1
|
Krishna GM, Dabas A, Mantan M, Kumar M A, Goswami B. Adrenocortical suppression in children with nephrotic syndrome treated with corticosteroids. Pediatr Nephrol 2024; 39:1817-1824. [PMID: 38253887 DOI: 10.1007/s00467-024-06294-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Children with nephrotic syndrome are exposed to alternate day steroids for prolonged periods and this poses the need for evaluation of adrenocortical suppression using the adrenocorticotropic hormone (ACTH) stimulation test. METHODS This cross-sectional study enrolled children (2-18 years) both with steroid sensitive nephrotic syndrome (SSNS) (n = 27) and steroid resistant (SRNS) (n = 25); those on daily prednisolone or having serious bacterial infections or hospitalized were excluded. The primary objective was to determine prevalence of adrenocortical suppression in those on low dose alternate day steroids for more than 8 weeks or having received > 2 mg/kg/d for > 2 weeks in the past 1 year and currently in remission. A baseline morning fasting sample of serum cortisol was taken and 25 IU of ACTH (Acton Prolongatum*) injected intramuscularly and repeat serum cortisol sample taken after 1 h. All patients with 1 h post ACTH cortisol < 18.0 µgm/dl were diagnosed with adrenal insufficiency. Receiver operating characteristic curve was drawn to predict the prednisolone dose for adrenal insufficiency. RESULTS Fifty-two (33 males) children were enrolled (mean age 9.4 years); proportion of adrenal insufficiency was 50% and 64% using baseline and post stimulation cutoffs. The total cumulative annual dose of prednisolone 0.22 mg/kg/day predicted adrenocortical suppression with AUC 0.76 (95% CI 0.63-0.89), with sensitivity of 63.9% and specificity of 81.3%. CONCLUSIONS A significant proportion of children with nephrotic syndrome were detected with adrenal insufficiency on ACTH stimulation test. A cumulative steroid intake of > 0.22 mg/kg/day on an alternate day basis emerged as a risk factor for predicting adrenocortical suppression.
Collapse
Affiliation(s)
- Ganesh M Krishna
- Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Aashima Dabas
- Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Mukta Mantan
- Division of Pediatric Nephrology, Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India.
| | - Akshay Kumar M
- Department of Pediatrics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| | - Binita Goswami
- Department of Biochemistry, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
| |
Collapse
|
2
|
Sinha A, Devi KG, Kalra S, Mani K, Hari P, Bagga A. An open label non-inferiority randomized controlled trial evaluated alternate day prednisolone given daily during infections vs. levamisole in frequently relapsing nephrotic syndrome. Kidney Int 2024; 105:1113-1123. [PMID: 38360110 DOI: 10.1016/j.kint.2024.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/27/2023] [Accepted: 01/02/2024] [Indexed: 02/17/2024]
Abstract
Initial therapies for children with frequently relapsing nephrotic syndrome include alternate-day prednisolone that is given daily during infections, or levamisole. In this open label, non-inferiority trial, 160 patients, 2 to 18-years-old with frequent relapses, were randomly assigned to receive either prednisolone (0.5-0.7 mg/kg/alternate-day, given daily during infections), or levamisole (2-2.5 mg/kg/alternate-days) for one-year. Patients with relapses on alternate day prednisolone at over 1 mg/kg, prior use of potent steroid-sparing therapies, eGFR under 60 ml/min/1.73 m2 and significant steroid toxicity were excluded. Primary outcome was the proportion of patients with frequent relapses, defined as three-relapses in one-year, or two-relapses within six-months if associated with significant steroid toxicity or loss to follow up. Eighty patients each were randomized to receive prednisolone and levamisole. Baseline features showed preponderance of young patients presenting within two-years of disease onset. On intention-to-treat analysis, frequent relapses were more common in patients administered prednisolone (40% versus 22.5%; risk difference 17.5%; 95% confidence interval 3.4-31.6%). Prednisolone was not non-inferior to levamisole in preventing frequent relapses. However, the two groups showed similar proportions of patients in sustained remission, comparable frequency of relapses, and low frequency of adverse events. The decline in steroid requirement from baseline was higher in the levamisole group. Per-protocol analysis showed similar results. These results have implications for choice of therapy for frequently relapsing nephrotic syndrome. Although therapy with alternate-day prednisolone was not non-inferior to levamisole in preventing frequent relapses, both therapies were effective in other outcome measures. Thus, levamisole was relatively steroid-sparing and may be preferred in patients at risk of steroid toxicity.
Collapse
Affiliation(s)
- Aditi Sinha
- Division of Nephrology, Indian Council of Medical Research (ICMR) Advanced Center for Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kshetrimayum Ghanapriya Devi
- Division of Nephrology, Indian Council of Medical Research (ICMR) Advanced Center for Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Suprita Kalra
- Division of Nephrology, Indian Council of Medical Research (ICMR) Advanced Center for Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India; Department of Pediatrics, Command Hospital, Pune, India
| | - Kalaivani Mani
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology, Indian Council of Medical Research (ICMR) Advanced Center for Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology, Indian Council of Medical Research (ICMR) Advanced Center for Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.
| |
Collapse
|
3
|
Sinha R, Sarkar S, Banerjee S, Akhtar S, Poddar S, Dasgupta D, Saha R, Sengupta J, Mandal M, Tse Y, Pahari A. Antineutrophil cytoplasmic antibody in children with nephrotic syndrome treated with levamisole: a cross-sectional cohort study. Pediatr Nephrol 2024:10.1007/s00467-024-06362-0. [PMID: 38589697 DOI: 10.1007/s00467-024-06362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Levamisole is a commonly used steroid-sparing agent (SSA), but the reported incidence of antineutrophil cytoplasmic antibody (ANCA) positivity has been concerning. METHODS Observational cross-sectional study wherein children aged 2 to 18 years with frequently relapsing/steroid dependent nephrotic syndrome (FRNS/SDNS) on levamisole for ≥ 12 months were tested for ANCA. RESULTS A total of 210 children (33% female), median age of 7.3 (IQR: 5.6-9.6) years, and a median duration of levamisole exposure of 21 (IQR: 15-30) months were tested. ANCA was positive in 18% (n = 37): 89% (n = 33) perinuclear ANCA (pANCA), 3% (n = 1) cytoplasmic ANCA (cANCA), and 8% (n = 3) both. Of ANCA-positive children, none had reduced eGFR or abnormal urinalysis. The majority of these children were asymptomatic (81%, n = 30). Rash was more common among ANCA-positive children [6/37 (16%) vs. 3/173 (2%), p = 0.0001]. On multivariate analysis, higher age (OR = 1.02, [95th CI: 1.01 to 1.03], p = 0.007) and longer duration of levamisole exposure (OR = 1.05, [95th CI: 1.02 to 1.08], p = 0.0007) were associated with ANCA positivity. Levamisole was stopped in ANCA-positive children with the resolution of any clinical manifestations if present. Repeat ANCA testing was performed in 54% (20/37), and all were ANCA negative by 18 months. CONCLUSIONS Children with FRNS/SDNS on longer duration of levamisole were associated with increasing prevalence of ANCA positivity, but most of these children were clinically asymptomatic. Prospective studies are required to determine the chronology of ANCA positivity and its clinical implication.
Collapse
Affiliation(s)
- Rajiv Sinha
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India.
| | | | - Sushmita Banerjee
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Shakil Akhtar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Sanjukta Poddar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Deblina Dasgupta
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Rana Saha
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Jayati Sengupta
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
| | - Mita Mandal
- All India Institute of Medical Sciences, Kalyani, India
| | - Yincent Tse
- Great North Children's Hospital, Newcastle Upon Tyne, UK
| | - Amitava Pahari
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, 700019, India
- Apollo Multispecialty Hospital, Kolkata, India
| |
Collapse
|
4
|
Gowda H, Bhatia A, Tiewsoh K, Saxena AK, Dawman L, Bansal M, Sodhi KS. Shear wave elastography of kidneys in children: utility in distinguishing steroid-resistant and steroid-sensitive nephrotic syndrome. Abdom Radiol (NY) 2024; 49:551-559. [PMID: 38150144 DOI: 10.1007/s00261-023-04138-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 11/14/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023]
Abstract
PURPOSE To assess the renal elasticity values using (SWE) and correlate the values with steroid sensitivity to distinguish between steroid-resistant nephrotic syndrome (SRNS) and steroid-sensitive nephrotic syndrome (SSNS) in children. METHODS In this IRB-approved cross-sectional study, 83 children (4-14 years) diagnosed with nephrotic syndrome were included from July 2021 to December 2022. SWE measurements were done for each kidney's upper pole, interpolar region, and lower pole. Mean as well as median SWE were calculated. Correlation of the renal stiffness values was done with different laboratory findings (blood urea, serum creatinine, 24 h urine protein, serum albumin, and serum cholesterol), the grayscale findings (cortical echogenicity, and corticomedullary differentiation), and the final diagnosis of SRNS and SSNS. The statistical tests were done at a significance level of α = 0.05. RESULTS The median (IQR) overall SWE of kidneys was higher in SRNS group 12.64 (8.4-19.68) kPa than SSNS group 9.87 (8.20-12.56) kPa. The difference was significant (p = 0.004). At a cut-off of ≥ 10.694 kPa (AUROC- 0.641), the overall SWE predicted SRNS group with a sensitivity of 70% and a specificity of 63%. A significant correlation (p < 0.05) was found between the SWE and 24-h urine protein, cortical echogenicity, and corticomedullary differentiation in SSNS, while only between SWE and corticomedullary differentiation in SRNS. CONCLUSION The mean SWE was higher in children with SRNS. While SWE has potential to differentiate SSNS from SRNS, a different study design where SWE is performed at presentation is needed for confirmation.
Collapse
Affiliation(s)
- Harshith Gowda
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
| | - Anmol Bhatia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India.
| | - Karalanglin Tiewsoh
- Division of Pediatric Nephrology, Department of Pediatric Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
| | - Akshay Kumar Saxena
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
| | - Lesa Dawman
- Division of Pediatric Nephrology, Department of Pediatric Medicine, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
| | - Madhav Bansal
- Institute of Medical Sciences and Sum Hospital, Bhubaneswar, India
| | - Kushaljit Singh Sodhi
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, 160012, India
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
5
|
Das H, Satapathy A, John J, Kar M, Mohakud S. Endothelial Dysfunction in Children With Nephrotic Syndrome: A Cross-Sectional Study. Cureus 2024; 16:e53628. [PMID: 38449929 PMCID: PMC10917071 DOI: 10.7759/cureus.53628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
Background Children with nephrotic syndrome (NS) have a higher risk of cardiovascular morbidity. Studies on the evaluation of arterial stiffness and endothelial function and its predictive risk factors in these children are limited. Objective The primary objective of the study was to determine arterial stiffness by measuring carotid intimal medial thickness, flow-mediated dilatation, and physiological parameters in children with nephrotic syndrome to predict the risk of premature atherosclerosis as compared to controls. Participants A total number of 33 children with NS in the age group of 2-14 years in remission and 39 healthy controls were enrolled in the study. Out of 33 children with nephrotic syndrome, five were infrequently relapsing NS, eight were frequently relapsing, 16 were steroid dependent, and four were steroid-resistant NS. Intervention Relevant history, physical examination, anthropometric measurements, and laboratory investigations were done. Carotid intimal medial thickness (cIMT), flow-mediated dilatation (FMD), and other physiological parameters were measured in both children with NS and control groups. Outcome Carotid intimal medial thickness (cIMT), flow-mediated dilatation (FMD), and other physiological parameters were compared between children with NS and healthy controls for detecting arterial stiffness and endothelial dysfunction. Results Dyslipidaemia was seen in more than 50% of children during remission. There was neither significant difference in mean cIMT in the common carotid artery nor FMD between the control and study groups. There was a trend of lower Reactive Hyperemia Index (RHI) in children with NS. Conclusion Dyslipidemia persists even during the remission phase in NS. No statistically significant difference is observed in cIMT and percentage proportionate change in FMD in both the study and control groups. Nevertheless, RHI is notably lower in children with NS. These findings need further validation in future studies.
Collapse
Affiliation(s)
- Harapriya Das
- Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, IND
| | - Amit Satapathy
- Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, IND
| | - Joseph John
- Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, IND
| | - Manisha Kar
- Physiology, All India Institute of Medical Sciences, Bhubaneswar, IND
| | - Sudipta Mohakud
- Radiology, All India Institute of Medical Sciences, Bhubaneswar, IND
| |
Collapse
|
6
|
Lai FFY, Chan EYH, Tullus K, Ma ALT. Therapeutic drug monitoring in childhood idiopathic nephrotic syndrome: a state of the art review. Pediatr Nephrol 2024; 39:85-103. [PMID: 37147510 DOI: 10.1007/s00467-023-05974-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 05/07/2023]
Abstract
Immunosuppressants are commonly used as steroid-sparing agents in childhood idiopathic nephrotic syndrome (NS) to induce and sustain remissions. These drugs have narrow therapeutic indices with high inter- and intra-patient variability. Therapeutic drug monitoring (TDM) would therefore be essential to guide the prescription. Multiple factors in NS contribute to additional variability in drug concentrations, especially during relapses. In this article, we review the currently available evidence of TDM in NS and suggest a practical approach for clinicians' reference.
Collapse
Affiliation(s)
- Fiona Fung-Yee Lai
- Department of Pharmacy, Hong Kong Children's Hospital, Kowloon City, Hong Kong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong
| | - Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong.
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong
| |
Collapse
|
7
|
Bekassy Z, Lindström M, Rosenblad T, Aradóttir S, Sartz L, Tullus K. Is kidney biopsy necessary in children with idiopathic nephrotic syndrome? Acta Paediatr 2023; 112:2611-2618. [PMID: 37642221 DOI: 10.1111/apa.16959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/02/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
AIM To investigate the need, in the Northern European setting, to perform kidney biopsy in children with steroid-sensitive nephrotic syndrome. METHODS In this retrospective study 124 individuals aged 1-18 years with idiopathic nephrotic syndrome, followed in the paediatric hospitals in southern Sweden from 1999 to 2018, were included. RESULTS There was a median follow-up time of 6.5 (0.2-16.8) years. The majority (92%) of children were steroid-sensitive and of them, 60.5% were frequently relapsing or steroid-dependent. Microscopic haematuria was found at onset in 81.1% and hypertension in 8.7%. At least one kidney biopsy was performed in 93 (75%). The most common indication was a steroid-dependent or relapsing course (58.4%). One of 79 steroid-sensitive children had another histological diagnosis than minimal change nephropathy 1.3%, 95% confidence interval (0.002, 0.068). Bleeding occurred after eight biopsies (6.6%). Twenty individuals (30.7%) were transferred to adult units, 18 still on immunosuppression. CONCLUSION We have in our cohort of unselected children with idiopathic nephrotic syndrome confirmed that a kidney biopsy rarely gives important medical information in steroid-sensitive children without any other complicating factor and that the liberal policy of kidney biopsy in the Nordic countries safely can be changed.
Collapse
Affiliation(s)
- Zivile Bekassy
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Section for Paediatric Nephrology, Skåne University Hospital, Lund, Sweden
| | - Martin Lindström
- Department of Clinical Sciences, Division of Pathology, Lund University, Lund, Sweden
| | - Therese Rosenblad
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Section for Paediatric Nephrology, Skåne University Hospital, Lund, Sweden
| | - Sunna Aradóttir
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Lisa Sartz
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
- Section for Paediatric Nephrology, Skåne University Hospital, Lund, Sweden
| | - Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children, London, UK
- Division of Paediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
8
|
Primack WA, Chevalier RL, Friedman A, Lemley KV, Norwood VF, Schwartz GJ, Silverstein D, Kaskel F. The first randomized controlled trial in pediatric nephrology: the history of the International Study of Kidney Disease in Children (ISKDC). Pediatr Nephrol 2023; 38:3947-3954. [PMID: 36625931 DOI: 10.1007/s00467-022-05838-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 01/11/2023]
Abstract
The International Study of Kidney Disease in Children (ISKDC), begun in 1966, conducted the first international collaborative randomized blinded controlled trial in pediatric nephrology and one of the first in either pediatrics or nephrology. For this trial, the ISKDC developed the criteria, such as those for response and relapse, used today to describe the clinical course of the nephrotic syndrome, and the trial generated the nephropathologic terminology and criteria which largely remain the current standards. Over an approximately 20-year span, the ISKDC followed the natural history and evaluated the therapeutic effectiveness of therapies in over 500 children with the nephrotic syndrome from three continents. It published 14 peer-reviewed studies and several reports and commentaries, many of which helped create current standards of practice for therapy of childhood nephrotic syndrome and consequently remain highly cited today. The ISKDC continues to be an important model for subsequent collaborative studies and was the impetus for the development of regional and national pediatric nephrology societies leading to the recognition and growth of pediatric nephrology as a separate subspecialty. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
| | - Robert L Chevalier
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | | | - Kevin V Lemley
- University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Victoria F Norwood
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | | | | | - Frederick Kaskel
- Department of Pediatrics (Montefiore), Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
9
|
Deepthi RV, George S, Mathew G, Roy S, Bindra M, Rebekah G, Agarwal I. The Clinical Profile and Long-Term Outcome of Children with Membranous Nephropathy, and the Evaluation of Anti-Phospholipase A2 Receptor Antibody Immunohistochemistry in Kidney Biopsy. Indian J Nephrol 2023; 33:432-439. [PMID: 38174298 PMCID: PMC10752404 DOI: 10.4103/ijn.ijn_228_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 10/11/2022] [Accepted: 11/02/2022] [Indexed: 01/05/2024] Open
Abstract
Introduction Idiopathic membranous nephropathy (iMN) is a rare cause of nephrotic syndrome in children (1%-7%). Anti-phospholipase A2 receptor (PLA2R) antibody positivity in kidney biopsy is observed in 52%-78% of adults and 45% of children with iMN. The objectives of the study are to analyze the clinical profile and outcome of membranous nephropathy in children, to assess the prevalence of anti-PLA2R immunohistochemistry (IHC) in kidney biopsy, and to correlate their presence with disease characteristics. Methods We are reporting a single-center retrospective study conducted in pediatric nephrology division. Clinical data and outcome parameters of children with membranous nephropathy were analyzed. PLA2R IHC was performed in kidney biopsy specimens retrospectively. Results We analyzed 43 children with membranous nephropathy (MN) from a single center. 18 (42%) had idiopathic MN (iMN). PLA2R IHC was performed in kidney biopsy specimens in 14/18 (78%) patients with iMN and 7/9 (78%) non-lupus secondary membranous nephropathy (SMN) patients. The most common cause of SMN was lupus nephritis in 16 patients (64%). The mean estimated glomerular filtration rate (eGFR) at onset was 156 ± 81 ml/min/1.73m2. The sensitivity and specificity of PLA2R IHC in diagnosing pediatric MN was 50% and 57%, respectively; positive and negative predictive values were 70% and 36%, respectively. At the final follow-up, chronic kidney disease stage 5 (CKD 5) developed in 2/14 (14.3%) iMN patients. Conclusions IHC PLA2R staining of glomerular tissue is a useful diagnostic marker of IMN. Though PLA2R prevalence is lower in children, its role in guiding treatment needs further exploration.
Collapse
Affiliation(s)
- RV Deepthi
- Departments of Child Health, Division of Pediatric Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sachin George
- Departments of Child Health, Division of Pediatric Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Georgie Mathew
- Departments of Child Health, Division of Pediatric Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sanjeet Roy
- Department of General Pathology, Division of Renal Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Mandeep Bindra
- Consultant in Pathology, Naruvi Hospital, Vellore, Tamil Nadu, India
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Indira Agarwal
- Departments of Child Health, Division of Pediatric Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
10
|
Yu L, Cheng S, Zhang M, Zhou T, Chen Y, Zhang Z, Yu Y. Successful treatment of peritoneal dialysis for two patients with refractory nephrotic syndrome and acute kidney injury: a case report. Front Med (Lausanne) 2023; 10:1263780. [PMID: 37920598 PMCID: PMC10618994 DOI: 10.3389/fmed.2023.1263780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/22/2023] [Indexed: 11/04/2023] Open
Abstract
Two patients with refractory nephrotic syndrome were treated with peritoneal dialysis (PD) for diuretic resistance, anasarca and acute kidney injury. Following PD, their fluid overload was promptly alleviated, accompanied by an increase in urine volume and an improvement in renal function. PD as an adjuvant approach enabled them to resume corticosteroids and immunosuppressive agents. Eventually, both patients could be withdrawn from PD and achieved remission of proteinuria.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Yusheng Yu
- National Clinical Research Center for Kidney Disease, Jinling Hospital, Nanjing, China
| |
Collapse
|
11
|
Mahajan V, Siddiqui A, Tahlan A, D 'Cruz S, Jaiswal S. Spectrum of Anemia in Indian children with Nephrotic Syndrome: a prospective observational study. Eur J Pediatr 2023; 182:4723-4729. [PMID: 37572146 DOI: 10.1007/s00431-023-05150-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/30/2023] [Accepted: 08/05/2023] [Indexed: 08/14/2023]
Abstract
We aimed to estimate the prevalence of anemia in children with nephrotic syndrome (NS), determine its etiology, and correlate severity with disease duration and response to steroids. This was a prospective cohort study carried from 15th July 2019-14th July 2021 at the pediatric nephrology clinic, of a teaching hospital in India. We screened children aged 3 months-18 years with NS for eligibility. We excluded those suffering from chronic kidney disease and, on haematinics. All children underwent investigations for evaluation of nephrotic syndrome and anemia. To define the clinical phenotype of nephrotic syndrome, the patients were classified as infrequent relapsers, frequent relapsers, steroid dependent and steroid resistant NS as per ISPN guidelines. Children were followed up at least for a period of one year to define their response to steroids. A total of 125 children were finally analysed for all treatment outcomes. Of 125, 37 (30%) children presented with the first episode of NS. Remaining 88 were follow up cases of NS. Of 125 children, 41 (33%) were found to be anemic as per the WHO criteria. Iron deficiency anemia was found in 21 (51%) children. Steroid resistance was twice more prevalent in the anemic group compared to the non-anemic group, 7.3% vs 4.8% respectively, however this difference was not statistically significant, p = 0.65. Anemic group had a trend of higher no. of children receiving antihypertensives compared to non-anemics (38 (93%) vs. 67 (80%), p = 0.07. CONCLUSION Iron deficiency anemia was the commonest cause of anemia and, anemia and need for anti-hypertensives to attain BP control and adequate proteinuria often coexisted in children suffering from nephrotic syndrome. WHAT IS KNOWN • Anemia is a significant complication in children suffering from nephrotic syndrome. • Cause of anemia in nephrotic syndrome is multifactorial. WHAT IS NEW • Iron deficiency anemia was the most common cause of anemia in Indian children with nephrotic syndrome. • Anemia and need for anti-hypertensives to attain adequate BP control and proteinuria often coexisted in children with nephrotic syndrome.
Collapse
Affiliation(s)
- Vidushi Mahajan
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India.
| | - Anam Siddiqui
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, 160030, India
| | - Anita Tahlan
- Department of Pathology and Hematology, Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Sanjay D 'Cruz
- Department of General Medicine (Nephrology), Government Medical College and Hospital, Sector 32, Chandigarh, India
| | - Shivani Jaiswal
- Department of Biochemistry, Government Medical College and Hospital, Sector 32, Chandigarh, India
| |
Collapse
|
12
|
Chan EYH, Yap DYH, Colucci M, Ma ALT, Parekh RS, Tullus K. Use of Rituximab in Childhood Idiopathic Nephrotic Syndrome. Clin J Am Soc Nephrol 2023; 18:533-548. [PMID: 36456193 PMCID: PMC10103321 DOI: 10.2215/cjn.08570722] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/11/2022] [Accepted: 10/31/2022] [Indexed: 12/04/2022]
Abstract
Rituximab is an established therapy in children with idiopathic nephrotic syndrome to sustain short- to medium-term disease remission and avoid steroid toxicities. Recent trials focus on its use as a first-line agent among those with milder disease severity. Rituximab is used in multidrug refractory nephrotic syndrome and post-transplant disease recurrence, although the evidence is much less substantial. Available data suggest that the treatment response to rituximab depends on various patient factors, dosing regimen, and the concomitant use of maintenance immunosuppression. After repeated treatments, patients are found to have an improving response overall with a longer relapse-free period. The drug effect, however, is not permanent, and 80% of patients eventually relapse and many will require an additional course of rituximab. This underpins the importance of understanding the long-term safety profile on repeated treatments. Although rituximab appears to be generally safe, there are concerns about long-term hypogammaglobulinemia, especially in young children. Reliable immunophenotyping and biomarkers are yet to be discovered to predict treatment success, risk of both rare and severe side effects, e.g. , persistent hypogammaglobulinemia, and guiding of redosing strategy. In this review, we highlight recent advances in the use of rituximab for childhood nephrotic syndrome and how the therapeutic landscape is evolving.
Collapse
Affiliation(s)
- Eugene Yu-hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatric and Adolescent Medicine, Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Desmond Yat-hin Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong
| | - Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alison Lap-tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatric and Adolescent Medicine, Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| | - Rulan S. Parekh
- Departments of Medicine and Pediatrics, Women's College Hospital, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
| |
Collapse
|
13
|
Nagai K. Immunosuppressive Agent Options for Primary Nephrotic Syndrome: A Review of Network Meta-Analyses and Cost-Effectiveness Analysis. Medicina (B Aires) 2023; 59:medicina59030601. [PMID: 36984602 PMCID: PMC10054564 DOI: 10.3390/medicina59030601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/22/2023] Open
Abstract
Therapeutic options with immunosuppressive agents for glomerular diseases have widened with refinements to the Kidney Disease Improving Global Outcomes (KDIGO) guidelines from 2012 to 2021. However, international guidelines do not necessarily match the reality in each country. Expensive therapies such as rituximab and calcineurin inhibitors are sometimes inaccessible to patients with refractory nephrotic syndrome due to cost or regulations. Under the Japanese medical insurance system, rituximab is accessible but still limited to steroid-dependent patients who developed idiopathic nephrotic syndrome in childhood. Based on international KDIGO guidelines and other national guidelines, possible applications of immunosuppressive agents for nephrotic syndrome are comprehensively examined in this review. While rituximab has become the mainstay of immunosuppressive therapy for nephrotic syndrome, clinical trials have indicated that options such as cyclophosphamide, calcineurin inhibitors, and mycophenolate mofetil would be preferable. Given the rising number of patients with nephrotic syndrome worldwide, KDIGO guidelines mention the need for further consideration of cost-effectiveness. If the new option of rituximab is to be the first choice in combination with steroids for nephrotic syndrome, its cost-effectiveness should also be verified. Among the few studies examining the cost-effectiveness of treatments for nephrotic syndrome, administration of rituximab to young adults has been shown to be cost-beneficial, at least in Japan. However, further large-scale studies involving multiple facilities are needed to verify such findings. Network meta-analyses have concluded that the efficacy of rituximab remains controversial and confirmation through high-quality studies of large cohorts is needed. To this end, the mechanisms of action underlying immunosuppressive agents, both old and new, need to be understood and experience must be accumulated to evaluate possible effects and side effects.
Collapse
Affiliation(s)
- Kei Nagai
- University of Tsukuba Hospital Hitachi Social Cooperation Education Research Center, Hitachi 317-0077, Ibaraki, Japan
| |
Collapse
|
14
|
Ghosh S, Akhtar S, Pradhan SK, Sarkar S, Dasgupta D, Parween R, Menon S, Sinha R. Incidence and risk factors of acute kidney injury among childhood nephrotic syndrome: a prospective cohort study. Eur J Pediatr 2023; 182:2443-2451. [PMID: 36920554 DOI: 10.1007/s00431-023-04903-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/17/2023] [Accepted: 02/25/2023] [Indexed: 03/16/2023]
Abstract
Acute kidney injury (AKI) is a known independent risk factor for morbidity/mortality but there is scarcity of robust data on it among childhood nephrotic syndrome (NS). We assessed the incidence of AKI among hospitalized children with NS as well as looked for any significant risk factors. Prospective observational study conducted across two tertiary pediatric hospitals in Eastern India from September 2020 to August 2021. Children aged 1-18 years admitted with NS and without any nephritic features or pre-existing chronic kidney disease (CKD) were included. In 200 admissions (n = 176; 63% female, median age 4 years [IQR: 3-7]), AKI occurred in 36 (18%; 95% CI 13 to 36%). Two children required kidney replacement therapy and one death was recorded. In 27/36 (75%), AKI resolved within 48 h, 4 had persistent AKI, 3 acute kidney disease, and two progressed to CKD. On multivariate regression analysis: fractional excretion of sodium ≤ 0.2% (OR 12.77; 95% CI 3.5-46.4), male gender (OR 6.38; 95% CI 2.76-14.74), underlying infection (OR 5.44; 95% CI 2.4-11.86), nephrotoxic drugs (OR 4.83; 95% CI 2.21-10.54), and albumin ≤ 1.4 g/dl (OR 4.35; 95% CI 1.55-12.8) were associated with AKI. A predictive equation using these five variables on admission had high AUC (0.86) in correctly identifying 17 children who subsequently developed AKI. Conclusion: In a low resource setting, AKI is common among hospitalized children with NS. Larger multi-center prospective studies are needed to refine prediction equations and test its utility in preventing AKI development. What is Known: • Acute Kidney Injury is a known independent risk factor for increased morbidity and mortality. • There are few studies to assess the incidence of Acute kidney injury in hospitalised cases of childhood nephrotic syndrome.. What is New: • This is the largest prospective cohort of children suffering from nephrotic syndrome, in India, proposing a novel algorithm for predicting the risk of AKI among hospitalised cases of childhood nephrotic syndrome.
Collapse
Affiliation(s)
- Sanchari Ghosh
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, India
| | - Shakil Akhtar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, India
| | - Subal Kumar Pradhan
- Division of Pediatric Nephrology, SVPPGIP and SCB Medical College, Cuttack, India
| | - Subhankar Sarkar
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, India
| | - Deblina Dasgupta
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, India
| | - Ruhi Parween
- Division of Pediatric Nephrology, SVPPGIP and SCB Medical College, Cuttack, India
| | - Shina Menon
- Division of Pediatric Nephrology, Seattle Children's Hospital, University of Washington, Seattle, USA
| | - Rajiv Sinha
- Division of Pediatric Nephrology, Institute of Child Health, Kolkata, India. .,Apollo Gleneagles Hospital, Kolkata, India.
| |
Collapse
|
15
|
Abstract
Nephrotic syndrome is a common childhood glomerular disease that is associated with massive proteinuria and edema. Children with nephrotic syndrome are at risk of chronic kidney disease, disease-related complications, and treatment-related complications. Patients with frequently relapsing disease or steroid toxicity may require newer immunosuppressive medications. However, access to these medications is limited in many African countries owing to prohibitive cost, the need for frequent therapeutic drug monitoring, and a lack of appropriate facilities. This narrative review examines the epidemiology of childhood nephrotic syndrome in Africa, including trends in treatment and patient outcomes. In most of North Africa, as well as among White and Indian populations in South Africa, the epidemiology and treatment of childhood nephrotic syndrome closely resembles that of European and North American populations. Historically, secondary causes of nephrotic syndrome (eg, quartan malaria nephropathy and hepatitis B-associated nephropathy) were predominant among Blacks in Africa. Over time, the proportion of secondary cases has decreased, along with rates of steroid resistance. However, focal segmental glomerulosclerosis increasingly has been reported among patients with steroid resistance. There is a need for consensus guidelines for the management of childhood nephrotic syndrome in Africa. Furthermore, establishing an African nephrotic syndrome registry could facilitate monitoring of disease and treatment trends, and provide opportunities for advocacy and research to improve patient outcomes.
Collapse
|
16
|
Kumar R, Shekhar R, Gupta AK, Kumar A, Prasad N, Kumar S, Sinha SR, Prakash J. Urinary Neutrophil Gelatinase Associated Lipocalin: A Novel Biomarker Determining Steroid Responsiveness in Nephrotic Syndrome. Cureus 2023; 15:e34503. [PMID: 36874337 PMCID: PMC9983706 DOI: 10.7759/cureus.34503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Urinary Neutrophil Gelatinase Associated Lipocalin (uNGAL) has been demonstrated to be a powerful marker of progression in chronic kidney disease. The present study was done to find out the ability of uNGAL as a biomarker to differentiate steroid-sensitive nephrotic syndrome (SSNS), steroid-dependent nephrotic syndrome (SDNS), and steroid-resistant nephrotic syndrome (SRNS) from each other. METHOD The cross-sectional study included 45 patients with Idiopathic Nephrotic Syndrome (INS) (15 each of SSNS, SDNS, and SRNS). uNGAL was measured by ELISA. Demographic profile of patients with INS, lab parameters including Serum albumin, cholesterol, urinary albumin, creatinine, etc., were estimated using standard laboratory methods. Various statistical methods were used to assay the usefulness of NGAL as a diagnostic marker. RESULTS Among the three groups, the median value of uNGAL was 8.68 ng/ml in SSNS, higher in SDNS (32.8 ng/ml), and highest in the SRNS group (50 ng/ml). The receiver operating curve (ROC) was generated for uNGAL to differentiate between SDNS and SSNS. Cut-off 13.26 ng/ml had a sensitivity of 86.7% and specificity of 97.4%, PPV 92.9%, and NPV 87.5 % with an area under the curve (AUC) of 0.958. Another ROC was generated for uNGAL to differentiate between SRNS and SDNS, and cut-off 40.02 ng/ml had a sensitivity of 80% and specificity of 86.7% with an AUC of 0.907. A similar result was observed when ROC was generated to differentiate SRNS from SSNS and SDNS combined. CONCLUSION uNGAL can distinguish between SSNS, SDNS, and SRNS.
Collapse
Affiliation(s)
- Rakesh Kumar
- Pediatrics, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Ravi Shekhar
- Diabetes and Endocrinology, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Anand K Gupta
- Pediatrics, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Amit Kumar
- Pediatrics, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Nidhi Prasad
- Community Medicine, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Santosh Kumar
- Genetics, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Seema R Sinha
- Hematology, Indira Gandhi Institute of Medical Sciences, Patna, IND
| | - Jayant Prakash
- Pediatrics, Indira Gandhi Institute of Medical Sciences, Patna, IND
| |
Collapse
|
17
|
Epidemiology and outcomes of pneumococcal sepsis in children with nephrotic syndrome in a developing country. Pediatr Nephrol 2023; 38:131-137. [PMID: 35425998 PMCID: PMC9009986 DOI: 10.1007/s00467-022-05550-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Pneumococcal infections are common in children with nephrotic syndrome. Knowledge of the commonly available serotypes and antibiotic susceptibility will help in prevention and appropriate management of pneumococcal sepsis, especially in resource-limited countries. METHODS Demographic, clinical, and laboratory data on children with nephrotic syndrome and pneumococcal infections were extracted from the electronic medical records. RESULTS Sixty-three isolates of pneumococci obtained from 60 children with nephrotic syndrome, over a period of 14 years, were included in the study. This represented 18% of all pneumococcal infections occurring in children during the same period. Commonly available vaccines covered up to 58% of all the serotypes causing infection. Severe disease, with shock, intensive care admission and/or meningitis, was observed in 38% children and mortality was observed in 10%. Resistance to commonly used antibiotics was not observed, except for erythromycin. CONCLUSIONS Pneumococcal sepsis was observed to be common in children with nephrotic syndrome and results in significant morbidity and mortality. Commonly used antibiotics were observed to be effective in management of the infections.
Collapse
|
18
|
Mattoo TK, Sanjad S. Current Understanding of Nephrotic Syndrome in Children. Pediatr Clin North Am 2022; 69:1079-1098. [PMID: 36880923 DOI: 10.1016/j.pcl.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Nephrotic syndrome in children is mostly idiopathic in origin. About 90% of patients respond to corticosteroids; 80-90% have at least one relapse and 3-10% become corticosteroid resistant after the initial response. A kidney biopsy is seldom indicated for diagnosis except in patients with atypical presentation or corticosteroid resistance. For those in remission, the risk of relapse is reduced by the administration of daily low dose corticosteroids for 5-7 days at the onset of an upper respiratory infection. Some patients may continue having relapses through adult life. Many country-specific practice guidelines have been published, which are very similar with clinically insignificant differences.
Collapse
Affiliation(s)
- Tej K Mattoo
- Department of Pediatrics, Wayne State University School of Medicine, 400 Mack Avenue, Suite 1 East, Detroit, MI 48201, USA.
| | - Sami Sanjad
- American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
19
|
Clinical practice guidelines for nephrotic syndrome: consensus is emerging. Pediatr Nephrol 2022; 37:2975-2984. [PMID: 35763086 DOI: 10.1007/s00467-022-05639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 01/10/2023]
|
20
|
Mantan M, Kansal A, Swarnim S. Effectiveness of a Low Dose Prednisolone Regimen for Treatment of Relapses in Children with Steroid Sensitive Nephrotic Syndrome. Indian J Nephrol 2022; 32:588-594. [PMID: 36704589 PMCID: PMC9872916 DOI: 10.4103/ijn.ijn_463_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/06/2022] [Accepted: 03/25/2022] [Indexed: 01/29/2023] Open
Abstract
Introduction There may be a role of reducing the total steroid doses for the treatment of relapses of nephrotic syndrome in children with milder and more stable disease. The primary objective of this study was to compare the effectiveness of a low-dose prednisolone regimen with standard therapy for the treatment of relapses in steroid-sensitive nephrotic syndrome (SSNS) at the end of treatment, the secondary objectives being time to remission and sustained remission after 3 months. Methods This randomized controlled trial included a total of 40 children (20 in each group) with SSNS (presently infrequently relapsing course) and with a relapse. Both groups received prednisolone at a dose of 2 mg/kg/day until remission; subsequently, the patients in the study group received 1 mg/kg, and the control group participants received 1.5 mg/kg prednisolone on alternate days for 4 weeks. The patients were followed up till 3 months after stopping the therapy. Results The median (IQR) age of children enrolled was 7.5 (range: 5-9.65) years, and the age at onset of nephrotic syndrome was 4 (range: 2.3-5.5) years. The median time to achieve remission was 9 days (comparable in low dose vs. standard therapy group; P = 0.14). All patients were in remission at the end of therapy; 85% of patients were in the low-dose group and 90% in the standard therapy group after 1 month (P = 0.32). At the end of 3 months, 60% continued to be in remission in the low-dose group and 65% with standard therapy (P = 0.37). Hazard ratios for relapse at the end of 1, 2, and 3 months were 1.05, 1.08, and 1.13, respectively. Patients who were infrequently relapsing (79%) from the onset of nephrotic syndrome had higher remission rates at the end of 3 months (80% in the low-dose group vs. 76.9% in the standard therapy group). Hazard ratios for relapse in these patients at the end of 1, 2, and 3 months were 1.01, 1.03, and 1.08, respectively. Conclusions Lower doses of prednisolone can be used for the treatment of relapse of steroid sensitive nephrotic syndrome, with an infrequently relapsing course.
Collapse
Affiliation(s)
- Mukta Mantan
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, University of Delhi, New Delhi, India
| | - Aparajita Kansal
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, University of Delhi, New Delhi, India
| | - Swarnim Swarnim
- Department of Pediatrics, Maulana Azad Medical College and Associated Lok Nayak Hospital, University of Delhi, New Delhi, India
| |
Collapse
|
21
|
Devi Padmanaban P, Jayaraman D, Shanmugam SG, Geminiganesan S. Nephrotic Syndrome and Hodgkins Lymphoma - an Unusual Association. EJIFCC 2022; 33:262-267. [PMID: 36447800 PMCID: PMC9644090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND An association between nephrotic syndrome and extrarenal neoplasia was described for the first time in 1922. The reported incidence of nephrotic syndrome in Hodgkin lymphoma is less than 1%. CLINICAL DESCRIPTION We present a 13 year old boy who was admitted with complaints of abdominal pain, vomiting and loose stools for 2 months. He had a history of significant weight loss of 5kg in a couple of months.On examination, he had bilateral pedal oedema and right cervical lymphadenopathy. Cervical lymph node biopsy revealed nodular sclerosis type of Hodgkin lymphoma. He also had hypoalbuminemia, massive proteinuria and hypercholesterolemia.Secondary nephrotic syndrome due to Hodgkin's lymphoma was made as a clinical diagnosis. MANAGEMENT AND OUTCOME He had been started on chemotherapy (with Prednisolone, Vincristine, Doxorubicin, Etoposide) for stage 3B Hodgkin lymphoma. He tolerated the chemotherapy well. Though he had symptomatic edema, managed conservatively as the urine output was adequate. On follow up, he attained spontaneous remission of nephrotic syndrome. CONCLUSION Overt proteinuria might be the manifestation of paraneoplastic syndrome in children with Hodgkin lymphoma and with the management of the primary disease, proteinuria resolves spontaneously.
Collapse
Affiliation(s)
- Priyanka Devi Padmanaban
- Department of Paediatric Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Dhaarani Jayaraman
- Department of Paediatric Medicine and Division of Paediatric Hemato-Oncology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Sri Gayathri Shanmugam
- Department of Paediatric Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| | - Sangeetha Geminiganesan
- Department of Paediatric Medicine and Division of Paediatric Nephrology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
| |
Collapse
|
22
|
KIAA0101 and IL2RA Were Identified as Core Genes in Hormone-Resistant Nephropathy. DISEASE MARKERS 2022; 2022:6545266. [PMID: 36164371 PMCID: PMC9509277 DOI: 10.1155/2022/6545266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022]
Abstract
Objectives To analyze the tissue heterogeneity of hormone-sensitive and drug-resistant nephrotic syndrome genes using a bioinformatics approach and to analyze gene-related functional pathways. Methods The limma package of R software was used to screen differential genes from the nephropathy datasets GSE145969 and GSE189734. The differential genes were analyzed for functional and pathway enrichment in terms of biological processes, cellular components, and molecular functions. The Metascape tool was used to construct protein networks for the differential genes, and the results were imported into Cytoscape software for visualization. The genes were identified as key modules and genes using the MCODE plug-in. Gene set enrichment analysis was performed for the HALLMARK analysis of the two microarray key genes to obtain the relevant pathways. Results GSE145969 screened 351 differential genes, 168 upregulated genes, and 183 downregulated genes. The differential genes were enriched in biological processes, cellular components, and molecular functions, such as myocardial contraction, intracellular nonmembrane organelles, and structural molecular activities. The protein-protein interaction (PPI) network contained 140 nodes, with the highest-scoring module containing seven genes, and the MCODE plug-in calculated the downseed. The key gene was KIAA0101, whose HALLMARK pathway was significantly enriched in the mTORC1 signaling pathway. A total of 263 differential genes were screened by GSE189734, and they were enriched in biological processes, molecular functions, and cellular components, such as immune system processes, signaling receptor binding, and the cytoplasmic matrix. The PPI network contained 253 nodes, with the highest-scoring module containing 37 genes. The seed gene obtained through the MCODE plug-in calculation was IL2RA, whose HALLMARK pathway was significantly enriched in the KRAS signaling pathway. Conclusion By analyzing the gene sets of different tissues in nephropathy, two key genes, namely KIAA0101 and IL2RA, were obtained. Their gene function enrichment is related to cell growth, development, and reproduction. Therefore, IL2RA and KIAA0101 can be used as diagnostic markers for hormone-resistant nephropathy.
Collapse
|
23
|
Institute of Child Health, Kolkata, 1956–2022. Indian Pediatr 2022. [PMID: 36101961 PMCID: PMC9518949 DOI: 10.1007/s13312-022-2613-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Institute of Child Health, Kolkata is an iconic pediatric institution of India, which had its inception as one of the first pediatric hospital of the country. Pediatrics, as a separate branch of medicine, different from the principles and practices of adult medicine, was conceptualized and materialized in India by the founder of this institution, who is referred to as one of the Father of Indian Pediatrics, Dr. Kshirode Chandra Chaudhuri. This article portrays the journey of ICH, the popular acronym of the famed Institute, through the last seven decades from 1956 till the present, trying to capture the initial years of its establishment in the late 1950s, followed by its gradual evolution to an institution of central importance in pediatric healthcare, medical education, research and development, and service to the society, particularly in Eastern India.
Collapse
|
24
|
Management of edema in pediatric nephrotic syndrome – Underfill or overfill? CURRENT PEDIATRICS REPORTS 2022. [DOI: 10.1007/s40124-022-00270-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
25
|
Sinha A, Mathew G, Arushi A, Govindarajan S, Ghanapriya K, Grewal N, Rai K, Brijwal M, Kalluru SL, Tewari P, Misra A, Khandelwal P, Hari P, Bagga A. Sequential rituximab therapy sustains remission of nephrotic syndrome but carries high risk of adverse effects. Nephrol Dial Transplant 2022; 38:939-949. [PMID: 36071552 DOI: 10.1093/ndt/gfac228] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Sequential rituximab (RTX) administration has emerged as an important strategy to sustain remission of disease in patients with difficult-to-treat nephrotic syndrome. METHODS We report the efficacy and safety of sequential therapy with two or more courses of intravenous RTX in 250 patients with difficult-to-treat steroid dependence (n = 127) and calcineurin inhibitor (CNI)-dependent or CNI-refractory steroid resistance (n = 123) managed at one center during 2015-2021. Subsets of patients were cross-sectionally tested for hypogammaglobulinemia, seroprotection against and hyporesponsiveness to vaccines for hepatitis B and tetanus, BK/JC viruria and human antichimeric antibodies (HACAs). RESULTS Sequential RTX therapy, initiated at a median of 10 years [interquartile range (IQR) 7.3-14.4], was administered for 1.8 courses/person-year [95% confidence interval (CI) 1.7-2.0] over 2.0 years (95% CI 1.2-3.0). Therapy was associated with postponement of relapses by a median of 3 years in patients with steroid-sensitive disease and 2 years in those with steroid resistance. Relapses were reduced by a mean of 2.0 relapses/person-year (95% CI 1.8-2.2), enabling a reduction in prednisolone dose to 0.04 mg/kg/day (95% CI 0.01-0.11) and withdrawal of additional immunosuppression in 154 (62%) patients. RTX-associated adverse events, occurring at 0.20 events/person-year (95% CI 0.17-0.23), were chiefly comprised of infusion reactions (n = 108) and infections (n = 46); serious adverse events were observed in 10.8% patients, at 0.03 events/person-year (95% CI 0.02-0.05). Hypogammaglobulinemia was observed in 35% of 177 patients and was moderate to severe in 8.5% of cases. Rates of seroprotection at baseline and response following vaccination were lower for hepatitis B [1.9% and 29.4% (n = 52)] than tetanus [65.5% and 34.5% (n = 58)]. BK/JC viruria, without viremia, was observed in 7.3% of 109 cases. A total of 19 of 107 patients (17.8%) had HACAs, which were associated with B cell nondepletion and serum sickness. Age at therapy of <9-10 years was associated with a risk of early relapse, treatment failure and hypogammaglobulinemia following RTX therapy. CONCLUSIONS Sequential therapy with RTX effectively reduces relapses in patients with difficult-to-treat steroid- and/or CNI-dependent or CNI-refractory nephrotic syndrome. Therapy is associated with high rates of hypogammaglobulinemia and infusion reactions.
Collapse
Affiliation(s)
- Aditi Sinha
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Georgie Mathew
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India.,Division of Pediatric Nephrology, Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India
| | - Arushi Arushi
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Srinivasavaradan Govindarajan
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Kshetrimayum Ghanapriya
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Neetu Grewal
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Khushboo Rai
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Megha Brijwal
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Sree Laya Kalluru
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Prachi Tewari
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | | | - Priyanka Khandelwal
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Pankaj Hari
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Bagga
- Division of Nephrology and ICMR Center for Advanced Research in Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
26
|
Bajeer I, Khatri S, Hashmi S, Lanewala A. Factors Predicting Short Term Outcome in Children With Idiopathic Nephrotic Syndrome: A Prospective Cohort Study. Cureus 2022; 14:e21538. [PMID: 35223311 PMCID: PMC8864329 DOI: 10.7759/cureus.21538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The objective of the article is to determine the risk factors associated with relapses in children with idiopathic nephrotic syndrome (INS). Material and methods Fifty-seven children with the first episode of INS were included and followed up prospectively for a minimum period of one year to identify the risk factors related to relapses. The study subjects were divided into early (less than eight days) and late (equal to or more than eight days) responder groups and were compared in terms of the number of days to achieve complete remission, time to first relapse, and the pattern of relapse at the last follow-up. Results Of the 57 children, 32 (56%) were male and 25 (44%) female. The mean age of the study cohort was 5.3 ± 3 years. Sixteen (55%) children with ages ranging from one to four years had a higher propensity to develop relapse, although the p-value (p=0.11) was not significant. Gender analysis did not reveal any significant correlation (p=0.32); however, a higher proportion of males (n=17; 63%) responded within eight days of starting steroids than female counterparts (n=10; 37%). Microscopic hematuria at the disease onset was seen in 12 (21%) children, and out of them, five (41.6%) remained in complete remission. The mean time to achieve complete remission was 8.1 ± 3.5 days, while the early responder group had delayed time to first relapse as compared to the late responders (3.1 ± 5.2 vs. 1.6± 3.8; p=0.21). Among all the study participants, a significant number of children (n=20; 51%) were in complete remission at their last follow-up visit. Baseline serum albumin, cholesterol, body mass index (BMI), and serum creatinine had no significant difference. Conclusion The delayed response to steroids and younger age at presentation can predict the time to first relapse and number of relapses in children with INS, respectively.
Collapse
|
27
|
Efficacy of rituximab versus tacrolimus in difficult-to-treat steroid-sensitive nephrotic syndrome: an open-label pilot randomized controlled trial. Pediatr Nephrol 2022; 37:3117-3126. [PMID: 35286456 PMCID: PMC8919684 DOI: 10.1007/s00467-022-05475-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Rituximab and tacrolimus are therapies reserved for patients with frequently relapsing or steroid-dependent nephrotic syndrome who have failed conventional steroid-sparing agents. Given their toxicities, demonstrating non-inferiority of rituximab to tacrolimus may enable choice between these medications. METHODS This investigator-initiated, single-center, open-label, pilot randomized controlled trial examined the non-inferiority of two doses of intravenous (IV) rituximab given one-week apart to oral therapy with tacrolimus (1:1 allocation), in maintaining sustained remission over 12 months follow-up, in patients with difficult-to-treat steroid-sensitive nephrotic syndrome, defined as frequently relapsing or steroid-dependent disease that had failed ≥ 2 steroid-sparing strategies. Secondary outcomes included frequency of relapses, proportion with frequent relapses, time to relapse and frequent relapses, and adverse events (CTRI/2018/11/016342). RESULTS Baseline characteristics were comparable for 41 patients randomized to receive rituximab (n = 21) or tacrolimus (n = 20). While 55% of patients in each limb were in sustained remission at 1 year, non-inferiority of rituximab to tacrolimus was not demonstrated (mean difference 0%; 95% CI - 30.8%, 30.8%; non-inferiority limit - 20%; P = 0.50). Frequent relapses were more common in patients administered rituximab compared to tacrolimus (risk difference 30%, 95% CI 7.0, 53.0, P = 0.023). Both groups showed similar reductions in relapse rates and prednisolone use. Common adverse events were infusion-related with rituximab and gastrointestinal symptoms with tacrolimus. CONCLUSIONS Therapy with rituximab was not shown to be non-inferior to 12-months treatment with tacrolimus in maintaining remission in patients with difficult-to-treat steroid-sensitive nephrotic syndrome. Frequent relapses were more common with rituximab. While effective, both agents require close monitoring for adverse events. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
|
28
|
Fujinaga S, Endo S, Morishita T, Takemasa Y, Onuki Y, Sakuraya K, Hirano D. Predictors of Treatment Response and Long-Term Outcomes in Young Children with Steroid-Dependent Nephrotic Syndrome Treated with High-Dose Mizoribine as First-Line Steroid-Sparing Agent. TOHOKU J EXP MED 2022; 256:85-91. [DOI: 10.1620/tjem.256.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Shota Endo
- Division of Nephrology, Saitama Children’s Medical Centerl
| | | | | | - Yuta Onuki
- Division of Nephrology, Saitama Children’s Medical Centerl
| | - Koji Sakuraya
- Division of Nephrology, Saitama Children’s Medical Centerl
| | - Daishi Hirano
- Department of Pediatrics, The Jikei University School of Medicinel
| |
Collapse
|
29
|
Hariharan R, Krishnamurthy S, Kaliaperumal S, Karunakar P, Deepthi B. Incidence and predictive risk factors for ophthalmological complications in children with nephrotic syndrome receiving long-term oral corticosteroids: a cohort study. Paediatr Int Child Health 2021; 41:199-205. [PMID: 34711131 DOI: 10.1080/20469047.2021.1983315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is a paucity of data from India on ophthalmological complications in children on long-term oral corticosteroids for idiopathic nephrotic syndrome. METHODS All children aged 4-18 years with idiopathic nephrotic syndrome who had received long-term oral steroids for >6 months and who attended the paediatric nephrology clinic between January 2019 and January 2021 were included. The majority of them (95/110) were being followed up in the paediatric nephrology clinic which was functioning from 2010. The children were screened for ophthalmological complications at 6-month intervals. RESULTS Overall, 110 children with nephrotic syndrome were enrolled. Their median (IQR) age was 9.4 (7.0-12.8) years, and the median (range) duration of follow-up following onset of nephrotic syndrome was 5 years (1.0-16). The incidence of cataract was 18.1% (20 of 110 cases). Visual acuity was impaired in seven (35%) of the children with cataract. Children with cataract were younger as compared to those without cataract [Median (IQR) age at onset of nephrotic syndrome [2.5 (2.0-4.0) yrs vs 4 (2.1-6.0) yrs] (p=0.03)]. Children with cataract also had higher cumulative dose of prednisolone intake (mg/m2) [28,669 (21,329-33,500) vs 14,995 (10,492-19,687)] (p<0.01)] and greater cumulative duration of prednisolone intake [4.3 (3.1-5.2) vs 2.25 (1.3-3.7) yrs] (p<0.01). The incidence of raised IOP was 9.1% (10 of 110 cases). CONCLUSIONS The incidence of cataract and raised IOP was high. The risk factors for the development of cataract were age at onset of nephrotic syndrome, cumulative dose and cumulative duration of steroid intake.
Collapse
Affiliation(s)
- Raja Hariharan
- Departments of Paediatrics and Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Sriram Krishnamurthy
- Departments of Paediatrics and Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Subashini Kaliaperumal
- Departments of Paediatrics and Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Pediredla Karunakar
- Departments of Paediatrics and Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Bobbity Deepthi
- Departments of Paediatrics and Ophthalmology, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| |
Collapse
|
30
|
|