulin A is an important covariate of ED50. Simulation of a mini-dose regimen with larger intervals (three 150 mg every 2 monthly) indicted longer B-cell depletion time (>7 months) compared to standard regimen.

Conclusion

The nomogram indicated optimal infusion timing before relapse and the K-PD model provided tailored rituximab regimens for children with INS to reduce safety risks and financial burden.

Successful Switch to Obinutuzumab in a Rituximab-Intolerant Child with Difficult-to-Treat Idiopathic Nephrotic Syndrome

Background: Idiopathic nephrotic syndrome (INS) is the most common cause of nephrotic syndrome in children. A hallmark of the disease is the rapid remission of proteinuria following a high dose of steroids. Recurrent disease or steroid dependence are common, leading to a high steroid burden and the introduction of steroid sparing therapy. Anti-CD20 antibodies have been increasingly used with excellent results in complicated INS. Nevertheless, their use can be limited by the occurrence of infusion-related reactions (IRRs). Methods: This report discusses further treatment options for children who are intolerant to RTX and presents the first report of a successful switch to obinutuzumab (OBI) for a child with difficult-to-treat steroid-dependent nephrotic syndrome (SDNS) and RTX intolerance who was unresponsive to a desensitization protocol. Results: A 12-year-old boy with SDNS since the age of 2, was treated with steroids, cyclophosphamide and cyclosporine A (CsA). Because of the prolonged use of calcineurin inhibitors, a course of rituximab (RTX) was planned. Unfortunately, during first infusion, the boy presented with IRR. A desensitization protocol following the first unsuccessful infusion also failed. Facing the risks of long-term cyclosporine therapy, a decision was made to switch to another type of anti-CD20 antibody. Obinutuzumab infusion with a modified premedication scheme was uneventful. Conclusions: Switching therapy to obinutuzumab may be considered an option in nephrotic children who are intolerant to RTX when alternative therapies have been exhausted. The addition of montelukast to premedication and employment of desensitization protocols may decrease the risk of infusion-related reactions to anti-CD20 agents.

Noninvasive assessment of pediatric glomerular disease: multimodal ultrasound

Background

Traditional 2-dimensional (2D) ultrasound is a noninvasive method in the assessment of glomerular disease. Ultrasound elastography shows promise in evaluating renal fibrosis, which plays a key role in glomerular disease progression. However, research in pediatric cohorts is limited. This study aimed to assess the diagnostic efficacy of multimodal ultrasound in pediatric patients with glomerular disease.

Methods

Pediatric patients undergoing kidney elasticity examination were recruited. Participants were categorized into a control group, nephritic group, and nephrotic group based on clinical presentation and pediatric nephrologist diagnosis. The nephritic group included cases with hematuria, proteinuria, kidney function impairment, and potentially edema or hypertension. The nephrotic group included cases with nephrotic syndrome. All participants underwent multimodal ultrasound of the right kidney to obtain 2D parameters, hemodynamic parameters, and elasticity values. Sound touch quantification (STQ) is a new shear wave elastography (SWE) technology that has been used in clinical applications in recent years. In this study, it was used to obtain kidney elasticity values. The diagnostic efficacy of multimodal ultrasound was evaluated through receiver operating characteristic (ROC) curve analysis. Logistic regression was further utilized to investigate the combined diagnostic efficacy of multiple parameters.

Results

This study included 154 females and 187 males with ages ranging from 4 to 16 years (mean age: 9.78±3.20 years). Cortical STQ and medullary STQ exhibited lower sensitivity but higher specificity. In logistic regression modeling, multimodal ultrasound showed good diagnostic performance. Between the nephritic group and the control group, the ROC curve yielded an area under the curve (AUC) of 0.71 [95% confidence interval (CI): 0.64-0.77]; sensitivity, 58.10%; specificity, 76.26% (P<0.01). Between the nephrotic group and the control group, the ROC curve yielded an AUC of 0.75 (95% CI: 0.69-0.82); sensitivity, 75.26%; specificity, 62.59% (P<0.01).

Conclusions

Ultrasound elastography demonstrates potential in detecting glomerular disease. Multimodal ultrasound can serve as a noninvasive approach for assessing glomerular disease, exhibiting good diagnostic performance.

Short and long-term outcome of levamisole in early versus late steroid responsive nephrotic syndrome: A single centre experience

Objectives

To determine the effectiveness of Levamisole (Leva) in maintaining short-term and long-term remission in early steroid responders (ESRs) and late steroid responders (LSRs).

Methods

This retrospective study on 106 cohorts, aged 2-14 years with frequent-relapsing (FR) and steroid-dependent nephrotic syndrome (SDNS) who received Leva over 10-years (2012-2023), was carried out at tertiary care centre, Karachi from January-August 2023. Patients were categorized based on steroid response during first episode of NS as ESRs if complete remission (CR) was achieved within two weeks of daily steroid and LSRs if CR achieved between two-four weeks. Leva was administered after inducing remission with daily steroid after labelling as FRNS and SDNS. Low-dose steroid was continued during Leva-therapy. Short-term outcome was assessed at completion of Leva and long-term outcome in terms of CR, relapse frequency, alternative immunosuppressive agents (ISAs) use and compliance was assessed at six, 12 and 36-months' follow-up while off levamisole therapy.

Results

Leva was used in 106 patients (male 67%) for 20.4±8months during the study period. The mean age at Leva-initiation was 6.3±3 years. Eighty-three were FRNS and 23 SDNS. ESRs were 64 and 42 were LSRs. Overall, Leva was effective in maintaining short-term CR (73%) at end of Leva and it was effective in both ESRs (75%) and LSRs (69%, p=0.51) as well as in FRNS (72%) and SDNS (74%), P=0.08). Post-Leva follow-up duration was 36±31 months. Long-term Leva was effective in both ESRs and LSRs (p=0.51). Complete remission in 22,17 and 26%; infrequent relapses in 50,40 and 5% and alternate ISAs use in 24,39 and 55% at six,12 and 36 months follow-up respectively.

Conclusion

Levamisole was effective in maintaining short-term and long-term remission in early and late initial steroid responsive nephrotic syndrome.

Association between Exclusive Breastfeeding and the Incidence of Childhood Nephrotic Syndrome

OBJECTIVE

To assess the relationship between breastfeeding and the risk of developing nephrotic syndrome using a population-based nationwide birth cohort in Korea.

STUDY DESIGN

This nationwide cohort study utilized data from the National Health Information Database and the National Health Screening Program for Infants and Children. The study included all children born between January 1, 2010, and December 31, 2018, who underwent their first health screening, which included a specific questionnaire on breastfeeding between 4 and 6 months of age. Associations between nephrotic syndrome and exclusive breastfeeding were estimated using adjusted hazard ratios (aHR) derived from Cox proportional hazards models, adjusted for sociodemographic variables, with follow-up until the occurrence of nephrotic syndrome, 8 years postindex date, death, or December 31, 2022, whichever was first.

RESULTS

The study population comprised 1 787 774 children (median follow-up: 7.96 years; IQR: 6.31-8.00 years), including 612 556 exclusively breastfed and 1 175 218 formula-fed children. Exclusive breastfeeding was associated with a decreased risk of developing nephrotic syndrome (aHR: 0.80; 95% CI: 0.69-0.93). Subgroup analysis stratified by sex mirrored the overall findings, although statistical significance was not observed in girls (boys: aHR, 0.75; 95% CI, 0.62-0.92; girls: aHR, 0.87; 95% CI, 0.70-1.09). Sensitivity analysis confirmed these results.

CONCLUSIONS

Exclusive breastfeeding was associated with a 20% reduced risk of developing nephrotic syndrome up to 8 years of age.

Rituximab as a first-line therapy in children with new-onset idiopathic nephrotic syndrome

Background

Idiopathic nephrotic syndrome (INS) in children, commonly treated with steroids, poses challenges due to associated side effects. Rituximab, known for its efficacy in reducing relapse frequency in difficult-to-treat cases, emerges a potential first-line therapy for pediatric new-onset INS.

Method

This is a single-center, retrospective, observational study to evaluate the efficacy and safety of rituximab as a first-line therapy for pediatric INS. The complete treatment strategy was weekly injections at a dose of 375 mg/m2 for four doses. Children with new-onset INS who received rituximab as a first-line monotherapy from 1 January 2022 to 31 December 2023 were included and followed until 31 May 2024.

Results

Seventeen patients (median age at diagnosis 4.8 years) were included. Twelve patients achieved complete remission within a median time of 19 days. Over a follow-up period ranging from 41 to 112 weeks, 11 patients maintained remission even after B-cell reconstitution, with one patient experiencing a relapse at 85 weeks. Three patients, who presented with hematuria, hypocomplementemia or renal injury at initial diagnosis, exhibited resistance to rituximab. No severe adverse events were noted.

Conclusion

Rituximab may be an effective and safe option as a first-line therapy for inducing and maintaining remission in newly diagnosed INS.

Heat shock protein 70 levels in children with nephrotic syndrome

BACKGROUND

Idiopathic nephrotic syndrome (NS) is the most prevalent glomerular disease in children. Heat shock protein 70 (HSP70) is synthesized in response to diverse stress factors like infections and oxidative stress. We aimed to evaluate serum and urine levels of HSP70 in children with steroid-sensitive nephrotic syndrome (SSNS) and to assess changes in HSP70 levels with prednisolone treatment. Additionally, we seek to determine whether serum and urine levels of HSP70 can differentiate between frequently relapsing and infrequently relapsing cases in children with SSNS.

METHODS

A total of 36 patients with SSNS and 35 healthy children were included in the study. Samples were taken from all patients at four time points; before corticosteroid treatment (day 0) and on days 15, 30, and 90 after the initiation of corticosteroid treatment. Serum and urine levels of HSP70 were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

In the NS group before steroid treatment (day 0), urine HSP70 (uHSP70) levels and urine HSP70/creatinine (uHSP70/Cre) ratios were significantly higher (p<0.0001), whereas serum HSP70 (sHSP70) levels were lower (p=0.002), compared to the healthy group. uHSP70 levels decreased gradually during prednisolone treatment in the patient group (p<0.0001). There was no difference in terms of sHSP70, uHSP70, and uHSP70/Cre ratios between patients with frequently relapsing and infrequently relapsing.

CONCLUSIONS

Our study demonstrates that uHSP70 levels are elevated in SSNS prior to treatment and decrease with prednisolone therapy, reflecting reduced renal stress and damage. uHSP70 may be a useful biomarker for monitoring renal damage and treatment response. Serum and urine levels of HSP70, as well as uHSP70/Cre ratios, did not differentiate between frequent and infrequent relapses.

Childhood idiopathic nephrotic syndrome: recent advancements shaping future guidelines

Childhood idiopathic nephrotic syndrome is an important pediatric kidney disease associated with significant morbidities and even mortality. Several guidelines have been developed to standardize the terminology and patient care among the pediatric nephrology community. Since the publication of these guidelines, there have been major breakthroughs in the disease management and the understanding of underlying pathogenesis through multi-omics investigations, including the identification of anti-nephrin autoantibodies, genetic susceptibility loci, and the pathogenic role of B cell subsets. In this educational review, we summarize the recent major advancements in idiopathic nephrotic syndrome and attempt to provide potential therapeutic approaches in both steroid-sensitive and steroid-resistant nephrotic syndrome that may shape future guideline development.

Prediction Model and Decision Analysis for Early Recognition of SDNS/FRNS in Children

Purpose

This study identified factors that identification of progression-predicting utility from steroid-sensitive nephrotic syndrome(SSNS) to steroid-dependent or frequently relapsing nephrotic syndrome (SDNS/FRNS) in patients and developed a corresponding predictive model.

Patients and Methods

This retrospective study analyzed clinical data from 756 patients aged 1 to 18 years, diagnosed with SSNS, who received treatment at the Department of Nephrology, Children's Hospital of Chongqing Medical University, between November 2007 and May 2023. We developed a shrinkage and selection operator (LASSO) - logistic regression model, which was visualized using a nomogram. The model's performance, validity, and clinical utility were evaluated through receiver operating characteristic curve analysis, confusion matrix, calibration plot, and decision curve analysis.

Results

The platelet-to-lymphocyte ratio (PLR) was identified as an independent risk factor for progression, with an odds ratio (OR) of 1.01 (95% confidence interval (CI) = 1.01-1.01, p = 0.009). Additionally, other significant factors included the time for urinary protein turned negative (OR = 1.17, 95% CI = 1.12-1.23, p < 0.001), estimated glomerular filtration rate(eGFR) (OR = 0.99, 95% CI = 0.98-0.99, p < 0.001), low-density lipoprotein (OR = 0.90, 95% CI = 0.83-0.97, p = 0.006), thrombin time (OR = 1.22, 95% CI = 1.07-1.39, p = 0.003), and neutrophil absolute counts (OR = 1.10, 95% CI = 1.02-1.18, p = 0.009). The model's performance was assessed through internal validation, yielding an area under the curve of 0.78 (0.73-0.82) for the training set and 0.81 (0.75-0.87) for the validation set.

Conclusion

PLR, eGFR, the time for urinary protein turned negative, low-density lipoprotein, thrombin time, and neutrophil absolute counts may be effective predictors for identifying SSNS patients at risk of progressing to SDNS/FRNS. These findings offer valuable insights for early detection and support the use of precision medicine strategies in managing SDNS/FRNS.

Retrospective Cohort Analysis of Class II Human Leukocyte Antigen (HLA) Alleles in Children With Steroid-Dependent Nephrotic Syndrome Treated With Cyclophosphamide

Background The role of specific human leukocyte antigen (HLA) alleles as a risk factor for susceptibility, protection, and response to cyclophosphamide (CYC) treatment has been studied in patients with idiopathic nephrotic syndrome (INS). This study investigates the association of class II HLA alleles and the treatment outcome in children with steroid-dependent nephrotic syndrome (SDNS) who were treated with CYC. Methods A total of 77 children who were diagnosed with SDNS and had received CYC at least a year before were enrolled. After obtaining informed consent from the parents, blood samples were collected to type the HLA class II locus (DR and DQ) using sequence-specific primers (SSP). An equal number of adult healthy controls (AHC) were included. Results The median age of the study participants at disease onset was five (IQ: 3-7) years with a male-to-female ratio of 1.48:1. The common HLA alleles found in the study cohort and controls were DRB1*7 45 (29%), DRB1*15 30 (19.5%), and DQB1*2 57 (37%), and DRB1*15 31(20%), DRB1*17 36 (23%), DQB1*6 42 (27%), and DQB1*2 38 (25%), respectively. Identification of a particular allele to predict a good or poor response was not statistically significant (p-value >0.05). Conclusion The study demonstrates the common HLA alleles in the cohort. However, a specific allele that can predict a good and poor response to CYP was not identified. Further large-scale, prospective multicenter studies are needed to identify such alleles to decide the use of CYC in the SDNS population judiciously.

Risk factors and renal outcomes of AKI in children with secondary steroid-resistant nephrotic syndrome

BACKGROUND

Acute kidney injury (AKI) is increasingly prevalent in children with nephrotic syndrome (NS). It is associated with adverse outcomes in NS, especially steroid-resistant nephrotic syndrome (SRNS). The incidence, risk factors and outcomes of AKI in secondary SRNS remain undefined. The main objectives of this study were to determine the risk factors and prognosis of AKI in hospitalized children with secondary SRNS.

MATERIAL AND METHODS

This retrospective study was conducted from January 2014 to December 2019, involving 172 hospitalizations with secondary SRNS admitted to the First Affiliated Hospital of Sun Yat-sen University. AKI was defined and classified in accordance with the 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines.

RESULTS

AKI was found in 67 (39.0%) of 172 hospitalizations with secondary SRNS. Average age of onset in our group is 4.4 (3.1, 6.7) years with AKI and 3.7 (1.8, 5.6) years without AKI. Urea nitrogen level is 5.9 (4.1, 10.0) mmol/L with AKI and 5.1 (3.7, 7.0) mmol/L. Uric acid level is 446.0 (340.0, 567.0) umol/L with AKI and 401.0 (303.0, 496.0) umol/L. 24-h urinary protein level is 4.14 (2.9, 6.5) g with AKI and 2.5 (1.3, 5.3) without AKI. Multivariate logistic regression revealed that infection (OR = 5.287; 95% confidence interval, 2.349 to 11.899; p < 0.001), age at onset (OR = 1.180; 95% confidence interval, 1.032 to 1.349; p = 0.015) and uric acid level (OR = 1.003; 95% confidence interval, 1.000 to 1.006; p = 0.031) were significantly associated with the development of AKI in children with secondary SRNS. Among 72 children with secondary SRNS, six went to end-stage kidney disease (ESKD). Children in the AKI group were more likely to progress to ESKD compared with children in the non-AKI group (p = 0.017) with a median follow-up of 48.5months.

CONCLUSION

AKI occurred in 39.0% of total hospitalizations associated with secondary SRNS. Risk factors including infection, age of onset, and uric acid level are associated with AKI in children with secondary SRNS. Furthermore, AKI was identified as a risk factor for the progression of secondary SRNS to ESKD.

Timing of relapse as a key indicator of steroid-sparing requirements in childhood idiopathic nephrotic syndrome

BACKGROUND

Managing children with frequent relapses or steroid-dependent nephrotic syndrome poses challenges due to recurrent relapses necessitating prolonged steroid exposure, thus increasing susceptibility to long-term complications. Identifying those at risk of poor response to steroid therapy may be helpful to guide timely intervention with steroid-sparing agents. This study aimed to identify factors associated with steroid-sparing agent needs in children with frequent relapses or steroid-dependent nephrotic syndrome.

METHODS

A retrospective multicenter cohort study was conducted by reviewing the medical records of children with idiopathic nephrotic syndrome treated between 2006 and 2023. Cox proportional regression analyzed prognostic factors for steroid-sparing agent requirements in children with frequent relapses or steroid-dependent nephrotic syndrome. The time-to-event analysis utilizing the Kaplan-Meier estimate examined the proportion of children needing steroid-sparing agents after diagnosis.

RESULTS

Medical records of 121 children (85 males) diagnosed with idiopathic nephrotic syndrome at a median age of 4.5 years (range 1.3-12.8) were reviewed over a median follow-up of 3.7 years (range 1.0-15.0). Time to subsequent relapse post-frequent relapses or steroid-dependent nephrotic syndrome diagnosis (at 3-month threshold) emerged as the sole significant predictor of steroid-sparing agent requirement, adjusted hazard ratio (aHR) = 2.26, 95% confidence interval (CI) 1.26-4.05. Kaplan-Meier analysis indicated that an earlier first relapse (< 3 months) led to earlier steroid-sparing agent requirement (log-rank p = 0.005). Children who relapsed within 3 months post-frequent relapses or steroid-dependent nephrotic syndrome diagnosis exhibited a higher frequency of relapses, a greater incidence of steroid-related adverse events, and were more likely to develop steroid dependency.

CONCLUSIONS

Early subsequent relapse following diagnosis of frequent relapses or steroid-dependent nephrotic syndrome was linked to earlier requirement of steroid-sparing agent therapy. Further prospective research is necessary to confirm this observation.

Circulating RAC1 contributed to steroid-sensitive nephrotic syndrome: Mendelian randomization, single-cell RNA-sequencing, proteomic, and experimental evidence

OBJECTIVES

The small GTPase Rac1 (RAC1) has been linked to podocyte disorders and steroid-sensitive nephrotic syndrome (SSNS). The aim of this study was to explore and validate the potential causal association between circulating RAC1 and SSNS.

METHODS

The association between circulating RAC1 and SSNS at both gene expression and proteomic levels was investigated using Mendelian randomization analysis, and further validated by single-cell RNA-sequencing, proteomic analysis, and experimental studies. The genetic instruments comprised cis-expression quantitative trait loci (cis-eQTLs) associated with RAC1 gene expression and protein QTLs correlated with plasma RAC1 protein levels. Causal associations were estimated utilizing the inverse variance weighted and MR-PRESSO methods. Validation of RAC1 expression was conducted through single-cell RNA-sequencing of peripheral blood mononuclear cells from patients with SSNS and healthy controls. Proteomic analysis was performed among patients with minimal change nephrotic syndrome. Experimental validation was conducted using a puromycin aminonucleoside (PAN)-induced nephrosis model.

RESULTS

Increased expression of RAC1 was associated with a higher risk of SSNS (gene expression level: odds ratio [OR], 1.53; 95% confidence interval [CI], 1.02-2.28; protein level: OR, 1.82; 95% CI, 1.05-3.17). The results of MR-PRESSO were consistent (gene expression level: OR, 1.49; 95% CI, 1.17-1.92; protein level: OR, 1.81; 95% CI, 1.16-2.85). Single-cell RNA sequencing and proteomic analysis confirmed elevated RAC1 expression in patients with SSNS compared to healthy controls. Experimental data further supported increased RAC1 expression in PAN-induced nephropathy.

CONCLUSIONS

Increased expression of RAC1 might be causally associated with SSNS, suggesting that targeting RAC1 might represent a potential therapeutic strategy for SSNS.

K acetyltransferase 2B (KAT2B) variants can be responsible for early onset steroid-resistant nephrotic syndrome

In children, 15% of nephrotic syndromes are steroid-resistant (SRNS); approximately 30% of early onset SRNS have a genetic origin, with more than 100 causal genes described so far. SRNS can be syndromic, if associated with signs and symptoms affecting other organs or systems, such as the central nervous system, the heart or the eyes. Patients with SRNS are at high risk of chronic kidney disease and progressive renal failure, and as such need multidisciplinary care, centred on renal protection. Recently, K acetyltransferase 2B (KAT2B) loss of function was identified as a risk factor for morphological and functional defects in Drosophila nephrocytes; in vitro knockdown of KAT2B also impaired the adhesion and migration ability of human podocytes.Here we provide the first clinical description of a family affected by a loss of function mutation of KAT2B Clinically, both siblings presented with early onset SRNS and bilateral cataract, without neurological or heart defects. Renal function was maintained in the teenage years; nephrotic-range proteinuria was insensitive to immunosuppressive therapies. Therefore, mutations of KAT2B should be sought in patients with unexplained syndromic SRNS affecting the eye.

Rituximab Administration to Treat Nephrotic Syndrome in Children: 2-Year Follow-Up

BACKGROUND

Steroid-sensitive nephrotic syndrome (SSNS) and steroid-resistant nephrotic syndrome (SRNS) significantly affect children's quality of life. There are frequent relapses in SSNS and progression in SRNS. IPNA guidelines suggest that monoclonal antibodies like rituximab (RTX) are promising treatments.

OBJECTIVE

This study aims to evaluate the long-term efficacy and safety of rituximab administration in children with SSNS, encompassing FRNS and SDNS, and SRNS over a two-year follow-up period, facilitating individualized management.

METHODS

We conducted an open-label, multicenter, randomized, and patient-oriented study (RICHNESS), involving children aged 3-18 with SRNS (18) and SSNS (11) undergoing 2 years continuous RTX therapy. The primary outcome was complete/partial remission (CR/PR), as defined by IPNA/KDIGO guidelines, at 6, 12, 18, and 24 months on RTX; secondary outcomes included adverse events. Key endpoints included the estimated glomerular filtration rate (eGFR), the albumin-to-creatinine ratio (ACR), CD20 levels, IgG levels, and the incidence of infections. Kidney biopsies were performed in 94% of SRNS patients. RTX was administered every 6-9 months, depending on CD20 levels, IgG levels, and the presence of infections. The eGFR and ACR were assessed every 6 months.

RESULTS

Some 31 children were selected for RTX treatment. Overall, 2 experienced severe allergic reactions, leading to their exclusion from the final analysis of 29 children. In the SSNS group, all children achieved and maintained complete remission within 2 years. Remission rates in the SRNS group ranged from 39% (RR 0.78; 95% CI: 16.4-61.4%, NNT 9) at the 6th month to 72% (RR 1.44; 95% CI: 51.5-92.9%) over the 2-year follow-up period due to continuous RTX therapy. The median duration of RTX use was 26.1 months, with a median cumulative dose of 1820 mg/m2. Adverse reactions and complications were presented by mild infusion-related reactions in 3 children (10.3%), severe allergic reactions in 2 children (6.2%), hypogammaglobulinemia in 7 children (24%), infections in 3 children (10.3%), severe destructive pneumonia in 1 child, recurrent respiratory infections in 2 children, and neutropenia in 1 child (3.44%).

CONCLUSIONS

RTX was tolerated well, and proved highly effective as a steroid-sparing agent, offering potential in terms of stopping relapses and minimizing steroid-related side effects. It also demonstrated efficacy in slowing progression in SRNS, indicating potential for use in ACR reduction and renal function restoration, but requires careful use given potential severe allergic reactions and infectious complications. Further studies should focus on long-term cost-effectiveness and deferred side effects.

Detailed Pathophysiology of Minimal Change Disease: Insights into Podocyte Dysfunction, Immune Dysregulation, and Genetic Susceptibility

Minimal Change Disease (MCD) is a predominant cause of idiopathic nephrotic syndrome in the pediatric population, yet presents significant clinical challenges due to its frequent relapses and steroid resistance. Despite its relatively benign histological appearance, MCD is characterized by severe proteinuria, hypoalbuminemia, and edema, which may affect patient outcomes. Current treatment strategies primarily rely on corticosteroids, which are effective in inducing remission but are associated with high relapse rates, steroid resistance, and numerous long-term side effects, underscoring the need for more targeted and effective therapeutic approaches. This narrative review synthesizes current knowledge on the pathophysiological mechanisms underlying MCD, focusing on the following three critical areas: podocyte dysfunction, immune dysregulation, and genetic susceptibility. Podocyte dysfunction, particularly involving alterations in nephrin, plays a central role in the breakdown of the glomerular filtration barrier, leading to the characteristic proteinuria observed in MCD. Immune dysregulation, including the presence of autoantibodies against nephrin and other podocyte components, exacerbates podocyte injury and contributes to disease progression, suggesting an autoimmune component to the disease. Genetic factors, particularly mutations in the NPHS1 and NPHS2 genes, have been identified as significant contributors to disease susceptibility, influencing the variability in treatment response and overall disease severity. Understanding these mechanisms is crucial for developing targeted therapies that address the underlying causes of MCD rather than merely managing its symptoms. This review highlights the need for further research into these pathophysiological processes to pave the way for more personalized and effective treatment strategies, ultimately improving patient outcomes and reducing reliance on corticosteroids.

Non-corticosteroid immunosuppressive medications for steroid-sensitive nephrotic syndrome in children

BACKGROUND

About 80% of children with steroid-sensitive nephrotic syndrome (SSNS) have relapses. Of these children, half will relapse frequently, and are at risk of adverse effects from corticosteroids. While non-corticosteroid immunosuppressive medications prolong periods of remission, they have significant potential adverse effects. Currently, there is no consensus about the most appropriate second-line agent in children with frequently relapsing SSNS. In addition, these medications could be used with corticosteroids in the initial episode of SSNS to prolong the period of remission. This is the fifth update of a review first published in 2001 and updated in 2005, 2008, 2013 and 2020.

OBJECTIVES

To evaluate the benefits and harms of non-corticosteroid immunosuppressive medications in SSNS in children with a relapsing course of SSNS and in children with their first episode of nephrotic syndrome.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to October 2024 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs were included if they involved children with SSNS and compared non-corticosteroid immunosuppressive medications with placebo, corticosteroids or no treatment; different non-corticosteroid immunosuppressive medications, or different doses, durations or routes of administration of the same non-corticosteroid immunosuppressive medication.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility, risk of bias and extracted data from the included studies. Statistical analyses were performed using a random-effects model and results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

We identified 58 studies (122 reports) randomising 3720 children. Half were multicentre studies, and most studies were undertaken in South and East Asia (28 studies) and Europe (20 studies). The numbers of children randomised ranged from 14 to 211. Risk of bias assessment indicated that 32 and 33 studies were at low risk of bias for sequence generation and allocation concealment, respectively. Eleven studies were at low risk of performance bias and 13 were at low risk of detection bias. Forty-eight and 36 studies were at low risk of incomplete and selective reporting, respectively. Rituximab with or without prednisone compared with placebo with or without prednisone probably reduces the number of children experiencing relapse at six months (5 studies, 182 children: RR 0.22, 95% CI 0.11 to 0.43) and 12 months (3 studies, 108 children: RR 0.38, 95% CI 0.13 to 1.09) (moderate certainty), may increase the number with severe infusion reactions (4 studies, 162 children: RR 5.21, 95% CI 1.19 to 22.89; low certainty), but not severe infection or arthropathy (low certainty). Rituximab compared with tacrolimus probably reduces the risk of relapse at 12 months (4 studies, 238 children: RR 0.64, 95% CI 0.42 to 0.96) and may reduce the risk of relapse when compared with low dose mycophenolate mofetil (MMF) (1 study, 30 children: RR 0.17, 95% CI 0.04 to 0.62). Rituximab followed by MMF for 500 days reduces the risk of relapse compared with rituximab followed by placebo for 500 days (1 study, 78 children: RR 0.29, 95% CI 0.13 to 0.63; high certainty). Rituximab probably does not differ from ofatumumab in the riisk of relapse and 12 months (1 study, 140 children: RR 1.03, 95% CI 0.75 to 1.41; moderate certainty) or in adverse events. MMF and levamisole (1 study, 149 children: RR 0.90, 95% CI 0.70 to 1.16) may have similar effects on the number of children who relapse at 12 months (low certainty). Cyclosporin compared with MMF may reduce the risk of relapse at 12 months (3 studies, 114 children: RR 1.57, 95% CI 1.08 to 2.30) (low certainty). Levamisole compared with steroids or placebo may reduce the number of children with relapse during treatment (8 studies, 474 children: RR 0.52, 95% CI 0.33 to 0.82) (low certainty). Preliminary data from single studies indicate that levamisole and prednisone compared with prednisone alone may delay the onset of relapse after the initial episode of SSNS and that levamisole compared with increasing prednisone administration from alternate day to daily at the onset of infection may reduce the risk of relapse with infection (low certainty). Cyclosporin compared with prednisone may reduce the number of children who relapse (1 study, 104 children: RR 0.33, 95% CI 0.13 to 0.83) (low certainty). Alkylating agents compared with cyclosporin may make little or no difference to the risk of relapse during cyclosporin treatment (2 studies, 95 children: RR 0.91, 95% CI 0.55 to 1.48) (low certainty evidence) but may reduce the risk of relapse at 12 to 24 months (2 studies, 95 children: RR 0.51, 95% CI 0.35 to 0.74) (low certainty). Alkylating agents (cyclophosphamide and chlorambucil) compared with prednisone probably reduce the number of children who experience relapse at six to 12 months (6 studies, 202 children: RR 0.44, 95% CI 0.32 to 0.60) and at 12 to 24 months (4 studies, 59 children: RR 0.20, 95% CI 0.09 to 0.46) (moderate certainty).

AUTHORS' CONCLUSIONS

New studies incorporated in this review update indicate that rituximab compared with prednisone, tacrolimus, or MMF is a valuable additional agent for managing children with relapsing SSNS. Comparative studies of CNIs, MMF, and levamisole suggest that CNIs may be more effective than MMF and that levamisole may be similar in efficacy to MMF. Important new studies suggest that MMF prolongs remission following rituximab, that levamisole may prevent infection-related relapse more effectively than changing from alternate-day to daily prednisone and that levamisole and prednisone compared with prednisone alone may prolong the time to first relapse. There are currently 23 ongoing studies which should improve our understanding of how to treat children with frequently relapsing SSNS.

Targeted Treatments for Myasthenia Gravis in Children and Adolescents

Myasthenia gravis (MG) is an antibody-mediated disorder of the neuromuscular junction affecting children and adults. MG is a treatable condition with most patients requiring immunosuppression for disease control and/or remission. Juvenile myasthenia gravis (JMG) is rare in comparison with adult-onset MG but given the same underlying pathophysiology, treatment strategies are similar to those in adults. Until recently, there were only a few randomised controlled trials (RCTs) for MG treatments in adults and none in children, and management strategies were primarily based on expert consensus. In addition, treatment options for refractory MG cases have been severely limited, resulting in poor long-term quality of life in such patients due to the significant disease burden. Recently, there have been several RCTs focussing on novel therapeutic strategies with potentially promising outcomes, suggesting a change in MG management over the coming years and access to more effective and faster-acting drugs for MG patients. This paper will review current and new MG treatments including efgartigimod, eculizumab, rozanolixizumab, ravulizumab, and zilucoplan, with a focus on juvenile myasthenia gravis.

Dried Blood Spot Sampling for Monitoring Children With Immune-Mediated Glomerulopathies and After Kidney Transplantation

Introduction

Monitoring kidney function and immunosuppressant levels in children post-kidney transplantation or those with glomerulopathies is challenging due to frequent venipunctures and clinic visits. Capillary dried blood spot sampling (DBS) offers a potential alternative.

Methods

In this prospective single-center study, 89 children (38% female and 62% male) requiring therapeutic drug monitoring (TDM) and kidney function assessment were enrolled. Of the patients, 79% were kidney transplant recipients, and 21% had immune-mediated glomerulopathies. The mean age was 13.4 (range, 5.7-18.0) years. DBS and standard venous serum samples were collected simultaneously for tacrolimus (TAC), cyclosporine A (CsA), everolimus (EVR), and creatinine levels. Furthermore, patient feedback on pain perception and feasibility was collected via questionnaire.

Results

No significant differences in parameter values between DBS and standard methods were observed (creatinine, -1.7 ± 14.5 μmol/l; EVR, 0.1 ± 1.2 μg/l; TAC, 0.3 ± 1.1 μg/l; CsA, 2.8 ± 9.8 μg/l). DBS demonstrated sufficient accuracy compared with standard methods. Patients favored DBS and telehealth consultations, especially due to less travel and school absences. Patients preferred finger pricking over ear pricking.

Conclusion

Capillary DBS proves reliable for TDM and kidney function assessment in pediatric kidney disease. It reduces patient and family burden compared with venous blood collection and enables telehealth consultations.

Efficacy of rituximab and risk factors for poor prognosis in patients with childhood-onset steroid-resistant nephrotic syndrome: a multicenter study

BACKGROUND

The efficacy of rituximab in steroid-resistant nephrotic syndrome (SRNS) is controversial. We previously reported that rituximab in combination with methylprednisolone pulse therapy (MPT) and immunosuppressants was associated with favorable outcomes. We determined risk factors for poor response following rituximab treatment, which remains unknown.

METHODS

This retrospective study included 45 patients with childhood-onset SRNS treated with rituximab across four pediatric kidney facilities. Treatment effects were categorized as complete remission (CR), partial remission (PR), and no remission (NR) at one year after rituximab treatment. The primary outcome was the rate of CR, PR, and NR. Risk factors for non-CR were calculated with multivariate logistic regression. Adverse events and the relationship between disease status at one year and long-term prognosis were also evaluated.

RESULTS

The rates of CR, PR, and NR at one year were 69%, 24%, and 7%, respectively. The median time from rituximab administration to CR was 90 days. The median follow-up period after rituximab administration was 7.4 years. In multivariate analysis, significant risk factors for poor response were the pathologic finding of focal segmental glomerular sclerosis and a long interval between SRNS diagnosis and rituximab administration. The rates of CR were 90.3% and 21.4% in patients receiving rituximab within and after 6 months following SRNS diagnosis, respectively (p < 0.001). Five patients developed chronic kidney disease stage G5, including 2 of the 11 patients with PR and all 3 patients with NR, whereas none of the 31 patients with CR developed chronic kidney disease stage G5.

CONCLUSION

Early administration of rituximab in combination with MPT and immunosuppressants might achieve favorable outcomes in patients with SRNS.

Lipoprotein glomerulopathy: a rare cause of steroid-resistant nephrotic syndrome in a child

Lipoprotein glomerulopathy (LPG) is a rare condition of renal lipidosis characterized by lipoprotein thrombi in glomeruli, an abnormal plasma lipoprotein profile, and a marked increase in serum apolipoprotein E (apo E) levels. It is a monogenic disorder with autosomal dominant inheritance and the average age of presentation is 32 years (4-69 years). It is rare in children. The presentation can be nephrotic syndrome, hematuria, or progressive renal failure. Here we report the first described case of LPG in an Indian 7.5-year-old boy who presented with steroid-resistant nephrotic syndrome with normal renal function. A renal biopsy was suggestive of lipoprotein glomerulopathy. The detection of a pathogenic variant in apo E, Kyoto type, by exome sequencing, confirmed the diagnosis of lipoprotein glomerulopathy. Complete response was achieved with Angiotensin-converting Enzyme inhibitor and fenofibrates.

Daily compared with alternate-day levamisole in pediatric nephrotic syndrome: an open-label randomized controlled study

BACKGROUND

Levamisole is less expensive and has a better toxicity profile compared to other steroid sparing agents used in nephrotic syndrome. It has a plasma half-life of 2.0 to 5.6 hours, but is conventionally administered on alternate days. We aimed to assess whether daily levamisole is safe and more effective than standard alternate-day therapy in maintaining remission in children with frequently relapsing or steroid-dependent nephrotic syndrome (FR/SDNS).

METHODS

An open-label randomized controlled trial was conducted in children with FR/SDNS. Group A received daily while Group B received alternate-day levamisole (2-3 mg/kg/dose) for 12 months. Prednisolone was tapered off by 3 months. Patients were monitored for relapses, further steroid requirement, and adverse effects.

RESULTS

A total of 190 children with FR/SDNS (94 in Group A and 96 in Group B) were analyzed. Sustained remission for 12 months was observed in 36% of Group A and 27% of Group B patients (p = 0.18). Numbers completing 12 months in the study were 67% in Group A and 56% in Group B (p = 0.13). Time to first relapse, persistent FR/SDNS, and withdrawal due to poor compliance were statistically similar in both groups, while relapse rate and cumulative steroid dosage were significantly lower in Group A compared to Group B (p = 0.03 and p = 0.02, respectively). The incidence of adverse effects was comparable in both groups, with reversible leucopenia and hepatic transaminitis being the commonest.

CONCLUSIONS

Daily levamisole therapy was not superior to alternate-day therapy in maintaining sustained remission over 12 months. Nevertheless, relapse rate and cumulative steroid dosage were significantly lower without increased adverse effects.