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Mazo A, Kilduff S, Pereira T, Solomon S, Matloff R, Zolotnitskaya A, Samsonov D. Mycophenolate Mofetil Versus Prednisone for Induction Therapy in Steroid-Sensitive Idiopathic Nephrotic Syndrome in Children: An Observational Study. Kidney Med 2024; 6:100776. [PMID: 38435073 PMCID: PMC10904994 DOI: 10.1016/j.xkme.2023.100776] [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] [Indexed: 03/05/2024] Open
Abstract
Rationale & Objective High-dose steroids are recommended for the induction of idiopathic nephrotic syndrome. The aim of this study was to compare standard induction therapy with Mycophenolate Mofetil (MMF). We hypothesized that MMF could be noninferior to steroids in maintaining steroid-induced remission. The second aim was to reduce steroid-induced side effects. Study Design This was an observational study. Setting & Population Patients 2-11 years with first episode of nephrotic syndrome who entered remission within 2 weeks of standard steroid treatment were eligible for enrollment. Patients in the experimental group completed 12-week induction with MMF, whereas the control group continued a standard 12-week steroid protocol. Exposures MMF and prednisolone were used in the study. Outcomes The primary study outcomes were relapse rate and relapse-free interval during a 52-week follow-up. Analytical Approach Descriptive statistics were used for analysis. Results Ten of 41 eligible patients consented to participate in the MMF group and 8 completed the study. The control group included 31 patients, with 23 patients who completed 52 weeks follow-up. During the induction phase, 3 out of 10 patients (30%) in the MMF group and 1 out of 31 (3%) in the control group (P = 0.04) developed relapse. During the 52 weeks follow-up period, 7 out of 10 patients (70%) in the MMF group and 19 out of 31 (61%) in the control group developed relapse (P = 0.72). The median relapse-free interval was 11 and 19 weeks in MMF and control groups, respectively (P = 0.60). No serious side effects were recorded in either group. Limitations The limitations of the study were low patient numbers receiving MMF and single-center design. Conclusions Our small cohort of patients treated with MMF reported a higher relapse rate during the induction phase. However, by 12 months of follow-up the relapse rate and relapse-free intervals were similar between both groups. All patients tolerated MMF without significant side effects, and those who relapsed remained steroid-sensitive.
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Affiliation(s)
- Alexandra Mazo
- Pediatric Nephrology Division, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York
| | - Stella Kilduff
- Pediatric Nephrology Division, Ann and Roberst H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tanya Pereira
- Pediatric Nephrology Division, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York
| | - Sonia Solomon
- Pediatric Nephrology Division, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York
| | - Robin Matloff
- Pediatric Nephrology Division, Connecticut Children’s, University of Connecticut School of Medicine, Hartford, Connecticut
| | - Anna Zolotnitskaya
- Pediatric Nephrology Division, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Dmitry Samsonov
- Pediatric Nephrology Division, Maria Fareri Children’s Hospital, Westchester Medical Center, Boston Children’s Health Physicians, New York Medical College, Valhalla, New York
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Estimation of childhood nephrotic syndrome incidence: data from the atlanta metropolitan statistical area and meta-analysis of worldwide cases. J Nephrol 2021; 35:575-583. [PMID: 34213762 DOI: 10.1007/s40620-021-01108-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/21/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Epidemiological data on childhood idiopathic nephrotic syndrome (INS) are limited. We estimated childhood INS incidence in a racially and ethnically diverse U.S. population and performed a meta-analysis of published reports to examine differences by race, ethnicity, and time. METHODS One hundred seventy-five children aged 1-17 years living in the Atlanta Metropolitan Statistical Area (MSA) between 2013 and 2018 were identified by retrospective chart review. Annual INS incidence was estimated by dividing cases by population data from the Georgia Department of Public Health. We calculated pooled incidence estimates using random-effects regression models in a meta-analysis of the current and prior studies. Subgroup incidence estimates by race, ethnicity, and time were compared and tested for heterogeneity. RESULTS One hundred seventy-five children aged 1-17 were diagnosed with INS between 2013 and 2018 in the Atlanta MSA. Average annual incidence was 2.13/100,000 (95% CI, 1.83-2.47). Twenty-four studies were included in meta-analysis. Our study was the only one to report incidence for Hispanic children, 2.13/100,000/y (95% CI, 1.40-3.10). In meta-analysis, incidence was highest in Asian children (7.14/ 100,000/y; 95% CI, 4.73-9.54), followed by Black (3.53/100,000/y; 95% CI, 2.93-4.12), and Caucasian (1.83/100,000/y; 95% CI, 1.52-2.14). Annual incidence in the U.S. was stable comparing studies performed before and after 1984, 2.05 vs. 2.26/100,000 (p 0.08). CONCLUSIONS Risk of INS may be higher among Asian and Black children compared to White children. Incidence appears stable over time in the U.S. Future studies should use standardized methodology and assess the contribution of demographic and genetic factors to INS incidence and long-term outcomes.
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Veltkamp F, Rensma LR, Bouts AHM. Incidence and Relapse of Idiopathic Nephrotic Syndrome: Meta-analysis. Pediatrics 2021; 148:peds.2020-029249. [PMID: 34193618 DOI: 10.1542/peds.2020-029249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Idiopathic nephrotic syndrome (INS) in children is a disease with considerable morbidity, yet the incidence and risk for relapse have not been systematically reviewed. OBJECTIVE To estimate the overall pooled weighted incidence and risk for relapse of INS in children. DATA SOURCES Medline and Embase (until December 2020). STUDY SELECTION All studies reporting incidence (per 100 000 children per year) and/or risk for relapse (the proportion of patients who experience ≥1 relapse) of INS in children (age: <18 years) were eligible. DATA EXTRACTION After quality assessment, data were extracted: study (design, localization, and sample size) and patient (age, sex, steroid response, and ethnicity) characteristics, incidence, and risk for relapse. RESULTS After screening, 73 studies were included for analysis (27 incidence, 54 relapse). The overall pooled weighted estimate and corresponding prediction interval (PI) of the incidence was 2.92 (95% PI: 0.00-6.51) per 100 000 children per year. Higher incidences were found in non-Western countries (P < .001). Incidence tended to be lower in white children, but this was not significant. The overall pooled weighted estimate of the risk for relapse was 71.9% (95% PI: 38.8-95.5). Between 1945 and 2011, incidence did not change (P = .39), yet the risk for relapse decreased significantly (P = .024), from 87.4% to 66.2%. LIMITATIONS There was no full-text availability (n = 33), considerable heterogeneity, and limited studies from Africa, Latin America, and Asia. CONCLUSIONS INS has a low incidence with ethnic variation but high risk for relapse. Although corticosteroids have significantly reduced the risk for relapse, it remains unacceptably high, underscoring the need for alternative treatment strategies.
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Affiliation(s)
- Floor Veltkamp
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Leonie R Rensma
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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Time to Relapse and Its Predictors among Children with Nephrotic Syndrome in Comprehensive Specialized Hospitals, Tigray, Ethiopia, 2019. Int J Pediatr 2020; 2020:8818953. [PMID: 33299427 PMCID: PMC7704192 DOI: 10.1155/2020/8818953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 09/16/2020] [Accepted: 10/29/2020] [Indexed: 01/19/2023] Open
Abstract
Background Relapse in children with nephrotic syndrome leads to a variety of complications due to prolonged treatment and potential dependency on steroids. However, there is no study conducted to determine the incidence and predictive factors of relapse for nephrotic syndrome in Ethiopia, especially in children. Thus, this study aimed to assess the incidence of relapse and its predictors among children with nephrotic syndrome in Ethiopia. Methods A retrospective study was conducted by reviewing all charts of children with an initial diagnosis of the nephrotic syndrome in tertiary hospitals from 2011 to 2018. Charts of children with a diagnosis of steroid-resistant cases were excluded. The extraction tool was used for data collection, Epi-data manager V-4.4.2 for data entry, and Stata V-14 for cleaning and analysis. Kaplan-Meier curve, log-rank test, life table, and crude hazard ratios were used to describe the data and adjusted hazard ratios with 95% CI and P value for analysis. Median relapse time, incidence rate of relapse, and cumulative relapse probabilities at a certain time interval were computed. Bivariable and multivariate analyses were performed using the Cox proportional hazard regression to identify the factors associated with relapse. Any variable at P < 0.25 in the bivariable analysis was transferred to multivariate analysis. Then, the adjusted hazard ratio with 95% CI and P ≤ 0.05 was used to report the association and to test the statistical significance, respectively. Finally, texts, tables, and graphs were used to present the results. Results and Conclusion. Majority, 64.5% (40/66), of relapses were recorded in the first 12 months of follow-up. The incidence rate of relapse was 42.6 per 1000 child-month-observations with an overall 1454 child-month-observations and the median relapse time of 16 months. Having undernutrition [AHR = 3.44; 95% CI 1.78-6.65], elevated triglyceride [AHR = 3.37; 95% CI 1.04-10.90], decreased serum albumin level [AHR = 3.51; 95% CI 1.81-6.80], and rural residence [AHR = 4.00; 95% CI 1.49-10.76] increased the hazard of relapse. Conclusion and Recommendation. Relapse was higher in the first year of the follow-up period. Undernutrition, hypoalbuminemia, hypertriglyceridemia, and being from rural areas were independent predictors of relapse. A focused evaluation of those predictors during the initial diagnosis of the disease is compulsory.
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Keita Y, Lemrabott AT, Sylla A, Niang B, Ka EHF, Dial CM, Ndongo AA, Sow A, Moreira C, Niang A, Ndiaye O, Diouf B, Sall MG. [Idiopathic nephrotic syndrome (INS) in children in Dakar: about 40 cases]. Pan Afr Med J 2017; 26:161. [PMID: 28533882 PMCID: PMC5429445 DOI: 10.11604/pamj.2017.26.161.10130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 03/02/2017] [Indexed: 12/02/2022] Open
Abstract
Introduction L’objectif de ce travail était d’analyser les caractéristiques diagnostiques, thérapeutiques et évolutives de l’enfant atteint de néphrose dans un service de pédiatrie de Dakar. Méthodes L’étude était réalisée au service de pédiatrie de l’hôpital Aristide Le Dantec. Il s’agissait d’une étude rétrospective sur une période de 03 ans allant du 1er janvier 2012 au 31 décembre 2014. Ont été inclus tous les patients âgés de 02 ans à 12 ans présentant un tableau de Syndrome néphrotique idiopathique. Résultats Quarante cas de néphrose étaient colligés soit une prévalence de 23% parmi les néphropathies prises en charge dans le service. L’âge moyen était de 7,11± 3,14 ans. Le syndrome néphrotique était pur chez 72,5% (n=29) des patients. Les œdèmes des membres inférieurs étaient présents chez 100% des patients, l’oligurie dans 55% (n=22) et l’HTA dans 5% (n=2) des cas. La protéinurie moyenne était de 145,05 ± 85,54 mg/kg/24heures. La protidémie moyenne était de 46,42 ±7,88 g/L et l’albuminémie moyenne de 17,90 ± 7,15 g/L. Trente-neuf patients avaient reçu une corticothérapie à base de prednisone. La corticosensibilité était retenue chez 77% (n=30) des patients et la corticorésistance chez 13% (n=5) des cas. Le facteur de mauvaise réponse à la corticothérapie était un niveau de protéinurie initiale supérieure à 150 mg/kg/jour (p = 0,024). La biopsie rénale était réalisée chez 18% (n=7) des patients et retrouvait dans 57,2% (n=4) des cas une hyalinose segmentaire et focale. Le cyclophosphamide et l’azathioprine étaient associés aux corticoïdes dans 10% (n=4) des cas chacun. Le taux de rémission globale était de 89,8%. L’évolution vers l’insuffisance rénale chronique était notée chez trois (03) des patients. Conclusion La néphrose représentait près du quart des néphropathies prises en charge dans notre service. Le taux de rémission globale était élevé. Le seul facteur de mauvaise réponse à la corticothérapie était le niveau de protéinurie initiale élevée. En cas d’indication de la biopsie rénale chez nos patients, la HSF était la lésion la plus fréquemment retrouvée.
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Affiliation(s)
| | | | - Assane Sylla
- Service de Pédiatrie CHU A Le Dantec, Dakar, Sénégal
| | - Babacar Niang
- Service d'Anatomopathologie de l'Hôpital Grand Yoff, Dakar, Sénégal
| | | | - Chérif Mohamed Dial
- Service de Pédiatrie de l'Hôpital d'Enfants Albert Royer CHU Fann, Dakar, Sénégal
| | | | - Amadou Sow
- Service de Pédiatrie CHU A Le Dantec, Dakar, Sénégal
| | | | - Abdou Niang
- Service de Néphrologie CHU A, Le Dantec, Dakar, Sénégal
| | - Ousmane Ndiaye
- Service de Pédiatrie de l'Hôpital Abass Ndao, Dakar, Sénégal
| | - Boucar Diouf
- Service de Néphrologie CHU A, Le Dantec, Dakar, Sénégal
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Kikunaga K, Ishikura K, Terano C, Sato M, Komaki F, Hamasaki Y, Sasaki S, Iijima K, Yoshikawa N, Nakanishi K, Nakazato H, Matsuyama T, Ando T, Ito S, Honda M. High incidence of idiopathic nephrotic syndrome in East Asian children: a nationwide survey in Japan (JP-SHINE study). Clin Exp Nephrol 2016; 21:651-657. [PMID: 27590892 DOI: 10.1007/s10157-016-1319-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/01/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Little is known regarding the epidemiology of idiopathic nephrotic syndrome (INS) in East Asia. Previous studies have suggested higher incidence of INS in Asian children, though decreasing trend of its incidence has also been shown. METHODS We conducted a nationwide study of Japanese children aged 6 months to 15 years with INS. Children who were newly diagnosed with INS between 1 January 2010 and 31 December 2012 were eligible. Children with congenital nephrotic syndrome or nephrotic syndrome secondary to nephritis were excluded. RESULTS A total of 2099 children were initially diagnosed with INS and were followed for up to 4 years. The estimated incidence of INS was 6.49 cases/100,000 children per year, without clear correlation with geographical region. The male:female ratio was 1.9 and approximately 50 % of children were <5 years old at diagnosis. During the 1-4 years follow-up, 32.7 % developed frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome. CONCLUSIONS Based on our nationwide survey, the incidence of INS in Japanese children is approximately 3-4 times higher than that in Caucasians. However, the male:female ratio and the age at onset were similar to those in previous studies. We are now planning a prospective cohort study to examine the course of INS in Japan.
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Affiliation(s)
- Kaori Kikunaga
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan. .,Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.
| | - Chikako Terano
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
| | - Fumiyo Komaki
- Department of Health and Welfare Bureau, Health and Welfare Bureau Health Center of Kawasaki City, Kanagawa, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Satoshi Sasaki
- Department of Pediatrics, Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Graduate School of Medicine, Kobe University, Kobe, Hyogo, Japan
| | | | - Koichi Nakanishi
- Clinical Research Center, Wakayama Medical University, Wakayama, Japan
| | - Hitoshi Nakazato
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | | | - Takashi Ando
- Japan Clinical Research Support Unit, Tokyo, Japan
| | - Shuichi Ito
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan.,Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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Moon RJ, Gilbert RD, Page A, Murphy L, Taylor P, Cooper C, Dennison EM, Davies JH. Children with nephrotic syndrome have greater bone area but similar volumetric bone mineral density to healthy controls. Bone 2014; 58:108-13. [PMID: 24145304 PMCID: PMC4968633 DOI: 10.1016/j.bone.2013.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/17/2013] [Accepted: 10/14/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND Glucocorticoid use has been associated with an increased fracture risk and reduced bone mineral density (BMD), particularly in the trabecular compartment. However the contribution of the underlying inflammatory disease process to these outcomes is poorly understood. Childhood nephrotic syndrome (NS) typically follows a relapsing-remitting course often requiring recurrent courses of glucocorticoids, but with low systemic inflammation during remission. NS therefore represents a useful clinical model to investigate the effects of glucocorticoids on BMD and bone geometry in childhood. METHODS Children with NS were compared to age and sex matched healthy controls. Body composition and areal BMD (whole body, lumbar spine and hip) were assessed by DXA. Peripheral quantitative computed tomography (pQCT) scans were obtained at metaphyseal (4%) and diaphyseal (66%) sites of the tibia to determine volumetric BMD and bone cross-sectional geometry. Lifetime cumulative glucocorticoid exposure was calculated from medical records. RESULTS 29 children with NS (55% male, age 10.7±3.1years) were compared to 29 healthy controls (55% male, age 11.0±3.0years). The children with NS were of similar height SDS to controls (p=0.28), but were heavier (0.65±1.28SDS vs -0.04±0.89SDS, p=0.022) and had greater body fat percentage SDS (0.31±1.01 vs -0.52±1.10, p=0.008). Tibial trabecular and cortical vBMD were similar between the two groups but bone cross-sectional area (CSA) was significantly greater in children with NS at both the metaphysis (954±234mm(2) vs 817±197mm(2), p=0.002) and diaphysis (534.9±162.7mm(2) vs 463.2±155.5mm(2), p=0.014). Endosteal and periosteal circumferences were greater in children with NS than controls (both p<0.01), resulting in reduced cortical thickness (2.4±0.7mm vs 2.8±0.7mm, p=0.018), but similar cortical CSA (p=0.22). The differences in cortical geometry were not statistically significant when weight was included as a confounding factor. There were no associations between cumulative steroid exposure, duration of NS or number of relapses and any bone parameter. CONCLUSIONS Tibial bone CSA is increased in children with NS. We speculate that this is a compensatory response to increased body weight. Defects in trabecular BMD were not identified in this cohort of children with NS.
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Affiliation(s)
- RJ Moon
- Paediatric Endocrinology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
- MRC Lifecourse Epidemiology Unit, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - RD Gilbert
- Paediatric Nephrology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - A Page
- Paediatric Endocrinology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - L Murphy
- Paediatric Endocrinology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - P Taylor
- Osteoporosis Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - C Cooper
- MRC Lifecourse Epidemiology Unit, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - EM Dennison
- MRC Lifecourse Epidemiology Unit, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - JH Davies
- Paediatric Endocrinology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
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TNFα pathway blockade ameliorates toxic effects of FSGS plasma on podocyte cytoskeleton and β3 integrin activation. Pediatr Nephrol 2012; 27:2217-26. [PMID: 22538781 DOI: 10.1007/s00467-012-2163-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2012] [Revised: 03/06/2012] [Accepted: 03/07/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND In the absence of mutant genes encoding components of the podocyte slit diaphragm, about 30-50 % of children with primary glucocorticoid-resistant focal segmental glomerulosclerosis (FSGS) develop recurrent proteinuria and slowly progressive FSGS lesions following renal transplantation. Recurrence of FSGS in the allograft strongly suggests a circulating factor that disturbs normal podocyte biology. To date, the nature of the circulating factor is unclear, and there is no cure for the recurrent form of FSGS (R-FSGS). METHODS Cultured differentiated human podocytes were exposed to the plasmapheresis effluent or blood plasma samples from pediatric patients with recurrent or primary FSGS; in some cases, podocytes were pre-incubated with specific antibodies to block the tumor necrosis factor-alpha (TNFα) signaling pathway. Integrity of focal adhesion complexes and actin cytoskeleton were investigated by immunofluorescent microscopy. RESULTS Plasmapheresis effluent from an R-FSGS child or fresh plasma from two children with primary FSGS rapidly disturbed the cytoskeleton of normal human podocytes in vitro. Plasma from a child with R-FSGS also activated β3 integrin and dispersed focal adhesion complexes. The effects were reversed by pre-incubation with antibodies against TNFα or either of the two TNFα receptors. When our patient with R-FSGS became resistant to plasmapheresis, we initiated treatment with twice weekly etanercept injections and then infliximab. Within 3 weeks of regular anti-TNFα therapy, the patient achieved sustained partial remission of proteinuria, allowing us to wean her off plasmapheresis completely. CONCLUSIONS We suggest that in some FSGS patients, disruption of the podocyte cytoskeleton and β3 integrin-mediated podocyte attachment are driven by the TNFα pathway.
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Recurrent focal segmental glomerulosclerosis: a discrete clinical entity. Int J Nephrol 2012; 2012:246128. [PMID: 22288013 PMCID: PMC3263622 DOI: 10.1155/2012/246128] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Revised: 10/04/2011] [Accepted: 10/04/2011] [Indexed: 12/01/2022] Open
Abstract
Focal segmental glomerulosclerosis refers to a set of particular histopathologic lesions in which steroid-resistant podocyte injury leads to patchy adhesions between the glomerular tuft and Bowman's capsule, followed by progressive glomerulosclerosis and proteinuric renal failure. Because of the nonspecific nature of this lesion, it has been difficult to classify the various forms of primary nephrotic syndrome in children. However, with the recognition of hereditary FSGS caused by mutations podocyte slit diaphragm genes, it is increasingly clear that the steroid-resistant form of FSGS that recurs in the renal allografts (R-FSGS) constitutes a distinct clinical entity. Capitalizing on recent studies in which patients have been screened for slit diaphragm gene mutations, this review focuses on the natural history and pathogenesis of R-FSGS.
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