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Category: Volume 10 Issue 01 January 2022
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Title: Predictors of steroid dependency in Indian children with Idiopathic Nephrotic Syndrome

Authors: Sreekanth Sagar, Bindu Sarojam, Geetha Saradakkutty, Susan Uthup

 DOI: https://dx.doi.org/10.18535/jmscr/v10i1.11

Abstract

Introduction: Idiopathic nephrotic syndrome is the commonest glomerular disease in children. Relapses are common and 50% with multiple relapses become steroid dependent requiring prolonged immunosuppressive treatment.

Methods: A hospital based prospective follow up study with nested case control design was conducted in children with first episode of Idiopathic Nephrotic syndrome to determine predictive risk factors for steroid dependency. Age at onset, birth weight, concurrent respiratory tract infections, hematuria at onset, hypertension and time to remission were assessed as predictive risk factors for dependency.

Results: 146 children were recruited. After excluding 6 steroid resistant ones, 137 were followed up for one year.14.5%[20] children became steroid dependent, 54.7% [75] had infrequent relapses and 30.65% [42] had no relapses. Small for gestational age (SGA),[P 0.000, OR 7.59, 95% CI 2.72 – 21.17], more than 10 days to attain remission [P 0.000, OR 7.19  ,  95% CI 2.58 – 20.0] and concurrent upper respiratory tract infection during relapses xz[P 0.000, OR 6.88, 95% CI 2.16 – 21.92] were significant factors associated with steroid dependence. The area under an ROC curve plotted to evaluate the prediction model based on the time to attain remission (more than 10 days) showed 0.792 (95% CI 0.678 – 0.906).

Conclusion: Time to remission of more than 10 days, concomitant respiratory tract infections with relapse and being SGA were significant predictors for development of steroid dependence. Identification of children at risk for dependency at onset will help in counseling and planning treatment strategies avoiding drug toxicity and reducing morbidity.

Keywords:  Nephrotic Syndrome; Remission, Relapses, Dependence.

References

  1. Chesney RW (1999) Idiopathic nephrotic syndrome. Curr Opin Pediatr 11:158–161
  2. Robson WL, Leung AK (1993) Nephrotic syndrome in childhood. Adv Pediatr 40:287–323
  3. International Study of Kidney Diseases in Children (1981).The primary nephrotic syndrome in children: identification of patients with minimal change nephrotic syndrome from initial response to prednisone. J Pediatr 98:561–564
  4. Andenmatten F, Bianchetti MG, Gerber HA, Zimmermann A,Meregalli P, Luthy C, Oetliker OH (1995) Outcome in idiopathic childhood nephrotic syndrome. Scand J Urol Nephrol29:15–19
  5. Bargman JM (1999) Management of minimal lesion glomerulonephritis: evidence-based recommendations. KidneyInt 55[Suppl 70]:S3–S16
  6. Constantinescu AR, Weiss LS et al (2000) Predicting first-year relapsers in children with nephrotic syndrome. Pediatrics 105:492–495
  7. Vivarelli M, Moscaritolo E, Tsalkidis A, Massella L, Emma F. Time for initial response to steroids is a prognostic factor in idiopathic nephrotic syndrome. J Pediatr. 2010;156: 965–97
  8. Mishra K, Kanwal SK, Sajjan SV, Bhaskar V, Rath B. Predictors of poor outcome in children with steroid sensitive nephrotic syndrome. Nefrologia. 2018 Jul-Aug; 38(4):420-424.
  9. AditiSinha, Panka jHari, Piyush Kumar Sharma. Disease Course in Steroid Sensitive Nephrotic Syndrome Indian Pediatr 2012; 49: 881-887
  10. Dawman L, Mehta, A., Sharawat I.K. . Risk Factors for Steroid Dependency in Children with Idiopathic Nephrotic Syndrome in India. Indian J Pediatr 83, 261 (2016). https://doi.org/10.1007/s12098-015-1819-y
  11. Agarwal, N., Abhinay, A., Mishra, R.N. et al. Validation of Predictors of Relapse in Steroid Sensitive Idiopathic Nephrotic Syndrome. Indian J Pediatr 85, 570–571 (2018). https://doi.org/10.1007/s12098-018-2656-6
  12. Dakshayani B, Premalatha R et al . Predictors of frequent relapsing and steroid-dependent nephrotic syndrome in children. Turk PediatriArs 2018: 53: 24-30.
  13. Uma Ali, arvind Bagga, S. Banerjee, Madhuri Kanitkar, K.D. Phadke, P. Senguttuvan, S.K. Sethi and Mehul Shah. Revised guidelines for management of steroid sensitive nephrotic syndrome. Indian Journal of Nephrology Jan 2008/ Vol18/ Issue 1
  14. Yap HK, Han EJ, Heng CK, Gong WK (2001) Risk factors for steroid dependency in children with idiopathic nephrotic syndrome. PediatrNephrol 16:1049–1052
  15. Pravitsitthikul N, Hodson EM, Craig JC (2013) Non-corticosteroid immunosuppressive medications for steroid-sensitive nephrotic syndrome in children. Cochrane Database Syst Rev 10:CD002290
  16. Sinha MD, MacLeod R, Rigby E, Clark AG (2006) Treatment of severe steroid-dependent nephrotic syndrome (SDNS) in children with tacrolimus. Nephrol Dial Transplant 21:1848–185
  17. Loeffler K, Gowrishankar M, Yiu V (2004) Tacrolimus therapy in pediatric patients with treatment-resistant nephrotic syndrome. PediatrNephrol 19:281–287
  18. Benz K, Dotsch J, Rascher W, Stachel D (2004) Change of the course of steroid-dependent nephrotic syndrome after rituximab therapy. Pediatr Nephrol 19:794–797
  19. Hodson EM, Craig JC (2014) Rituximab for childhood-onset nephrotic syndrome. Lancet 384(9950):1242–1243
  20. Ravani P, Ponticelli A, Siciliano C, et al : Rituximab is a safe and effective long-term treatment for children with steroid and calcineurin inhibitor-dependent idiopathic nephrotic syndrome. Kidney Int. 2013;84(5):1025–33. 10.1038/ki.2013.211
  21. Gulati S, Kher V, Sharma RK, Gupta A. Steroid response pattern in Indian children with nephrotic syndrome. Acta Pædiatr 1994;83:530–3
  22. Kabuki N, Okugawa T, Hayakawa H, Tomizawa S, Kasahara T, Uchiyama M (1998) Influence of age at onset on the outcome of steroid-sensitive nephrotic syndrome. Pediatr Nephrol 12:467–470
  23. Cornfield D, Schwartz MW (1966) Nephrosis: a long term study of children treated with corticosteroids. J Pediatr 68:507–515
  24. Nynke Teeninga, Michiel F. Schreuder et al. Influence of low birth weight on minimal change nephrotic syndrome in children, including a meta-analysis Nephrol Dial Transplant (2007) 0: 1–6 doi: 10.1093/ndt/gfm829
  25. N Konstantelos et al .Association of low birth weight and prematurity with clinical outcomes of childhood nephrotic syndrome: a prospective cohort study. 2019Pediatric Nephrology 34(9) DOI: 10.1007/s00467-019-04255-1
  26. Takeda, MasuhiroSimoda et al ; Prediction of subsequent relapse in children with steroid-sensitive nephrotic syndrome Pediatric Nephrology 2001, Volume 16, Issue 11, pp 888-893
  27. Maher Ahmed Abdel-Hafez, Nagy Mohamed Abou-El-Hana, Adel Ali Erfan, Mohamed El-Gamasy, Hend Abdel-Nabi. Predictive risk factors of steroid dependent nephrotic syndrome in children. J Nephropathol. 2017;6(3):180-186

Corresponding Author

Bindu Sarojam MD Pediatrics

Department of Pediatrics, SAT Hospital, Govt. Medical College, Thiruvananthapuram, Kerala, India