ISSN - 0973-0958
ISSN - 0973-0958
Advance Search
Sign In | Sign Up
Pediatric Oncall
Current Issue
Archives
Information for Authors
Aims & Scope
Collections
Submit Article
REVIEW ARTICLE

STEROID RESISTANT NEPHROTIC SYNDROME IN CHILDREN
RAJENDRA BHIMMA
DEPARTMENT OF MOTHER and CHILD HEALTH, NELSON R MANDELA SCHOOL OF MEDICINE, UNIVERSITY OF KWAZULU-NATAL, DURBAN, SOUTH AFRICA
Abstract
In children with idiopathic nephrotic syndrome (NS), minimal change disease accounts for approximately 90% of cases under seven years of age and for more than 50% of cases in older children. This condition is characterized by a predictable and gratifying response to steroids and an excellent long-term prognosis. On the other hand steroid resistant (SR) forms of NS are characterized by frequent relapses, an increased propensity to complications such as growth retardation, infections, thrombosis and progression to end stage renal disease.

Why a proportion of children develop resistance to steroids remains an unresolved issue. Recent work however has shown the presence of specific genetic mutations as being a principle mechanism for the development of steroid resistance.

In treating this condition, the management is primarily aimed at abrogating proteinuria and by so doing, aiming to preserve renal function. In the past, children with SRNS were treated with long-term alternate day steroids, alkylating agents, levamisole, azathioprine and cyclosporine. Newer agents include high dose pulse methylprednisolone, mycophenolate mofetil, and tacrolimus are now being used, often in combination with low doses of steroids.

This article reviews the pathogenetic mechanisms leading to the development of steroid resistance and the current therapies used in the management of this condition.


Introduction
The idiopathic nephrotic syndrome (NS) of childhood is a heterogenous disorder characterised by massive proteinuria, hypoalbuminemia, hyperlipidemia and edema. Histological characteristics are non-specific and range from minimal change disease, focal and diffuse mesangial proliferation to focal and segmental glomerulosclerosis (FSGS). Immunofluorescence is usually negative and electron microscopy shows fusion of the epithelial cell foot processes [1]. Over 80% of children presenting with an initial episode of NS respond to steroids (steroid sensitive), whilst the remaining 20% do not respond and are considered steroid resistant (SR) [2]. On follow up, 50-60% of children in the steroid responsive group have frequent relapses or develop steroid dependant disease. This group of children are at risk for extrarenal complications of NS as well as progression to end-stage renal disease necessitating renal replacement therapy. In these children who undergo transplantation, the overall risk for recurrence of the primary disease is about 25% [1]. The aim of therapy is to control the nephrotic state and thus prevent complications and to especially try and halt or delay progression to end-stage renal disease. To date the plethora of agents in our therapeutic armamentarium has failed to produce a drug that is the panacea for this condition. Thus management of SRNS therefore poses a major therapeutic challenge to the attending clinician.

There are certain clinical and histological characteristics that may predict the likelihood of steroid resistance. These include:

  • Hypertension (50-60% likelihood)

  • Hematuria (30%)

  • Hypertension plus hematuria (20%)

  • Elevated plasma creatinine

  • Massive proteinuria (>10g/day)

  • Age of first presentation in infancy, after 8 years or post puberty

  • Tubulointerstitial disease on renal biopsy or collapsing FSGS and percentage of globally sclerosed glomeruli

  • Black race

  • Selectivity index >0.2

  • Tubular proteinuria (Increase excretion of B2 -microglobulin retinol-binding protein, lysozyme [3].


Complications

Patients with SRNS are more likely to have complications from their disease compared to those with steroid sensitive NS.

  • Acute Renal Failure
    During relapses, children have a reduced glomerular filtration rate secondary to hypovolemia [4]. Other causes of acute renal failure include bilateral renal vein thrombosis and interstitial nephritis. The latter is often found in association with overzealous diuretic therapy e.g. furosemide.

  • Chronic Renal Failure
    Progression to end-stage renal disease occurs in at least 50% of children with SRNS. As patients develop ESRD, all features of their NS may improve because of a decrease in urinary protein excretion that parallels their glomerular filtration rate. Progression to end stage renal failure is more rapid in children with African or Hispanic descent.

  • Growth
    In children with unremitting relapse, growth retardation secondary to their state of malnutrition is common. The development of hypoparathyroidism secondary to urinary loss of iodinated proteins is an additional contributory factor.

  • Infections
    Factors predisposing to the increased risk of infection in these children include:

    • Low IgG levels due to impaired synthesis.

    • Urinary loss of factor B

    • Impaired T-lymphocyte function

    The most common infection is peritonitis. Organisms involved include Streptococcus pneumonia, Escherichia coli, Streptococcus bovis, Haemophilis influenzae.

  • Thrombosis
    Several factors contribute to the increased risk of thrombosis in these children. These include:

    • Hypercoagulability state

    • Hypovolemia

    • Immobilization

    • Infection

Haemostatic abnormalities encountered in these children include :

  • Increased platelet aggregability, fibrinogen, and factors V, VII, VIII, X, and XIII.

  • Decreased levels of antithrombin III, heparin cofactor, protein C and S, and factors XI and XII.

  • Increased fibrinolytic system components (eg. tissue plasminogen activator, plasminogen activator inhibitor-1)

The majority of thrombotic events are silent and symptomatic disease is found in only about 30% of patients. However in a study by Hoyer et al [5], systematic ventilation perfusion scans demonstrated defects consistent with pulmonary embolism in 28% of patients with steroid dependant or resistant NS. Thrombosis can occur in both arteries and veins.

Pathogenesis

The pathogenesis of glomerulosclerosis is still unknown. Several factors, including hemodynamic factors, cytokines and growth factors, hyperlipidemia, and platelet activation, lead to an increase of mesangial matrix production by resident cells in patients with FSGS. These patients have glomerular hypertrophy even if typical findings of FSGS are absent. There are several growth factors involved in the sclerotic process including platelet derived growth factor, TGF-ß, angiotensin II, thromboxane A2, coagulation factors and lipids [6,7,8].

Mechanism of Steroid Resistance

Why some children develop resistance to steroids is not well understood [9]. Recent studies have shown that specific genetic mutations constitute a principle mechanism for steroid resistance. Mutations of NPHS1, NPHS2, ACTN4 and WTI genes are responsible for severe forms of SRNS in childhood, progressing to end-stage renal failure [10]. Positional cloning has revealed defects in these 4 different genes as monogenic causes of SRNS in familial cases [11]. See table 1.

Table 1: Genetic mutations associated with SRNS in childhood.

GENE
TYPE OF NS
NPHS1
Recessive mutations, encoding nephrin, (OMIM No. 602716) causes congenital NS of the Finnish type.
NPHS2
Recessive mutations, encoding podocin (OMIN no. 604766), causes SRNS

Type 1.
ACTN4
Mutations encoding actinin 4, (OMIN no. 604638), causes autosomal dominant form of SRNS. An additional locus for an autosomal dominant form of NS has been mapped to chromosome 11q21-q22 (OMIN no. 603965).
WT1
Mutations are associated with congenital NS and diffuse mesangial sclerosis in the Denys-Drash syndrome and Frasier syndrome.



The Denys-Drash syndrome is characterised by early onset of NS progressing rapidly to end-stage renal disease, male pseudohermaphroditism, and Wilm's tumour [12]. The Frasier syndrome is characterised by the association of male pseudohermaphroditism and progressive glomerulopathy [13,14].

Podocin mutations Podocin, a 383-amino-acid protein, is a lipid raft-associated protein at the filtration slit, which is exclusively expressed in the podocytes at the foot processes [15]. Podocin interacts with nephrin [16]. Podocin also interacts with CD2AP, an adaptor protein that anchors CD2, a protein that stabilizes contact between podocytes [17]. The podocin plays a major role in the structural integrity and function of the slit diaphragm, which is the maintenance of glomerular permselectivity. Mutations in this gene can be observed in patients with both familial and sporadic disease. In a study by Weber et al, [18] NPHS2 mutation analysis was performed in 338 children from 272 families with SRNS: 81 families had autosomal recessive (AR) SRNS, 72 patients had sporadic SRNS, and 19 diffuse mesangial sclerosis [18]. The following results were obtained:

  • The detection rate of NPHS2 mutations (homozygous or compound heterozygous) for AR SRNS was 43%. The average age of onset was 58 months.

  • For those with sporadic forms of SRNS, it was 11%. The average age of onset was 103 months.

  • Relatively late onset of NS was observed in patients with only one pathogenetic NPHS2 mutation.

In a second large study by Ruf et al [19] direct sequencing of the NPHS2 gene was performed in 190 patients with SRNS (from 165 different families) as well as 124 patients with steroid-sensitive NS (from 120 families). The following results were obtained:

  • In the SR families, 43 (26%) of 165 SRNS families had homozygous or compound heterozygous mutations in NPHS2. Of the 29 patients with such mutations treated with cyclosporin or cyclophosphamide, more experienced a complete remission.

  • No homozygous or compound heterozygous mutations in NPHS2 were observed for the 120 steroid-sensitive NS families.

  • Recurrence of FSGS in a renal transplant was noted for 7 of 20 patients with SRNS (35%) without NPHS2 mutations, whereas it occurred for only 2 of 24 patients with SRNS (8%) with homozygous or compound heterozygous mutations in NPHS2.

It was concluded that patients with SRNS with homozygous or compound heterozygous mutations in NPHS2 do not respond to standard steroid therapy and have a reduced risk for recurrence of FSGS in a renal transplant. The authors further advocate that mutational analysis of NPHS2, if the patient consents, be done in parallel with the first course of standard steroid therapy in children with NS to avoid unnecessary side effects from prolonged or repeated course of steroids and cytotoxic agents. They further concluded that because patients with SRNS and homozygous or compound heterozygous mutations in NPHS2 have reduced risk for recurrence of FSGS in a renal transplant, compared to children without mutations, living related donor transplants might be considered more readily. However, given that 85% of children are steroid-sensitive and only approximately 20% of SR patients have NPHS2 mutations, screening for abnormalities at this gene locus will identify less than 5 percent of all cases [20]. Also, not all familial cases of SRNS are associated with NPHS2 mutations, suggesting that yet to be identified genes are responsible in these cases [21]. These genes may in fact be responsible for a higher proportion of sporadic SRNS.

WT1 mutations
The WT1 gene, which encodes a transcription factor, contains ten exons [21]. WT1 is strongly expressed during embryofetal life [22]. In the mature kidney, WT1 expression persists only in podocytes and epithelial cells of Bowman's capsule. Disruption of the WT1 gene in mice results in the absence of both kidneys and gonads, suggesting a crucial role of WT1 in the development of the genitourinary tract. Mutations in WT1, the Wilm's tumour suppressor gene, have been reported in children with sporadic SRNS and several forms of hereditary NS.

CD2-Associated protein
CD2AP anchors CD2 receptors of T-lymphocytes to the cytoskeleton. It is also expressed in the podocyte. It has been shown in murine studies that CD2AP and nephrin interact directly, suggesting an important role of this protein in the anchoring of nephrin to the slit diaphragm or into the signalling pathways [23]. No mutations of the CD2AP gene to date have been reported to be associated with SRNS.

HLA associations with SRNS
Several studies have failed to demonstrate any significant association of SRNS with class II antigens [24,25,26,27]. Other studies from Europe and the United States have shown an association of HLA-DR7 with the frequency of relapses in steroid sensitive NS [28,29,30,31,26]. Bakr et al [32] studied 20 Egyptian children with frequent relapses/steroid-dependant NS and 14 children with SRNS. The DRBI * 07011 allele frequency was significantly higher among patients than the 121 unrelated healthy controls (64.3% vs. 16.5%, Pc <0.001). The aetiological fraction was high at 0.57 (RR=9.6, Cl 2.9-31.7).

Clinical Presentation

The majority of patients present between 2-7 years of age. There is a preponderance of males with a ratio of males: females of 2:1. The disease is characterized by the sudden onset of oedema. Anasarca may develop with ascites, pleural and pericardial effusions. Blood pressure is usually normal but is sometimes elevated. Abdominal pain is occasionally due to complications such as peritonitis, thrombosis, or rarely pancreatitis. Sometimes the rapid development of ascites with concomitant hypovolemia leads to abdominal pain and malaise. In some patients, oedema is minimal and the nephrotic state is only discovered during routine urine analysis. Macroscopic hematuria may occur in a few cases. SRNS may also present with an infection or thrombotic complication.

Treatment

Symptomatic treatment is similarly to that of children who are steroid sensitive. This includes dietary recommendations if no added salt and adequate intake of proteins and vitamins with reduced intake of foods high in cholesterol. Diuretics are used for the treatment of edema. If there is anasarca, salt free albumin with loop diuretics are given for control of edema. In addition, prevention and appropriate treatment of infections and thromboembolic complications, and treatment of hypovolemia, hypertension and hyperlipidemia. If the latter is not controlled by dietary restriction alone, lipid lowering agents are used.

Immunosuppressive therapy

The optimal approach to SRNS is uncertain. The reports of the large number of agents used as specific therapy bears testimony to the lack of a single effective agent for the treatment of this condition.

    Alkylating Agents
    Cyclophosphamide and chlorambucil have been used either alone, in combination with oral steroids or with high dose pulse steroids. These regimens have met with variable success rates of inducing remission ranging from 10% to 70% [33,34,35,36,37,38]. Many patients exhibit features of steroid toxicity. The use of pulse dose cyclophosphamide over a few months induced remission in 25-60% of children with SRNS [38,39,40].

    Cyclosporin
    Initial studies evaluating the efficacy of cyclosporin in patients with SRNS showed a relatively small benefit. In eight uncontrolled studies involving 60 patients, complete remission was induced in only 12 (20%) [41]. In the study by the French Society of Pediatric Nephrology involving 65 children with SRNS, complete remission was observed in 42% of children (48% with minimal change disease and 32% with FSGS). Eight of the 27 responders became steroid-sensitive when they subsequently relapsed [42]. Patients who respond to cyclosporin often relapse when the dose is tapered or discontinued [43]. Many reports indicate that the prolonged use of cyclosporin is associated with chronic nephrotoxicity. The most prominent histological feature of chronic cyclosporin nephrotoxicity is the presence of tubulointerstitial lesions, characterised by striped interstitial fibrosis containing groups of atrophic tubules. Cyclosporin associated arteriolopathy is rarely observed. Other side effects include elevation of blood pressure, hyperkalaemia, hypertrichosis, gum hypertrophy, and hypomagnesaemia.

    Mycophenolate Mofetil
    Mycophenolate Mofetil (MMF) is the prodrug of mycophenolic acid which is formed by hydrolysis. Mycophenolic acid is a potent, selective, uncompetitive, and reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH). The latter is an enzyme required for de novo purine synthesis. Mycophenolic acid inhibits B and T-lymphocyte proliferation, as these cells are critically dependant upon de novo purine synthesis for their proliferation whereas other cell types can utilize salvation pathways for purine synthesis. Mycophenolic acid also prevents glycosylation of lymphocyte and monocyte glycoproteins that are involved in the intracellular adhesion of leucocytes to endothelium [44]. Mycophenolic acid also induces lymphocyte apoptosis and alters cell-surface adhesion molecules and cytokine gene expression [45]. MMF has been used in a few children with SRNS and FSGS [46]. Although in this study it was shown to decrease proteinuria, none of the patients achieved complete remission. In a study by Mendizabal et al [47], MMF was given to 5 children with SRNS. Only one achieved complete remission. Withdrawal of the drug led to relapse with one patient developing chronic renal failure. To date a paucity of data exists concerning the use of MMF in SRNS. The advantage with the use of MMF is its benign side effect profile compared to prednisone and cyclosporine. Its use is not associated with nephrotoxicity, hepatotoxicity, neurotoxicity, hyperglycaemia or abnormalities of lipid metabolism.

    Tacrolimus
    The main mechanism of action of tacrolimus is through the inhibition of 1L-2 dependant T-cell activation, a process occurring during the early phase of T-cell activation [48]. Tacrolimus also inhibits B-cell activation, in part through its action on T-cells and also directly by blocking TNF- a gene transcription by anti-Ig antibody [48]. The drug only becomes active when complexed with a distinct endogenous intracellular receptor (cystocolic binding protein-FRBP12) known as immunophilin [49]. The immunophilin drug complex interferes with intracellular calcium-dependent signal transduction pathways, processes that are central to T-cell activation [50,51,52,53]. The common biological target for the resulting complex is the calcium and calmodulin-dependent protein phosphatase, calcineurin. Case reports and single centre studies have shown tacrolimus to be effective in treating SR FSGS [54,55,56,57].

    Other Agents
    Other agents used in steroid dependent or SRNS include inter alia vincristine, azathioprine, sirolimus and mizoribine. Immunoglobulin transfusions have also been used with varying success.

Conclusion
Childhood SRNS continues to pose a major challenge to the attending physician. Although specific genetic factors such as mutations in the NPHS2 and other genes have been identified, suggesting a possible genetic basis for the SRNS with FSGS in a subgroup of patients, in the majority of patients, the pathogenesis remains elusive. The plethora of agents used in the treatment of this condition bears testimony to the lack of an optimal approach in managing this condition. Although data are lacking, use of these drugs, often in combination, is warranted in children with SR idiopathic NS together with adjunctive therapy.
References :
  1. Niaudet P. Steroid-resistant idiopathic nephrotic syndrome in children.In:Niaudet P, Avner ED, Harmon WE, eds. Pediatric Nephrology. Philadelphia, Blackwell, 2004;28:557-573
  2. Churg J, Habib R, White RHR, (1970). Pathology of nephrotic syndrome in children: a report for the International Study of Kidney Disease in Children. Lancet 760:1299-1302
  3. Ramjee G, Coovadia HM, Adhikari M (1997) Comparison of non-invasive methods of distinguishing steroid sensitive nephrotic syndrome from focal glomerulosclerosis. J Lab Clinic Med 129(1) : 47-52
  4. White RHR, Glasgow EF, Mills RJ (1970). Clinicopathological studies of nephrotic syndrome in childhood. Lancet;i: 1353-1359
  5. Hoyer PF, Gonda S, Barthels M, et al (1986). Thromboembolic complications in children in children with nephrotic syndrome. Acta Paediatr Scand;75:804-810.
  6. Border WA, Noble NA, Ketteler M (1995). TGF-: a cytokine mediator of glomerulosclerosis and a target for therapeutic intervention. Kidney Int; 47: 559-561
  7. Ichikawa I, Ikoma M, Fogo A (1991). Glomerular growth promoters, the common key mediator for progressive glomerular sclerosis in chronic renal diseases. Adv Nephrol ;20:127-148
  8. Tanaka R, Sugihare K, Tatematsu A, Fogo A (1995). Internephron heterogeneity of growth factors and sclerosis -Modulation of platelet-derived growth factor by angiotensin II. Kidney Int;47:131-139
  9. Haack D, Scharer K, Asam-Tauscher A, Vecsei P (1999). Glucocorticoid receptors in idiopathic nephrotic syndrome. Pediatr Nephrol; 13:653
  10. Niaudet P (2004). Genetic forms of nephrotic syndrome. Pediatr Nephrol 19: 1313-1318
  11. Ruf RG, Lichtenburger A, Karle SM, Haas JP et al (2004). Patients with mutations in NPHS2 (Podocin) Do Not Respond to Standard Steroid Treatment of Nephrotic Syndrome. J Am Soc Nephrol 15: 722-732
  12. Habib R, Loirat C, Gubler MC, Niaudet P, Bensman A, Levy M, Broyer M (1985). The nephropathy associated with male pseudohermaphroditism and Wilm's tumor (Drash Syndrome): a distinctive glomerular lesion, report of 10 cases. Clin Nephrol 24:269-278
  13. Koziell A, Grech V, Hussain S, Lee G, Lenkkeri U, Truggvasen K, Scambler P (2002). Genotype/phenotype correlations of NPHS1 and NPHS2 mutations in nephrotic syndrome advocate a functional inter-relationship in glomerular filtration. Hum Mol Genet 11:379-388
  14. Schultheis M, Ruf RG, Mucha BE, Wiggins R, Fuchshuber A, Lichtenberger A, Hildebrandt F (2004). No evidence for genotype/phenotype correlation in NPHS1 and NPHS2 mutations. Pediatr Nephrol (in press)
  15. Roselli S, Gribouval O, Boute N, Sich M, Benessy F, Attie T, Gubler MC, Antignac C (2002) Podocin localizes in the kidney to the slit diaphragm area. Am J Pathol 160:131-139
  16. Huber TB, Simons M, Hartleben, Sernetz L, Schmidts M, Gundlech E, Saleem MA, Walz G, Benzing T (2003) Molecular basis of the functional podocin-nephrin complex: mutations in the NPHS2 gene disrupt nephrin targeting to the lipid raft microdomains. Hum Mol Genet 12: 3397-3405f the glomerular slit diaphragm, interacts with CD2AP and nephrin. J Clin Invest 108:1621-1629
  17. Schwarz K, Simons M, Reiser J, Saleem MA, Faul C, Kriz W, Shaw AS, Holzman LB, Mundel P (2001) Podocin- a raft associated component
  18. Weber S, Gribouval O, Esquivel EL et al (2004). NPHS2 mutation analysis shows genetic heterogeneity of steroid-resistant nephrotic syndrome and low post-transplant recurrence. Kidney Int;66:571
  19. Ruf RG, Litchenberger A, Karle SM, et al (2004). Patients with mutations in NPHS2 (podocin) do not respond to standard steroid treatment of nephrotic syndrome. J Am Soc Nephrol; 15:722
  20. Niaudet P (2004). Podocin and nephrotic syndrome: implications for the clinician. J Am Soc Nephrol;15:832
  21. Niaudet P (2004). Genetic forms of nephrotic syndrome. Pediatr Nephrol;19:1313-1318
  22. Pritchard-Jones K, Fleming S, Davidson D, Bickmore W, Porteous D, Gosden C, Bard J, Buckler A, Pellettier J, Housman D (1990) The candidate Wilms' tumor gene is involved in genitourinary development. Nature 346:194-197
  23. Shih NY, Li J, Cotran R et al (2001). CD2AP localizes to the slit diaphragm and binds to nephrin via a novel C-terminal domain. Am J Pathol;159:2303-2308
  24. Lagueruela CC, Buettner TL, Cole BR, Kissane JM, Robson AM (1990) HLA extended haplotypes in steroid-sensitive nephrotic syndrome of childhood. Kidney Int 38:145-150
  25. Al-Eisa AA, Haider MZ, Srivasta BS (2000) HLA-DQB1 and DRB1 alleles in Kuwaiti children with idiopathic nephrotic syndrome. Pediatr Nephrol 15:79-81
  26. Haeffener A, Abbal M, Mytilineous J, Konrad M, Krammer I, Bouissou F, Opelz G, Scharer K, Cambon-Thomson A (1997) Oligotyping for HLA-DQA, -DQB and -DPB in idiopathic nephrotic syndrome. Paediatr Nephrol 11:291-295
  27. Zaki M, Daoud AS, Al-Saleh QA, Al-Najedi AK, White AG (1994) HLA antigens in Arab children with steroid-resistant responsive nephrotic syndrome. Pediatr Nephrol 8:74-75
  28. Krasowsa-Kwiecien A, Sancewicz-Pach K, Pogan A (2001) Class II human leukocyte antigens in minimal change nephrotic syndrome and focal segmental glomerulosclerosis-preliminary study. Pol Merkuriusz Lek 10:256-258
  29. Cambon-Thomsen A, Bouissou F, Abbel M, Duprat MP, Barthe P, Calot M, Ohayon E (1986) HLA and Bf in idiopathic nephrotic syndrome in children: differences between corticosensitive and corticoresistant forms. Pathol Biol (Paris) 34:725-730
  30. Clark AG, Vaughan RW, Stephens HA, Chantler C, Williams DG, Welsh KI (1990) Genes encoding the beta-chains of HLA-DR7 and HLA-DQw2 define major susceptibility determinants for idiopathic nephrotic syndrome. Clin Sci 78:391-397
  31. Ruder H, Scharer K, Opelz G, Lenhard V, Waldherr R, Muller-Wiefel DE, Wingen AM, Dippel J (1990) Human leucocyte antigens in idiopathic nephrotic syndrome in children. Pediatr Nephrol 4:478-481
  32. Bakr AM, El-Chenawi F (1998) HLA-DQB1 alleles in Egyptian children with steroid sensitive nephrotic syndrome.
  33. Grisweld WR, Tune BM, Reznik VM, Varquez M, Prime DJ, Brock P, Mendoza SA (1987) Treatment of childhood prednisone resistant nephrotic syndrome and focal segmental glomerulosclerosis with intravenous pulse methylprednisolone and oral alkylating agents. Nephron 46:73-77
  34. Adhikari M, Bhimma R, Coovadia HM (1997) Intensive pulse therapies for focal glomerulosclerosis in South African children. Pediatr Nephrol 11:423-428
  35. Mendoza SA, Reznik VM, Grisweld WR, Krensky AM, Yorgin PD, Tune BM (1990) Treatment of steroid-resistant focal segmental glomerulosclerosis with intravenous pulse methylprednisolone and alkylating agents. Pediatr Nephrol 4:303-307
  36. Hari P, Bagga A, Jindal N, Srivastava RN (2001) Treatment of focal glomerulosclerosis with pulse steroids and cyclophosphamide. Pediatr Nephrol 16:901-905
  37. Tune BM, Kirpekar R, Sibley RK, Reznik VM, Grisweld WR, Mendoza SA (1995) Intravenous pulse methylprednisolone and oral alkylating agent therapy of prednisone-resistant pediatric focal segmental glomerulosclerosis: A long-term follow-up. Clin Nephrol 43:84-88
  38. Waldo FB, Benefield MR, Kohaut EC (1992) Methylprednisolone treatment of patients with steroid-resistant nephrotic syndrome. Pediatr Nephrol 6:503-505
  39. Elhence R, Gulati S, Kher V, Gupta A, Sharma RK (1994) Intravenous pulse cyclophosphamide-a new regime for steroid-resistant minimal change nephrotic syndrome. Pediatr Nephrol 8:1-3
  40. Rennert WP, Kala UK, Jacobs D, Goetsch S, Verhaart S (1999) Pulse cyclophosphamide for steroid-resistant focal segmental glomerulosclerosis. Pediatr Nephrol 13:113-11651
  41. Niaudet P, Habib R (1994). Cyclosporin in the treatment of idiopathic nephrosis. J Am Soc Nephrol; 5: 1049
  42. Niaudet P for the French Society of Pediatric Nephrology (1994). Treatment of childhood steroid resistant idiopathic nephrosis with a combination of cyclosporin and prednisone. J Pediatr;125:981
  43. Niaudet P, Broyer M (1989). Cyclosporin in the therapy of idiopathic nephrotic syndrome in children. In: Andreucci VE, ed. International yearbook of nephrology. Boston: Kluver Academic Publishers:155-168
  44. Laurent AF, Dumont S, Poindron P, Muller CD (1996) Mycophenolic acid suppresses protein N-linked glycosylation in human monocytes and their adhesion to endothelial cells and some substrates. Exp Hematol 24:59-67
  45. Gummert JF, Barten MJ, Sherwood SW, Vangelder R, Billingham ME, Morris RE (1999) Pharmacodynamics of immunosuppression by mycophenolic acid: inhibition of both lymphocyte proliferation and activation correlates with pharmacokinetics. Pharmacol Exp Ther 291:1100-1112
  46. Day CJ, Cockwell P, Liokin GW, Savage CO, Howie AJ, Adu D (2002) Mycophenolate mofetil in the treatment of resistant idiopathic nephrotic syndrome. Nephrol Dial Transplant 17:2011-2013
  47. S Mendizabal, I Zamora, O Berbel, Sanahuja MJ, Fuentes J, Simon J (2005) Mycophenolate Mofetil in steroid/cyclosporine-dependant /resistant nephrotic syndrome. Paediatric Nephrology 20:914-919
  48. Peters DH, Fitton A, Plosker GL, Faulds D (1993). Tacrolimus: a review of its pharmacology and therapeutic potential in hepatic and renal transplantation. Drugs 46(4):746-794
  49. Schreiber SL, Liu J, Albers MW et al (1991). Immunophilin-ligand complexes as probes to intracellular signalling pathways. Transpl Proc;23(6):2839-2844
  50. Schreiber SL (1991). Chemistry and biology of the immunophilins and their immunosuppressive ligands. Science;251:283-287
  51. Bierer BE, Somers PK, Wandless TJ, Burakeff SJ, Schreiber SL (1990). Probing immunosuppressant action with a nonnatural immunophilin ligand. Science 250:556-559
  52. Bierer BE, Mattila PS, Standaert RF et al (1990). Two distinct signal transmission pathways in T lymphocytes are inhibited by complexes formed between an immunophilin and either FK506 or rapamycin. Proc Natl Acad Sci USA;87:9231-9235
  53. DeFranco AL (1991). Immunosuppressants at work. Nature 352:754-755
  54. Tsugawa K, Tunaka H, Nakhatu T, Ito E (2004 Nov) Effective therapy of a child case of refractory nephrotic syndrome with tacrolimus. J Exp Med 204(3): 237-41
  55. Meyrier A (2003 Aug). Treatment of idiopathic nephrosis by immunophilin modulation. Nephrol Dial Transplant Aug:18, Suppl 6: Vi-79-86
  56. Loeffler K, Gowrishanker M, Yiu V (2004 Mar). Tacrolimus therapy in pediatric patients with treatment-resistant nephrotic syndrome. Ped Nephrol,19(3):281-287
  57. McCauley J, Shapiro R, Ellis D, Fydal H, Tzaku A, Starzl TE (1993) Pilot trial of FK 506 in the management of steroid-resistant nephrotic syndrome. Nephrol Dial Trans(8)(11); 1286-90
Last Updated : Thursday, December 01, 2005 Vol 2 Issue 12 Art #52
How to Cite URL :
Natal) ( B R. STEROID RESISTANT NEPHROTIC SYNDROME IN CHILDREN. Pediatric Oncall [serial online] 2005[cited 2005 January 1];2. Art #52. Available From : http://www.pediatriconcall.com/Journal/Article/FullText.aspx?artid=757&type=J&tid=&imgid=&reportid=403&tbltype=
This Article
Google Scholar
Pubmed
Other
Image Gallery
What is the diagnosis_?
Teaching Files
A 7 years old boy presented with fever and right hypochondriac abdominal pain for a 1 month. There was no vomiting or jaundice. He underwent an ultrasound {USG} abdomen that showed edematous common bile duct with round worm like linear structure at ...
Pediatric Oncall
Apps
Download From
App Store | Google Play
Editorial Board | Reviewers & Experts Panel | Contact us | Indexed In | Want to Become a Reviewer
Pediatric Oncall Home | Conferences & CME Center | Diseases & Conditions | Medical Calculators | Drugs & Poisoning Center | Diagnostic Center | MCQ Quiz | Vaccination Center | Question of the Day | Search Directory | Baby Names | Diet & Diseases | Alternative Medicines | Kids Corner | RSS Feed RSS
Disclaimer: The information given by www.pediatriconcall.com is provided by medical and paramedical & Health providers voluntarily for display & is meant only for informational purpose. The site does not guarantee the accuracy or authenticity of the information. Use of any information is solely at the user's own risk. The appearance of advertisement or product information in the various section in the website does not constitute an endorsement or approval by Pediatric Oncall of the quality or value of the said product or of claims made by its manufacturer.