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Jin J, Li Y, Zhu Y, Ni J. A single center, retrospective chart review of associations between cessation of second-line therapies and relapse rates of childhood refractory minimal change nephrotic syndrome. Curr Ther Res Clin Exp 2022; 96:100671. [PMID: 35574245 PMCID: PMC9092853 DOI: 10.1016/j.curtheres.2022.100671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 04/07/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Yufeng Li
- Address correspondence to: Yu-Feng Li, MD, PhD, Department of Pediatric Nephrology, Rheumatology, and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, No.1665, Kongjiang Rd, Yangpu District, Shanghai 200092, China.
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2
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Lee JM, Kronbichler A, Shin JI, Oh J. Current understandings in treating children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2021; 36:747-761. [PMID: 32086590 PMCID: PMC7910243 DOI: 10.1007/s00467-020-04476-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 12/22/2019] [Accepted: 01/07/2020] [Indexed: 12/27/2022]
Abstract
Steroid-resistant nephrotic syndrome (SRNS) remains a challenge for paediatric nephrologists. SRNS is viewed as a heterogeneous disease entity including immune-based and monogenic aetiologies. Because SRNS is rare, treatment strategies are individualized and vary among centres of expertise. Calcineurin inhibitors (CNI) have been effectively used to induce remission in patients with immune-based SRNS; however, there is still no consensus on treating children who become either CNI-dependent or CNI-resistant. Rituximab is a steroid-sparing agent for patients with steroid-sensitive nephrotic syndrome, but its efficacy in SRNS is controversial. Recently, several novel monoclonal antibodies are emerging as treatment option, but their efficacy remains to be seen. Non-immune therapies, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, have been proven efficacious in children with SRNS and are recommended as adjuvant agents. This review summarizes and discusses our current understandings in treating children with idiopathic SRNS.
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Affiliation(s)
- Jiwon M. Lee
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, South Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752 South Korea ,Division of Pediatric Nephrology, Severance Children’s Hospital, Seoul, South Korea ,Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Oh
- Department of Pediatrics Nephrology, University Hamburg-Eppendorf, Martinistrasse, 52 20246, Hamburg, Germany.
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Hao GX, Song LL, Zhang DF, Su LQ, Jacqz-Aigrain E, Zhao W. Off-label use of tacrolimus in children with glomerular disease: Effectiveness, safety and pharmacokinetics. Br J Clin Pharmacol 2020; 86:274-284. [PMID: 31725919 DOI: 10.1111/bcp.14174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022] Open
Abstract
Glomerular diseases are leading causes of end-stage renal disease in children. Tacrolimus is frequently used off-label in the treatment of glomerular diseases. The effectiveness, safety and pharmacokinetic data of tacrolimus in the treatment of glomerular diseases in children are reviewed in this paper to provide evidence to support its rational use in clinical practice. The remission rates in previously published studies were different. In 19 clinical trials on children with nephrotic syndrome, the overall remission rate was 52.6-97.6%. In four clinical trials on children with lupus nephritis, the overall remission rate was 81.8-89.5%. In a pilot study with paediatric Henoch-Schönlein purpura nephritis patients, the overall remission rate was 100.0%. Infection, nephrotoxicity, gastrointestinal symptoms and hypertension are the most common adverse events. Body weight, age, CYP3A5 genotype, cystatin-C and daily dose of tacrolimus may have significant effects on the pharmacokinetics of tacrolimus in children with glomerular disease. More prospective controlled trials with long follow-up are needed to demonstrate definitely the effectiveness, safety and pharmacokinetics of tacrolimus in children with glomerular diseases.
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Affiliation(s)
- Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Lin-Lin Song
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Dong-Feng Zhang
- Department of Pediatric Nephrology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Le-Qun Su
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
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4
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Mycophenolate mofetil for sustained remission in nephrotic syndrome. Pediatr Nephrol 2018; 33:2253-2265. [PMID: 29750317 DOI: 10.1007/s00467-018-3970-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 04/13/2018] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
Abstract
The clinical application of mycophenolate mofetil (MMF) has significantly widened beyond the prophylaxis of acute and chronic rejections in solid organ transplantation. MMF has been recognized as an excellent treatment option in many immunologic glomerulopathies. For children with frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS) experiencing steroid toxicity, MMF has been recommended as a steroid-sparing drug. Uncontrolled studies in patients with FRNS and SDSN have shown that many patients can achieve sustained remission of proteinuria with MMF monotherapy. Three randomized controlled trials have similarly demonstrated that MMF is beneficial in these patients, but less effective than the calcineurin inhibitors cyclosporin A or tacrolimus. Some, but not all, patients with steroid-resistant nephrotic syndrome (SRNS) may also respond to MMF, usually given in combination with other drugs, with partial or complete remission. There are important limitations to the interpretation and comparability of these studies including study design, sample size, patient selection, clinical endpoints, carry-over effects, and duration of follow-up. In all studies, MMF had relatively few side effects, no nephrotoxicity, or no systemic toxicity. MMF is teratogenic, and contraceptive advice is required in females. There is a poor correlation between MMF dose and mycophenolic acid (MPA) exposure and significant inter- and intra-patient variability in drug pharmacokinetics. A higher estimated MPA-AUC0-12 target range than recommended for pediatric renal transplant recipients is essential to prevent relapses. Therefore, therapy should be guided by drug monitoring to avoid relapses. Further studies are needed to test the efficacy of MMF in inducing remission and, as part of a combination therapy, achieving sustained remission in patients with SRNS.
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5
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Jiang X, Shen W, Xu X, Shen X, Li Y, He Q. Immunosuppressive therapy for steroid-resistant nephrotic syndrome: a Bayesian network meta-analysis of randomized controlled studies. Clin Exp Nephrol 2017; 22:562-569. [PMID: 29080118 DOI: 10.1007/s10157-017-1484-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 09/04/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this study was to conduct a meta-analysis examining the efficacy of cyclophosphamide, cyclosporin, and tacrolimus in treating steroid resistant nephrotic syndrome. METHODS Medline, Cochrane, EMBASE, and Google Scholar were searched until May 02, 2017 using the keywords: immunosuppressive therapy, steroid-resistant nephrotic syndrome, cyclophosphamide, cyclosporine A, and tacrolimus. Inclusion criteria were randomized controlled trials (RCTs) including patients with SRNS treated with an immunosuppressive therapy or placebo. RESULTS Seven RCTs were included, and the number of patients ranged from 30 to 131. Conventional pair-wise meta-analysis indicated a higher odds of complete or partial remission with tacrolimus as compared to cyclophosphamide [odds ratio (OR) 4.908, 95% confidence interval (CI) 2.278-10.576, P < 0.001], and cyclophosphamide (OR 0.143, 95% CI 0.028-0.721, P = 0.019) and placebo (OR 0.043, 95% CI 0.012-0.157, P < 0.001) were associated with a lower likelihood of complete or partial remission than cyclosporine. Bayesian analysis indicated that tacrolimus and cyclosporine were the best and the second-best agents for inducing a complete or partial remission (rank probability = 0.53 for tacrolimus and 0.46 for cyclosporine). CONCLUSION As compared to cyclophosphamide and cyclosporin, tacrolimus is more effective at inducing remission in patients with SRNS.
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Affiliation(s)
- Xinxin Jiang
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Wei Shen
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Xiujun Xu
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Xiaogang Shen
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Yiwen Li
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China
| | - Qiang He
- Department of Nephrology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, 158 Shangtang Road, Xiachen District, Hangzhou, 310014, Zhejiang, People's Republic of China.
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[Childhood steroid-dependent idiopathic nephrotic syndrome: Predictive factors for the need of immunosuppressive treatment]. Arch Pediatr 2017; 24:1096-1102. [PMID: 28941627 DOI: 10.1016/j.arcped.2017.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/09/2017] [Accepted: 08/17/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS More than half of the children with idiopathic nephrotic syndrome become steroid-dependent (or frequent relapsers) and will later require the use of complementary treatment aiming to reduce steroids' side effects and to limit the number of proteinuria relapses. It appears important to identify these children as early as possible in order to adapt their treatment. The aim of this study was to analyze the population of children, under 18 years of age, diagnosed between 1/01/2000 and 31/05/2015 with an idiopathic nephrotic syndrome and followed at the Montpellier University Hospital to search for criteria predictive of steroid-sparing agent use. METHODS In this retrospective study of children with idiopathic nephrotic syndrome, the exclusion criteria were primary steroid resistance and children with no proteinuria relapse after diagnosis. RESULTS Eighty-four children (54 boys) were included in this study. The mean follow-up duration was 5.5 years (0.75-16). The mean age at diagnosis was 4.6 years. Sixty-five children (77%) received at least one steroid-sparing agent during their follow-up, within a mean 10 months after diagnosis. In these patients, the first relapse of the disease occurred earlier when compared with the children who were maintained on steroid alone (4 months vs 7 months; P<0.001). The use of methylprednisolone pulses to obtain a remission, the cumulative dose of steroid treatment, and the number of proteinuria relapses were also significantly correlated with the use of complementary immunosuppressive therapy. CONCLUSION We found no predictive criteria of the use of steroid-sparing agents at diagnosis in our population of children. Nevertheless, with the steroid regimen used, the time within which the first proteinuria relapse occurred appears to be a significant criterion for the secondary use of a steroid-sparing agent. These data should be taken into account when choosing the treatment regimen.
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7
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Beaudreuil S, Lorenzo HK, Elias M, Nnang Obada E, Charpentier B, Durrbach A. Optimal management of primary focal segmental glomerulosclerosis in adults. Int J Nephrol Renovasc Dis 2017; 10:97-107. [PMID: 28546764 PMCID: PMC5436760 DOI: 10.2147/ijnrd.s126844] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a frequent glomerular kidney disease that is revealed by proteinuria or even nephrotic syndrome. A diagnosis can be established from a kidney biopsy that shows focal and segmental glomerulosclerosis. This histopathological lesion may be caused by a primary podocyte injury (idiopathic FSGS) but is also associated with other pathologies (secondary FSGS). The first-line treatment for idiopathic FSGS with nephrotic syndrome is a prolonged course of corticosteroids. However, steroid resistance or steroid dependence is frequent, and despite intensified immunosuppressive treatment, FSGS can lead to end-stage renal failure. In addition, in some cases, FSGS can recur on a graft after kidney transplantation: an unidentified circulating factor may be implicated. Understanding of its physiopathology is unclear, and it remains an important challenge for the scientific community to identify a specific diagnostic biomarker and to develop specific therapeutics. This study reviews the treatment of primary FSGS and the recurrence of FSGS after kidney transplantation in adults.
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Affiliation(s)
- Séverine Beaudreuil
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre.,INSERM Unit 1197, Paris-Sud University Hospital, Villejuif, France
| | - Hans Kristian Lorenzo
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre.,INSERM Unit 1197, Paris-Sud University Hospital, Villejuif, France
| | - Michele Elias
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre
| | - Erika Nnang Obada
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre
| | - Bernard Charpentier
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre.,INSERM Unit 1197, Paris-Sud University Hospital, Villejuif, France
| | - Antoine Durrbach
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre.,INSERM Unit 1197, Paris-Sud University Hospital, Villejuif, France
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Nourbakhsh N, Mak RH. Steroid-resistant nephrotic syndrome: past and current perspectives. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2017; 8:29-37. [PMID: 29388620 PMCID: PMC5774596 DOI: 10.2147/phmt.s100803] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Patients with steroid-resistant nephrotic syndrome (SRNS) represent a challenging subset of patients with nephrotic syndrome who often fail standard immunosuppression and have a higher likelihood of progressing to end-stage renal disease. Appropriate treatment of SRNS requires an adequate understanding of the historical treatment, renal histopathology, and genetics associated with the disease. The aim of this review is to present a comprehensive appraisal of the history, role of renal biopsy, genetics, and treatment of SRNS.
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Affiliation(s)
- Noureddin Nourbakhsh
- Division of Pediatric Nephrology, Rady Children's Hospital San Diego, University of California, San Diego, La Jolla, CA, USA
| | - Robert H Mak
- Division of Pediatric Nephrology, Rady Children's Hospital San Diego, University of California, San Diego, La Jolla, CA, USA
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Ladapo TA, Esezobor CI, Lesi FE. Cyclosporine in the treatment of childhood idiopathic steroid resistant nephrotic syndrome: a single centre experience in Nigeria. Pan Afr Med J 2017; 25:258. [PMID: 28293374 PMCID: PMC5337300 DOI: 10.11604/pamj.2016.25.258.9802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 09/19/2016] [Indexed: 11/11/2022] Open
Abstract
Introduction Children with steroid resistant nephrotic syndrome usually require treatment with second-line agents and calcineurin inhibitors such as cyclosporine are now recommended as initial therapy. These agents only recently become available in our environment and their impact on care is unknown. We reviewed the short-term treatment outcomes of their use in comparison with previous outcomes. Methods Medical records of children managed for idiopathic steroid resistant nephrotic syndrome over a 5 year period were reviewed. Remission rates and improvement in renal function following use of various agents were compared. Results Of 103 children with idiopathic nephrotic syndrome, 25(24.3%) were steroid resistant, of whom 17 received additional medications. Full remission rate for cyclosporine was 70% (7/10). Remission rates prior to the availability of cyclosporine were 40% (2/5) for cyclophosphamide and 66% (2/3), (partial remission only) with enalapril, an angiotensin converting enzyme inhibitor used in combination with alternate day prednisolone. One child with cyclophosphamide resistance subsequently achieved remission with cyclosporine. Remission was not related to sex (p=0.96), age (p=0.54), serum albumin (p=0.37) or hypertension (p=0.43) but to serum cholesterol (p= 0.02). The estimated glomerular filteration rate (eGFR) among children treated with cyclosporine ranged from 30-167 ml/min/1.73m2 as follows: >90 (5); 60-89 (3); 30-59 (2) while the mean pre and post treatment eGFR in those with eGFR <90 were 60 and 104ml/min/1.73m2 respectively (p=0.03). Mortality rate was 10% (1/10) in children treated with cyclosporine compared with 28.6% (2/7) in those treated with other medications (p=0.54). Conclusion Cyclosporine resulted in improved treatment outcomes in children with idiopathic steroid resistant nephrotic syndrome.
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Affiliation(s)
- Taiwo Augustina Ladapo
- Department of Pediatrics, College of Medicine, University of Lagos, PMB 12003, Idi-Araba, Lagos, Nigeria; Lagos University Teaching Hospital, PMB 12003, Idi-Araba, Lagos, Nigeria
| | - Christopher Imokhuede Esezobor
- Department of Pediatrics, College of Medicine, University of Lagos, PMB 12003, Idi-Araba, Lagos, Nigeria; Lagos University Teaching Hospital, PMB 12003, Idi-Araba, Lagos, Nigeria
| | - Foluso Ebunoluwa Lesi
- Department of Pediatrics, College of Medicine, University of Lagos, PMB 12003, Idi-Araba, Lagos, Nigeria; Lagos University Teaching Hospital, PMB 12003, Idi-Araba, Lagos, Nigeria
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10
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Filler G, Alvarez-Elías AC, McIntyre C, Medeiros M. The compelling case for therapeutic drug monitoring of mycophenolate mofetil therapy. Pediatr Nephrol 2017; 32:21-29. [PMID: 26921212 DOI: 10.1007/s00467-016-3352-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/25/2016] [Accepted: 01/29/2016] [Indexed: 11/26/2022]
Abstract
We have reviewed current evidence on the therapeutic drug monitoring (TDM) of mycophenolic acid (MPA) in relationship to drug efficacy and safety. The relationship between actual MPA exposure and mycophenolate mofetil (MMF) dose has been shown to be weak in children and adolescents. The TDM of MPA exposure should ideally be performed using full pharmacokinetic profiles or limited sampling strategies. Recent evidence has provided some rationale for using the post-dose trough level as a single measure. In terms of short-term efficacy, there is strong evidence that a MPA area under the time-concentration curve of >30 mg × h/L reduces acute rejection episodes early after renal transplantation, and there is evolving evidence that aiming for the same exposure over the long term may be a viable strategy to reduce the formation of donor-specific antibodies. Strong evidence also supports the existence of important drug interactions and age/developmental dependent differences in drug metabolism that may necessitate the need for TDM of MMF therapy. Based on these findings and given the substantial inter- and intra-patient variability of MPA exposure, it would appear that MMF therapy should be subject to TDM to avoid over- and under-dosing. This may be a viable strategy to reduce treatment-emergent adverse events and to increase the effective pediatric transplant survival rates.
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Affiliation(s)
- Guido Filler
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada.
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N5A 5A5, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada.
- Department of Pediatrics, Children's Hospital, London Health Science Centre, Western University, 800 Commissioners Road East, London, ON, N6A 5 W9, Canada.
| | - Ana Catalina Alvarez-Elías
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada
- Universidad Nacional Autónoma de México, Mexico City, 04510, Mexico
- Laboratorio de Investigacion en Nefrologia, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
| | - Christopher McIntyre
- Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5 W9, Canada
| | - Mara Medeiros
- Laboratorio de Investigacion en Nefrologia, Hospital Infantil de Mexico Federico Gomez, Mexico City, Mexico
- Departamento de Farmacología, Facultad de Medicina, Universidad Nacional Autónoma de México, México City, Mexico
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Yang J, Zhang BL. [Advances in clinical research on C1q nephropathy]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016. [PMID: 27817791 DOI: 10.7499/j.issn.1008-8830.2016.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
C1q nephropathy is a rare type of glomerulonephritis manifested as the deposition of C1q in the glomerular mesangium during immunofluorescent staining. Systemic lupus erythematosus and type I membranoproliferative glomerulonephropathy need to be excluded in the diagnosis of C1q nephropathy. C1q nephropathy has various manifestations under a light microscope, mainly including minimal change disease, focal segmental glomerulosclerosis, and proliferative glomerulonephritis. This disease is mainly manifested as persistent proteinuria or nephrotic syndrome and occurs more frequently in boys. Currently, glucocorticoids are mainly used for the treatment of this disease. Patients with C1q nephropathy show a good response to immunosuppressant treatment, but have a high rate of glucocorticoid resistance. Therefore, in this case, methylprednisolone pulse therapy or a combination with immunosuppressant treatment helps to achieve a good prognosis.
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Affiliation(s)
- Juan Yang
- Department of Nephrology, Tianjin Children's Hospital, Tianjin 300074, China.
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12
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Liu Y, Qu X, Chen W, Zhang Y, Liu L. Efficacy of leflunomide combined with prednisone in the treatment of refractory nephrotic syndrome. Ren Fail 2016; 38:1616-1621. [PMID: 27819170 DOI: 10.3109/0886022x.2016.1172917] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To assess the safety and clinical efficacy of leflunomide (LEF) and prednisone on refractory nephrotic syndrome (RNS). METHODS A total of 52 patients with RNS were treated for 24 weeks between 2010 and 2014 in our hospital. In the treated group, 26 patients were treated with LEF and prednisone, and, in the control group, 26 patients were treated with cyclophosphamide (CTX) and prednisone. During the treatment, 24 h urinary protein excretion and the serum levels of albumin and cholesterol, and kidney function were assayed before and after the therapy. Adverse reactions during treatment were recorded. RESULTS In the LEF group, the medication was markedly effective in eight cases and effective in nine cases; the total efficacy rate was 65.30%. In the CTX group, the treatment was markedly effective in six cases and effective in nine cases; the total efficacy rate was 57%. There were no significant differences between the results of the total efficacy rate (p > .05). The 24 h urinary protein excretion and serum cholesterol levels in both groups decreased after therapy and the serum levels of albumin in both groups increased after therapy. There were significant differences between the results for the 24 h urinary protein excretion, serum levels of albumin and cholesterol in the two groups (p < .05). The treatments were well tolerated in both groups. CONCLUSION LEF combined with prednisone has a certain efficacy on the RNS and displays few adverse reactions. A large-sample, randomized double-blind controlled study and long-term follow-up are needed to verify the efficacy of LEF combined with prednisone.
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Affiliation(s)
- Yuping Liu
- a Department of Nephrology , The First Affiliated Hospital of Bengbu Medical College , Bengbu , Anhui , China
| | - Xiaolong Qu
- b Department of Cardiology , The First Affiliated Hospital of Bengbu Medical College , Bengbu , Anhui , China
| | - Weidong Chen
- a Department of Nephrology , The First Affiliated Hospital of Bengbu Medical College , Bengbu , Anhui , China
| | - Yan Zhang
- a Department of Nephrology , The First Affiliated Hospital of Bengbu Medical College , Bengbu , Anhui , China
| | - Lei Liu
- a Department of Nephrology , The First Affiliated Hospital of Bengbu Medical College , Bengbu , Anhui , China
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13
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Dehoux L, Hogan J, Dossier C, Fila M, Niel O, Maisin A, Macher MA, Kwon T, Baudouin V, Deschênes G. Mycophenolate mofetil in steroid-dependent idiopathic nephrotic syndrome. Pediatr Nephrol 2016; 31:2095-101. [PMID: 27263020 DOI: 10.1007/s00467-016-3400-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/02/2016] [Accepted: 03/22/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prospective studies have established the mycophenolate mofetil (MMF) efficiency in childhood idiopathic nephrotic syndrome (INS) but reports on the long-term outcome are lacking. Moreover, the search for factors influencing its efficiency would be useful to define its place among the other treatments. METHODS We performed a monocentric retrospective study including 96 children with steroid-dependent INS followed for 4.7 years (median) (IQ 3-6) after the onset of MMF treatment. The characteristics of responder patients (n = 74), as defined by a 50 % decrease of relapse rate and/or a 60 % decrease of steroid dose, and of non-responder patients (n = 22) were compared by univariate analysis and multivariate logistic regression. RESULTS Withdrawal of prednisone was achieved in 48/96 patients after a median duration of 18.1 months (IQ 7.8-30.0) of MMF. Only 26/48 patients did not relapse under MMF alone. After MMF was stopped in these patients, only six remained in remission without any treatment at last follow-up. Responders had a shorter time to remission at the first flare (9.5 vs. 15 days, p = 0.02), a shorter disease duration prior to the onset of MMF (22.2 vs. 94.5 months, p = 0.001), and were younger at the MMF initiation (6.7 vs. 10.1 years, p = 0.02) than non-responder patients. The age of MMF initiation was an independent factor associated with efficiency (OR = 0.80, 95 % CI [0.69, 0.93], p < 0.01). CONCLUSIONS MMF is more efficient in young patients treated early in the disease course. Nevertheless, MMF has no remnant effect while nearly all patients relapsed after withdrawal of the drug.
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Affiliation(s)
- Laurène Dehoux
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France.
| | - Julien Hogan
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
| | - Claire Dossier
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
| | - Marc Fila
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
| | - Olivier Niel
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
| | - Anne Maisin
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
| | - Marie Alice Macher
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
| | - Thérésa Kwon
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
| | - Véronique Baudouin
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
| | - Georges Deschênes
- Department of Pediatric Nephrology, Hôpital Robert Debré, APHP, 48 Boulevard Sérurier, 75935, Paris, Cedex 19, France
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14
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Banh TH, Hussain-Shamsy N, Patel V, Vasilevska-Ristovska J, Borges K, Sibbald C, Lipszyc D, Brooke J, Geary D, Langlois V, Reddon M, Pearl R, Levin L, Piekut M, Licht CP, Radhakrishnan S, Aitken-Menezes K, Harvey E, Hebert D, Piscione TD, Parekh RS. Ethnic Differences in Incidence and Outcomes of Childhood Nephrotic Syndrome. Clin J Am Soc Nephrol 2016; 11:1760-1768. [PMID: 27445165 PMCID: PMC5053779 DOI: 10.2215/cjn.00380116] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/31/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Ethnic differences in outcomes among children with nephrotic syndrome are unknown. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a longitudinal study at a single regional pediatric center comparing ethnic differences in incidence from 2001 to 2011 census data and longitudinal outcomes, including relapse rates, time to first relapse, frequently relapsing disease, and use of cyclophosphamide. Among 711 children, 24% were European, 33% were South Asian, 10% were East/Southeast Asian, and 33% were of other origins. RESULTS Over 10 years, the overall incidence increased from 1.99/100,000 to 4.71/100,000 among children ages 1-18 years old. In 2011, South Asians had a higher incidence rate ratio of 6.61 (95% confidence interval, 3.16 to 15.1) compared with Europeans. East/Southeast Asians had a similar incidence rate ratio (0.76; 95% confidence interval, 0.13 to 2.94) to Europeans. We determined outcomes in 455 children from the three largest ethnic groups with steroid-sensitive disease over a median of 4 years. South Asian and East/Southeast Asian children had significantly lower odds of frequently relapsing disease at 12 months (South Asian: adjusted odds ratio; 0.55; 95% confidence interval, 0.39 to 0.77; East/Southeast Asian: adjusted odds ratio; 0.42; 95% confidence interval, 0.34 to 0.51), fewer subsequent relapses (South Asian: adjusted odds ratio; 0.64; 95% confidence interval, 0.50 to 0.81; East/Southeast Asian: adjusted odds ratio; 0.47; 95% confidence interval, 0.24 to 0.91), lower risk of a first relapse (South Asian: adjusted hazard ratio, 0.74; 95% confidence interval, 0.67 to 0.83; East/Southeast Asian: adjusted hazard ratio, 0.65; 95% CI, 0.63 to 0.68), and lower use of cyclophosphamide (South Asian: adjusted hazard ratio, 0.82; 95% confidence interval, 0.53 to 1.28; East/Southeast Asian: adjusted hazard ratio, 0.54; 95% confidence interval, 0.41 to 0.71) compared with European children. CONCLUSIONS Despite the higher incidence among South Asians, South and East/Southeast Asian children have significantly less complicated clinical outcomes compared with Europeans.
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Affiliation(s)
| | | | - Viral Patel
- Child Health Evaluative Sciences, Research Institute
| | | | | | | | | | | | - Denis Geary
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Valerie Langlois
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | | | - Rachel Pearl
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Leo Levin
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | | | - Christoph P.B. Licht
- Division of Nephrology, and
- Program in Cell Biology, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Elizabeth Harvey
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Diane Hebert
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Tino D. Piscione
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
| | - Rulan S. Parekh
- Child Health Evaluative Sciences, Research Institute
- Division of Nephrology, and
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto, Ontario, Canada; and
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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15
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Recent Advances in Treatments of Primary Focal Segmental Glomerulosclerosis in Children. BIOMED RESEARCH INTERNATIONAL 2016; 2016:3053706. [PMID: 27195285 PMCID: PMC4852325 DOI: 10.1155/2016/3053706] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/21/2016] [Accepted: 03/30/2016] [Indexed: 11/18/2022]
Abstract
Focal segmental glomerulosclerosis (FSGS) is a nephrotic syndrome. Up to around 80% of cases of primary FSGS are resistant to steroid treatment. A large proportion of patients with steroid-resistant FSGS progress to end-stage renal disease. The purpose of treatment is to obtain a complete remission of proteinuria, a necessary step that precedes improved renal survival and reduces the risk of progression to chronic kidney disease. When this is not possible, the secondary goal is a partial remission of proteinuria. Reduction or remission of proteinuria is the most important factor predictive of renal survival. We will review the current updated strategies for treatment of primary FSGS in children, including traditional therapies consisting of corticosteroids and calcineurin inhibitors and novel therapies such as rituximab, abatacept, adalimumab, and fresolimumab.
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16
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Tacrolimus for children with refractory nephrotic syndrome: a one-year prospective, multicenter, and open-label study of Tacrobell®, a generic formula. World J Pediatr 2016; 12:60-5. [PMID: 26684309 DOI: 10.1007/s12519-015-0062-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 12/04/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND Cyclosporine A and tacrolimus (TAC) are often used as a second-line treatment for children with refractory nephrotic syndrome (NS). This study was undertaken to investigate the efficacy and safety of Tacrobell®, a locally produced generic form of TAC. METHODS This study was a one-year prospective, open-label, single-arm, multicenter trial. Fourty-four children with steroid-dependent NS (SDNS) and 33 children with steroid-resistant NS (SRNS) were enrolled. The primary endpoints were defined as the remission rates, whereas the secondary endpoints were recognized as the duration of remission and adverse effects of TAC. RESULTS After one-year treatment, 34 (77.3%) of the 44 patients with SDNS were in complete remission, and 6 (13.6%) were in partial remission. Nineteen (43.2%) patients did not relapse during the study; for those who did relapse, the mean duration of remission was 4.6±2.9 months. The number of relapse episodes during the study period (0.90 per patient-year) was significantly lower than that in the preceding year (2.8 per patient-year). After treatment for 3 and 6 months, 12 (36.4%) of the 33 patients with SRNS were in remission, and after treatment for 12 months, the number of patients had increased to 13 (39.4%). The mean time to achieve remission was 4.0±3.2 months. After remission (duration, 3.7±2.7 months), 12 (54.5%) of 22 patients relapsed. The fasting blood glucose and blood pressure levels during the therapy were similar to those at the time of study entry. CONCLUSIONS Treatment with Tacrobell® was effective and safe for children with refractory NS. The efficacy of this generic form of TAC was better than that of the original TAC formula.
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17
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Wu B, Mao J, Shen H, Fu H, Wang J, Liu A, Gu W, Shu Q, Du L. Triple immunosuppressive therapy in steroid-resistant nephrotic syndrome children with tacrolimus resistance or tacrolimus sensitivity but frequently relapsing. Nephrology (Carlton) 2015; 20:18-24. [PMID: 25312783 DOI: 10.1111/nep.12351] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2014] [Indexed: 11/28/2022]
Abstract
AIM The treatment strategy for steroid-resistant nephrotic syndrome remains uncertain at present, especially in those with calcineurin inhibitor resistance or intolerance. To date, few studies have been published using multiple combination therapy of immunosuppressive reagents for children with calcineurin inhibitor-resistant or -intolerant nephrotic syndrome. METHODS Eighteen consecutive children with steroid- and tacrolimus (TAC)-resistant (n = 10) or TAC-sensitive but frequent relapsing nephrotic syndrome (n = 8) were randomly recruited in the present study. All of them received further triple-combination therapy by cyclophosphamide (CTX, n = 6), mycophenolate mofetil (MMF, n = 5) or leflunomide (LEF, n = 7). Their clinical data were collected and efficacy of triple-combination therapy was evaluated. RESULTS Compared with previous double-combination therapy of prednisone (Pre) and TAC, the short-term remission rate in all 18 patients was significantly improved after the triple-combination therapy, while the frequent relapse rate in the following 12 months was also significantly decreased. Among three different subgroups with CTX, MMF or LEF therapy, no significant difference was found in short-term remission rate and the relapse rate within 1 year follow up by Kaplan-Meier plot. CONCLUSION Triple-combination therapy with Pre + TAC + CTX/MMF/LEF is effective for short-term response and 1 year remission, without significant additional side-effects seen in children with steroid-resistant and tacrolimus-resistant or tacrolimus-sensitive but frequently relapsing nephrotic syndrome. Further study for evaluating long-term efficacy and safety of triple-combination therapy with Pre + TAC + CTX/MMF/LEF would be necessary for these patients.
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Affiliation(s)
- Boying Wu
- Department of Nephrology, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China; Department of Pediatrics, Ningbo Yinzhou People's Hospital, Ningbo, China
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18
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Sethna CB, Gipson DS. Treatment of FSGS in Children. Adv Chronic Kidney Dis 2014; 21:194-9. [PMID: 24602468 DOI: 10.1053/j.ackd.2014.01.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 01/16/2014] [Indexed: 01/17/2023]
Abstract
Focal segmental glomerulosclerosis (FSGS) is a pathologic condition that represents many disease entities. The goals of therapy are to cure the disease. When this is not possible, the secondary goals are to reduce proteinuria to avoid the complications of nephrotic syndrome and to delay progression of kidney disease. Proteinuria remission is one of the most important independent predictors of kidney survival. Children with FSGS who do not achieve partial or complete remission have a 50% risk of progression to ESRD within 5 years whereas those who enter complete remission have a 5-year kidney survival rate of 90%. Treatment of idiopathic FSGS commonly involves immune-based and nonimmunologic therapy options. This manuscript will review the current state of FSGS therapy for children.
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