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Aydin M, Franke I, Kurylowicz L, Ganschow R, Lentze M, Born M, Hagemann R. The long-term outcome of childhood nephrotic syndrome in Germany: a cross-sectional study. Clin Exp Nephrol 2019; 23:676-688. [PMID: 30721392 DOI: 10.1007/s10157-019-01696-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 01/14/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Long-term outcomes of children with nephrotic syndrome have not been well described in the literature. METHODS Cross-sectional study data analysis of n = 43 patients with steroid-sensitive (SSNS) and n = 7 patients with steroid-resistant (SRNS) nephrotic syndrome were retrospectively collected; patients were clinically examined at a follow-up visit (FUV), on average 30 years after onset, there was the longest follow-up period to date. RESULTS The mean age at FUV was 33.6 years (14.4-50.8 years, n = 41). The mean age of patients with SSNS at onset was 4.7 years (median 3.8 years (1.2-14.5 years), the mean number of relapses was 5.8 (0 to 29 relapses). Seven patients (16.3%) had no relapses. Eleven patients were "frequent relapsers" (25.6%) and four patients still had relapses beyond the age of 18 years. Except of cataracts and arterial hypertension, there were no negative long-term outcomes and only one patient was using immunosuppressant therapy at FUV. 55% of patients suffered from allergies and 47.5% had hypercholesterolemia. Two patients suffered a heart attack in adulthood. A younger age at onset (< 4 years) was a risk factor for frequent relapses. An early relapse (within 6 months after onset) was a risk factor and a low birth weight was not a significant risk factor for a complicated NS course. The mean age of patients with SRNS at onset was 4.6 ± 4.4 years and 27.5 ± 9.9 years at FUV. Three patients received kidney transplantations. CONCLUSIONS The positive long-term prognosis of SSNS can reduce the concern of parents about the probability of the child developing a chronic renal disease during the clinical course after onset.
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Affiliation(s)
- Malik Aydin
- Department of General Pediatrics, University Children's Hospital Bonn, Bonn, Germany. .,HELIOS University Medical Center Wuppertal, Children's Hospital, Center for Clinical and Translational Research (CCTR), Center for Biomedical Education and Research (ZBAF), Witten/Herdecke University, Heusnerstr. 40, 42283, Wuppertal, Germany.
| | - Ingo Franke
- Department of General Pediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Lisa Kurylowicz
- Department of General Pediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Rainer Ganschow
- Department of General Pediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Michael Lentze
- Department of General Pediatrics, University Children's Hospital Bonn, Bonn, Germany
| | - Mark Born
- Department of Radiology, Pediatric Radiology, University Hospital Bonn, Bonn, Germany
| | - Rebekka Hagemann
- Department of General Pediatrics, University Children's Hospital Bonn, Bonn, Germany
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Dhooria GS, Singh HP, Bhat D, Bains HS, Soni RK, Kumar M. Multidimensional impact on families of children with steroid-sensitive nephrotic syndrome. J Paediatr Child Health 2017; 53:354-357. [PMID: 28058746 DOI: 10.1111/jpc.13445] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/07/2016] [Accepted: 11/13/2016] [Indexed: 11/29/2022]
Abstract
AIM Children with nephrotic syndrome (NS) have prolonged disease course with relapses requiring frequent visits and prolonged steroid therapy with their long-term concerns. All these factors affect the child and their families in many domains of functioning. The objective of this study was to assess multidimensional impact on families of children with nephrotic syndrome using (PedsQL) Family Impact Module (FIM). METHODS This cross-sectional study was conducted in a paediatric nephrology clinic of a tertiary care hospital. Fifty cases of steroid-sensitive nephrotic syndrome between age group of 2-18 years were included, and equal age-sex matched healthy children were taken as controls. Baseline demographic factors including age, gender and education status, modified Kuppuswamy's socio-economic status were collected and clinical variables of NS cases were recorded. FIM is a parent-reported instrument that measures the impact of paediatric chronic health conditions on care giver's HRQOL and their family function. Mean FIM scores were compared among the cases and controls, and different predictive factors affecting family impact (FI) were analysed. RESULTS The FI total score showed significantly lower scores in cases (mean score: 60.76 ± 15.66) as compared to controls (mean 100). Among the individual groups, lowest scores were found in two domains, namely 'worry' and 'emotional function' with mean scores of 46.20 ± 20.66 and 46.80 ± 24.61, respectively, although other domains were also significantly affected. CONCLUSION FI score should be evaluated in all cases of NS as parenting such children may significantly affect all domains of family functioning.
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Affiliation(s)
- Gurdeep S Dhooria
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, India
| | - Harmeet P Singh
- Department of Medicine, Dayanand Medical College and Hospital, Ludhiana, India
| | - Deepak Bhat
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, India
| | - Harmesh S Bains
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, India
| | - Ravinder K Soni
- Department of Statistics, Preventive Medicine, Dayanand Medical College and Hospital, Ludhiana, India
| | - Mohit Kumar
- Department of Pediatrics, Dayanand Medical College and Hospital, Ludhiana, India
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Systematic Review of the Toxicity of Long-Course Oral Corticosteroids in Children. PLoS One 2017; 12:e0170259. [PMID: 28125632 PMCID: PMC5268779 DOI: 10.1371/journal.pone.0170259] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/01/2017] [Indexed: 02/05/2023] Open
Abstract
Background Long courses of oral corticosteroids are commonly used in children in the management of chronic conditions. Various adverse drug reactions (ADRs) are known to occur with their use. This systematic review aimed to identify the most common and serious ADRs and to determine their relative risk levels. Methods A literature search of Embase, Medline, International Pharmaceutical Abstracts, CINAHL, Cochrane Library and PubMed was performed with no language restrictions in order to identify studies where oral corticosteroids were administered to patients aged 28 days to 18 years of age for at least 15 days of treatment. Each database was searched from their earliest dates to January 2016. All studies providing clear information on ADRs were included. Results One hundred and one studies including 33 prospective cohort studies; 21 randomised controlled trials; 21 case series and 26 case reports met the inclusion criteria. These involved 6817 children and reported 4321 ADRs. The three ADRs experienced by the highest number of patients were weight gain, growth retardation and Cushingoid features with respective incidence rates of 21.1%, 18.1% and 19.4% of patients assessed for these ADRs. 21.5% of patients measured showed decreased bone density and 0.8% of patients showed osteoporosis. Biochemical HPA axis suppression was detected in 269 of 487 patients where it was measured. Infection was the most serious ADR, with twenty one deaths. Varicella zoster was the most frequent infection (9 deaths). Conclusions Weight gain, growth retardation and Cushingoid features were the most frequent ADRs seen when long-course oral corticosteroids were given to children. Increased susceptibility to infection was the most serious ADR.
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The non-immunosuppressive management of childhood nephrotic syndrome. Pediatr Nephrol 2016; 31:1383-402. [PMID: 26556028 PMCID: PMC4943972 DOI: 10.1007/s00467-015-3241-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/21/2015] [Accepted: 09/30/2015] [Indexed: 12/20/2022]
Abstract
Idiopathic nephrotic syndrome (INS) is one of the most common renal diseases found in the paediatric population and is associated with significant complications, including infection and thrombosis. A high proportion of children enter sustained remission before adulthood, and therapy must therefore mitigate the childhood complications, while minimising the long-term risk to health. Here we address the main complications of INS and summarise the available evidence and guidance to aid the clinician in determining the appropriate treatment for children with INS under their care. Additionally, we highlight areas where no consensus regarding appropriate management has been reached. In this review, we detail the reasons why routine prophylactic antimicrobial and antithrombotic therapy are not warranted in INS and emphasise the conservative management of oedema. When pharmacological intervention is required for the treatment of oedema, we provide guidance to aid the clinician in determining the appropriate therapy. Additionally, we discuss obesity and growth, fracture risk, dyslipidaemia and thyroid dysfunction associated with INS. Where appropriate, we describe how recent developments in research have identified potential novel therapeutic targets.
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Effect of glucocorticoids on growth and bone mineral density in children with nephrotic syndrome. Eur J Pediatr 2015; 174:911-7. [PMID: 25573461 DOI: 10.1007/s00431-014-2479-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 12/11/2014] [Accepted: 12/12/2014] [Indexed: 01/29/2023]
Abstract
UNLABELLED Glucocorticosteroids (GCs) are the first-line treatment for idiopathic nephrotic syndrome (NS), but prolonged administration interferes with growth and bone mineralization. We conducted a retrospective study to analyze the long-term impact of prednisone on growth and bone mineral density (BMD) in children with NS. Data from children with NS followed during almost 10 years were analyzed. Height and spine BMD values were converted to Z-scores (standard deviation [SD]). The mean cumulative dose of GCs received was calculated and correlated to patient's growth and spine BMD using linear regression and subgroup analysis. We included 30 patients diagnosed at 3.7 years old (interquartile range (IQR) 2.6-4.8) and followed over 9.8 years (IQR 6.6-11.7). The one half of NS patients was steroid sensitive and one half dependent or resistant. The median cumulative dose of GCs received was 0.27 mg/kg/day (IQR 0.18-0.35). Growth and spine BMD were both negatively associated with the cumulative dose of GCs (P=0.001 and P=0.037, respectively). Final height Z-scores were significantly lower in patients receiving >0.2 mg/kg/day GCs (P=0.001). No difference was observed in spine BMD between subgroups. CONCLUSION Increasing doses of GCs were significantly associated with lower height and BMD Z-scores. A significant effect on growth was observed with cutoff doses above 0.2 mg/kg/day.
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Sato M, Ito S, Ogura M, Kamei K. Impact of rituximab on height and weight in children with refractory steroid-dependent nephrotic syndrome. Pediatr Nephrol 2014; 29:1373-9. [PMID: 24599443 DOI: 10.1007/s00467-014-2792-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 02/05/2014] [Accepted: 02/12/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Children with steroid-dependent nephrotic syndrome (SDNS) often suffer from serious adverse events, including growth retardation and obesity. Rituximab (RTX) is a promising therapeutic option to overcome steroid dependency. We have examined the impact of RTX on growth and obesity in children with SDNS. METHODS Thirteen pediatric patients with SDNS who were refractory despite treatment with multiple immunosuppressive agents received RTX infusions. Mean follow-up was 2.3 years from the first administration of RTX. Improvement in the height and obesity indexes from prior to the initial RTX infusion through to the last visit was assessed. RESULTS After RTX, the number of relapses [2.8 (before RTX) vs. 0.8/year (after RTX); p = 0.0008] and the prednisolone dose (287.9 vs. 70.7 mg/kg/year, respectively; p = 0.0002) were significantly decreased. Marked improvement in the height standard deviation score (SDS) was achieved by ten of the 13 patients (77 %) [n = 13; -1.6 (before RTX) vs. -0.8 SDS (after RTX); p = 0.03]. Notably, the height SDS of seven of the eight patients whose height was less than average at the first RTX improved from -2.6 to -1.4 SDS with RTX therapy. At the same time, the obesity index of 12 of the 13 patients (92 %) significantly improved (n = 13; 16.9 vs. 3.1 %; p = 0.004). CONCLUSION Therapy with RTX may contribute to an improvement in the growth and obesity indexes in some patients suffering from severe side effects of steroids.
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Affiliation(s)
- Mai Sato
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, Tokyo, 157-8535, Japan
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Cammas B, Harambat J, Bertholet-Thomas A, Bouissou F, Morin D, Guigonis V, Bendeddouche S, Afroukh-Hacini N, Cochat P, Llanas B, Decramer S, Ranchin B. Long-term effects of cyclophosphamide therapy in steroid-dependent or frequently relapsing idiopathic nephrotic syndrome. Nephrol Dial Transplant 2010; 26:178-84. [DOI: 10.1093/ndt/gfq405] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Growth in boys with idiopathic nephrotic syndrome on long-term cyclosporin and steroid treatment. Pediatr Nephrol 2009; 24:2393-400. [PMID: 19669799 DOI: 10.1007/s00467-009-1266-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 06/11/2009] [Accepted: 06/15/2009] [Indexed: 10/20/2022]
Abstract
Although steroid-free remission can usually be achieved with cyclosporin A (CsA) in patients with steroid-dependent nephrotic syndrome (SDNS), some CsA-treated patients require long-term steroid therapy. Data on growth in these patients are scarce. Sixty-four boys with SDNS receiving long-term CsA and steroid therapy were retrospectively analyzed. During the 10-year follow-up period, height standard deviation score (HSDS) remained in the normal range in 47 patients but was below -2 SD in 17 patients. The occurrence of growth retardation was influenced by height at diagnosis and the number of relapses. Thirty patients were followed for at least 3 years before and after age 12. The decrease in HSDS per year of disease in patients older than 12 years was twice that observed in children younger than 12. However, adult height was < or = -2 SD in only two of the 14 patients reaching adult height, reflecting potential catch-up growth during late puberty. Careful monitoring of growth is recommended, given than up to 25% of patients experienced severe growth retardation during the course of their disease.
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Abstract
BACKGROUND Growth retardation following steroid treatment in children is a major problem. Reduction of steroid dose has been tried using immunosuppressive agents such as cyclosporine A or mizoribine in children with frequently relapsing nephrotic syndrome. Few reports concerning final height in steroid-sensitive nephrotic syndrome (SSNS) are available. METHOD Patients who developed SSNS before 15 years of age and reached their final height were retrospectively studied by standard deviation score (SDS) of height and target height calculated by their parental height. RESULTS A total of 34 patients were evaluated for their final height. The mean age at onset of SSNS was 8.0 years and the mean age at last follow up was 21.6 years. In total, 22 patients had frequent relapses and were treated with cyclophosphamide, mizoribine or cyclosporin A. All patients had normal renal function at the last evaluation. The mean final height was 168 cm in males and 155 cm in females. The mean height SDS was 0.37 at the time of onset and was -0.43 when they reached their final height (P = 0.0001). The final height was a mean of 2.5 cm below target height and was significantly lower than their siblings (P = 0.007). Final height of two boys who continued to have frequent relapses during puberty and were not treated with cyclosporin A was 146 and 150 cm. CONCLUSION Final height in children with SSNS was slightly affected by steroid treatment and two patients had severe growth retardation.
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Affiliation(s)
- Osamu Motoyama
- Department of Pediatrics, Toho University Medical Center, Sakura Hospital, Chiba, Japan.
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Hegarty J, Mughal MZ, Adams J, Webb NJA. Reduced bone mineral density in adults treated with high-dose corticosteroids for childhood nephrotic syndrome. Kidney Int 2006; 68:2304-9. [PMID: 16221233 DOI: 10.1111/j.1523-1755.2005.00690.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Children with minimal change nephrotic syndrome (MCNS) receive repeated courses of high dose oral prednisolone. No previous study has investigated the impact of this on final bone mineral density (BMD). Young adults previously reported in a large follow-up study of children with MCNS were invited to participate in a cross-sectional study. Areal BMD (aBMD) of the spine (L1-4), left femoral neck, and total left hip was measured using dual x-ray absorptiometry (DXA), and volumetric BMD (vBMD) of the distal radius was measured by pQCT. BMD results were compared with reference data provided by the manufacturers of the densitometers. METHODS Thirty-four (24 male) of the original cohort of 62 participated in the study. The mean (SD) final height Z score of the cohort was -0.45 (0.92) (P = 0.007) and mean BMI Z score 1.62 (1.53) (P < 0.0001). RESULTS There was a highly significant reduction in distal radial trabecular vBMD; the mean Z score was -0.95 (0.99) and T score -1.04 (1.01) (both P < 0.0001); however, there was no reduction in distal radial total vBMD, the mean Z score being 0.00 (0.95) and T score -0.08 (0.99), (P = 0.99 and 0.66, respectively). The aBMD of the lumbar spine and femoral neck also showed a reduction in T scores [-0.45 (1.27), P = 0.045 and -0.49 (0.86), P = 0.002, respectively], but not Z scores [-0.37 (1.28) and -0.15 (0.87), respectively, both P = NS]. Total hip aBMD was not different from the control population. CONCLUSION Adult survivors of childhood MCNS have a significant reduction in forearm trabecular vBMD, placing them at increased fracture risk at this site.
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Affiliation(s)
- Janet Hegarty
- Department of Nephrology, Salford Royal Hospitals NHS Trust, Hope Hospital, UK
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Levine A, Shamir R, Wine E, Weiss B, Karban A, Shaoul RR, Reif SS, Yakir B, Friedlander M, Kaniel Y, Leshinsky-Silver E. TNF promoter polymorphisms and modulation of growth retardation and disease severity in pediatric Crohn's disease. Am J Gastroenterol 2005; 100:1598-604. [PMID: 15984988 DOI: 10.1111/j.1572-0241.2005.41737.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Delayed growth is common in pediatric Crohn's disease (CD). Multiple factors have been shown to affect growth in this situation, the most prominent being the presence and severity of inflammation and inadequate nutritional intake. Inflammation, anorexia, and weight loss are all manifestations of circulating TNF-alpha, which is elevated in CD. The ability to secrete TNF-alpha may be affected by polymorphisms in the TNF-alpha promoter. The aim of our study was to determine whether growth retardation and disease severity in pediatric onset CD are affected by TNF promoter genotype. METHODS Genotyping for TNF-alpha and NOD2/CARD15 single nucleotide polymorphisms was performed in 87 patients with detailed growth records. Parameters including disease location and disease severity were recorded, and the effect of these polymorphisms on Z-scores for height and weight at disease onset and during follow-up were analyzed. RESULTS Lower age of onset was linked to more height retardation, while the presence of colonic disease and the absence of ileal disease were more likely to predict the absence of growth retardation. The presence of two polymorphisms thought to decrease circulating TNF-alpha was associated with higher mean Z-scores for height and a trend toward less growth retardation. Two other polymorphisms were modestly associated with disease severity. CONCLUSION Polymorphisms in the TNF-alpha promoter may independently modulate growth and disease severity in pediatric onset CD. The effect of these polymorphisms does not appear to be mediated via weight loss, and is relatively modest.
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Affiliation(s)
- Arie Levine
- Pediatric Gastroenterology and Nutrition Unit, E. Wolfson Medical Center, Holon, Israel
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Foster BJ, Shults J, Zemel BS, Leonard MB. Interactions between growth and body composition in children treated with high-dose chronic glucocorticoids. Am J Clin Nutr 2004; 80:1334-41. [PMID: 15531684 DOI: 10.1093/ajcn/80.5.1334] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Glucocorticoid therapy retards growth during childhood and is believed to lead to a Cushingoid body habitus. However, despite prolonged, repeated courses of glucocorticoid, children with steroid-sensitive nephrotic syndrome (SSNS) have almost normal adult height. Little information exists on body composition. OBJECTIVE We sought to assess the effect of glucocorticoids on height and body composition by comparing children with SSNS with concurrent healthy reference children. We hypothesized that chronic glucocorticoid therapy leads to obesity, decreased lean mass, and distorted distributions of fat and lean. DESIGN We performed a cross-sectional study of 52 subjects with SSNS (4-21 y) and 259 reference subjects. The evaluation included height, weight, and pubertal status. Fat and lean masses were assessed by dual-energy X-ray absorptiometry in all subjects. Lifetime glucocorticoid exposure was recorded for subjects with SSNS. Outcomes were expressed as SD scores (SDS). RESULTS Forty-one percent of subjects with SSNS were obese [body mass index (BMI) > 95th percentile], but regional fat distribution was normal. Mean total lean mass-for-height was 0.43 SD (95% CI: 0.15, 0.72) higher and mean appendicular lean mass-for-total-lean-mass was lower (-0.39 SD; 95% CI: -0.64, -0.14) in SSNS compared with reference children. The mean height-SDS in SSNS was -0.08 SD (95% CI: -0.37, 0.21) relative to national reference data, but height-SDS was significantly decreased given the degree of obesity. Height-SDS was positively associated with BMI-SDS among subjects with SSNS. CONCLUSION Glucocorticoid therapy for SSNS is complicated by obesity and relatively low appendicular lean mass. Overall height-SDS is normal because of a mitigating effect of elevated BMI on glucocorticoid-induced growth retardation.
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Affiliation(s)
- Bethany J Foster
- Department of Pediatrics, Division of Nephrology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, USA.
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Wine E, Reif SS, Leshinsky-Silver E, Weiss B, Shaoul RR, Shamir R, Wasserman D, Lerner A, Boaz M, Levine A. Pediatric Crohn's disease and growth retardation: the role of genotype, phenotype, and disease severity. Pediatrics 2004; 114:1281-6. [PMID: 15520108 DOI: 10.1542/peds.2004-0417] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Delayed growth is a well-established feature of pediatric Crohn's disease. Several factors have been shown to affect growth, including disease location, severity, and treatment. The recently discovered NOD2 gene has been correlated to ileal location of Crohn's disease and subsequently could affect growth through the resulting phenotype or as an independent risk factor. The aim of our study was to determine if growth retardation is affected by genotype independently of disease location or severity. METHODS Genotyping for 3 NOD2 single-nucleotide polymorphisms was performed in 93 patients with detailed growth records. Parameters including disease location, disease severity, and NOD 2 genotype and their effect on z scores for height and weight at disease onset and during follow-up were analyzed. RESULTS NOD2 mutations were correlated with ileal location but not with disease severity or growth retardation. Ileal involvement was significantly associated with height retardation at disease onset and the lowest z score during follow-up. Use of steroids affected weight but not height. Regression models for growth variables revealed that the strongest association with impaired growth is with disease severity (weight- and height-failure odds ratios: 6.17 and 4.52, respectively). CONCLUSIONS Severity of disease is correlated with growth failure for both height and weight. Location of disease is a weaker predictor of disordered growth and is correlated with growth retardation but not growth failure. The NOD2 genotype was not correlated with growth retardation or growth failure.
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Affiliation(s)
- Eytan Wine
- Pediatric Gastroenterology and Nutrition Unit, E. Wolfson Medical Center, Holon, Israel
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Emma F, Sesto A, Rizzoni G. Long-term linear growth of children with severe steroid-responsive nephrotic syndrome. Pediatr Nephrol 2003; 18:783-8. [PMID: 12811653 DOI: 10.1007/s00467-003-1176-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2002] [Revised: 03/20/2003] [Accepted: 03/23/2003] [Indexed: 11/26/2022]
Abstract
The present study was designed to evaluate the risk of permanent linear growth impairment in a selected group of 42 children with steroid-dependent nephrotic syndrome (SDNS) and 14 children with frequently relapsing nephrotic syndrome (FRNS). Longitudinal height measurements were available in all patients from the onset of the disease for a mean follow-up of 11.7+/-3.5 years. During the prepubertal period, patients lost 0.49+/-0.6 height SD score (HtSDS) ( P<0.001). Twenty-three patients have reached their final height with an average loss of 0.92+/-0.8 HtSDS from the onset of their disease ( P<0.001) and 0.68+/-0.7 from their target HtSDS ( P<0.001). The pubertal growth spurt was mildly delayed in male but not female patients. Steroid therapy, calculated as the mean duration of prednisone (PDN) treatment or as the average cumulative PDN dose, was the only predictor of poor growth evolution. Partial catch-up growth occurred after PDN withdrawal. Children with early onset NS and adolescent patients, who were still receiving PDN after the age of 9 years in girls and 11 years in boys, were at higher risk for HtSDS loss. In conclusion, children with severe steroid-responsive NS are at risk of permanent growth retardation secondary to prolonged courses of steroid treatment.
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Affiliation(s)
- Francesco Emma
- Division of Nephrology, Children's Hospital and Research Institute Bambino Gesu', Piazza S. Onofrio 4, 00165 Rome, Italy.
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Fakhouri F, Bocquet N, Taupin P, Presne C, Gagnadoux MF, Landais P, Lesavre P, Chauveau D, Knebelmann B, Broyer M, Grünfeld JP, Niaudet P. Steroid-sensitive nephrotic syndrome: from childhood to adulthood. Am J Kidney Dis 2003; 41:550-7. [PMID: 12612977 DOI: 10.1053/ajkd.2003.50116] [Citation(s) in RCA: 114] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The clinical presentation, treatment, and outcome of steroid-sensitive nephrotic syndrome (SSNS) during childhood have been extensively studied. Conversely, few data regarding the outcome in adulthood of childhood SSNS have been published previously. We undertook to conduct a retrospective study of the outcome in adulthood of a large cohort of patients diagnosed with an SSNS during childhood. METHODS We identified all children born between 1970 and 1975 who had been admitted to our institution for an SSNS. Data regarding the outcome in adulthood of these patients were obtained through mailed questionnaires or phone calls to patients and/or their parents or through attending physicians. RESULTS One hundred seventeen patients were identified. Data regarding the outcome of SSNS in adulthood were available for 102 patients (87.2%). Forty-three patients (42.2%) experienced at least one relapse of nephrotic syndrome in adulthood. By univariate analysis, young age at onset (<6 years) and more severe disease in childhood, indicated by a greater number of relapses (12.9 for adulthood relapsers versus 5.4 for adulthood nonrelapsers; P < 0.0001) and more frequent use of immunosuppressors (74.4% versus 31.6%; P < 0.0001) or cyclosporine (42.9% versus 7.3%; P < 0.0001) were predictive of the occurrence of SSNS relapse in adulthood. Conversely, relapse rate in the first 6 months of disease was not predictive of further relapses in adulthood. By multivariate analysis, only number of relapses during childhood was predictive of adulthood relapses (P < 0.0058). Long-term side effects of steroids were found in 44.2% of adulthood relapsers; the most frequent were osteoporosis and excess weight. CONCLUSION The incidence of childhood SSNS relapses in adulthood was relatively high in our study. Further studies are required to assess long-term complications in adults with relapses and a history of prolonged steroid and immunosuppressor use.
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Affiliation(s)
- Fadi Fakhouri
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France.
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17
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Abstract
Delayed puberty can be defined as the lack of pubertal development at an age of 2 SD above the mean, which corresponds to an age of approximately 14 years for males and 13 years for females, taking both sex and ethnic origin into consideration. Its incidence associated with chronic illnesses is unknown; however, its clinical importance is relevant due to the larger percentage of patients with chronic disorders surviving until the age of puberty. Virtually every child with any chronic disease could present with delayed puberty (due to recurrent infections, immunodeficiency, gastrointestinal disease, renal disturbances, respiratory illnesses, chronic anaemia, endocrine disease, eating disorders, exercise and a number of miscellaneous abnormalities). Pubertal delay associated with chronic illness is accompanied by a delay in growth and the pubertal growth spurt. The degree to which growth and pubertal development are affected in chronic illness depends upon the type of disease and individual factors, as well as on the age at illness onset, its duration and severity. The earlier its onset and the longer and more severe the illness, the greater the repercussions on growth and pubertal development. The mechanism that trigger the start of physiological puberty remain unknown. Although malnutrition is probably the most important mechanism responsible for delayed puberty, emotional deprivation, toxic substances, stress and the side effects of chronic therapy, among others, have been implicated in the pathophysiology of delayed puberty. Therefore, early diagnosis is essential and appropriate and specific therapy fundamental.
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Affiliation(s)
- Jesús Pozo
- Department of Paediatric Endocrinology, University Autónoma, Hospital Universitario Infantil Niño Jesús, Avda. Menéndez Pelayo 65, E-28009 Madrid, Spain
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18
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Abstract
BACKGROUND Corticosteroids have been used for the treatment of inflammatory bowel disease since the late 1940s. Upwards of 80% of patients may respond acutely to treatment with these medications, although 20% or more may be refractory and others become dependent on corticosteroid use to suppress disease activity. Side effects in the acute situation are relatively minor, although significant side effects (e.g., psychosis) have been encountered; the long-term use of corticosteroids is more problematic. This creates a milieu for the potential for serious and irreversible problems. These side effects are discussed in detail. The side effects from corticosteroids emulate from exogenous hypercortisolism, which is similar to the clinical syndrome of Cushing's disease. STUDY PubMed search for years 1966-2000, author's personal manuscript/abstract files, and citations of known references. CONCLUSION Short-term corticosteroid use is associated with generally mild side effects, including cutaneous effects, electrolyte abnormalities, hypertension, hyperglycemia, pancreatitis, hematologic, immunologic, and neuropsychologic effects, although occasionally, clinically significant side effects may occur. Long-term corticosteroid use may be associated with more serious sequel, including osteoporosis, aseptic joint necrosis, adrenal insufficiency, gastrointestinal, hepatic, and ophthalmologic effects, hyperlipidemia, growth suppression, and possible congenital malformations.
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Affiliation(s)
- A L Buchman
- Division of Gastroenterology and Hepatology, Northwestern University Medical School, Chicago, Illinois 60611, USA.
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19
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Polito C, La Manna A, Papale MR, Villani G. Delayed pubertal growth spurt and normal adult height attainment in boys receiving long-term alternate-day prednisone therapy. Clin Pediatr (Phila) 1999; 38:279-85. [PMID: 10349525 DOI: 10.1177/000992289903800505] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Statural growth to age > or = 20 years was studied in 10 boys with glomerulonephritis who received alternate-day prednisone (mean 1.2 mg/kg) for at least 2 consecutive years during pubertal age. Peak growth velocity was delayed after age 15 years in six patients and it was less than 7 cm/year in five. However, after age 16, growth velocity was significantly (p = 0.02) higher than expected and allowed patients to ultimately reach their genetic height potential.
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Affiliation(s)
- C Polito
- Department of Pediatrics, Second University of Naples, Italy
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20
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Affiliation(s)
- B Boersma
- Department of Pediatrics, Leiden University Hospital, The Netherlands
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21
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Bircan Z, Soran M, Yildirim I, Doğan M, Sahin A, Bilici A, Danaci M. The effect of alternate-day low dose prednisolone on bone age in children with steroid dependent nephrotic syndrome. Int Urol Nephrol 1997; 29:357-61. [PMID: 9285311 DOI: 10.1007/bf02550936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Radius, ulna, short bones (RUS), carpal (CARP) bone age (BA), tibial cortico-diaphyseal (C/D) ratio and trabecular aspect were assessed in 19 children with steroid dependent nephrotic syndrome and 15 age matched healthy children. Both RUS and CARP BA were significantly lower than in the controls. Trabecular aspect and tibial C/D ratio did not show any statistical significance. There was a positive correlation between HSDS and RUS BA delay (r = -0.476, p < 0.05); CARP BA delay and RUS BA delay (r = 0.563, p < 0.01) and RUS BA and CARP BA (r = 0.891, p < 0.001). In conclusion, RUS and CARP BA are both retarded and positively correlated in steroid dependent nephrotic children.
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Affiliation(s)
- Z Bircan
- Dicle University Hospital Pediatrics, Radiology and Statistics, Diyarbakir, Turkey
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22
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Abstract
Glucocorticoids exert multiple growth-suppressing effects, interfering with endocrine (e.g., endogenous GH secretion) and metabolic (e.g., bone formation, nitrogen retention, collagen formation) processes essential for normal growth. Relatively small oral doses of daily exogenous GC, alternate-day oral GC therapy, and even IC are capable of slowing growth in some children. These growth-inhibiting and catabolic effects of GC can be variably counterbalanced by GH therapy. With regard to linear growth, GH responsiveness depends on the GC dose and severity of underlying GC-dependent disease. Short-term risks of combined GH and GC therapy are low; longer term risks (e.g., reduced allograft function, survival, or both; increased underlying disease activity; oncologic risk) require further study. GH therapy in GC-dependent children remains experimental; children considered for such treatment should be enrolled in studies that facilitate careful monitoring and collective data analysis.
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Affiliation(s)
- D B Allen
- Department of Pediatrics, University of Wisconsin School of Medicine, Madison, USA
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23
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Lettgen B, Jeken C, Reiners C. Influence of steroid medication on bone mineral density in children with nephrotic syndrome. Pediatr Nephrol 1994; 8:667-70. [PMID: 7696102 DOI: 10.1007/bf00869084] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Bone mineral density (BMD) was studied in 26 children with idiopathic nephrotic syndrome and in age- and sex-matched healthy controls. BMD was selectively measured in trabecular (TBD), cortical (CBD) and total bone (BD) using peripheral quantitative computed tomography. Patients showed a decrease in BD, CBD and TBD. BD and CBD were inversely correlated with the cumulative dose of steroid treatment. Of the 26 patients with high cumulative doses of steroid, 16 were also treated with cyclophosphamide. In this group BD and CBD were decreased significantly compared with the children with a low cumulative steroid dose only. Compared with controls for each subgroup, significant decreases in BD, CBD and TBD were found in the group with high cumulative doses of steroids only. The higher cumulative steroid dose and the initial steroid toxicity which made cytotoxic therapy necessary, rather than cyclophosphamide itself, may be responsible for these findings.
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Affiliation(s)
- B Lettgen
- Department of Paediatric Medicine, University of Essen, Germany
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24
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Motil KJ, Grand RJ, Davis-Kraft L, Ferlic LL, Smith EO. Growth failure in children with inflammatory bowel disease: a prospective study. Gastroenterology 1993; 105:681-91. [PMID: 8359640 DOI: 10.1016/0016-5085(93)90883-e] [Citation(s) in RCA: 211] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Growth failure frequently complicates the clinical course of inflammatory bowel disease (IBD) in children. This study was designed to investigate the role of disease activity versus steroid therapy on growth faltering in this disorder. METHODS We studied growth failure and its relationship to disease activity and steroid therapy in 69 children who have IBD by prospectively monitoring height for a maximum of 3 years. Disease activity and steroid use were recorded at entry into the study. RESULTS The prevalence of growth failure was 24%, 23%, and 39% by height velocity, Z score, and height-for-age criteria, respectively; deficits were equally prevalent regardless of the stage of pubertal development. A delay in linear growth persisted throughout puberty and was not reversed after surgery. Patients who had Crohn's disease were twice as likely to have growth abnormalities than patients who had ulcerative colitis. We detected significant negative associations between linear growth and disease activity but not steroid therapy. CONCLUSIONS In a unique group of children, growth failure is an early, "prepatterned" manifestation of IBD. The inflammatory process, rather than steroid use, has a predominant influence on the development of growth faltering.
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Affiliation(s)
- K J Motil
- United States Department of Agriculture/Agricultural Research Service Children's Nutrition Research Center, Houston, Texas
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25
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Adhikari M, Manikkam NE, Coovadia HM. Effects of repeated courses of daily steroids and of persistent proteinuria on linear growth in children with nephrotic syndrome. Pediatr Nephrol 1992; 6:4-9. [PMID: 1536738 DOI: 10.1007/bf00856818] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The growth-inhibitory effects of courses of daily steroid therapy and of persistent proteinuria were assessed in 125 Indian and African children with nephrotic syndrome (NS) who were followed for an average of 3.9 years (range 0.25-14 years). Among the biopsied patients, 81% of Indians had minimal--change nephropathy and 49% of Africans had membranous nephropathy. The mean height standard deviation score (SDS) in 87 children who had received prednisone for an average of 36 weeks (range 4-250 weeks) was compared with that in 38 patients who had been managed symptomatically. Heights of untreated African children with persistent proteinuria were within the normal range for age, race and sex. The height SDS +/- SD for 77 Indian children in the prednisone-treated group was -1.06 +/- 1.44, which was not significantly different from -0.92 +/- 0.96 observed among 6 children in the untreated group (P = 0.75). In Africans the height SDS in 10 prednisone-treated children was -1.82 +/- 0.81 which was similar to that observed (P = 0.74) in 32 untreated patients -1.77 +/- 1.61. No significant correlation was found between the duration of prednisone therapy and height SDS for individual children among the 87 treated patients using regression analysis. The findings remained unchanged when children who had received less than 12 weeks of prednisone were excluded, or when comparison were drawn between those treated for less than and longer than 36 weeks. We conclude that courses of daily steroids or persistent proteinuria do not inhibit linear growth in Indian and African children with NS.
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Affiliation(s)
- M Adhikari
- Department of Peadiatrics and Child Health, Faculty of Medicine, University of Natal, South Africa
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26
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Rees L, Rigden SP, Chantler C. The influence of steroid therapy and recombinant human erythropoietin on the growth of children with renal disease. Pediatr Nephrol 1991; 5:556-8. [PMID: 1911137 DOI: 10.1007/bf01453701] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Long-term steroid therapy has a depressant effect on hypothalamo-pituitary pulsatile secretion of growth hormone (GH), and this results in an attenuated pubertal growth spurt. Oxandrolone and recombinant human GH improve growth rates in children taking long-term steroid therapy for renal disease, but there are potential side effects. Treatment with recombinant human erythropoietin improved the growth of three prepubertal, but not three pubertal haemodialysis patients.
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Affiliation(s)
- L Rees
- Department of Paediatrics, United Medical School, Guy's Hospital, London, UK
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27
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Krieg RJ, Niimi K, Chan JC, Santos F, Hanna JD, Poletti LF. Cortisone effects on growth, food efficiency, and in vitro growth hormone release. Kidney Int 1991; 39:1135-9. [PMID: 1895668 DOI: 10.1038/ki.1991.144] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
These studies were designed to investigate the cause of growth retardation during glucocorticoid treatment in rats. In young animals, body weights and amounts of food consumed were measured at two-day intervals, beginning at 29 days of age. Average food intake and food efficiency were calculated. Animals were treated with cortisone (CORT, 5 mg/rat/day, s.c.) or saline (SAL) for eight days between 37 and 44 days. Growth hormone (GH) release by dispersed pituitary cells in response to nine concentrations of GH-releasing hormone (GHRH) were tested by in vitro perifusion at 45 and 73 days. As previously shown, CORT caused a cessation of growth during the treatment period, and body weight failed to catch up. Food efficiency was decreased during CORT treatment. All parameters of in vitro GH release including basal GH secretory rate, overall GH response to GHRH, and the GHRH concentration-response curves were significantly increased by CORT in the 45-day-old animals. An age-related increase in GH release was also observed between the 45 and 73 day saline-treated animals. These results support the hypothesis that glucocorticoids inhibit growth by induction of changes in food metabolism and GH secretion. The effect on the pituitary gland itself paradoxically involves an increase in GH secretory capacity in response to GHRH.
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Affiliation(s)
- R J Krieg
- Department of Pediatrics, Medical College of Virginia, Richmond
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28
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Rees L, Chantler C. Growth and endocrine function in children receiving long-term steroid therapy for renal disease. ACTA PAEDIATRICA SCANDINAVICA. SUPPLEMENT 1990; 366:93-6; discussion 97. [PMID: 2206012 DOI: 10.1111/j.1651-2227.1990.tb11606.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- L Rees
- Evelina Children's Unit, United Medical School, Guy's Hospital, London, UK
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29
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Affiliation(s)
- J S Hyams
- Department of Pediatrics, Hartford Hospital, CT 06115
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30
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Kher KK, Makker SP, Sweet M. Modern management of nephrotic syndrome. Indian J Pediatr 1988; 55:527-40. [PMID: 3049334 DOI: 10.1007/bf02868436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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31
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Rees L, Greene SA, Adlard P, Jones J, Haycock GB, Rigden SP, Preece M, Chantler C. Growth and endocrine function in steroid sensitive nephrotic syndrome. Arch Dis Child 1988; 63:484-90. [PMID: 3133989 PMCID: PMC1778944 DOI: 10.1136/adc.63.5.484] [Citation(s) in RCA: 58] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Longitudinal height data and physical development were assessed in 29 boys and 12 girls taking long term steroid treatment for steroid sensitive nephrotic syndrome. Growth in both boys and girls, assessed by changes in height standard deviation score (delta Ht SDS), worsened significantly with chronological age. There was a significant negative correlation between delta Ht SDS and duration of treatment in boys, but not in girls. There was no correlation between delta Ht SDS and relapse rate or the use of cyclophosphamide. In the boys, Ht SDS decreased significantly only after the age of 10 years and was associated with delay in the appearance of secondary sexual characteristics. Eight adolescent boys were assessed endocrinologically by an overnight hormone profile. Blunting of the pulsatility of growth hormone and gonadotrophins was seen in six. Normal profiles were seen in two subjects who were both off steroid treatment at the time of study. Abnormal endocrine function in adolescent boys treated long term for steroid sensitive nephrotic syndrome corresponded with the clinical picture of delayed onset of puberty, which accounted for severe growth retardation in a substantial proportion of subjects.
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Affiliation(s)
- L Rees
- Evelina Children's Hospital, London
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32
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Kher KK, Sweet M, Makker SP. Nephrotic syndrome in children. CURRENT PROBLEMS IN PEDIATRICS 1988; 18:197-251. [PMID: 3292157 DOI: 10.1016/0045-9380(88)90007-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- K K Kher
- Division of Pediatric Nephrology, University of Texas Health Science Center, San Antonio
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33
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Ueda N, Chihara M, Kawaguchi S, Niinomi Y, Nonoda T, Matsumoto J, Ohnishi M, Yasaki T. Intermittent versus long-term tapering prednisolone for initial therapy in children with idiopathic nephrotic syndrome. J Pediatr 1988; 112:122-6. [PMID: 3335948 DOI: 10.1016/s0022-3476(88)80136-7] [Citation(s) in RCA: 60] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Forty-six children with steroid-responsive nephrotic syndrome were randomly allocated to receive two different prednisolone regimens for initial therapy. Twenty-nine children (group 1) received an intermittent regimen (60 mg/m2/day for 4 weeks, followed by 40/mg/m2/day on 3 days a week for 4 weeks); 17 children (group 2) had a long-term regimen (60 mg/m2/day for 4 weeks, followed by the same dose on alternate days for 4 weeks and the doses tapered by 10 mg/m2, given on alternate days every 4 weeks for 5 months). There was no difference between the two groups in the regimen used to treat relapses, steroid responsiveness, number of patients with relapses, and frequency of toxic reactions to steroids. However, the number of patients with a relapse within 6 months after initial therapy and the number of those with frequent relapses or steroid dependence were significantly higher in group 1 than in group 2 (P less than 0.05 for both). The data indicate that the long-term tapering regimen appears to be both safe and preferable to the intermittent regimen for initial therapy in children with idiopathic nephrotic syndrome.
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Affiliation(s)
- N Ueda
- Department of Pediatrics, Fujita Gakuen Health University School of Medicine, Aichi, Japan
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34
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Strauss J, Zilleruelo G, Freundlich M, Abitol C. Less commonly recognized features of childhood nephrotic syndrome. Pediatr Clin North Am 1987; 34:591-607. [PMID: 3295718 DOI: 10.1016/s0031-3955(16)36252-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This article reviews aspects in the clinical presentation of nephrotic syndrome that are not generally considered characteristics of the syndrome's definition. The importance of various general clinical aspects such as hematuria, hypertension, and other laboratory or histologic findings are discussed. The clinical relevance and management of other specific aspects such as lipid alterations, coagulation abnormalities, calcium and vitamin D metabolism, and nutritional complications derived from the nephrotic syndrome also are included in this review.
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35
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Sanderson IR, Udeen S, Davies PS, Savage MO, Walker-Smith JA. Remission induced by an elemental diet in small bowel Crohn's disease. Arch Dis Child 1987; 62:123-7. [PMID: 3548602 PMCID: PMC1778272 DOI: 10.1136/adc.62.2.123] [Citation(s) in RCA: 191] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Seventeen children with active Crohn's disease of the small intestine were entered into a randomised control trial comparing the efficacy of an elemental diet with that of a high dose steroid regimen. Eight children received an elemental diet (Flexical) through a nasogastric tube for six weeks, followed by reintroduction of food over six weeks during which the Flexical was stopped. Seven children were given intramuscular adrenocorticotrophic hormone followed by oral prednisolone with sulphasalazine. Two children were withdrawn from the trial. The elemental diet was equally effective in inducing an improvement in Lloyd-Still disease activity index, erythrocyte sedimentation rate, C reactive protein and albumin concentrations, and body weight as the high dose steroid regimen. Linear growth, assessed from height velocity over six months, was significantly greater in the children receiving an elemental diet.
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36
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Berns JS, Gaudio KM, Krassner LS, Anderson FP, Durante D, McDonald BM, Siegel NJ. Steroid-responsive nephrotic syndrome of childhood: a long-term study of clinical course, histopathology, efficacy of cyclophosphamide therapy, and effects on growth. Am J Kidney Dis 1987; 9:108-14. [PMID: 3826059 DOI: 10.1016/s0272-6386(87)80087-2] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The long-term clinical course of 60 children with steroid-responsive nephrotic syndrome, observed for a minimum of 10 years from onset, was studied (mean 14.5 +/- 0.5 years). Four children had only a single episode, seven children experienced only one to three relapses early in their course, and the remaining 49 patients (82%) experienced frequently relapsing steroid-dependent disease. Nearly half of these (47%) continued to relapse into their late teens and early twenties. All 20 children treated with cyclophosphamide because of steroid-induced side effects developed complete remissions of the nephrotic syndrome. These were sustained in 70% for 9.1 +/- 0.6 years, with a reduction of disease severity in the remaining 30%. In contrast, only 48% of patients treated with prednisone alone were in remission at last follow-up (P = .06). Ten of the children treated with cyclophosphamide had the minimal change lesion prior to therapy; 90% of these had permanent remissions. Only 50% of the six children with focal glomerulosclerosis and four children with mesangial proliferation have had permanent remissions. None of the patients developed renal insufficiency. Children treated with prednisone alone were -0.93 +/- 0.3 SD below the mean for height at last follow-up. Cyclophosphamide treatment was associated with an increase in height SD scores from -0.84 +/- 0.4 to -0.28 +/- 0.3. Children with severe growth impairment demonstrated dramatic catch-up growth when treated with cyclophosphamide with SD scores increasing from -2.29 +/- 0.8 to -0.43 +/- 0.6 (P less than .05).(ABSTRACT TRUNCATED AT 250 WORDS)
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