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Hogan J, Perez A, Sellier-Leclerc AL, Vrillon I, Broux F, Nobili F, Harambat J, Bessenay L, Audard V, Faudeux C, Morin D, Pietrement C, Tellier S, Djeddi D, Eckart P, Lahoche A, Roussey-Kesler G, Ulinski T, Boyer O, Plaisier E, Cloarec S, Jolivot A, Guigonis V, Guilmin-Crepon S, Baudouin V, Dossier C, Deschênes G. Efficacy and safety of intravenous immunoglobulin with rituximab versus rituximab alone in childhood-onset steroid-dependent and frequently relapsing nephrotic syndrome: protocol for a multicentre randomised controlled trial. BMJ Open 2020; 10:e037306. [PMID: 32967877 PMCID: PMC7513594 DOI: 10.1136/bmjopen-2020-037306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Guidelines for the treatment of steroid-dependent nephrotic syndrome (SDNS) and frequently relapsing nephrotic syndrome (FRNS) are lacking. Given the substantial impact of SDNS/FRNS on quality of life, strategies aiming to provide long-term remission while minimising treatment side effects are needed. Several studies confirm that rituximab is effective in preventing early relapses in SDNS/FRNS; however, the long-term relapse rate remains high (~70% at 2 years). This trial will assess the association of intravenous immunoglobulins (IVIgs) to rituximab in patients with SDNS/FRNS and inform clinicians on whether IVIg's immunomodulatory properties can alter the course of the disease and reduce the use of immunosuppressive drugs and their side effects. METHODS AND ANALYSIS We conduct an open-label multicentre, randomised, parallel group in a 1:1 ratio, controlled, superiority trial to assess the safety and efficacy of a single infusion of rituximab followed by IVIg compared with rituximab alone in childhood-onset FRNS/SDNS. The primary outcome is the occurrence of first relapse within 24 months. Patients are allocated to receive either rituximab alone (375 mg/m²) or rituximab followed by IVIg, which includes an initial Ig dose of 2 g/kg, followed by 1.5 g/kg injections once a month for the following 5 months (maximum dose: 100 g). ETHICS AND DISSEMINATION The study has been approved by the ethics committee (Comité de Protection des Personnes) of Ouest I and authorised by the French drug regulatory agency (Agence Nationale de Sécurité du Médicament et des Produits de Santé). Results of the primary study and the secondary aims will be disseminated through peer-reviewed publications. TRIAL REGISTRATION NUMBER NCT03560011.
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Affiliation(s)
- Julien Hogan
- Department of Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Aubriana Perez
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | | | - Isabelle Vrillon
- Department of Pediatric Nephrology, Hopital Brabois enfants, Vandoeuvre-les-Nancy, France
| | - Francoise Broux
- Department of Pediatric Nephrology, University Hospital Centre Rouen, Rouen, France
| | - Francois Nobili
- Department of Pediatric Nephrology, University Hospital Centre Besancon, Besancon, France
| | - Jerome Harambat
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Bordeaux Groupe hospitalier Pellegrin, Bordeaux, France
| | - Lucie Bessenay
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - V Audard
- Department of Nephrology and Transplantation, Henri Mondor Hospital, APHP, Université Paris-Est, Créteil, France
| | - Camille Faudeux
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Denis Morin
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Christine Pietrement
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Reims Hôpital d'enfants, Reims, France
| | - Stephanie Tellier
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Djamal Djeddi
- Department of Paediatrics, Amiens University Hospital and University of Amiens, Amiens, France
| | - Philippe Eckart
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire Amiens-Picardie, Amiens, France
| | - Annie Lahoche
- Department of Pediatric Nephrology, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - G Roussey-Kesler
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Tim Ulinski
- Department of Pediatric Nephrology, Hopital Trousseau la Roche-Guyon, Paris, France
| | - Olivia Boyer
- Department of Pediatric Nephrology, Hopital Necker-Enfants Malades, Paris, France
| | | | - Sylvie Cloarec
- Department of Pediatric Nephrology, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Anne Jolivot
- Department of Nephrology, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Vincent Guigonis
- Department of Pediatric Nephrology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | | | - Veronique Baudouin
- Department of Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
| | - Claire Dossier
- Department of Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
| | - Georges Deschênes
- Department of Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
- Université Sorbonne Paris Cité, Paris, France
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Humbert J, Roussey-Kesler G, Guerin P, LeFrançois T, Connault J, Chenouard A, Warin-Fresse K, Salomon R, Bruel A, Allain-Launay E. Diagnostic and medical strategy for renovascular hypertension: report from a monocentric pediatric cohort. Eur J Pediatr 2015; 174:23-32. [PMID: 24953377 DOI: 10.1007/s00431-014-2355-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/20/2014] [Accepted: 05/29/2014] [Indexed: 11/26/2022]
Abstract
UNLABELLED Renovascular hypertension accounts for 5-10 % of hypertension cases in children; there is currently no consensus on treatment. Here, we report on our clinical experience with this disease and outline the different pathways in which to investigate it. We report retrospectively on ten children diagnosed with renovascular hypertension at the University Hospital of Nantes from 2001 to 2012. The main findings were obtained by fortuitous screening of children aged 2 months to 14 years old with neurofibromatosis (n = 2) and fibromuscular dysplasia (n = 8). The hypertension was always severe yet asymptomatic. Lesions were complicated in nine out of ten cases and included bilateral, multiple, mid-aortic syndrome and aneurysm. Doppler ultrasound associated with computed tomography allowed for a precise diagnosis in seven out of ten cases. Where ambiguities persisted, they were highlighted by arteriography, the gold standard investigation. Medical treatment was insufficient, leading to invasive procedures in nine out of ten children: 2 nephrectomies, 2 autotransplantations, and 21 repetitive percutaneous transluminal angioplasties. After invasive procedures, blood pressure control improved in four cases and was resolved in three. CONCLUSION Arteriography remains to be the gold standard technique for renovascular hypertension in children and can be combined with angioplasty when medical treatment is rendered obsolete. The role of computed tomography is controversial. Despite the heterogeneity of the children studied, we present a general medical and therapeutic management pathway for the treatment of this disease.
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Affiliation(s)
- J Humbert
- Pediatric Nephrology Department, University Hospital of Nantes, Nantes, France
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Blanchais T, Legrand A, Allain Launay E, Leclair MD, Caillon J, Roussey-Kesler G. [Comparison of two protocols of febrile urinary tract infection management in children]. Arch Pediatr 2011; 18:955-61. [PMID: 21795028 DOI: 10.1016/j.arcped.2011.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 05/19/2011] [Accepted: 06/10/2011] [Indexed: 01/27/2023]
Abstract
PURPOSE To compare two first febrile urinary tract infection (UTI) management protocols with regards to the diagnosis of high-grade vesicoureteral reflux (VUR) and cost. METHODS This study compared two cohorts of children under 16 years of age, admitted for a first episode of febrile UTI. The first group (in 2005) was managed according to previous recommendations (IV treatment and cystography performed for all children under 3 years of age). The second group (in 2006) was managed according to age and procalcitonin level. High-grade VUR frequency, UTI recurrence, hospitalization rate, and cost were compared between the two cohorts. RESULTS A total of 225 children were included in 2005 and 116 in 2006. High-grade VUR was found in 6.2 and 9.5% of the patients in 2005 and 2006, respectively (P=0.274). There was no statistically significant difference in the UTI recurrence rate between the two cohorts (5.3% in 2005 and 8.6% in 2006; P=0.237). The mean cost of an episode of febrile UTI was not significantly different in 2005 and 2006 (€2235 in 2005, €2256 in 2006; P=0.902), but was lower for children older than 6 months in 2006 (€1292 versus €1882 in 2005; P=0.0042). CONCLUSION Our management protocol for a first febrile UTI episode in children based on procalcitonin levels seems to be suitable for the diagnosis of high-grade VUR. The hospitalization rate and the mean cost of management for children older than 6 months of age was significantly reduced in 2006. The management guidelines for a first occurrence of febrile UTI in children should be reconsidered.
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Affiliation(s)
- T Blanchais
- Clinique médicale pédiatrique, hôpital Mère-Enfant, CHU de Nantes, 7, Quai-Moncousu, 44093 Nantes cedex, France
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Allain-Launay E, Roussey-Kesler G, Ranchin B, Guest G, Maisin A, Novo R, André JL, Cloarec S, Guyot C. Mortality in pediatric renal transplantation: a study of the French pediatric kidney database. Pediatr Transplant 2009; 13:725-30. [PMID: 19691564 DOI: 10.1111/j.1399-3046.2009.01036.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE AND METHODS To assess patient survival in pediatric renal transplantation, we retrospectively reviewed 573 transplants in 553 patients, registered from 1995 to 2005. RESULTS Mean age at transplantation was 9.9 years. Patient survival at 1, 5 and 10 years was respectively 99%, 97% and 96%. Death occurred at a median time of 2.6 years after transplantation. Long-term patient survival was significantly lower in recipients younger than 5 years old. Seventeen patients (3.1%) died. Two deaths occurred while under maintenance dialysis. Among the remaining patients, the two main causes of death were infections (33%) and malignancies (27%). Interestingly, initial disease-related complications were a major cause of death (34%). CONCLUSION A low mortality rate was observed, with the majority of deaths due to malignancies and infections, and with a notable participation of complications related to the initial disease. No impact of cardiovascular disease was noted with the given follow-up period. Improvements in managing immunosuppression may contribute to reducing mortality in pediatric renal transplantation.
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Affiliation(s)
- E Allain-Launay
- Pediatric Department, Centre Hospitalier et Universitaire, Nantes, France.
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Ballet C, Roussey-Kesler G, Aubin JT, Brouard S, Giral M, Miqueu P, Louis S, van der Werf S, Soulillou JP. Humoral and cellular responses to influenza vaccination in human recipients naturally tolerant to a kidney allograft. Am J Transplant 2006; 6:2796-801. [PMID: 17049065 DOI: 10.1111/j.1600-6143.2006.01533.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Rare kidney allograft recipients enjoy unaltered graft function years after interruption of their immunosuppressive treatment. To assess the extent to which this state of 'operational tolerance' (TOL) is specific to the graft and not the result of a global immunodeficiency, we analyzed the response of such patients following influenza vaccination. Hemagglutination inhibition titers and frequency of IFNgamma-secreting T cells were measured before 1 and 3 months after vaccination. The proportion of healthy volunteers (HV) responding to vaccine was significantly higher than that of immunosuppressed (IS) patients. Three 'TOL' patients presented a humoral response similar to that of HV, whereas the two others had a poor response, like the IS recipients. Although the small number of patients does not allow for definitive conclusions to be made, these data suggest that the status of tolerance may be heterogeneous, with some patients with a global immunodeficiency and others with an adapted response to vaccination.
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Affiliation(s)
- C Ballet
- Institut National de la Santé et de la Recherche Médicale (I.N.S.E.R.M.), Unité 643: Immunointervention dans les Allo et xenotransplantations CHU-HOTEL DIEU, 30 Bd Jean Monnet, 44035 Nantes Cedex 01, France
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Roussey-Kesler G, Giral M, Moreau A, Subra JF, Legendre C, Noël C, Pillebout E, Brouard S, Soulillou JP. Clinical operational tolerance after kidney transplantation. Am J Transplant 2006; 6:736-46. [PMID: 16539630 DOI: 10.1111/j.1600-6143.2006.01280.x] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Induction of allograft-specific tolerance and the detection of a "tolerance" state in recipients under immunosuppression with long-term stable graft function are major challenges in transplantation. Clinical "operational tolerance," defined as stable and acceptable graft function without immunosuppression for years, is a rare event. There is no report on the clinical history of such patients. In this article, we report on the medical history of 10 kidney recipients who display an immunosuppressive drug-free "operational tolerance" for 9.4 +/- 5.2 years. Clinical factors that may favor such a tolerant state are underlined. Firstly, most of the patients interrupted immunosuppression over a long time period (until 4 years), which mimics the procedure of intentional immunosuppression weaning following liver transplantation. Secondly, donor age was younger (median 25 years) than the one of the general transplanted population, suggesting that graft quality is one of the conditions favoring "operational tolerance." Moreover, the "operationally tolerant" recipients may be 'low responders' to blood transfusions (PRA 6 +/- 5.4%, six blood transfusions). We also show that "operational tolerance" occurs in the presence of anti-donor class II antibodies, as assessed in two patients. Finally, two patients degraded their renal function 9 to 13 years after treatment withdrawal, however only one presented histological lesions of chronic rejection.
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Affiliation(s)
- G Roussey-Kesler
- Institut National de la Santé Et de la Recherche Médicale (I.N.S.E.R.M.)--Unité 643: Immunointervention dans les Allo et xenotransplantations, CHU-HOTEL DIEU, 30 Bd Jean Monnet, 44035 Nantes Cedex 01, France
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