Steroid Sensitive Nephrotic Syndrome: Revised Guidelines

Optimal functioning of hypothalamic-pituitary-adrenal axis after cessation of prednisolone therapy: a cross-sectional study in children with nephrotic syndrome

BACKGROUND

Hypothalamic-pituitary-adrenal (HPA) axis recovery after cessation of steroid therapy in children with nephrotic syndrome (NS) has hardly been studied in the literature.

METHODS

This 22-month cross-sectional study recruited children (2-14 years) with NS, having received a minimum 3 months of prednisolone, now in remission, and off steroids for 1, 3, or 6 months. Serum cortisol-basal and stimulated (with long-acting intramuscular adrenocorticotropic hormone), and factors affecting them, were assessed. Low basal and stimulated cortisol were taken as < 138 nmol/L and < 500 nmol/L, respectively.

RESULTS

Of 80 (60 males) children, median (IQR) age 64 (43, 91.7) months, most were infrequently relapsing (34; 42.5%) or had a single episode of NS (35; 43.8%). As per duration since discontinuation, 23 (28.8%), 35 (43.8%), and 22 (27.4%) children were off steroids for 1, 3, and 6 months, respectively. Overall, 8 (10%) and 26 (32.5%) had low basal and stimulated cortisol levels, respectively. Proportions of children with HPA axis suppression (low peak cortisol) were 9/23 (39%), 12/35 (34%), and 5/22 (23%) in the groups off steroids for 1, 3, and 6 months, respectively. Optimal peak cortisol level, indicating adrenal recovery, was independently associated with duration since cessation of prednisolone [odds ratio (6 months vs. 1 month) was 10.07 (95%CI 1.46 to 69.51); P = 0.019] and basal cortisol levels > 138 nmol/L (odds ratio 25.0 (95%CI 2.94 to 200); P = 0.03).

CONCLUSIONS

Nearly two-thirds of children with mild courses of NS demonstrate optimal HPA axis function between 1 and 6 months post cessation of steroids. Duration since cessation and basal cortisol independently predict optimal adrenal response.

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.

MicroRNAs in idiopathic childhood nephrotic syndrome

BACKGROUND

miRNAs are non-coding RNA that are recognized as biomarkers of kidney disorders. There is limited information on the differential expression of miRNA and their target genes in idiopathic nephrotic syndrome of childhood.

METHODS

We enrolled patients, 2-18 years old, with steroid-sensitive nephrotic syndrome, either at onset or during relapse, and steroid-resistant disease, at diagnosis of steroid-resistance. Patients with steroid-sensitive disease were off immunosuppressive medications, while those with steroid-resistance were on therapy with prednisolone at enrollment. Controls were healthy children attending the hospital for vaccinations or for minor non-infectious, non-kidney ailments. Following RNA extraction from whole blood, differential expression of 2549 miRNAs was examined to identify differentially expressed miRNA, defined as those with absolute log2 fold change > 2 and adjusted P < 0.05. Target genes, predicted using miRNet, were compared against the genes for nephrotic syndrome in the NCBI database, and the ontology of selected genes was examined using DAVID.

RESULTS

Comparison of miRNA expression in 36 patients and 12 controls led to the identification of 62 and 12 differentially expressed miRNA in patients with steroid-sensitive and steroid-resistant disease, respectively. Of 76 miRNAs that were differentially regulated between the two disease categories, 26 were unique to steroid-sensitive disease and 11 to steroid-resistance. Of 5955 and 2813 genes targeted by the miRNAs specific to steroid-sensitive and steroid-resistant nephrotic syndrome, respectively, 79 were relevant in context of the disease.

CONCLUSION

Steroid-sensitive and steroid-resistant nephrotic syndrome have distinct miRNA expression profiles, which can be examined as biomarkers and in pathogenetic pathways.

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.

Seroprevalence of SARS-CoV-2 antibodies in children with nephrotic syndrome and chronic kidney disease: a cross-sectional study from India

BACKGROUND

There is a paucity of literature on the seroprevalence of SARS-CoV-2 antibodies among pediatric patients with underlying kidney disorders; few serosurveys among healthy children have shown seropositivity of 20-65% after different waves of infections.

METHODS

The study had a cross-sectional design and was conducted between January 2023 and July 2023; 163 children and adolescents (1-18 years) with nephrotic syndrome and chronic kidney disease (CKD) were screened for Anti-Spike SARS-COV-2 IgG antibodies as detected by a quantitative chemiluminescence immunoassay. Children with nephrotic syndrome, both steroid sensitive (SSNS) and steroid resistant (SRNS) were enrolled during disease remission. Correlation of SARS-CoV-2 seropositivity status was done with age, gender, disease type, treatment duration, immunosuppressants, previous SARS-CoV-2 infection, and immunization status.

RESULTS

Of 163 children (63.8% boys) with median age of 9 years; 101 (62%) had underlying nephrotic syndrome (61 SSNS and 40 SRNS), and 62 (38%) children had CKD. Seroprotective titers for SARS-COV2 antibodies were present in 100 (61.3%) children. The median titers for all patients were 37.1 BAU/mL; for nephrotic syndrome they were 27.1 BAU/mL and for CKD they were 76.7 BAU/mL (p = 0.0033). A total of 43 (26.4%) children had high positive antibody levels (> 200 BAU/ml). Among those with nephrotic syndrome 60.7% with SSNS and 43.5% SRNS had seropositive titers. Only 4 (2.5%) children had a history of previous COVID infection and 6 (3.7%) were vaccinated.

CONCLUSIONS

In a largely unvaccinated population of children with nephrotic syndrome and CKD, 61.3% were seropositive for SARS-CoV-2 IgG antibody indicating a past asymptomatic infection; titers were significantly higher in CKD compared to nephrotic syndrome.

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.

Past and future in vitro and in vivo approaches toward circulating factors and biomarkers in idiopathic nephrotic syndrome

Predicting the risks of progression to chronic kidney disease (CKD) stage 5 in idiopathic nephrotic syndrome (NS) and recurrence of the disease (rNS) following kidney transplantation (KT) is a key assessment to provide essential management information. NS has been categorized etiologically as genetic and immune-based. A genetic cause can be identified in ~ 30% of children with steroid-resistant NS (SRNS), a finding associated with a very low risk of rNS following KT. In immune-based NS, clinical overlap is observed among steroid-sensitive NS, secondary-resistant NS, and SRNS not associated with disease-causing genetic variants (non-monogenic SRNS). While ~ 50% of SRNS patients with no identified monogenic disease respond to intensified immunosuppressive treatments, the ones that do not respond to this therapy have a high risk of progression to CKD stage 5 and post-KT rNS. Secondary-resistant patients who progress to CKD stage 5 display the highest risk of post-KT rNS. The proposed shared underlying mechanism of the immune-based NS associated with post-KT rNS is based on a systemic circulating factor (CF) that affects glomerular permeability by inducing foot process effacement and focal segmental glomerulosclerosis. However, identifying patients without a detected genetic form who will recur post-KT is a major challenge. Extensive efforts, therefore, have been made to identify CFs and biomarkers potentially capable of predicting the risk of progression to CKD stage 5 and post-KT rNS. This review discusses the in vitro and in vivo approaches employed to date to identify and characterize potential CFs and CF-induced biomarkers of recurrent NS and offers an assessment of their potential to improve outcomes of KT in this patient population.

Determinants of Acute Kidney Injury in Children With Nephrotic Syndrome: A Prospective Observational Study

Background Nephrotic syndrome (NS) is a common renal ailment among children, typically manifesting as a relapsing-remitting pattern. Most of the cases are managed on an outpatient basis, but a subset of patients experience complications, e.g., acute kidney injury (AKI). Although historically more prevalent in secondary NS, AKI is now occurring increasingly in children with idiopathic NS. However, the literature on AKI in this population consists of case reports and retrospective studies, particularly from India, so the study was planned to identify various risk factors that precipitate AKI in a child with NS. The secondary objective was to assess the hydration status of children having NS and its association with the development of AKI. Materials and methods This longitudinal study was conducted in the Department of Pediatrics at the All India Institute of Medical Sciences, Raipur, Chhattisgarh, from October 2021 to April 2023. Children of both genders and age groups between three months and 15 years, satisfying the International Society for Pediatric Neurosurgery 2021 guideline for the diagnosis of NS, were included in the study. Children having chronic kidney disease were excluded. Using the non-probability convenient sampling technique, 57 patients with NS were enrolled in the study. The patients without AKI were evaluated daily for the development of AKI using the Kidney Disease Improving Global Outcomes 2012 guideline until day 14 or discharge and followed up for six months. Records of those children who were admitted with AKI were reviewed for possible risk factors of AKI. Data was analyzed on Epi Info software enUS version 7.3.2 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Categorical data were expressed as a percentage and/or 95% confidence interval (CI) of the estimate and compared using Chi-square or Fisher's exact test. A p-value ≤0.05 was considered statistically significant. The odds ratio (OR) for risk factors for AKI was determined using logistic regression. Results The mean age of the study subjects at the onset of the disease was 5.34 ± 3.66 years. The common presentations were edema (94.74%) and oliguria (80.7%). The majority (89.2%) showed a response to steroid therapy. About 56.14% of children developed AKI, and stages 2 and 3 AKI were more common, 37.5% each. About 53.12% and 46.88% of children developed pre-renal AKI and intrinsic AKI, respectively; 45.61% had hypertension at admission, with the majority having stage 1 hypertension (38.46%). Only six (10.5%) children had sickle cell trait, and all developed AKI during follow-up. Forty-two (73.68%) children had nephrotoxic drug exposure, with the most common drug being enalapril, followed by nephrotoxic antibiotics. Out of 10 children with AKI who underwent renal biopsy, focal segmental glomerulosclerosis was the most common entity (60%). The notable parameters that were found to have statistical significance for AKI were low eGFR at admission, hypertension, nephrotoxic drug exposure, inadequate water intake, fractional excretion of sodium (FeNa), and urine potassium index as markers of renal hypoperfusion, infections, steroid-resistant nephrotic syndrome, and significant glomerular lesions. Conclusion The present study demonstrates an association between traditional risk factors and the causation of AKI. However, high urine osmolality, raised urine K+ index, and FeNa suggestive of raised aldosterone levels had a significant association with AKI.

Outcomes Using a Standardized Provincial Childhood Nephrotic Syndrome Clinical Pathway

Background

In 2013, the British Columbia (BC) Childhood Nephrotic Syndrome Clinical Pathway (CNSCP) was developed to standardize the care of children with nephrotic syndrome (NS). In BC, children access nephrology care at BC Children's Hospital (BCCH) and multiple regional clinics.

Objective

The primary objective was to compare induction therapy and clinical outcomes between BCCH and regional clinics since implementation of the CNSCP.

Design setting and patients

This was a retrospective cohort study of children with NS in BC.

Measurements and methods

We conducted a retrospective cohort study of children 1 to 17 years old with new-onset NS from 2013 to 2019 inclusive with minimum 12 months of follow-up. Children with non-minimal change disease, steroid resistance, incomplete induction therapy, or less than 6 months of pathway treatment within their first year post-diagnosis were excluded. Clinics were categorized as BCCH or regional (Surrey, Prince George, or Kelowna).

Results

Sixty-nine patients were included, with 52 (75%) at BCCH and 17 (25%) at regional clinics. There were no significant between-group differences in age, sex, or clinical characteristics at time of diagnosis. Comparing BCCH and regional clinics, there was no difference in induction prednisone exposure (median 3400, interquartile range [IQR] 3331-3585 mg/m2 vs 3492, IQR 3397-3644 mg/m2, P = .167), annualized relapse rate (median 3.3, IQR 1.1-5.3 vs 2.3, IQR 0.5-4.2, P = .575), or development of frequently relapsing courses (50% vs 62%, P = .475). There was a similar number of first-year clinic visits (4.2 ± 1.2 vs 4.0 ± 1.8, P = .655) and dietitian-reviewed food records (67% vs 47%, P = .135, BCCH vs regional). More children at BCCH had a recommended ophthalmology surveillance visit (87% vs 59%, P = .01, BCCH vs regional).

Limitations

Study limitations include small sample size and exclusion of children with complicated NS (ie, relapse during induction, steroid resistance).

Conclusion

Since we implemented the CNSCP, children with NS received comparable care and had similar outcomes at BCCH and regional clinics without significant practice variation.

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.

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.

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.

Efficacy and safety of oral cyclophosphamide versus mycophenolate mofetil in childhood nephrotic syndrome: an open-label comparative study

INTRODUCTION

There is a scarcity of research comparing the efficacy of cyclophosphamide and mycophenolate mofetil in childhood nephrotic syndrome. The aim was to evaluate the efficacy and safety of oral cyclophosphamide (CYC) and mycophenolate mofetil (MMF) in children with steroid-sensitive nephrotic syndrome in terms of the proportion of children who have been off steroids for at least 6 months without proteinuria (responders).

METHODS

This open-label retrospective-prospective comparative study was conducted in a pediatric nephrology clinic of a referral center for children between 1 and 18 years of age with FR/SD nephrotic syndrome. Group A consisted of patients who received oral cyclophosphamide (100, 25% female) at a dose of 2-2.5 mg/kg once daily for a period of 8-12 weeks. Group B consisted of patients who received oral mycophenolate mofetil (n = 61, 18% female) (dose: 800-1200 mg/m2) for at least 12 months. Responders were defined as children who were off steroids for at least 6 months along with absence of proteinuria.

RESULTS

In the CYC group, 50% of the patients were responders, whereas 54% of the patients in the MMF group were responders (p = 0.614). The time to first relapse with CYC was 7 months (IQR 5.25-11) compared to 7 months (IQR 3.5-12) with MMF (p = 0.092). The relapse rate in the CYC group was 1.77 relapses per patient-year compared to 1.295 relapses per patient-year in the MMF group. The difference in relapse rate was significant (-0.474; 95% CI, 0.09 to 0.86 relapses/person-year) (p value = 0.009). Multivariate analysis revealed that an age of less than 5 years at the start of treatment was a significant factor for a better response to MMF (p value = 0.039, OR = 2.988, CI -1.055-8.468).

CONCLUSIONS

The efficacy of MMF was similar to that of CYC in terms of response (6 months without steroids) in children with FR/SD nephrotic syndrome. MMF showed a favorable response in terms of the frequency of relapse and treatment failure. REGISTRATION OF THE STUDY WITH CLINICAL TRIALS REGISTRY OF INDIA: ( http://ctri.nic.in ;CTRI/2021/06/034421) (Dt: 28/06/2021).

Serum tumour necrosis factor-alpha as a marker of disease activity in children with nephrotic syndrome

Idiopathic nephrotic syndrome (NS) is a common glomerular disease in children throughout the world; however, the exact pathogenesis of the disease remains unknown. Several studies have shown that tumour necrosis factor-alpha (TNF-α), a proinflammatory cytokine, plays a significant role in the pathogenesis of NS. The literature lacks sufficient data to establish the relationship between TNF-α and NS. This prospective study was conducted on children aged 1-14 years diagnosed with idiopathic NS. All enrolled individuals were followed up from disease onset or relapse of NS until remission or at least 42 days with steroid therapy if remission was not achieved. Serum TNF-α levels were measured at presentation and remission or after 42 days of steroid therapy if remission was not achieved. The role of TNF-α levels in response to steroid therapy in NS was also assessed. One hundred and twelve children (68% boys) with idiopathic NS were enrolled. The median age (interquartile range) at enrolment was 58.5 (37-84.7) months, while the median age at symptom onset was 47.5 (24-60.7) months. The median TNF-α level at presentation was 7.5 (3.5-12.1) pg/ml, and that at remission was 5.25 (1.62-8.8) pg/ml. The median TNF-α levels among first-episode NS at presentation were 3.98 pg/ml and 1.88 pg/ml (P = .04) at remission, whereas in steroid-resistant NS, it was 6.59 pg/ml at presentation and 9.02 pg/ml at 42 days (P = .45). There was a significant negative correlation between the duration of steroid therapy and TNF-α levels, with a correlation factor of -0.021 and R2 of 0.154 (P≤.001). Serum TNF-α levels decrease with steroid therapy in children with steroid-sensitive NS, which correlates clinically with the achievement of remission.

Antineutrophil cytoplasmic antibody in children with nephrotic syndrome treated with levamisole: a cross-sectional cohort study

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.

Adrenocortical suppression in children with nephrotic syndrome treated with corticosteroids

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.

An open label non-inferiority randomized controlled trial evaluated alternate day prednisolone given daily during infections vs. levamisole in frequently relapsing nephrotic syndrome

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.

Shear wave elastography of kidneys in children: utility in distinguishing steroid-resistant and steroid-sensitive nephrotic syndrome

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.

Endothelial Dysfunction in Children With Nephrotic Syndrome: A Cross-Sectional Study

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.

Therapeutic drug monitoring in childhood idiopathic nephrotic syndrome: a state of the art review

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.

Cyclophosphamide Toxicity in Pediatric Nephrotic Syndrome Patient: A Case Report and Literature Review

BACKGROUND

Primary membranous nephropathy is a rare presentation in children. Patients unresponsive to steroids and experiencing frequent relapse are considered steroid-resistant. They often require complex treatment regimens consisting of immunosuppressants like cyclophosphamide, tacrolimus, and cyclosporin A.

CASE

In the present case, a 5-year-old child was suffering from steroid-resistant nephrotic syndrome for the past 10 months. He was initially treated with prednisolone 20mg but was subsequently found to be steroid-resistant. A renal biopsy revealed primary podocytopathy with immunocomplex deposits in podocyte tissues, suggesting primary membranous nephropathy as the cause of SRNS (steroid-resistant nephrotic syndrome). Cyclophosphamide 25mg twice daily was added to the treatment plan since the child did not tolerate tacrolimus therapy. During a subsequent follow-up, the physician reduced the cyclophosphamide 25mg dose to once a day, but parents misinterpreted this, and the child received a larger dose, cyclophosphamide 25mg, four times a day for 20 days. This resulted in cyclophosphamide toxicity-induced neutropenia, alopecia and posing the child at greater risk of sepsis.

CONCLUSION

Nephrotic syndrome is a chronic disease that demands extensive treatment plans and strict monitoring. Medication errors are common among parents or caregivers of pediatric patients. This case is a take-home message emphasizing the significance of patient-centered communication in preventing medication errors. A clinical pharmacist can aid in conveying simple and unambiguous information to parents or caregivers.

Is kidney biopsy necessary in children with idiopathic nephrotic syndrome?

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.

The first randomized controlled trial in pediatric nephrology: the history of the International Study of Kidney Disease in Children (ISKDC)

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.

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

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.

Successful treatment of peritoneal dialysis for two patients with refractory nephrotic syndrome and acute kidney injury: a case report

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.

Spectrum of Anemia in Indian children with Nephrotic Syndrome: a prospective observational study

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.

Incidence and risk factors of acute kidney injury among childhood nephrotic syndrome: a prospective cohort study

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.

Use of Rituximab in Childhood Idiopathic Nephrotic Syndrome

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.

Immunosuppressive Agent Options for Primary Nephrotic Syndrome: A Review of Network Meta-Analyses and Cost-Effectiveness Analysis

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.

Childhood Nephrotic Syndrome in Africa: Epidemiology, Treatment Trends, and Outcomes

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.

Urinary Neutrophil Gelatinase Associated Lipocalin: A Novel Biomarker Determining Steroid Responsiveness in Nephrotic Syndrome

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.

Epidemiology and outcomes of pneumococcal sepsis in children with nephrotic syndrome in a developing country

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.

Current Understanding of Nephrotic Syndrome in Children

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.

Effectiveness of a Low Dose Prednisolone Regimen for Treatment of Relapses in Children with Steroid Sensitive Nephrotic Syndrome

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.

Nephrotic Syndrome and Hodgkins Lymphoma - an Unusual Association

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.

KIAA0101 and IL2RA Were Identified as Core Genes in Hormone-Resistant Nephropathy

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.

Institute of Child Health, Kolkata, 1956–2022

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.

Sequential rituximab therapy sustains remission of nephrotic syndrome but carries high risk of adverse effects

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.

Factors Predicting Short Term Outcome in Children With Idiopathic Nephrotic Syndrome: A Prospective Cohort Study

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.

Efficacy of rituximab versus tacrolimus in difficult-to-treat steroid-sensitive nephrotic syndrome: an open-label pilot randomized controlled trial

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.

Incidence and predictive risk factors for ophthalmological complications in children with nephrotic syndrome receiving long-term oral corticosteroids: a cohort study

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.