You are on page 1of 21

ABSTRACTS

12th Asian Congress of Pediatric Nephrology
Delhi, India, 4-6 December 2014. President: Arvind Bagga
Selected Abstracts
Acute kidney injury
Fluid overload and renal angina index are associated with worse
outcomes in critically ill children
S.K. Sethi
1
, V. Raghunathan
1
, R. Raina
2
, M. Kumar
1
, M. Dhaliwal
1
, J.
Sharma
1
, V. Kher
1
1
Kidney Institute &Pediatric Intensive Care, Medanta Medicity Hospital,
Gurgaon, India;
2
Pediatric Nephrology, Akron Children's Hospital, Cleveland, Ohio,
USA
2
Objectives: We investigated the association of fluid overload and oxy-
genation, and correlated with outcomes (duration of ventilation, ICUstay
and mortality). We also assessed whether renal angina index (RAI) at
admission, can predict acute kidney injury (AKI) on day 3, and mortality.
Design and setting: Prospective study, pediatric intensive care in a
tertiary hospital
Duration: June 2013- June 2014
Patients: Need for invasive mechanical ventilation for >24 hr and pres-
ence of an indwelling arterial catheter. Patients with congenital heart
disease or those who received renal replacement therapy were excluded.
Methods: Oxygenation index, fluid overload percent (daily, cumulative),
RAI at admission and pediatric logistic organ dysfunction (PELOD) score
were obtained in all critically ill children. Admission data included for
determination of RAI included the use of vasopressors; invasive mechanical
ventilation; percent fluid overload and change in kidney function (estimated
creatinine clearance). Univariate and multivariate approaches were used to
assess the independent relation between fluid overload, oxygenation index
and clinical outcomes. RAI cutoff >8 was used to analyze the predictive
performance to predict AKI on day 3 of admission and mortality.
Results: 102 patients were recruited. Fluid overload predicted oxygena-
tion index, independent of age, gender and PELOD score (P <0.05). Peak
fluid overload was associated with longer duration of ventilation, and
intensive care unit and hospital length of stay (P <0.05), controlled for age
and gender, PELOD. Day-3 AKI rates were higher in patients with RAI of
8 or more with the area under the curve of RAI higher for predicting Day-
3 AKI. An RAI <8 had high negative predictive values (92–99%) for
Day-3 AKI. RAI was as good as traditional markers of pediatric severity
of illness (pediatric risk of mortality) for prediction of AKI on day 3.
Conclusions: This study emphasizes that positive fluid balance adversely
affects the intensive care unit course in critically ill children. Renal angina
index prediction model may further help in a reliable prediction of AKI
and help optimize treatment.
Activation of Tim-3/Gal-9 pathway promotes the proliferation
of Foxp3
+
Treg in mice with renal ischemia reperfusion injury
W. Yamei, T. Yuhong
Department of Pediatrics, West China Second University hospital, Si-
chuan University, Chengdu, China
Background: Foxp3
+
regulatory T cells (Tregs) participate in the repair
of renal ischemia reperfusion injury (IRI). Others have shown that
galactin-9 (Gal-9), a β-galactoside binding mammalian lectin, binds to
negative regulatory molecule Tim-3 on CD4
+
T cells and regulates im-
mune responses by increasing Foxp3
+
Treg in vitro and in vivo.
Objectives: To study if activation of Tim-3/Gal-9 pathway promotes
proliferation of Foxp3
+
Treg in mice with renal IRI.
Methods: The left renal pedicle was clamped in C57BL6 male mice for
45 min, followed by reperfusion. Animals were sacrificed at baseline, and
day 1, 3, 10, 21 after renal IRI. Expression of renal Gal-9 was detected by
real-time RT-PCR, immunohistochemistry staining and Western blot.
Tim-3 in kidney mononuclear cells (KMNC) was determined using
real-time RT-PCR and flow cytometry. The percentage of Foxp3
+
Treg
in KMNC and renal Foxp3 mRNA in kidney were measured with flow
cytometry and real-time RT-PCR. To research the influence of Tim-3/Gal-
9 pathway to the proliferation of Foxp3
+
Treg and the protection effect of
renal IRI, recombinant adeno associated virus (rAAV) carrying Gal-9 was
injected to mice two days before kidney IRI surgery in order to overex-
press Gal-9 and activate Tim-3/Gal-9 pathway. The proportion of Foxp3
+
Tregs, Foxp3 mRNA and cytokines (TNF-α, IFN-γ, IL-10 and TGF-β)
in kidney were evaluated on day 3, 10 and 21.
Results: The expression of Gal-9 and Tim-3 in the injured kidney at day3, 10
and 21 increased significantly compared with injured kidney at day 1 and
baseline (P<0. 05). The percentage of Foxp3
+
Treg in CD4
+
Tcells and Foxp3
mRNAwas up-regulated with time. The mRNAexpressionof Gal-9 andTim-
3 was positively correlated with the percentage of Foxp3
+
Tregs and Foxp3
mRNA at day 3, 10 and 21. Mice treated with RAAV carrying Gal-9 were
significantly protected fromrenal IRI. Over expression of Gal-9 decreased the
level of inflammatory cytokines (TNF-α and IFN-γ) and increased the levels
of IL-10 and TGF-βin injured kidney. Furthermore, the proportion of Foxp3
+
Treg cells and the level of Foxp3 mRNAin injured kidney were significantly
higher than those in uninjured kidney and adenovirus group.
Conclusion: Tim-3/Gal-9 pathway involves proliferation of Foxp3
+
Treg
in mice with renal IRI. Gal-9 is a potential therapeutic target in renal IRI.
Independent risk factors for acute kidney injury after surgery
for congenital heart disease
D. Hirano, A. Ito, A. Yamada, D. Kakegawa, S. Miwa, H. Ida
Department of Pediatrics, Jikei University School of Medicine, Tokyo,
Japan
Objectives: Despite advances in surgical treatment and postoperative
care for congenital heart disease (CHD), 30% patients develop acute
kidney disease (AKI). Risk factors for postoperative AKI include usage
time of cardiopulmonary bypass, presence of ischemia, reduced postop-
erative cardiac output, young age, type of heart disease, and use of
cardiovascular agents. This study aimed to investigate the incidence and
risk factors of postoperative AKI.
Methods: This study retrospectively investigated 418 patients (males: 259;
females: 159; median age: 5 months) who underwent heart surgery for CHD
at our hospital over the6-year period fromApril 2007 through August 2013.
AKI was defined according to pediatric RIFLE (pRIFLE) classifications and
required a decrease in estimated creatinine clearance of ≥25%.
Pediatr Nephrol
DOI 10.1007/s00467-014-2981-6
Results and Conclusions: AKI developed postoperatively in 104 cases
(24.9%). Approximately 80% patients were allocated into risk category
according to pRIFLE classification and did not require treatment. Multi-
variate analysis revealed the following independent risk factors for AKI:
young age at surgery (<1-yr), surgery with risk adjusted classification of
congenital heart surgery score (RACHS-1) grade ≥4 and long usage time
of cardiopulmonary bypass (≥90 minutes).
NGAL and IL-18 levels in first spontaneous void urine samples are
biomarkers of renal dysfunction in babies born after fetal distress
S.K. Patnaik
1, 2
, P Haritha
2
, M Udhayakumar
2
, R Joshi
2
, V Venkateshwar
2
1
Department of Pediatrics, Army Hospital, Delhi;
2
Department of Pedi-
atrics, Command Hospital, Bangalore, India
Objectives: We hypothesized that high levels of NGAL and IL-18 in the
first urine passed at birth is a biomarker of in utero/intrapartumacute renal
dysfunction. We conducted a study of the utility of measurement of
NGAL and IL-18 levels in spontaneous first void urine samples in babies
born with or without fetal distress as a marker of renal dysfunction.
Methods: Prospective follow-up of 2 cohorts of neonates over 1 week
after birth during a 1-yr period. Group A: Neonates with fetal distress
defined as abnormal cardiotocography, fetal bradycardia or tachycardia,
cord pH <7.15 or fresh meconium stained liquor; group B: Normal
spontaneous labor in healthy mothers with no signs of fetal distress.
Patients with premature rupture of membranes, maternal fever, positive
sepsis screen within first week, IUGR, congenital malformations or small
kidneys on postnatal ultrasound were excluded. Serial creatinine and
urinary NGAL and IL-18 levels were estimated at 24, 48 hr and day 7.
Outcomes: Urinary NGAL and IL-18 levels in first void samples; tem-
poral profile of urinary biomarkers, AKI in first week of life, change in
serum creatinine between birth and day 7.
Results: Spontaneous void urine samples could be collected in the
delivery suite for 61 babies (Group A: 26; Group B: 35). Resuscitation
and intensive care was needed for 17 babies. Apart from neonatal jaun-
dice, no significant co morbidity was observed in Group B. Median
urinary biomarker levels were significantly elevated at birth (IL-18 56.5
vs. 22.4 pg/ml; NGAL 53.6 vs. 20.5 ng/ml), 24-hr (IL-18: 59.2 vs. 23.2
pg/ml; NGAL: 57.4 vs. 21.9 ng/ml) and 48-hr (NGAL: 49.1 vs. 16.6 ng/
ml) birth in babies with fetal distress and were associated with a mean
change of serum creatinine of 0.62 (0.2-0.9) mg/dl in gr. A compared to
0.25 (0.1-0.29) mg/dl in gr. B within the first week. Biomarker levels had
a trend for being higher in girls and normalized by day 7 with no
significant effect of male sex (r=-0.18), birth weight (r=0.19) and gesta-
tional age (r= 0.13). There was a significant correlation with occurrence
of fetal distress on univariate and multivariate regression.
Conclusions: Babies with fetal distress had significantly higher levels of
NGALand IL-18 in the first voided urine sample and significantly greater
change in serum creatinine levels in the first week. The biomarker levels
reached comparable levels for normal neonates by day 7 of life.
Outcome of acute kidney injury in children with falciparum malaria
R. Prasad, O.P. Mishra, A. Abhinay, U.K. Singh
Departments of Pediatrics, Institute of Medical Sciences, Banaras Hindu
University, Varanasi
Objectives: Acute kidney injury (AKI) in P. falciparum malaria is an
important morbidity in children. The present study was done to observe
the changes in renal functions and their outcome.
Methods: Patients admitted to pediatric ward of a tertiary-care hospital
with severe falciparum malaria who developed AKI were included.
Results: Of 156 patients, 31(19.9%) had AKI; 4 patients were classified
at Risk, 11 Injury and 16 Failure, per pRIFLE criteria. There were 20
males, and mean age of patients with AKI was 7.7±3.2 years. Blood urea
and creatinine levels were 132.6±40.4 and 3.9±1.9 mg/dL, respectively.
Anemia (90.3%), hypoglycemia (41.9%), jaundice (38.7%), convulsions
(35.5%), pulmonary edema (32%), coma (29%), disseminated intravas-
cular coagulation (29%) and shock (26%) were co-morbidities. Twelve
cases (38.7%) required peritoneal dialysis; 8 patients (25.8%) with AKI
died. Non-survivors had longer duration of illness (P=0.003), oliguria (P
<0.001), and high levels of urea (P <0.01) and creatinine (P=0.042). On
regression analysis, DIC (odds ratio 73.5, 95% CI 6.9-707.9), jaundice
(OR 25.2, CI 3.0-188.8) and pulmonary edema (OR 6, CI 1.1-31.8) were
determinants of outcome.
Conclusions: AKI in falciparum malaria is a severe complication; dura-
tion of illness and presence of co-morbidities adversely affect outcomes.
RIFLE criteria in critically ill neonates with acute renal failure
M. Mohkam, A. Afjeii, F. Golchin, A. Ghafari
Pediatric Infectious Research Center, Shahid Beheshti University of
Medical Sciences, Tehran, Iran
Introduction: Neonatal ARF is defined as urine flow rate <1 ml/kg/hr,
with serum creatinine >1.5 mg/dl for at least 24-hr. The aim of this study
was to compare the RIFLE criteria to the old definition of ARF for
diagnosis of neonatal acute kidney injury (AKI) and prediction of
mortality.
Methods: This cohort study was conducted on 904 critically ill neonates.
RIFLE score was determined for each neonate based on serum creatinine
and urine output on the second day of admission. Prevalence of AKI was
detected based on old definition of ARF and RIFLE criteria.
Results: Based on RIFLE criteria, 22.5%of study group had normal renal
function and 77.5% had AKI at the second day of admission. Among
patients with AKI 43% met the risk, 51% the injury and about 6% the
failure criterion. Based on old definition of ARF in neonates, the rate of
ARF in our study group was 3.2%. There was a significant difference
between AKI prevalence by RIFLE criteria and old definition (P <0.001).
The overall mortality rate in critically ill neonates was 14%. Of those who
died, 81.9%had AKI. In patients with normal renal function there was no
mortality and in patients with AKI based on RIFLE criteria the mortality
rate was 21.7%(P=0.031, OR1.1, 95%CI 1.05-1.16) and in patients with
ARF based on old definition the mortality rate was 61.5% (P <0.001, OR
6.7). A progressive and significant elevation in mortality was correlated
with increasing RIFLE severity in neonates.
Conclusion: RIFLE criteria can detect neonatal AKI earlier and is a
satisfactory predictor for mortality in critically ill neonates.
Chronic kidney disease
Effect of cholecalciferol supplementation on FGF-23 levels
in children with chronic kidney disease (CKD) having vitamin D
insufficiency
A. Sheriff, P. Hari, R.W. Thergaonkar, D. Bhatia, S. Hari, N. Gupta, A.
Sinha, A. Bagga
Department of Pediatrics, All India Institute of Medical Sciences, Delhi,
India
Objectives: Primary objective was to compare FGF-23 before and 8 wk
after supplementation of cholecalciferol in children with CKD having
vitamin D insufficiency. Secondary objectives included comparison of
serum calcium, phosphate, parathormone, 25 hydroxyvitamin D and
brachial artery flow mediated dilatation (FMD).
Methods: Children between 2-12 yr of age with CKD stages II to IV,
having vitamin D insufficiency (25 OH vitamin D <30 ng/ml) were
administered 600000 IU of cholecalciferol over 3 days. Children with
phosphate > 6 mg/dl, calcium >10.5 mg/dl, those having received
Pediatr Nephrol
cholecalciferol supplements in past 3 months, or currently receiving
sevelamer, statins, cinacalcet and corticosteroids were excluded.
Results: Of 71 patients with CKDstage II-IVscreened, 41 had vitamin D
insufficiency. The rise in median (95% CI) FGF-23 levels after interven-
tion from 157.3 (99.6-181.9) to169.4 (133.7-215.8) RU/ml was not
statistically significant (P=0.3). Median phosphate levels did not rise after
intervention (4.6 vs. 4.9 mg/dl) (P=0.8). However, on subgroup analysis,
median FGF-23 increased significantly from 77.4 (55.8-128.5) RU/ml to
140.9 (77.4-177.4) RU/ml (P=0.01) and phosphate increased significant-
ly from 4.7 (4.2-5.1) pg/ml to 5.0 (4.7-5.2) pg/ml in stage II CKD
(P=0.01). Median calcium levels increased significantly from 9.1 (8.9-
9.5) to 9.5 (9.2-9.8) mg/dl (P=0.02). The alkaline phosphatase and
parathormone levels reduced from 742 (600-871) to 615 (553-723) IU
(P <0.001) and 72.5 (43-93) to 50.8 (28-67) (P <0.001), respectively.
Median 25-hydroxyvitamin Dlevels rose from13 (11-18.5) to 50 (39-62)
ng/ml (P <0.001). The change in median FMDafter intervention from7.7
(5.2-8.7) to 8.3 (5.8-9.0) % was not significant (P=0.6).
Conclusions: There is a high prevalence of vitamin D insufficiency in
Indian children with CKD II to IV and is effectively corrected by high
dose cholecalciferol. Cholecalciferol supplementation leads to rise in
phosphate & FGF-23 level in early CKD, but not later stages. There is
no change in brachial artery FMD with cholecalciferol supplementation.
Estimated GFR is an independent predictor of FGF levels.
A composite risk score of novel biomarkers predicts arteriopathy
in pediatric CKD and ESRD
S. Chaturvedi
1
, I.D. Liu
1
, Y.W. Lau
1
, L.P. Resontoc
1
, M. Tan
1
, K.H.
NG
1,2
, W.S. Yeo
1
, Y.H. Chan
3
, L.L. Gong
4
, L.H. Ling
4
, A.M. Richards
5
,
H.K. Yap
1,2
1
Shaw-NKF-NUH Children’s Kidney Center, KTP University Children's
Institute, National University Health System;
2
Yong Loo Lin School of
Medicine, National University of Singapore (NUS);
3
Biostatistics Unit,
Yong Loo Lin School of Medicine, NUS;
4
Department of Medicine,
Yong Loo Lin School of Medicine, NUS;
5
Cardiovascular Research
Institute, National University Health System
Background: Children with chronic kidney disease (CKD) have in-
creased risk of death from cardiovascular disease. This study explored
novel biomarkers for early detection of arteriopathy among high-risk
children with CKD.
Methods: 16 pre-dialysis CKD stages 3-4 (Group 1) and 25 CKD stage
5D patients (Group 2) were recruited. High resolution B-mode ultraso-
nography was performed on carotid, brachial and femoral arteries and
arteriopathy parameters measured were augmentation index, pulse wave
velocity/height, age-height standardized carotid and femoral intima-
media thickness, stiffness parameter and flow-mediated dilatation. An
arteriopathy score was computed by adding the scores of individual
arteriopathy parameters (abnormal=1, normal=0). ABPMwas performed,
and diastolic and systolic BP scores were calculated by adding individual
scores for 24-h, wake, sleep blood pressure index and load and dipping.
Biomarkers such as time averaged hemoglobin, uric acid, calcium, phos-
phate and parathormone were examined. Novel biomarkers such as serum
GDF-15, ST2, hsTNT, homocysteine, ADMA, hsCRP, NT-proBNP and
urine NGAL were examined. An ROC model using the odds ratios as the
risk score from a multivariate logistic regression on univariate significant
clinical and biochemical parameters was developed.
Results: All patients, mean age 16.2±6.6 years and CKDduration 4.2±3.7
years, had at least one abnormal arteriopathy parameter (median
arteriopathy score=4). Only pulse wave velocity/height [PWV (ht)] was
significantly different between group 1 (3.3±0.7 m/s) and group 2 (4.1±0.9
m/s) (P=0.006). Parameters which were associated with abnormal PWV
(ht) (defined as ≥3.74 m/s) were uric acid, diastolic BP score >5, GDF-15,
hsTNT, ADMA and NTproBNP. The risk score model developed includ-
ing these parameters had AUCof 0.806. Using a threshold score of 15, the
sensitivity, specificity, PPV and NPV were 76.2%, 85.0%, 84.2% and
77.3% respectively.
Conclusion: Arteriopathy abnormalities were detected in all patients with
CKD, with significant worsening of vascular reactivity as measured by
PWV in advanced CKD stage 5. The composite risk score model devel-
oped is a useful predictor of severe arteriopathy in CKD.
Growth in children with chronic kidney disease: report from Korean
cohort study for outcome in patients with pediatric chronic kidney
disease (KNOW-Ped CKD)
E. Park
1
, Y.H. Ahn
1
, J.M. Lee
1
, H.J. Choi
1
, H.G. Kang
1
, H.Y. Cho
2
, J.H.
Lee
3
, J.I. Shin
4
, M.H. Cho
5
, Y.S. Park
3
, H.I. Cheong
1
, I.S. Ha
1
, C. Ahn
6
1
Seoul National University Children’s Hospital, Seoul;
2
Samsung Med-
ical Center, Seoul;
3
University of Ulsan College of Medicine, Seoul;
4
Yonsei University College of Medicine, Seoul;
5
Kyungpook National
University Hospital, Daegu;
6
Department of Internal Medicine, National
University Hospital, Seoul, Korea
Objective: We investigated the risk factors related with stunted growth in
children with CKD.
Methods: Growth of 309 children (M: F 206:103) enrolled in KNOW-
Ped CKD (2011-13) were quantified by age-sex-specific height SDS
score. Cox regression analysis was done to identify risk factors for growth
impairment (height SDS <-1.88) before growth hormone (GH) treatment.
Results: Median height SDS of overall patients were -0.85 with the
interquartile range -1.75~0.05. Growth impairment was observed in
21% patients and 15% of them were treated with GH. Children with
growth impairment were mostly girls and had lower BMI, advanced CKD
stage, preterm birth and low birth weight.
Conclusion: Girls, lowBMI, advanced CKDstage, pretermbirth and low
birth weight are associated with growth failure in children with CKD.
Children with these findings may require close attention on their growth
and earlier intervention to avoid severe growth impairment.
Acknowledgement: This work was supported by the Research Program
funded by the Korea Centers for Disease Control and Prevention
(2013E3301600, 2013E33081601).
Complement associated diseases
Anti-factor H autoantibodies associated with atypical HUS or C3
glomerulopathy: one target, two diseases
S.K. Togarsimalimath
1
, C. Blanc
1
, L. Roumenina
1
, S. Chauvet
3
, Y.
Ashraf
1
, B. Moulin
4
, P.L. Pogamp
5
, A. Bagga
6
, V. Fremeaux-Bacchi
1,2
,
MA Dragon-Durey
1,2,7
1
INSERM UMRS1138, Paris;
2
Service d’immunologie biologique,
Hôpital Européen Georges Pompidou, APHP, Paris;
3
Service de
Néphrologie, Hôpital Tenon, APHP, Paris;
4
Service de Néphrologie et
Transplantation rénale, CHU Hautepierre, Strasbourg;
5
Service de
Néphrologie, CHU Pontchaillou, Rennes;
6
Department of Pediatrics,
AIIMS, New Delhi, India;
7
Université Paris Descartes, Paris, France
Objectives: Dysregulation of complement factor H (CFH) results in
kidney disease. One mechanism is production of anti-factor H autoanti-
bodies (aFH) as atypical hemolytic uremic syndrome defining the autoim-
mune form (AI-aHUS), leading to acute renal insufficiency. Anti-FH anti-
bodies are also present in some chronic diseases comprising C3 glomeru-
lopathies (GP), dense deposit disease & type I membranoproliferative GN
leading to progressive renal insufficiency. This study compares the func-
tional consequences of aFH developed in context of GP and AI-aHUS.
Methods: Samples from7 children (mean age 7.5 yr) presenting with GP
associated with aFH were studied. Samples from17 children with AI-
aHUS (mean age 8.9 yr) were used as controls. Immune complexes
Pediatr Nephrol
quantification and epitope mapping of aFH were performed by ELISA;
cell lysis assays were performed using non sensitized sheep erythrocytes
and genetic analysis was performed by MLPA.
Results: GP and AI-aHUS patients had comparable antibody titers, but
GP patients had very lowFH-anti-FHIgGcirculating immune complexes
(CIC) in comparison to aHUS patients. Epitope mapping revealed that
aFH bound to only the N-terminal part in GP, whereas they bound to both
N and C-terminal domains of FH in AI-aHUS. Cell lysis assays showed
low levels of lysis with GP samples as compared to AI-aHUS samples.
None of the GP patients had homozygous CFHR1/R3 deletion, which is
the predisposing factor for AI-aHUS; 6/7 patients were C3Nef positive.
Conclusions: Anti-factor H autoantibodies of GP bound to epitopes
different from AI-aHUS and impair the alternative pathway in a distinct
mechanism. They are not developed in the same genetic condition. This
data provides an insight of differences between aHUS and GP and also an
example of autoantibodies directed against the same protein associated
with two pathologically distinct diseases.
Clinical features and outcomes in children with C3 glomerulopathy
S. Bhardwaj
1
, A. Sinha
1
, P. Hari
1
, G. Singh
2
, A.K. Dinda
2
, A. Bagga
1
1
Division of Nephrology, Department of Pediatrics;
2
Department of
Pathology, All India Institute of Medical Sciences, New Delhi, India
Background: Dense deposit disease (DDD) and C3 glomerulonephritis
(C3GN), classified together as C3 glomerulopathy, are rare diseases
characterized by glomerular deposition of C3 without significant immu-
noglobulin deposits. Information on management and outcomes of C3
glomerulopathies is limited to case series.
Methods: Records of patients, 1-18 yr-old, with biopsy between 2004
and 2014 were reviewed to identify patients with C3 glomerulopathy.
Diagnosis was based on light microscopy suggesting proliferative GN,
with glomerular C3 staining in absence of immunoglobulin on immuno-
fluorescence, and electron dense deposits that are intramembranous
(DDD) or in subendothelial and mesangial location (C3GN).
Results: 22 children (59% boys) were diagnosed with DDD (n=19) or
C3GN (n=3) at mean±SD age 9.6±2.2 yr. Findings included anasarca
(n=22), hematuria (n=6), stage II hypertension (n=13) and nephrotic
range proteinuria (21); renal function was impaired at onset in 41%.
Indications for biopsy were steroid resistant nephrotic syndrome (54%),
atypical GN (18%) and rapidly progressive GN (23%). Low levels of
complement C3 were present in 91% patients. Investigations excluded
lupus, HIVand hepatitis Band Cin all patients. There were no differences
in clinical features between patients with DDD and C3GN. Light micros-
copy confirmed basement membrane thickening and splitting in 70%
cases. Patients received therapy with prednisolone and enalapril (100%)
along with mycophenolate mofetil (72%), cyclophosphamide (27%),
tacrolimus (13%) or rituximab (18%); therapeutic plasmapheresis was
performed in 3 patients for rapidly progressive glomerulonephritis & in
one for disease recurrence in the allograft. Five patients progressed to
chronic kidney disease stage 5 over 3 months to 10.7 yr.
Conclusions: Membranoproliferative pattern of injury is not universal in
C3 glomerulopathy. Presentation and disease course are heterogeneous
and response to therapy is variable. A significant proportion of patients
progresses to advanced kidney disease.
Nationwide data on anti-complement factor H associated hemolytic
uremic syndrome
A. Bagga, A. Sinha, A. Gupta, S. Saini on behalf of HUS database
Division of Pediatric Nephrology, All India Institute of Medical Sciences,
New Delhi, India
Objectives: Antibodies to complement factor H (CFH) are an important
cause of atypical hemolytic uremic syndrome (HUS) in children, where
specific therapy enables satisfactory outcomes.
Results: We report findings from a multicenter cohort of 209
Indian children with anti-CFH antibodies, constituting 55.4% pa-
tients with HUS. Antibody titers, chiefly IgG3, were high (mean
±SEM 7436±1374 AU/ml) & correlated inversely with levels of
C3, but not CFH. Homozygous CFHR1 deletion was found in
88% patients & 9% healthy subjects. Therapies included dialysis
(86%) and plasma exchanges (PEX, 76%). Median decline of
antibodies was 74%, 88% & 84% after 3, 5 & 7 PEX respectively
(P=0.08). Induction consisted of prednisone & IV cyclophospha-
mide or rituximab; serial antibody titers over 12-months were
similar in those receiving either therapy (GEE; P=0.63). Adverse
outcome (stage 4-5 CKD, death) was seen in 26% at 3-mo and
30% at follow up; 6-mo from the onset, 11% had relapses. Risk
factors for adverse outcome were antibody titer >8000 AU/ml,
low C3 & delayed PEX; titer >1300 AU/ml at 6-mo predicted
relapses (sensitivity 80%, specificity 76%). Combined PEX &
induction therapy resulted in better renal survival; one adverse
outcome prevented for every 2.6 patients treated. Maintenance
immunosuppression reduced the risk of relapses.
Conclusions: Anti-CFH antibody associated HUS associated
with homozygous deletion in CFHR1 affects school children
and is characterized by severe features. Prompt PEX & immu-
nosuppressive agents are useful for improving outcomes. Pa-
tients with persistent high antibody titers are at risk of
relapses.
When to start and how to stop eculizumab in children with atypical
hemolytic uremic syndrome?
C. Terano
1
, K. Ishikura
1
, Y. Yoshida
1
, W. Kubota
1
, Y. Okuda
1
, S.
Shinozuka
1
, J. Hashimoto
1
, R. Hamada
1
, R. Harada
1
, H. Hataya
1
, S.
Iyoda
2
, T. Miyata
3
, Y. Yoshida
4
, Y. Fujimura
4
, M. Honda
1
1
Department of Nephrology, Tokyo Metropolitan Children’s
Medical Center;
2
Department of Bacteriology I, National Insti-
tute of Infectious Diseases;
3
Department of Molecular Patho-
genesis, National Cerebral and Cardiovascular Center;
4
Depart-
ment of Blood Transfusion Medicine, Nara Medical University,
Japan
Introduction: Diagnosis of atypical hemolytic uremic syndrome
(aHUS), particularly in infants, is difficult and may be detrimental
to outcome. Eculizumab (ECZ) can be a first-line therapy for
aHUS, but the rationale for long-term use of ECZ needs to be
carefully discussed.
Cases: We experienced 4 patients with suspected aHUS in whom
ECZ was administered from the acute phase. ECZ was
discontinued in only 1 patient, without relapse of HUS. In this
case, after confirmation of negative stool culture, ECZ was
started. However, after more detailed investigation of stool cul-
ture, enterohemorrhagic Escherichia coli O76 was detected and
lead to diagnosis of typical HUS. In others, lacking definite
etiological confirmation, ECZ has been continued without signif-
icant side effects.
Discussion: We recommend that ECZ treatment be started as soon as
aHUS is suspected, because early treatment results in better prog-
nosis, and complication of plasma exchange, particularly for in-
fants, can be avoided. Concerns with long-term use of ECZ
include: (i) increased risk for infection by encapsulated organisms;
(ii) unknown long-term side effects; and (iii) frequent and regular
administration has negative impact on patients’ QOL. These con-
cerns should be balanced against the risk of relapse of thrombotic
microangiopathy, not only in the kidney, but also in other critical
organs. Improvement of detection rate of relevant gene mutations
is also warranted.
Conclusion: ECZis effective in acute phase of aHUS, but rationale for its
long-term use has yet to be established.
Pediatr Nephrol
Developmental nephrology and disorders of development
Seventeen known dominant disease causing genes in patients
with congenital abnormality of kidneys and urinary tract
X. Wang, Q. Shen, L. Sun, Y. Gong, J. Liu, C. Wang, H. Xu
Department of Nephrology and Rheumatology, Children’s Hospital of
Fudan University, Shanghai, China
Objective: Congenital anomalies of the kidney and urinary tract
(CAKUT) account for 40-50% of children with chronic kidney disease.
The aim of this study was to determine patients with CAKUT that could
be explained by mutations in 17 known dominant CAKUT-causing
genes.
Method: By next generation sequence technology, we analyzed the
coding exons and UTR of 17 known dominant CAKUT-causing genes
in 7 patients (vesicoureteric reflux in 3; ureteropelvic junction obstruc-
tion, ureterovesical junction obstruction, renal aplasia and agenesis 1
each). The genes were: BMP4, BMP7, CDC5L, CHD1L, EYA1, GATA3,
HNF1B, PAX2, RET, ROBO2, SALL1, SIX1, SIX2, SIX5, SOX17, UMOD,
and UPK3A.
Result: We identified 19 novel heterozygous mutations in 10 of the 17
known genes: PAX2 (2), GATA3 (1), RET (2), ROBO2 (1), UMOD (1),
SALL1 (2), SOX17 (3), SIX5 (4), BMP4 (2), HNF1B (1). 14 were non-
synonymous mutations in the coding sequence, 2 were located in splice
sites and 3 were UTR variations. Damaging mutations predicted by Sift
and Polyphen 2 were: PAX2: c.1094A>C, P.365N>T; GATA3: c.466A>C,
p.156T>P; ROBO2: c.775-c.779 frameshift deletion. The PAX2 mutation
was seen in one patient each with VUR and UVJO; ROBO2 deletion was
seen with UVJO; GATA3 mutation was seen in the patient with unilateral
VUR.
Conclusion: To date, 23 monogenic CAKUT- causing genes have been
identified that result in isolated CAKUTor syndromic CAKUTwith mild
extra-renal manifestations, most of which are dominant inheritance. Our
research revealed that GATA3, PAX2, ROBO2 are common disease
causing genes in CAKUT patients, which is coincident with previous
reports. More samples are needed to identify the relation between geno-
type and phenotype by next generation sequencing.
NPHP2 and NPHP3 mutation in 15 Chinese patients with infantile
nephronophthisis: Correlation of genetics and clinical data
L. Sun
1
, H. Tong
1
, H. Wang
2
, T. Liu
1
, C. Wang
3
, J. Li
3
, X. Jiang
1
, Y. Mo
1
,
Z. Yue
1
1
Department of Pediatrics, the First Affiliated Hospital, Sun Yat-Sen
University, Guangzhou;
2
Department of Pediatrics, Sun Yat-Sen Memo-
rial Hospital, Guangzhou;
3
Department of Transplantation, Sun Yat-Sen
Memorial Hospital, Guangzhou, PR China
Objectives: To determine the frequency and clinico-genetic correlation of
NPHP2 and NPHP3 mutations in cases of infantile NPHP
Method: Of 15 patients included, DNA was available in 14 patients.
NPHP1 homozygous deletion was excluded by PCR amplification of
satellite markers initially. All patients were screened for mutations and
polymorphisms with Sanger sequencing in NPHP2 and NPHP3.
Results: We identified NPHP3 mutations in 8 patients: compound mu-
tations in 7 (P1~P7) and a heterozygous mutation in P8. There were 11
novel mutations (p.Ala434 del, p.Glu602Glyfs621X, p.Gln153Pro,
p.Lys678X, p.Cys816X, p.Asn711Ser, p.Arg756Gln, ISV9-40T→G,
p.Asp216His, IVS13-11T→G, ISV14+5 G→A, respectively) and 2
known mutations (p.Leu790Pro, p.Arg973Pro). P9 was from the same
family and considered with the same mutation as P8. All patients (P1~P9)
had growth retardation; anemia was seen in 7, liver lesion (P3) and
respiratory infection (P5) in one patient each. All presented with ESRD
before 5-yr age, except for P8. Renal pathology was diverse with pre-
dominantly chronic tubulointerstitial nephritis and tubular cysts, dilated
Bowman capsule, irregular tubular basement membrane, and
glomerulosclerosis or mesangial proliferation. Eight patients had hepatic
involvement, and one each had congenital heart disease and hypothyroid-
ism with thyroid cyst. Only1 patient had NPHP2 mutation, which
progressed to ESRD at 1 month and had inguinal hernia.
Conclusion: NPHP2 and NPHP3 mutations in infantile NPHP were high
(64.3%); patients with NPHP3 mutations also had liver lesions.
NPHP1 knockdown induced epithelial-mesenchymal
transdifferentiation in MDCK cells and activation of ZO-1/ZONAB
signalling pathway
H. Tong
1
, L. Liu
1
, H. Wang
2
, X. Li
3
, T. Liu
1
, Z. Yue
1
, L. Sun
1
1
Department of Pediatrics, First Affiliated Hospital, Sun Yat-Sen Univer-
sity, Guangzhou;
2
Department of Pediatrics, Sun Yat-Sen Memorial
Hospital, Guangzhou;
3
Department of Nephrology, First Affiliated Hos-
pital, Sun Yat-Sen University, Ministry of Health, Guangzhou, PR China
Objective: To explore the pathogenesis of tubular interstitial fibrosis in
nephronophthisis type I
Methods: The expression of NPHP1 in MDCKcells were knockdown by
siRNA. Cell morphology and cell migration were observed under micro-
scope. The expressions of E-cadherin, β-catenin, ZO-1, ZONAB and α-
SMA both in mRNA and in protein were analyzed by real time PCR,
western blot and immunofluorescence, respectively. The mRNAlevels of
MMP-2, MMP-9 and FSP-1 were detected by real time PCR. The activity
of MMP-2 and MMP-9 were detected by gelatin zymography.
Result: MDCK cells become elongated and the migration capacity
enhanced after NPHP1 knockdown. The expressions of E-cadherin, β-
catenin and ZO-1 decreased whereas ZONAB increased both in mRNA
and in protein in NPHP1 knockdown MDCK cells. mRNA expression of
FSP-1 and the protein level of α-SMAwere both increased. Both mRNA
expressions and activities of MMP-9 and MMP-2 were increased.
Conclusion: NPHP1 knockdown by siRNA interference induced ep-
ithelial mesenchymal transition (EMT) in MDCK cells. ZO-1/
ZONAB signaling pathway was activated in NPHP1 knockdown
MDCK cells. These contribute to tubular interstitial fibrosis in
nephronophthisis type I.
The role of perlecan in the prenatal kidney programming
X.S. Tang, H. Xu, Q. Shen, J. Chen
Department of Nephrology and Rheumatology, Children’s Hospital of
Fudan University, Shanghai, China
Objectives: Maternal protein restriction results in intrauterine growth
restriction (IUGR) with reduced nephron number. We studied the expres-
sion of perlecan in kidney development of IUGR rat and association with
cell apoptosis and proliferation level to investigate its role in prenatal
kidney programming.
Methods: IUGR rat model was established with maternal low-
protein (6%) isocaloric diets through gestation. mRNA transcription
of perlecan during kidney development was detected by real-time
PCR. Perlecan immunohistochemistry was performed to show pro-
tein expression. Ki-67 and TUNEL were applied to mark prolifera-
tion and apoptotic cells; changes of cell apoptosis and proliferation
level were detected.
Results: 1. At four weeks postnatally, IUGR offspring had fewer glo-
meruli per kidney than those in controls (2670±213 vs. 3666±2889,
P<0.05). IUGR newborn weights were significantly lower. 2. In embry-
onic period overall, perlecan mRNA transcription level gradually in-
creased and then to a lower level for four weeks after birth. Embryonic
18-day and neonatal rats of IUGRgroup perlecan transcription level were
lower than control group (E18: 0.47±0.082 vs. 0.76±0.164, P<0.001; P0:
0.41±0.043 vs. 0.55±0.094, P<0.05). 3. Perlecan is mainly expressed
around the ureteric bud and the matrix of mesenchymal cells in
Pediatr Nephrol
nephrogenic zone during embryonic period. For embryonic 18-day
(0.019±0.0048 vs. 0.044±0.0086, P<0.001) and neonatal rats (0.0034
±0.0016 vs. 0.011±0.0037, P<0.05) of IUGR group, perlecan protein
level were also lower than control group. 4. Cell apoptosis and prolifer-
ation of various kidney developmental periods are mainly located in
nephrogenic zone and IUGR proliferation level was significantly lower
than controls at embryonic 18-day (44.17±7.3 vs. 76.32±7.6, P<0.001). In
addition, cell apoptosis level of IUGR newborn (315.18±55.7 vs. 157.1
±40.32, P<0.001) and 1 week-old rats (77.87±11.11 vs. 23.69±5.47,
P<0.001) were much more.
Conclusion: Perlecan is expressed around the ureteric bud and the matrix
of mesenchymal cells in nephrogenic zone during kidney development.
For middle stage (E18 and P0), perlecan expression level of IUGR group
were significantly lower than controls and was related to imbalance of cell
proliferation and apoptosis.
Influence of cyclosporine on glomerular growth and protective effect
of mizoribine & losartan on cyclosporine nephrotoxicity in rat
J.H. Kim
Department of Pediatrics, Gangnam Severance Hospital, Yonsei Univer-
sity College of Medicine, Seoul, Korea
Introduction: The pathogenesis of chronic CsA-induced nephropathy is
multifactorial. The main factors include (i) activation of the intrarenal
renin-angiotensin system (RAS), (ii) renal ischemia via arteriolar con-
striction, (iii) increases in transforming growth factor (TGF-β1) and
inflammatory cytokines such as osteopontin (OPN).
Objective: Mizoribine (MZR) suppresses infiltration of macrophages,
which play a role in development of interstitial fibrosis. Since the RAS
plays an important role in pathogenesis of chronic CsAinduced nephrop-
athy, blocking this system with either losartan (LSRT), or angiotensin
converting enzyme inhibitors (ACEI) suppresses expression of pro-
inflammatory mediators and profibrogenic cytokines. The study tested
the hypothesis that the administration of MZR & LSAR prevents CsA
induced chronic nephropathy in rats.
Methods: Six-weeks old male Spraque Dawley rats maintained on low
salt diet were given vehicle, CsA (15 mg/kg), CsA and LSRT (30 mg/kg/
day), CsA and MZR (5 mg/kg), or a combination of CsA, LSRT and
MZR for 4 and 7 weeks. Blood chemistry and histopathology (tubular
vacuolization and drop out, arteriolopathy, tubulointerstitial fibro-
sis, and inflammatory cell infiltration) was compared among treat-
ed groups. Inflammatory and fibrotic factors, OPN and TGF-β1
were studied by immunohistochemistry and quantification with real-time
PCR.
Results: MZR attenuated the tubular cell vacuolization and drop out at 4
weeks (P<0.05). MZR and MZR+LSRT reduced tubulointerstitial fibro-
sis at 7 weeks (P<0.01, P<0.05). Arteriolopathy was decreased in MZR+
LSRT at 7 weeks (P<0.05). OPN and TGF-β1 mRNA expression was
decreased in MZR (P<0.01) and MZR+LSRT (P<0.05) at 4 weeks. OPN
mRNA expression was decreased at 7 weeks in MZR+LSRT (P<0.05).
TGF-β1 mRNA expression was decreased at 7 weeks in MZR (P<0.01)
and MZR+LSRT (P<0.01). ED-1(+) cell decreased in MZR
(P<0.05) and MZR+LSRT (P<0.05). Glomerular decreased in
CsA group and recovered in MZR (P<0.01) and MZR+LSRT
(P<0.05) at 7 weeks.
Conclusions: This study shows that MZR has protective effects on
inflammatory process in chronic CsA nephropathy and led to improve-
ment of tubular damage, tubulointerstitial fibrosis and arteriolopathy by
down regulation of OPN and TGF-β1. Combined treatment with MZR
and LSRT provided synergistic effects in attenuating inflammatory and
fibrotic processes in chronic CsA induced nephropathy. MZR &
LSRT can potentially be used for protecting against CsA nephro-
toxicity and glomerular size contraction as an adjuvant for long
term CsA treatment.
The effects of bone marrow derived-mesenchymal stem cells
in adriamycin induced nephropathy in the rat
Y.H. Park
1
, K.J. Jung
2
, I.H. Song
2
1
Departments of Pediatrics and
2
Anatomy, YeungnamUniversity College
of Medicine, Daegu, Korea
Objectives: Adriamycin (ADR) induced nephropathy is widely used
animal model of progressive renal disease resulting in glomerulosclerosis,
podocyte injury and fibrosis. The present study investigated the protective
effects of human bone marrow derived mesenchymal stem cells
(hBMSC) on ADR induced nephropathy rat model.
Methods: Male Sprague-Dawley rats were divided into normal controls
(Normal), ADR+Vehicle (CON) and ADR+hMSC (MSC) groups. Ne-
phropathy was induced by single injection of ADR (4 mg/kg IV). Four
days later, 0.5 ml of saline with or without 2×10
7
hBMSC was injected
via tail vein for CON or MSCgroup. The rats were sacrificed 1 week and
6 weeks after ADR injection. hBMSC were characterized by cell surface
CD marks expression as well as differentiation induction into osteoblasts
and adipocytes. To evaluate homing of hBMSC, the cells were labeled
with CFSE (5(6)-carboxyfluorescein N-hydroxysuccinimidyl ester) and
examined several tissues 3 h after injection. Kidney and body weight, as
well as serum level of protein, albumin, cholesterol, triglycerides and
creatinine were measured at 1- and 6-weeks. Western blot for inflamma-
tory cytokines, nephrin, type I collagen was carried out. Light and
electron microscopic observation were done for structural analysis.
Results and Conclusions: hBMSC were observed in lung, liver and
spleen but hardly detected in kidney. There was no significant difference
in body and kidney weight as well as serum levels of protein, albumin,
cholesterol, triglycerides and creatinine between CON and MSC groups.
Pro-inflammatory cytokines (COX2, TNF-α, INF-γ and IL-12) expres-
sion was decreased in MSC compared to CON but nephrin expression
was increased. hBMSC have little effect for improving nephropathy by
direct regeneration but preserve kidneys by indirect anti-inflammatory
effect.
Dialysis
The development of pediatric peritoneal dialysis in China: Brief data
report from IPPN China
Y. Zhai
1
, H. Xu
1
, Q. Yang
2
, X. Dang
3
, S. Sun
4
, X. Shao
5
, X. Liu
6
, Y. Wu
7
,
J. Wu
8
, A. Liu
9
, Y. Dong
10
, Q. Ma
11
, C. Yan
12
, G. Kang
13
, W. Huang
14
,
Y. Guo
15
, R. Fu
16
, H. Bao
17
, R. Xu
18
, Q. Sun
19
, L. Lai
20
, Y. Mo
21
, J.
Huang
22
, J. Luan
23
on behalf of IPPN China investigators
1
Department of Nephrology and Rheumatology, Children’s Hospital of
Fudan University, Shanghai;
2
Yuying Children’s Hospital of Wenzhou
Medical College, Wenzhou;
3
The Second Xiangya Hospital of Central
South University, Changsha;
4
Shandong Provincial Hospital, Jinan;
5
Gui-
yang Children’s Hospital, Guiyang;
6
Jinan Children’s Hospital, Jinan;
7
Shenjing Hospital of China Medical University, Shenyang;
8
The First
Affiliated Hospital of Xiamen University, Xiamen;
9
The Children’s Hos-
pital of Zhejiang University School of Medicine, Hangzhou;
10
Anhui
Provincial Children’s Hospital, Hefei;
11
Departments of Pediatric Ne-
phrology and
12
Neonatology, The First Hospital of Jilin University, Jilin;
13
Ningbo Women and Children’s Hospital, Ningbo;
14
Shanghai Chil-
dren’s Hospital, Shanghai;
15
The First Hospital of Xinjiang Medical
University, Urumqi;
16
Jiangxi Children’s Hospital, Nanchang;
17
Nanjing
Children’s Hospital, Nanjing;
18
Qilu Hospital of Shandong University,
Jinan;
19
Qingdao Women and Children’s Hospital, Qingdao;
20
The Third
People’s Hospital of Jingdezhen, Jingdezhen;
21
The First Affiliated Hos-
pital, Sun Yat-sen University, Guangzhou;
22
Bayi Children’s Hospital of
the Military General Hospital of Beijing PLA, Beijing;
23
Wuhan Women
and Children’s Hospital, Wuhan, China.
Pediatr Nephrol
Objective: To investigate the development of pediatric peritoneal dialysis
in China
Methods: Analyze the data from IPPN China (www.pedpd.org.cn)
Results: IPPN China is the Chinese version of International Pediatric
Peritoneal Dialysis Network (IPPN). It is managed by Children’s Hospital
of Fudan University, to increase the communication among Chinese
pediatric renal centers and improve the development of pediatric perito-
neal dialysis in China. It was online on Jul. 2012. The members of IPPN
China increased from13 to 23 for now, which distributed in 19 cities from
16 provinces in China. The registered data of the year 2014 show the
number of patients on the current chronic PD (CPD) is 113, distributed in
18 centers from15 cities. These 18 centers can offer CAPD, among which
11 can offer APD. Among all the centers, only 3 have the current CPD
patients more than 10, which cover 51.3% of all the CPD patients
registered. Eight centers have improved significantly from 2012 to
2014, whose number of CPD patients increased 1.24~8 times. Children’s
Hospital of Fudan University is the biggest CPD center in China for now,
with 36 cases of current CPD and over 80 in total. The percentage of
patients with weekly Kt/V<1.8 has decreased from7.7%to 5.7%between
2011 and 2014. The average level of Hb increased from 10.8±2.1 g/L to
11.5±2.5 g/L. The percentage of patients with severe LVHdecreased from
38.5%to 27%. The peritonitis rate decreased from26.5 per patient month
to 40.1 per patient month.
Conclusion: According to our data which represent some of the pediatric
renal centers in China, many cities in China can offer CPD for pediatric
patients. Although these centers are with different scale and level, most of
them make progression in recent years. We believe that IPPN China, as a
good communication platform, can help improving the development of
pediatric CPD in China.
Rotary Southend Sparsh Initiative: pediatric hemodialysis services
in New Delhi
A. Agarwal
1
, A. Bagga
2
1
Batra Hospital and Medical Research Center, New Delhi;
2
Department
of Pediatrics, All India Institute of Medical Sciences, New Delhi
India is a developing country in the lower middle income stratum (World
Bank 2013, GNI per capita). The outcome in children with end stage renal
disease (ESRD) depends on availability of health services. More than 70-
80 percent children with ESRD do not receive any form of renal replace-
ment therapy, chiefly due to financial constraints, lack of health care
facilities and scarcity of trained physicians and technical staff that can
cater to the specific needs of children and adolescents.
Objectives: With the intent of providing free, state of art care to children
with ESRD, who were awaiting kidney transplantation, an exclusive
pediatric dialysis centre “Southend Sparsh” began services from June
2013. We report the activities undertaken at the unit and the
achievements.
Methods: Manpower for the 3-bed pediatric hemodialysis unit, inaugu-
rated in June 2013, includes 1 pediatric nephrologist, 1 dialysis techni-
cian, 3 staff nurses and 1 nursing aid. The personnel were recruited and
trained in pediatric dialysis at the All India Institute of Medical Sciences.
Other challenges included generating funds and finding a center where
the Unit could be located, in order to provide medical facilities in case of
emergency. Funds were generated by Rotary Southend Charitable Trust,
New Delhi and rent free space with optimum back up services was
provided by Batra Hospital and Medical Research Centre, New Delhi.
The cost of setting up a 3-bed dialysis unit was about INR 3.2 million,
while the annual running cost is almost same at INR 3 million, which
includes staff salaries and consumables. Annual cost does not include
maintenance of hemodialysis machines and water treatment. The approx-
imate cost of a single dialysis session at this center is INR 3250, which
does not include other medications apart from those used during dialysis.
Results: During one year (2013-14), 28 patients (17 boys) have received
a total of 1029 hemodialysis sessions. The chief cause of chronic kidney
disease was steroid resistant nephrotic syndrome secondary to FSGS; the
next diagnosis was atypical hemolytic uremic syndrome. Of 28 patients 2
needed support for acute kidney injury and eventually become dialysis
independent. During 1029 dialysis sessions 197 adverse events were
noted, including hypotension (32.9%), pain abdomen, dizziness,
intradialytic hypertension, vomiting, catheter malfunction, muscle
cramps, hypersensitivity reaction and headache. Four received kidney
transplant, one was shifted to continuous ambulatory peritoneal dialysis,
2 patients with AKI improved and become dialysis independent; 5 were
lost to follow up, 1 child died at home and 15 are undergoing
hemodialysis.
Conclusion: Considering the large number of children with ESRD, there
is need for more dedicated pediatric dialysis centers, which provide
comprehensive care to children.
Vitamin C overload leads to secondary hyperoxalosis in young
pediatric dialysis patients
S.S. Thyle
1
, A. Perilloux
1
, R. Pereira
1
, G. Handelman
2
, I.B. Salusky
1
, K.
Wesseling-Perry
1
1
Division of Pediatric Nephrology, UCLA, Los Angeles, CA;
2
Health
and Clinical Sciences, University of Massachusetts, Lowell, MA
Objective: Vitamin C supplementation is recommended in dialysis pa-
tients to prevent anemia, gingival disease and scurvy. Case reports sug-
gest that very large doses of vitamin C intake led to secondary
hyperoxalosis in some adult dialysis patients. We sought to study the
impact of current enteral formulas on vitamin C and oxalate levels in
dialyzed children.
Methods: We identified oxalate crystal deposits in bone of two 5-year-
old hemodialysis patients who underwent routine bone biopsy prior to
parathyroidectomy. Gene analysis for AGXT ruled out primary
hyperoxaluria, and both had a history of high vitamin C intake from
enteral feeding. Therefore, we assessed the daily recommended intake
(DRI) of vitamin C from enteral feedings in 13 pediatric patients aged 8
months to 8 years fed primarily formula through a gastrostomy tube,
treated with either hemodialysis (n=3) or peritoneal dialysis (n=10) in
order to assess the impact on oxalate burden. Total vitamin C intake,
serum oxalate levels and ascorbic acid levels were assessed in these
patients.
Results: All patients were receiving 1.2-8.3 times the DRI for vitamin C
from enteral feedings. Ascorbic acid levels ranged from 1.5 to 10.0 mg/
dL (ref range: 0.2-1.9 mg/dL); values were elevated in 85% patients.
Oxalate levels were elevated (>30 μmol/L) in 69% patients and ascorbic
acid levels did not correlate with oxalate levels (r=0.44, P=0.13). Ascor-
bic acid and oxalate levels did not correlate with the amount of vitamin C
received corrected by the DRI (r=0.42, P=0.15 and r=0.09, P=0.77
respectively).
Conclusion: Oxalate deposition in bone demonstrates that oxalate is
present in toxic levels in some dialyzed children; excess vitamin C
ingestion contributes to secondary oxalosis in predominantly formula-
fed infants and children. Plasma ascorbic acid levels vary, correlate poorly
with oxalate levels, and may not reflect total body stores, suggesting that a
portion of ascorbic acid is unavailable for clearance during dialysis.
Retrospective study of arteriovenous fistula used in pediatric patients
of ESRD
L. Ying, S. Ning, W. Hui, S. Ying
Department of Nephrology, Beijing Children Hospital, Beijing, PRChina
Objective: To study the clinical features of arteriovenous-fistula (AVF) in
pediatric patients who need maintenance hemodialysis.
Methods: Comprehensive analyses were performed on data of patients
who had AVF surgery in our hospital during June 2007 to April 2014,
including clinical features and laboratory examination. Sex, choice of
Pediatr Nephrol
surgery side and vein, anesthesia, model of vascular suture were assessed
with chi-square statistics respectively, age of surgery, inner diameter,
hemoglobin, platelets, hematocrit, serum creatinine, prothrombin time,
fibrinogen, activated prothrombin time were assessed with t-test
respectively.
Result: 41 male, average age of surgery was 10y11m (2y4m to 16y1m).
Underlying diagnosis was chronic glomerulonephritis (29%), kidney
dysplasia (27.4%), nephrotic syndrome (11.3%), reflux nephropathy
(11.3%), obstructive nephropathy (4.8%) and others (24.2%). Average
interval from diagnosis to surgery was 30.8 days. General anesthesia
(n=42), brachial plexus block (n=7) were used. All AVF were made on
forearm; 58 on left, 4 on right. 55 were radio-cephalic end-to-lateral
anastomosis, 7 were radio-non cephalic anastomosis. Inner diameter of
AVF was 2 mm in 22 (35.5%), 2.5 mm in 3 (4.8%), 3 mm in 31 (50%),
4 mmin 3(4.8%). We regarded “tremor and vascular bruit at the operative
site 1 week after surgery” as success standard, success rate was 80.7%
(50/62); failure rate was 19.4% (12/62). Acute complication were throm-
bosis in 6 (9.7%), errhysis in 5(8.0%), pain and swelling in 4 (6.5%),
hemorrhage and anesthesia in fingers in 1 each (1.6%). Type of anesthe-
sia, inner diameter of AVF and Hb affected success rate (P <0.05).
Conclusion: The interval from diagnosis to surgery was shorter than
suggested by 2006 NKF-KDOQI guidelines. We preferred to choose
radiocephalic end-to-lateral anastomosis on left wrist. The most common
acute complication was thrombosis and errhysis. Anesthesia, inner diam-
eter of AVF and Hb may affect success rates.
Training evaluation results of caregivers in children’s peritoneal
dialysis and teachings on nursing intervention
Q. Zhou, Ru-Ping Gao, Pei-Lian Yao, H. Zhang, J. Zhou, Er-Zhuang
Qian, H. Xu
Department of Nephrology and Rheumatology, Children’s Hospital of
Fudan University, Shanghai, China
Objective: To prevent peritonitis and other complications for children
undergoing peritoneal dialysis (PD), the aim of this study is to analyze
training evaluation results of home PD caregivers, and to explore the
appropriate frequency of re-training.
Methods: From Jan 2012 to Dec 2013, 32 children received surgical
placement of PD catheters and obtained training certificates with their
caregivers. Based on time intervals of training, the patients were divided
into two groups: experimental group (every 3 months) and routine group
(every 6 months). Hand-washing, exit-site care, continuous ambulatory
peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD)
operating procedure were brought into evaluation standards. PD special-
ized nurses took charge of children in peri-operative period. Evaluation
results and peritonitis incidences in the first 6 months after catheterizing
were analyzed.
Results: There is no statistic difference in the gender, age, education level
of caregivers and surgical method between these two groups (P>0.05).
Qualified rates of hand-washing and exit-site care were significantly
higher in experimental group (87.5% and 81.25% respectively) than in
routine group (both 37.5%, P<0.05). Compared with 31.25% of cases in
routine group, peritonitis occurred zero in experimental group (P<0.05).
Conclusion: Re-training and evaluating on home PD caregivers every 3
months, shows a positive effect on reducing peritonitis. However, further
clinical randomized controlled trials are needed to explore an effective
and reasonable training program for home PD caregivers, in accord with
health economics.
Application of portable water-treatment system in chronic
hemodialysis in children with end stage renal disease in China
Q Zhang
1
, H. Xu
2
, Q. Shen
2
, J. Rao
2
, X. Fang
2
, Y. Zhai
2
, Q. Zhou
2
, H.
Zhang
2
1
Department of Nephrology, Ningbo Women’s and Children’s Hospital,
Zhejiang Province;
2
Department of Nephrology and Rheumatology, Chil-
dren’s Hospital of Fudan University, Shanghai, China
Objective: To explore the value and safety of single-bed mobile dialysis
water treatment system in chronic hemodialysis (HD) in ESRD.
Methods: Dialysis water produced by the portable water-treatment sys-
tem, composed of water pretreatment device, water softening machine
and reverse osmosis water treatment machine, was used for chronic HD.
The water quality index as well as the dialysis adequacy, complications
and outcome of 20 children with ESRD, on chronic HDin our center from
Aug 2010 to Mar 2014, was analyzed. Before April 2013, the compo-
nents of water pretreatment device were a PP polypropylene filter in
series with two charcoal canisters. After May 2013, the components of
water pretreatment device were the first PP polypropylene filter, quartz
sand filter, activated carbon filter and the second PP polypropylene filter.
Results: The water quality index, including endotoxin level, bacteria
culture and heavy metals’ level, were consistent with the criteria of
standard operation procedures of blood purification (SOP) issued by the
Chinese Ministry of Health. From May 2013, dialysis water endotoxin
level was further decreased after the water pretreatment device was
improved, with the quantitative values less than 0.5 EU/ml, of which,
85.2% was less than 0.25 EU/ml. During HD, there was no heat reaction,
hemolysis, hard water syndrome and other water-related complications.
The dialysis Kt/v was 1.2 ± 0.23 and urea clearance was 66.68 ± 7.32%.
The achieved rate of hemoglobin, serum calcium, serum phosphorus and
PTH after 6 months of HD were 66.7%, 53.3%, 13.3% and 20% respec-
tively, 60%, 50%, 50%and 20% respectively after 12 months and 87.5%,
62.5%, 37.5% and 87.5% after 18 months. At the end of follow-up,
patient survival rate was 95%; 11 cases returned to normal schooling
during HD.
Conclusion: The quality of dialysis water produced by portable water-
treatment system conformed to the standard of dialysis water, which was
superior to the criteria of SOP recommendation. The portable water-
treatment system was suitable for children with chronic HD in China.
Glomerulonephritis and glomerular diseases
The validation study of Oxford Classification of IgA nephropathy
in Chinese children
B. Su
1
, J. Ding
1
, Y. Ren
1
, S. Wang
1
, N. Zhou
2
, Y. Shen
2
, C. Zhou
2
, M.
Chu
3
, L. Cao
3
, J. Liu
1
, X. Yang
4
1
Pediatric Department, Peking University First Hospital, Beijing;
2
Beijing Children’s Hospital;
3
Capital Institute of Pediatrics;
4
First
Affiliated Hospital of Henan College of Traditional Chinese Medicine,
China
Background: The Oxford classification of IgA nephropathy presented
that four histopathological features had independent predictive value of
clinical prognosis. Considering the limitations of study cohort, validation
study in Chinese children is necessary.
Methods: 223 children with IgA nephropathy from 4 centers in China
were included. The inclusion criteria referred to the Oxford study.
Results: Depending on the Oxford Classification, with scoring of path-
ological features, the extended pathology dataset included 18 pathologi-
cal lesions. After analyzing the reproducibility and independency of these
variables, 4 features were selected. Three lesions, mesangial proliferation,
endocapillary proliferation and interstitial fibrosis/tubular atrophy were
similar to original Oxford study (instead of segmental sclerosis/adhesion)
and crescents were picked out. There were 165 (74%) with mesangial
proliferation (M1), 153 (69%) with endocapillary proliferation (E1), 87
(39%) with crescent, 3 (1%) with moderate tubulointerstitial fibrosis (T1
26-50% of cortex scarred) and 4 (2%) with severe tubulointerstitial
Pediatr Nephrol
fibrosis (T2, >50% of cortex scarred). In our single center study (156
patients) the median follow-up duration was 17 months; 80 patients had
follow up >6 months. We completed the correlations study between
pathological lesions and clinical prognostic indicators like proteinuria.
Conclusions: Mesangial proliferation, endocapillary proliferation and
crescents were common in Chinese children with IgA nephropathy then
adults. The reproducibility of scoring of histological lesions was impor-
tant in the classification.
DNA methylation in Cosmc promoter region and aberrantly
glycosylated IgA1 associated with pediatric IgA nephropathy
Q. Sun, J. Zhang, N. Zhou, X. Liu, Y. Shen
Department of Nephrology, Beijing Children Hospital, Beijing, PRChina
Objectives: IgA nephropathy (IgAN) is one of the most common glo-
merular diseases leading to end-stage renal failure. Elevation of aberrantly
glycosylated IgA1 is a key feature. The expression of the specific molec-
ular chaperone of core1ß1, 3galactosyltransferase (Cosmc) is known to
be reduced in IgAN. We aimed to investigate whether the methylation of
CpG islands of Cosmc gene promoter reign could act as a possible
mechanism responsible for down-regulation of Cosmc and related higher
secretion of aberrantly glycosylated IgA1 in lymphocytes from children
with IgA nephropathy.
Methods: Three groups were included: IgANchildren (n=26), other renal
diseases (n=11) and healthy children (n=13). B-lymphocytes were isolat-
ed and cultured, treated or not with IL-4 or 5-Aza-2'-deoxycytidine
(AZA).
Results: The levels of DNA methylation of Cosmc promoter region were
not different between the lymphocytes of the three children populations
(P=0.113), but there were significant differences between IgAN lympho-
cytes and lymphocytes of the other two children populations after IL-4
(P<0.0001) or AZA (P<0.0001). Cosmc mRNA expression was low in
IgAN lymphocytes compared to the other two groups (P<0.0001). The
level of aberrantly glycosylated IgA1 was markedly higher in IgAN
group compared to the other groups (P<0.0001). After treatment with
IL-4, the levels of Cosmc DNA methylation and aberrantly glycosylated
IgA1 in IgAN lymphocytes were remarkably higher than the other two
groups (P<0.0001) with more markedly decreased Cosmc mRNAcontent
(P<0.0001). After treatment with AZA, the levels in IgAN lymphocytes
were decreased, but was still remarkably higher than the other two groups
(P<0.0001), while Cosmc mRNA content in IgAN lymphocytes were
more markedly increased than the other two groups (P<0.0001). The
alteration of DNA methylation by IL-4 or AZA specifically correlates
in IgAN lymphocytes with alterations in Cosmc mRNA expression and
with the level of aberrantly glycosylated IgA1 (r= -0.95, r=0.71).
Conclusion: Our results suggested that hypermethylation of Cosmc
promoter reign could be a key mechanism for the reduction of Cosmc
mRNA expression in IgAN lymphocytes with associated increase in
aberrantly glycosylated IgA1.
Long-term outcomes with multi-targeted immunosuppressive
protocol in severe pediatric lupus nephritis
YWLau, ETAragon, LP Resontoc, YHChan, KHNg, Yeo WS, HKYap
Shaw-NKF-NUH Children’s Kidney Center, National University Health
System, Singapore
Background: The gold standard of treatment of proliferative lupus
nephritis (LN) using corticosteroid and intravenous cyclophosphamide
(CYC) resulted in improved patient and renal survival rate. Alternative
treatment is the multi-targeted induction protocol using intravenous
methylprednisolone, mycophenolate and cyclosporine to induce remis-
sion in our patients with severe proliferative lupus nephritis. This study
examined the long-term renal outcomes using the multi-targeted induc-
tion and maintenance protocol.
Method: 16 children with severe proliferative LN (WHO class III and
IV) treated with multi-targeted therapy were studied. Median follow-up
was 9.2 yr (range 3.8-12.8). Primary treatment outcome was complete
renal remission. Secondary outcomes were patient and renal survival and
relapse- and event-free survival. Mixed-model analysis was performed to
compare pre-induction and last follow-up parameters, adjusting for age at
induction, gender, duration of disease prior to induction, prior treatment
with CYCand/or azathioprine (AZA), and duration of follow-up. Kaplan-
Meier was used to analyze relapse- and event-free survival.
Results: All patients achieved complete renal remission within a median
time of 8.7 months (range 4- 24). Clinical and laboratory parameters at
induction and last follow-up, SLEDAI score (25.4±8.7 vs. 0.4±0.8),
serum C3 (47±15 vs. 107±27 mg/dL,), C4 (12±14 vs. 23±14 mg/dL)
and urine protein (6.9±7.1 vs. 0.2±0.02 g/day/1.73 m
2
) improved signif-
icantly (P<0.05). Kaplan-Meier analysis showed a cumulative 10-yr renal
relapse-free survival of 73.3% when considering relapses with severe
proteinuria. Cumulative probability that hospitalization would not be
required was 93.8% at 1-yr and 71.4% at 10-yr.
Conclusion: Our multi-targeted induction and maintenance protocol for
treatment in children with severe proliferative LN resulted in good long-
term patient survival and renal preservation, with a good safety profile.
Hypertension
Risk factors for increased blood pressure among aboriginal children
& adolescents
S. Kim
1,2
, P. Macaskill
2
, E.M. Hodson
1,2
, J. Daylight
1
, R. Williams
1
, N.
Vukasin
1
, R. Kearns
1
, D.M. Lyle
3
, J.C. Craig
1,2
1
Centre for Kidney Research, The Children's Hospital at Westmead,
Westmead;
2
Sydney School of Public Health University of Sydney,
Camperdown;
3
Department of Rural Health, University of Sydney,
Camperdown NSW, Australia
Objective: To determine relative changes in blood pressure between
Aboriginal and non-Aboriginal children as they move through adoles-
cence into young adulthood.
Background: Hypertension is associated with increased risk of chronic
kidney disease (CKD) in adulthood. Aboriginal children have a higher
prevalence of overweight/obesity, a known risk factor for hypertension in
adolescence.
Methods: A prospective cohort study of Aboriginal and non-Aboriginal
school children commenced in 2002 across 15 different screening centers
involving 38 primary schools and 213 high schools across urban, regional
and remote NSW. Blood pressure, BMI and urinalysis were measured
every 2 years. Systolic blood pressure (SBP) and diastolic blood pressure
(DBP) were standardized for sex, age and height. We fitted a series of
mixed linear regression models adjusting for age, sex, BMI SDS,
Aboriginality, birth weight and socioeconomic status (SES).
Results: 3418 (1949 Aboriginal) participants were screened over a total
of 11 years followup. At baseline, the prevalence of systolic hypertension
(SBP SDS >95
th
centile) was 7.2% (mean age 11 yr) which increased to
15.4% at 8-yr follow up. The prevalence of diastolic hypertension
remained relatively unchanged at 3.1% and 2.9% at baseline and 8-yr
follow up respectively. Multivariate analysis showed mean SBP SDS
increased with increasing age (0.06 SDS per yr of age, P<0.01) but there
was no significant difference in SBP between Aboriginal and non-
Aboriginal children. Low birth weight was significantly associated with
an increase in mean SBP (0.12 SDS, P=0.01) as was increasing BMI
(0.31 SDS per 1 unit increase in BMI SDS, P<0.01). Lower SES was
associated with increasing SBP (<25
th
quartile: 0.20 SDS, P <0.01). A
similar effect of increasing age (0.03 SDS per yr of age, P<0.01) and BMI
(0.14 SDS per 1 unit increase in BMI SDS, P<0.01) was seen for DBP,
whilst lower SES was associated with a lower DBP (<25
th
quartile: -0.12
Pediatr Nephrol
SDS, P<0.01). The mean DBP was not significantly different between
Aboriginal and non-Aboriginal children.
Conclusions: Increasing BMI remains the greatest modifiable risk factor
for SBP and DBP, with prevention of low birth weight and improving
SES also important to reduce cardiovascular risk in children and
adolescents.
Screening of hypertension in school going children of Dhaka and its
downtown in Bangladesh
Md AH Khan, ANM Saiful Hasan
Department of Pediatric Nephrology, National Institute of Kidney Dis-
eases and Urology (NIKDU), Dhaka, Bangladesh
Background: Hypertension is an important cause of morbidity and
mortality and childhood hypertension is the predictor of adult hyperten-
sion. Different studies worldwide documented that hypertension may
begin in adolescent and perhaps even in childhood. The purpose of this
study was to screen hypertension and its risk factors among school going
children in Dhaka and its downtown.
Methods: School going children aged between 4-16 yr, of five schools
were selected randomly and blood pressure (BP) measurements were
taken by mercury sphygmomanometer. Hypertension was considered as
BP more than 95
th
percentile by age and sex. BP was recorded among
1682 children. Children were screened for hematuria and proteinuria.
Dietary history and family history of hypertension was recorded.
Results: Total children having hypertension was 43 (2.6%); male (2.8%)
and female (2.2%). One boy had hypertension, proteinuria and hematuria;
5 patients (0.3%) had hypertension with proteinuria and 5 (0.3%) had
hypertension with hematuria. Among hypertensive children 13 (30.2%)
had family history of hypertension. 1495 (88.9%) had come from lower
and lower middle socioeconomic condition. 5 (0.3%) were underweight
with hypertension and 7 (0.4%) had stunting with hypertension.
Conclusion: We found that prevalence of hypertension was 2.6% diag-
nosed only after screening. So, for the prevention of complications of
hypertension every child should be screened for hypertension and remain
under follow up.
Hypertension prevalence and risk factors in children and adolescents
of school-going age in the Phoenix Area, Durban, South Africa
R. Bhimma
1
, M. Pillay
1
, D.P. Naidoo
1
, M. van den Bergh
2
, P.F. Smuts
3
,
R. Onia
3
1
School of Clinical Medicine, University of KwaZulu-Natal, Durban;
2
HEXOR, Johannesburg;
3
Merck Serono, Johannesburg, South Africa
Introduction: Hypertension is a leading cause of morbidity and mortality
in adults, but few studies have presented the significance of the preva-
lence of pre-hypertension and hypertension in school-going populations.
Objective: The objective of this study was to determine the prevalence of
hypertension, and define its contributing risk factors in children and
adolescents of school-going age within an urban community in Durban,
South Africa.
Methods: A cross-sectional assessment of blood pressure was conducted
in the central Phoenix region, KwaZulu-Natal, South Africa in 2012.
Initial measurements of the 423 children and adolescents (ages 6-18
years) included height, weight, and waist circumference and oscillometric
blood pressure readings. Furthermore, demographic information, factors
of lifestyle, medical and family history of suspected risk factors as well as
biochemical measurements of blood glucose, triglycerides and HDL
cholesterol levels were obtained by finger prick testing to describe their
significance on influencing blood pressure.
Results: The prevalence of pre-hypertension and hypertension amongst
school going children in the central Phoenix area in Durban, South Africa
is estimated to be 2.1% (0.8-3.5%) and 2.6% (1.1-4.1%) respectively,
similar to the 3-5% indicated in the literature. The risk of high blood
pressure was found to rise with an increase in age, weight, height, waist
circumference, increased triglyceride levels and heart rate, family history
of high blood pressure and diabetes and suspected substance abuse. Lack
of exercise and consumption of soft drinks were associated with increased
risk for hypertension; probably related to high BMI associated with
lifestyle factors.
Conclusions: Given the prevalence of the disease in the community, the
fact that the condition is undetected as well as long-term sequelae with
respect to target-organ damage, this study will help inform authorities in
making recommendations on the evaluation and management of high
blood pressure in the young in developing countries.
Nephrotic syndrome
Randomized controlled trial to compare the eff icacy and safety
of mycophenolate mofetil versus levamisole in children
with frequently relapsing and steroid dependent nephrotic syndrome
A. Sinha, M. Puraswani, M. Rawat, P. Hari, A. Bagga
Department of Pediatrics, All India Institute of Medical Sciences, New
Delhi
Introduction: While observational studies suggest that relapses in fre-
quently relapsing steroid sensitive nephrotic syndrome (NS) are
prevented by use of levamisole or mycophenolate mofetil (MMF), the
relative efficacy of these corticosteroid-sparing agents has not been
studied in clinical trials. This open label randomized controlled trial
examines the efficacy & safety of oral levamisole versus MMF
during1-yr of therapy in patients with frequently relapsing & steroid
dependent NS [CTRI/2012/02/002394].
Methods: Following written consent, consecutive patients with steroid
sensitive NS, 6-18 yr-old, with frequent relapses or steroid dependence in
the preceding six months are randomized to receive oral levamisole (2-2.5
mg/kg on alternate days) or MMF (800-1000 mg/m
2
daily) for 12-
months, while stratifying for disease severity and ensuring allocation
concealment. Therapy with prednisolone is tapered & discontinued at 4
months; relapses are treated with prednisolone 2 mg/kg/d until remission,
followed by 1.5 mg/kg/d for 4-wk.The relative proportions of T and B
lymphocyte subsets is compared at baseline and during therapy in a
subset of consecutive patients randomized to either arm. Outcomes, based
on intention-to-treat analysis at 12 months of therapy, include the fre-
quency of relapses, the proportions in sustained remission and frequent
relapses, the time to first relapse, the cumulative prednisolone require-
ment, the types & number of adverse effects, the types & rates of
infections in the groups, and the growth and growth velocity. Assuming
that therapy with MMF shall reduce relapse rates by 40%over the relapse
rates observed during therapy with levamisole, 66 patients are required in
each group at a power of 80% and two-tailed alpha error of 0.05, while
allowing for 10% loss of follow up.
Results: Baseline characteristics of 146 patients (123 boys) randomized,
including 44 with steroid dependence are presented.
Conclusions: Randomization into the study was completed in September
2013 and analysis of 1-yr outcomes is due in August 2014. Results of the
study shall have implications for guiding the choice of corticosteroid
sparing agents in patients with frequent relapses.
Effect of zinc supplements in reducing relapses among steroid
sensitive nephrotic syndrome and steroid dependent nephrotic
syndrome in children, a randomized double blind placebo control
study
R.P. Pardillo, Z. Antonio, M. Rosel, O. de Leon, M.A. Marbella, C.A.
Imbisan, R. Manuel
National Kidney and Transplant Institute, Quezon City, Philippines
Pediatr Nephrol
Objective: To determine the effect of zinc supplements in reducing
relapse rates in steroid-dependent (SDNS) and steroid-sensitive (SSNS)
nephrotic syndrome.
Methods: A randomized, double-blind, placebo control study done at the
outpatient section of our Institute from May 2010-January 2013. 34
pediatric patients with steroid-sensitive (SSNS) or steroid-dependent
nephrotic syndrome (SDNS) were divided into two arms: those who
received zinc supplementation at the recommended daily allowance for
age and those who received placebo. Monthly urinalysis and follow up
were done for 6 months. The incidence of relapse at 3 and 6 months of
placebo/zinc supplementation as well as the incidence of infection rate
during episodes of relapse was determined.
Results: More than half of the patients were children with SSNS. Base-
line characteristics were similar in both groups. Patients who
received zinc showed fewer relapse at 6 months’ treatment. Pa-
tients who received zinc had higher likelihood of achieving re-
mission compared to the placebo. Relapses occurring at 3 and 6
months of zinc/placebo supplementation were associated with
infections.
Conclusion: There was no significant difference in the mean relapse rates
at 3 months of therapy with either zinc or placebo; after 6 months there
was significant decrease in the mean relapses among patients using Zinc.
Patients receiving zinc had higher likelihood of achieving sustained
remissions. Relapses occurring at 3 and 6 months of zinc/placebo sup-
plementation are associated with the incidence of infection. Nephrotic
children have an increased susceptibility to infections due to a defect in T-
lymphocyte function. These infections may result in relapses and poor
response to steroid therapy. Zinc supplementation is proposed to augment
gene expression in the activation of T lymphocytes, resulting in decreased
incidence of infection.
Understanding the mechanisms of CD80 induced podocyte injury
B. Khullar
1
, A. Sharma
1
, N. Jain
2
, V. Bal
2
, S. Rath
2
, S. Sopory
1
1
Translational Health Science and Technology Institute, Gurgaon;
2
National Institute of Immunology, New Delhi, India
Objective: CD80/B7-1 (a T cell co-stimulatory molecule expressed on
antigen presenting cells) expression was induced in the podocytes in
genetic, bacterial toxin and drug induced experimental models of protein-
uria in mice. Subsequently, CD80 expression was also detected in the
podocytes of patients with Minimal change disease (MCD) and elevated
secretion of CD80 was detected in the urine of these patients during an
active episode of the disease. The objective of this study is to understand
the mechanisms and signaling pathways which lead to elevated levels of
CD80 in the podocytes and the consequences of these elevated levels at
the molecular level, specifically looking at the disruption of the slit
diaphragm which forms the final barrier to urinary protein loss.
Methods: Serum from LPS treated mice is added to podocytes followed
by RT-PCR to detect CD80 induction in the podocytes. Podocyte cell
lines stably expressing CD80 were generated and various techniques
including immunoblotting, immunofluorescence microscopy, RT-PCR
analysis, co-immunoprecipitation were used to look for changes in ex-
pression and localization of slit diaphragm (SD) proteins.
Results and Conclusions: There was no major change in the absolute
levels of podocyte proteins in presence of CD80. Therefore effects of
CD80 could be at the level of causing mislocalization or sequestration of
SD proteins. Preliminary data indicates possible interaction of Neph 1
with CD80, which could prevent interactions with endogenous proteins
essential for maintaining the SD structure. Serum from LPS treated wild
type and CD80
-/-
mice both induced CD80 in cultured podocytes, on the
other hand serum from LPS treated mice defective in TLR4 (receptor for
LPS) signaling did not induce CD80 on podocytes suggesting that a
soluble factor downstreamof TLR4 signaling is involved in inflammation
induced proteinuria.
Quantitation of serumand urine angiopoietin-like 3 and 4 in children
with nephrotic syndrome
R. Dai, H. Xu, G. Li, H. Liu, Y. Zhai
Department of Nephrology and Rheumatology, Children’s Hospital of
Fudan University, Shanghai, China
Objectives: Studies have explored several circulating or podocyte-
secreted proteins, such as the angiopoietin-like-4 (Angptl4) which results
in damage to the glomerular filtration barrier via an autocrine or paracrine
pathway. Studies have shown that Angptl3, a homologue of Angptl4, is a
secreted protein. The aim of this study is to quantify the serum and urine
ANGPTL3 and 4 levels in children with nephrotic syndrome (NS).
Methods: Serum and urine ANGPTL3 concentration were detected by
ELISA.
Results: Serum and urine samples (n=280) of 180 children (age 6±4yr)
with NS were analyzed. The average serum concentration of ANGPTL3
was 713.94±432.65 ng/ml [higher than healthy children 308.20 ± 87.93
ng/ml], and of ANGPTL433.32±57.71 ng/ml, similar to healthy children.
Urine concentration of ANGPTL3 was 1.94±1.97 ng/ml (similar to
healthy children) and of ANGPTL4 0.18 ± 0.07 ng/ml [higher than
healthy children 0.02±0.01 ng/ml, n=18]. ANGPTL3 serum level was
positively correlated with 24-hr urine protein excretion (P=0.004), Up/
Ucr (P=0.006), triglyceride (P=0.021), and cholesterol (P=0.001), but not
with creatinine (P=0.477) or BUN (P=0.717); ANGPTL4 urine levels
was positively correlated with Up/Ucr (r=0.318, P=0.01); ANGPTL3
urine levels and ANGPTL4 serum levels had no difference with all the
selected clinical parameters. Serum ANGPTL3 level varied in different
conditions: minimal change disease (438.35±200.61 ng/ml), FSGS
(678.35±361.67 ng/ml), membranous nephropathy (343.51±169.85 ng/
ml), mesangial proliferative glomerulonephritis (1112.39±446.53 ng/ml)
and membranoproliferative glomerulonephritis (489.31±247.76 ng/ml).
ANGPTL3 serumlevels may indicate the degree of proteinuria in NS and
not be affected by lipid levels. In terms of treatment response, no differ-
ence of serum and urine ANGPTL3 and 4 levels were found among
steroid sensitive, steroid-resistant, or steroid-dependent NS group, as well
as between the frequently relapsing and infrequently elapsing group.
Conclusions: Our data showed that serum ANGPTL3 level and urine
ANGPTL4 level were elevated in children with NS. Serum ANGPTL3
level was positively related to proteinuria and serum lipid level in NS.
Urine ANGPTL4 level correlated with proteinuria.
Predictive markers of relapse in pediatric focal segmental
glomerulosclerosis (FSGS) patients treated with rituximab
W.S. Yeo, C.Y. Chan, L.P. Resontoc, I.D. Liu, Y.W. Lau, K.H. Ng, H.K.
Yap
Department of Pediatrics, National University Health System, Singapore
Objectives: Rituximab is increasingly used in nephrotic children with
FSGS who failed conventional immunosuppressive therapy. The effect of
rituximab, however, is not sustained especially post-B-cell recovery. This
study aimed to determine the immunological markers that predict relapse
in rituximab-treated FSGS patients with complete response.
Methods: 15 FSGS nephrotic children (median age 15 yr, duration of
follow-up 7.4-32.8 months) treated with rituximab were studied. Urinary/
blood biochemical parameters and 31 T- and B-cell subsets were moni-
tored at day 0, day 14, 3 and 6 months and at relapse. Complete
responders to rituximab were defined as urine protein: creatinine ratio
<0.02 g/mmol and ability to wean off steroids and calcineurin inhibitors
within 3 months. Statistical analysis was performed using Mann-Whitney
U test and receiver-operating curve (ROC) analysis.
Results: CD19+ subset was significantly decreased in all patients post-
rituximab (11.57±1.36% vs. 0.23±0.06%, P<0.001). Nine (60%) patients
achieved complete response with 7/9 (78%) eventually relapsing (dura-
tion of remission: 262-484 days). All patients who relapsed had B-cell
Pediatr Nephrol
recovery. Amongst the various immunological subsets, ICOS+CD8+
CD3+ and FAS+ICOS+CD8+ cells at day 0 were predictive of relapse
within 300 days of rituximab therapy (R<300). Mean ICOS+CD8+CD3+
of R<300 group was 1.24±0.37% compared to 0.15±0.06% in non-
R<300 group (P=0.04), whereas mean FAS+ICOS+CD8+ of R<300
group was 0.70±0.06% compared to 0.14±0.06% in non-R<300 group
(P=0.037). ROC analysis revealed an area under curve of 1.00 (95% CI:
1.00-1.00, P=0.027) for both markers. Using a threshold subset value of
>0.64% for ICOS+CD8+CD3+ and >0.52% for FAS+ICOS+CD8+ cells
yielded a sensitivity and specificity of 1for predicting relapse within 300
days of rituximab therapy for both markers.
Conclusions: Our study illustrated the potential utilization of ICOS+
CD8+CD3+ and FAS+ICOS+CD8+ as predictive markers of relapse
within 300 days of rituximab therapy, possibly providing a guide for
further rituximab dosing following B-cell recovery but prior to clinical
relapse.
Analysis of risk factors for cyclosporine nephrotoxicity in children
with idiopathic nephrotic syndrome
M. Takahashi
1
, K. Kamei
1
, M. Fuyama
1
, K. Saida
1
, Z. Kiuchi
1
, M. Sato
1
,
M. Ogura
1
, K. Matsuoka
2
, S. Ito
1
1
Department of Nephrology and Rheumatology, National Center for
Child Health and Development, Tokyo;
2
Department of Pathology,
National Center for Child Health and Development, Tokyo, Japan
Objective: Cyclosporine (CsA) is a well-established treatment for
steroid-dependent nephrotic syndrome (SDNS) and steroid-resistant ne-
phrotic syndrome (SRNS), with high-grade evidence. However, chronic
CsA nephrotoxicity (CsAN), including tubulointerstitial and vascular
lesions is a major concern, especially with long-termuse. Previous reports
suggest that it is related to long-term CsA administration, frequent re-
lapses during CsA treatment, and higher CsA trough levels, but it has
seldom been assessed in large numbers of patients. We evaluated the risk
factors for CsANin children with idiopathic NS receiving CsAtreatment.
Methods: We retrospectively evaluated medical records and renal pa-
thology of 83 patients (56 male and 27 female) with idiopathic NS who
were treated with long-term CsA for >6 months (mean 34.8 months,
range 8–128 months) and underwent biopsy between January 2005 and
January 2014. Thirty-six patients started CsAbecause of SRNS, but all of
them had become steroid sensitive at the last observation. CsA treatment
was continued without intermission until biopsy in all patients. CsAN
was defined as the presence of tubulointerstitial lesions and/or CsA-
associated arteriolar hyalinosis. We evaluated the risk factors for CsAN
with regard to 11 clinical and laboratory factors (sex, age of NS onset, age
at biopsy, histological findings, past history of SRNS, duration of NS,
number of relapses, duration of CsA treatment, number of relapses on
CsA treatment, 2-hour CsA concentration (C2), and angiotensin-
converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker
(ARB) treatment for >6 months, by univariate and multivariate analysis.
Results: CsA-associated arteriolopathy was observed in 34 patients
(41%) and tubulointerstitial lesions in 31 patients (37%). Sex, age at renal
biopsy, duration of NS, duration of CsA treatment, number of relapse on
CsA treatment and use of ACEIs/ARBs were positively associated with
CsA associated arteriolopathy by univariate analysis and only use of
ACEIs/ARBs was independent risk factor by multivariate analysis
[P=0.03, odds ratio (OR): 5.45, 95% CI: 1.2-28.0]. On the other hand,
age at biopsy, histological findings, CsA C2 and use of ACEIs/ARBs
were positively associated with tubulointerstitial lesion by univariate
analysis and CsA C2 (>502.1 ng/ml, P=0.003, OR: 22.7, 95% CI: 2.7-
533.6) and age at biopsy (>9.9 years, P=0.04, OR: 14.37, 95% CI, 1.1-
588.0) were independent risk factors by multivariate analysis.
Conclusions: The use of ACEIs/ARBs, C2 and age at biopsy were
independent, significant risk factors for CsAN in children with NS.
Combination treatment with CsA and ACEI/ARB should be avoided if
possible.
HRM as a screening tool to detect variants in Wilms tumor 1 (WT1)
gene in children with steroid resistant nephrotic syndrome
A. Siji
1
, A. Vasudevan
1
, D.K. Babu
1
, K.D. Phadke
2
, A. Vasudevan
1, 2
1
St. John’s Research Institute, Bengaluru;
2
St. John’s Medical College
Hospital, Bengaluru, India
Objective: The objective of the study was to determine if real-time
polymerase chain reaction and high resolution melt (HRM) curve analysis
could be used as a screening tool to identify for variants in the Wilms
tumor 1 (WT1) gene in comparison to DNA Sanger sequencing.
Methods: HRM assay for the analysis of exons 8 and 9 of the WT1 gene
were designed, and optimized. Stringent criteria were employed for
primer designing in order to enable reproducible detection of variants
within the amplicon. HRManalysis for exons 8 and 9 of the WT1 gene in
a final set of 60 genomic DNAsamples (5 samples for standardization, 55
samples for validation, including 10 blinded samples) were performed
under identical amplification conditions.
Results: After the initial standardization, WT1 exons 8 and 9 displayed
unique melt curve profiles that were reproducible. A blinded assessment
was performed on 10 samples for validation of the HRM technique as
compared to sequencing. A 100% specificity and sensitivity was ob-
served for prediction of normal variants when compared with the
Sanger’s sequencing. Similar results were obtained during the subsequent
analysis of the remaining 45 samples. Both the techniques did not reveal
any abnormal pathogenic variant. The screening result using HRM was
obtained in 2 hours 15 minutes, while sequencing required a minimumof
5 days.
Conclusion: Although sequencing is the gold standard for detecting
variants, it involves additional steps and requires a more turnaround time
as compared to HRM. Our results showed that HRM could be used as a
robust screening technique to detect abnormal variants, which could be
further sequenced, to determine the precise variation. HRM curve analy-
sis is a quick, reliable and a high throughput post-PCR method to analyze
genetic mutations or variances in nucleic acid sequences. Since HRM is a
closed tube method, it eliminates the possibility of template contamina-
tion. The characteristics of HRM such as its simplicity ease of use, low
cost, high sensitivity, and specificity, makes it an efficient tool for se-
quence variant detection.
The study of urinary CD80 in children with minimal change disease
and focal segmental glomerulosclerosis
L. Chen, L. Xiaorong, S. Ying, C. Zhi, F. Jianfeng, J. Yeping, M. Qun
Department of Nephrology, Beijing Children’s Hospital affiliated to
Capital Medical University, Beijing, PR China
Background: Early diagnosis of minimal change disease (MCD) in
nephrotic syndrome (NS) patients remains challenging. CD80, a trans-
membrane protein, is present on podocytes in a number of experimental
models of NS. Urinary CD80 levels are significantly elevated in MCDbut
not in focal segmental glomerulosclerosis (FSGS) or other glomerulopa-
thies. The purpose of this study was to investigate the feasibility of using
urinary CD80 levels as a biomarker for diagnosis of MCD.
Methods: The clinical data and morning urine samples have been
collected from 37 patients with MCD, 27 patients with FSGS, 30
patients with other glomerulopathies who underwent renal biopsy.
71 healthy controls were included. ELISA was used to determine
urine CD80 concentration. CD80 concentration between MCD,
FSGS, other glomerulopathies and control group were compared.
The receiver operating characteristic curve (ROC) analysis was used
to determine the cut-off point of urinary CD80 as a biological
marker for the diagnosis of MCD.
Results: The concentration of urinary CD80 was significantly higher in
the active MCD group (689.66±378.21 ng/g creat) than FSGS [48.28
(10.36, 163.94) ng/g creat], other glomerulopathies [52.20 (11.41,
Pediatr Nephrol
249.75) ng/g creat] and controls (81.83±23.01 ng/g creat); P value <0.001
in all. A cut-off value of 328.98 (ng/g creat) was proposed, with sensi-
tivity of 81.1% and specificity of 94.4%. The area under the ROC curve
was 0.925 (95% CI: 0.87-0.98). Urinary CD80 was elevated in three
patients with tip lesion and one with NOS. Mean value was 334.58
±208.92 ng/g creat in the patients with tip lesion and 38.54(5.36, 80.16)
ng/g creat in NOS. Urinary CD80 was higher in tip lesions than in NOS
(P <0.05). Urinary CD80 was elevated in two patients with IgA nephrop-
athy and one patient with lupus nephritis.
Conclusions: Urine CD80 increased significantly in children with MCD,
and can be used as a biomarker to identify MCD with FSGS.
A randomized controlled trial to assess the effect of calcium
and vitamin D supplementation on bone biochemistry and bone
mineral density in pediatric steroid sensitive nephrotic syndrome
S. Banerjee, S. Basu, J. Sengupta
Institute of Child Health, Kolkata
Objectives: Low vitamin D levels, osteoporosis and hypercalciuria are
known complications of nephrotic syndrome (NS) and its treatment. The
aim is to assess whether supplementation with vitamin D and calcium
after relapse protects against hypovitaminosis and maintains bone mineral
density (BMD) over 6 months.
Methods: A randomized controlled open label trial was designed, with
30 patients in each arm to yield over 90% power. Children (2-10 yr)
presenting in active NS relapse are being recruited. Standard treatment of
NS is continued. Centralized computer randomisation is followed to allot
patients into test group or control group. The test group receives vitamin
D and calcium supplementation. Levels of serum creatinine, albumin,
calcium, phosphate, alkaline phosphatase, and 25-hydroxy-
cholecalciferol [25(OH)D]; urine protein/creatinine and calcium/
creatinine ratios are documented at study entry, 1 month and 6 months.
In addition 25(OH)D levels are assessed in case of interim relapse and
further supplementation given to optimize levels if required. Ultrasound
of the renal tract and lumbar BMD are performed at study entry and at 6
months. At study completion, vitamin D levels and difference in lumbar
BMD will be compared between groups and assessed for any correlation
with number of interim relapses and cumulative steroid therapy.
Results: This is an ongoing study and till date, 28 patients have under-
gone randomization. Twenty children have completed the study, 9 in the
test group and 11 in the control group. Their mean age is 4.9 years, 6 are
female, 12 had a first episode of NS or have infrequent relapses, whereas
8 have frequent relapses or are steroid dependent. The mean vitamin D
level at recruitment was 7.7ng/ml, and mean lumbar BMD was 0.52gm/
cm
2
.The mean difference over 6 months in 25(OH)D levels was +
22.95ng/dl in the test group and +1.47ng/ml in the control group, while
mean difference in BMD was +11% and +3.4% respectively. None of the
children in either group had hypercalciuria or nephrocalcinosis.
Conclusions: On study completion we expect to understand whether
calciumand vitamin Dsupplementation improves serumvitamin Dlevels
and maintains BMD in children with NS, in the short term. This will help
in formulating definitive guidelines for the requirement of such supple-
ments, in this chronically relapsing disease.
Mammalian target of rapamycin complex 2 signaling pathway
regulates transient receptor potential cation channel 6 in podocytes
F. Ding, X. Li, X. Zhang, Y. Zhang, B. Li, Jie Ding
Department of Pediatrics, Peking University First Hospital, Beijing,
China
Objectives: Abnormal expression and gain of function of TRPC6 were
involved in the pathogenesis of hereditary and nonhereditary forms of
renal diseases. Although underlying molecular mechanisms of this re-
main poorly understood, recent research found that there were many cell
signaling pathways involved in regulating the expression and function of
TRPC6. The purpose of our study is to examine the effect of distinct
mammalian target of rapamycin complex (mTORC1 or mTORC2) sig-
naling pathway on TRPC6 in podocytes.
Methods: We applied pharmacological inhibitors of mTOR and siRNA
specific for component of mTOR to explore mTOR signaling to regulate
TRPC6 in podocytes. Podocytes were exposed to rapamycin, an inhibitor
of mTORC1 signaling pathway, and ku0063794, a dual inhibitor of
mTORC1 and mTORC2. In addition, using specific siRNAknocked down
the component of mTORC1 raptor and the component of mTORC2 rictor.
By using real-time reverse transcription PCR and western blotting, mRNA
and protein expression of TRPC6 were examined. Also, fluorescence
calcium imaging was used to study the function of TRPC6 in podocytes.
Results: Rapamycin has no effect on mRNA and protein expression
levels of TRPC6 at different time points and concentrations.
Ku0063794 could down-regulate mRNA and protein of TRPC6 in
podocytes. In addition, ku0063794, but not rapamycin suppressed
TRPC6-dependent intracellular calcium influx. Furthermore, while
knockdown of rictor suppressed TRPC6 protein expression and
TRPC6-dependent calcium influx into podocytes, knockdown of raptor
didn’t change the above.
Conclusions: These findings indicate that mTORC2 signaling pathway
regulates TRPC6 in podocytes, while mTORC1 signaling pathway may
have no effect on TRPC6.
Molecular mechanisms of minimal change nephrotic syndrome: Role
of CD80
B. Khullar
1
, A. Sharma
1
, N. Jain
2
, V. Bal
2
, S. Rath
2
, S. Sopory
1
1
Translational Health Science &Technology Institute, Gurgaon;
2
National
Institute of Immunology, New Delhi, India
Objectives: Expression of CD80 (a T cell costimulatory molecule) is
induced in LPS, PANand α3-/- mouse models of podocyte injury (Reiser
et al. 2004). Proteinuria in response to LPS is not observed in CD80-/-
mice which show that CD80 induction is important in LPS-mediated
podocyte injury. The objective of our study is to understand the role of
CD80 in podocyte disease biology.
Methods: Podocyte cell lines which stably express C-terminus Myc-
tagged CD80 were generated by transfection and cell sorting to study
the role of CD80 expression in podocytes. By confocal microscopy, the
CD80+ and wild type (wt) podocytes were compared for changes in the
actin morphology to see if CD80 expression alone can cause actin
derangement in the cells. Reverse Transcriptase PCR and western blot
analysis were done to compare CD80+ and wt podocytes for differences
in the expression of important proteins to check if CD80 expression
affects the expression of SD and other important podocyte proteins. By
monitoring the total cell count of CD80+ and wt podocytes in culture, the
growth curves of CD80+ and wt podocytes were compared to see if CD80
affects cell division and/or cell death. To understand the mechanism by
which CD80 may be mediating podocyte injury, we are trying to find
CD80-interacting podocyte proteins by CoIP and pull down assays. We
also examined the interaction of CD80 with major SD proteins by
transfection and CoIP studies in a heterologous system i.e. HEK293.
Results: Podocyte cell line stably expressing high levels of CD80 were
generated. The CD80+ podocytes were similar to the wt podocytes in the
actin morphology, in the expression levels of major SDproteins and in the
growth curve. In trying to find out CD80-interacting proteins, we have
found a novel interaction of CD80 and Neph1 by transfecting the two
proteins in a heterologous system and doing a CoIP.
Conclusions: The expression of CD80 alone in the podocytes does not
cause actin derangement and does not affect the expression levels of
major SD and podocyte proteins. CD80 expression causes no change in
cell growth and/or death. CD80 may mediate its effects by its interaction
with Neph1. The possible mechanism by which CD80-Neph1 interaction
affects downstream podocyte SD signaling is under investigation.
Pediatr Nephrol
Trehalose alleviates human podocyte injury via the induction
of autophagy in an mTOR independent manner
YL Kang
1,2
, MA Saleem
3
, KW Chan
4
, BYM Yung
1
, HKW Law
1
1
Department of Health Technology & Informatics, Faculty of Health and
Social Sciences, Hong Kong Polytechnic University;
2
Department of
Nephrology & Rheumatology, Shanghai Children’s Hospital, Jiao Tong
University;
3
Academic Renal Unit, University of Bristol, Southmead
Hospital, United Kingdom;
4
Department of Pathology, Li KaShing Fac-
ulty of Medicine, University of Hong Kong, Hong Kong, China
Objectives: Podocytes are highly differentiated cells which play an
important role in guarding the permeability of the tripartite renal filtra-
tion barrier. Many glomerular diseases are attributed to podocyte dam-
age. Strategies for alleviating podocyte injury remain insufficient. Au-
tophagy has been regarded as a vital cytoprotective mechanism in
podocyte homeostasis. Trehalose, a natural disaccharide, is an mTOR
independent autophagy inducer. It is unclear whether trehalose allevi-
ates podocyte injury. Therefore, we investigated the efficacy of treha-
lose in puromycin aminonucleoside (PAN)-induced podocyte injury
model.
Methods: Human conditional immortalized podocytes were treated with
PAN or (and) trehalose. Autophagy and its signaling pathways were
investigated by immunofluorescence staining for LC3 puncta and western
blotting for LC3, Atg5, p-mTOR, p-p70S6K, p-4E-BP-1 and p-AMPK.
Reactive oxygen species (ROS) was measured by H
2
DCFDA assay. The
outcome measurement includes the evaluation of apoptosis, necrosis, and
actin cytoskeleton and podocyte motility. Podocyte apoptosis was ana-
lyzed by flow cytometry (YO-PRO-1/PI assay and active caspase-3
assay), while necrosis was evaluated by measuring lactate dehydrogenase
activity. F-actin was stained for studying the stability of actin cytoskele-
ton. In addition, we performed migration assay to examine podocyte
motility. To verify the role of trehalose-induced autophagy in alleviating
podocyte injury, chloroquine (CQ) and wortmannin (WT) were used to
block the autophagic flux.
Results: It was shown that trehalose induced podocyte autophagy in an
mTOR independent manner without ROS involvement. Podocyte apo-
ptosis significantly decreased after trehalose treatment, while inhibition of
trehalose-induced autophagy abolished its protective effect. No signifi-
cant changes were found in podocyte necrosis after PAN with or without
trehalose treatment. The disrupted actin cytoskeleton was partially re-
versed by trehalose, accompanying with less lamellipodias and dimin-
ished mobility.
Conclusions: Trehalose induced podocyte autophagy in an mTOR inde-
pendent manner and showed cytoprotective effects in PAN-treated human
podocytes.
A novel biomarker for predicting steroid resistance in childhood
nephrotic syndrome
Mahesh Kumar KB
1
, Senguttuvan P
1
, Soundararajan P
1
, Aravind
Selvinkumar R
1
, Rathika C
2
, Balakrishnan K
2
1
Department of Nephrology, Sri Ramachandra University, Porur, Chennai;
2
Department of Immunology, Madurai Kamaraj University, Madurai
Objectives: Our aim was to study the association of HLA class II (DR &
DQ) alleles with steroid resistance in south Indian nephrotic children.
Methods: All steroid resistant nephrotic children in the age group of 1 to
12 years were included. Steroid sensitive nephrotics served as controls..
3ml of whole blood was collected and DNAwas isolated. Genotyping of
HLA DR1* and DQB1* by PCR-SSP method was done and the PCR
products were run in 2% agarose gel and the allelic frequencies and
haplotypes were estimated.
Results: We enrolled 95 SRNS and 91 controls. Biopsy was available for
all the patients. 47 children had MCN, 40 FSGS, and DMP in 8 cases.
HLA-DRB1*07 and DRB1*03 and HLA-DQB1*02 were significantly
more frequent in cases when compared to controls. (27.1% vs.16.5%,
OR=2.4; P<0.006 and 17.6% vs.10.4%; OR=2.0; P<0.047 and 26.6%
vs.12.6%; OR=3.3; P<0.001 respectively). DQB1*07 (subset of DQB1*03)
was increased (14.9% vs. 8.8%; OR=1.96; P<0.076) and DQB1*05 was
decreased and the results were statistically significant (23.9% vs. 39.0%;
OR=0.26; P<0.001). Haplotype analysis revealed the predominance of
DRB1*07-DQB1*02 (0.001), DRB1*03-DQB1*02(0.013) DRB1*15-
DQB1*05 (0.013) DRB1*10-DQB1*06(0.045).
Conclusions: DRB1*07, DRB1*03, DQB1*02 and DQB1*0301,
0304(DQ7) alleles were found to be significantly higher among SRNS
patients comparable to the reports of Caucasian, Egyptian and Kuwaiti
SRNS Children. DR/ DQ alleles/ allelic combination greatly influences
the age of onset. DQB1*05 was found to be strongly protective (P<0.001)
against steroid resistance. Alleles DQB1*02, DRB1*03 and DRB1*07
strongly predicts steroid resistance. These alleles could serve as novel
biomarkers for steroid resistance in the future.
TRPC6 gene promoter polymorphism in steroid resistant nephrotic
children
Mahesh Kumar KB, P. Senguttuvan, Bhaskar LVKS, Soundararajan P
Department of Nephrology, Department of Biomedical Sciences, Sri
Ramachandra University, Chennai, India
Objectives: To study the prevalence of TRPC6 [calcium ion channel on
podocytes] gene promoter polymorphisms in south Indian children with
steroid resistant nephrotic syndrome [SRNS].
Methods: A prospective case-control study of SRNS [KDIGO definition]
children attending the nephrology clinic at SRMC during 2012-2014 was
conducted. Nonproteinuric childrenwere takenas controls. Institutional ethical
committee approval was obtained. 2 ml of peripheral blood was collected from
all subjects and two promoter polymorphism of TRPC 6 gene (-218A/G:
rs56134796 -254C/G: rs3824934) were analyzed using PCR-RFLP.
Results: 49 patients with SRNS and 45 controls were enrolled into the
study. The mean age of the SRNS and control subjects were 7.78±4.12
and 9.49±3.92 years, respectively. Both case and control groups were
dominated by male subjects. Renal biopsy was performed on 16 subjects,
among whom 12 patients (24.5%) had minimal change nephropathy
(MCN), 4 patients (8.2%) had focal segmental glomerulosclerosis
(FSGS). Both promoter variants were polymorphic in the study popula-
tion with the minor allele frequency of 9% and 17.4% respectively for -
218A/G and -254C/G and followed Hardy-Weinberg equilibrium. The
frequencies of promoter polymorphisms -218A/G and -254C/G were
20.4% and 34.0% in SRNS children vs. 15.6% and 35.6% in controls
and their distribution were not statistically significant (P=0.37; P=0.88).
The distribution of -218A/Gand -254C/Gpolymorphisms were similar in
MCN, FSGS and non biopsied cases. Since these markers are separated
by only 36 bp, linkage disequilibrium was not strong and the haplotypes
were not associated with SRNS.
Conclusions: Both -218A/Gand -254C/Ggenotypes and alleles were not
associated with SRNS predisposition in south Indian children as reported
in Chinese children. The knowledge of the mutated gene carrier status
warrants these children to be monitored periodically and screened for the
development of renal disease in future.
Protective effect of Angptl3 knock-out on LPS-induced nephropathy
mice
J. Liu
1
, Y. Zhai
1
, H. Xu
1
, Q. Shen
1
, L. Sun
1
, J. Rao
1
, M. Guo
2
, D. Ma
3
1
Department of Nephrology and Rheumatology, Children’s Hospital of
Fudan University, Shanghai;
2
Department of Pathology, Shanghai Med-
ical College of Fudan University, Shanghai;
3
Institute of Biomedical
Sciences, Fudan University, Shanghai, China
Objectives: In previous study, we found that the expression of
ANGPTL3 in podocytes was upregulated in children with nephrotic
Pediatr Nephrol
syndrome and adriamycin-induced nephropathy rats. The aim of this
study is to investigate the impact of Angptl3 knock-out on LPS-induced
nephropathy mice.
Methods: LPS-induced nephropathy model was established in B6;
129Sv-Angptl3+/+and B6; 129Sv-Angptl3-/- mice by intraperitoneal
injection of 13μg/kg LPS. Serum albumin, serum lipid levels, and urine
albumin were examined by automatic chemical analyzer. Renal patho-
logic analysis, including light microscopy and electron microscopy were
performed.
Results: Urine protein was negative in both B6; 129Sv-Angptl3-/- mice
and B6; 129Sv-Angptl3+/+mice. B6; 129Sv-Angptl3-/- mice had normal
serum albumin as B6; 129Sv-Angptl3+/+mice (29.85±0.71 vs. 28.75
±0.41 g/L, P>0.05), but B6; 129Sv-Angptl3-/- mice had lower cholesterol
and triglycerides compared to B6; 129Sv-Angptl3+/+mice (cholesterol
1.82±0.15 vs. 2.86±0.13 mmol/L, P<0.05; triglyceride 0.48±0.02 vs. 0.87
±0.12 mmol/L, P<0.05). Light and electron microscopy showed no
difference in histology in B6; 129Sv-Angptl3-/- & B6; 129Sv-
Angptl3+/+mice. In LPS-induced nephropathy model, 30 hours after
injection of LPS, B6; 129Sv-Angptl3+/+mice had significant proteinuria
(32.03±0.48 mg/mmol), hypoalbuminemia (23.61±1.19 g/L) and hyper-
cholesterolemia (3.45±0.29 mmol/L). The urinary albumin creatinine
ratio in B6; 129Sv-Angptl3+/+mice was nearly 2 folds higher than that
in B6; 129Sv-Angptl3-/- mice (32.03±0.48 vs. 17.31±3.21 mg/mmol P
<0.05), though both had low serum albumin level (23.61±1.19 vs. KO
22.14±1.31g/L, P >0.05). Serum cholesterol in B6; 129Sv-Angptl3+/+
mice was significantly higher (3.45±0.29 vs. 1.59±0.33 mmol/L). Light
microscopy showed no difference between two groups; electron micros-
copy showed severe injury of podocytes in Angptl3+/+mice, and no
manifestation of podocyte injury in Angptl3-/- mice 30 hr after LPS
injection.
Conclusions: Angptl3 knock-out can significantly attenuate proteinuria
and prevent hypercholesterolemia in mice after LPS injection, which
indicate that Angptl3 might be related to podocyte injury. Reduction of
Angptl3 expression might be a potential way to decrease proteinuria in
nephrotic syndrome.
Screening strategies of causative genes in children with nephrotic
syndrome
G. Li
1
, H. Xu
1
, Q. Shen
1
, S. Li
1
, H. Liu
1
, Y. An
2
1
Department of Nephrology and Rheumatology, Children's Hospital of
Fudan University, Shanghai, China;
2
Institutes of Biomedical Sciences of
Fudan University, Shanghai, China
Objectives: To explore the major causative genes, and to establish
screening strategies of causative genes in children with NS.
Methods: NPHS1, NPHS2, PLCE1, LAMB2, LMX1B, COQ2 and WT1
genes were tested in patients with congenital NS while NPHS1, NPHS2,
PLCE1 and WT1 were tested in patients with infantile NS by direct
sequencing. In early- and late-onset NS group and familial AR, we tested
NPHS2 and WT1 by direct sequencing, as well as 42 common gene
mutations involved in 8 main genes by Snapshot analysis. ACTN4,
TRPC6 and INF2 were tested in familial AD group. Whole exon se-
quencing (WES) was done when no causative mutation was found in
familial forms.
Results: Causative mutations of NPHS1 were found in 8; no other
mutation was found in CNS (n=10). Among the 12 cases with infantile
NS, 6 had mutations in WT1 (n=3), NPHS2 (n=2) and NPHS1 (n=1)
mutations, respectively. In 32 cases of initial SRNS 6 had mutations in
WT1 (n=3), NPHS2 (n=2) and INF2 (n=1). In 19 cases of later SRNS
children, one had mutation of NPHS1 gene. In 42 cases of frequent
relapsing SSNS children, one had mutation of NPHS1 gene. There were
no causative mutations detected among 84 cases of delayed onset NS
children. In two AR-NS pedigrees, we found one pedigree with NPHS2
mutation, while no mutation of NPHS2 and WT1was found in other
pedigree, no causative genes were found by WES analysis. In an AD-
NS family, all the patients were found had INF2 deletion mutation.
Conclusions: NPHS1 is the main causative gene in CNS children, so
NPHS1 analysis is recommended. It is recommended to test WT1 and
NPHS2 in children of infantile NS. In children of early-onset NS, 18.8%
presented related genetic mutations. Among initial SRNS, the major
genes were WT1 and NPHS2, testing for these genes is recommended.
In children of delayed-onset NS, it is not suggested to analyze gene
mutation. NPHS2 and INF2 were causative genes of AR-NS and AD-
NS, respectively, and analysis of NPHS2 and INF2 was recommended in
families with AR-NS and AD-NS.
Influence of tacrolimus on expression and distribution of TRPC6
in podocytes
Zhang-Yao, Ma-yuanyuan, Yuli, Yu-shengyou
Department of Pediatrics, Guangzhou First People's Hospital, Affiliated
to Guangzhou Medical University, Guangdong, 510180, China
Objective: By observing the expression and distribution changes of
transient receptor potential cation channel protein 6 (TRPC6) in glomer-
ular podocytes after puromycin (PAN) stimulation and the following
tacrolimus (FK506) intervention, this study investigated the protective
effect of FK506 in podocytes and the correlation of TRPC6 with
podocyte injury repair.
Methods: MPC5 were cultured in vitro, paralleled with the control group,
PAN stimulation group, and FK506 intervention group. The control
group was cultured in RPMI 1640; PAN stimulation group was added
PAN to stimulate Mouse podocyte cell line (MPC5), and FK506 inter-
vention group was added with PAN and FK506 simultaneously, then
observed cell morphology and collected the cells at 8h, 24h and 48h,
respectively. The experiments were further assayed the activity of
podocytes using the MTT method and the apoptosis rate with flow
cytometry, also detected TRPC6 mRNA and protein expression by RT-
PCR and Western blot, and then observed the distribution of TRPC6 with
indirect immunofluorescence labeling under confocal microscope.
Results: After PAN stimulation, the cell bodies of podocytes were
significantly reduced, the foot processes showed retraction and the inter-
cellular junctions were lost. At 24-h and 48-h the activities of podocytes
were significantly lower, apoptosis rate were increased, TRPC6 mRNA
and protein expression were significantly increased when compared with
control group; the distribution of TRPC6 was apparently different from
the control group. After FK506 intervention, the cell bodies were bigger
than in PAN group, most cells maintain normal foot processes; the
activities of podocytes significantly increased after FK506 intervention
for 24-h and 48-h and the apoptosis rate was markedly lower than that of
PAN stimulation group.
Conclusion: FK506 can directly act on the podocytes to inhibit PAN-
induced damage on podocyte structure and reduce the apoptosis rate of
podocytes, which may be related to stabilizing TRPC6 expression and
distribution in podocytes by FK506, thus maintaining structure and
function integrality of slit diaphragm (SD), and playing a role in
protecting podocytes and resulting in antiproteinuric effects.
Dexamethasone inhibits glomerular podocyte apoptosis
by stabilizing the PI3K/Akt signal pathway
Yu-li, Yu-shengyou, Hao-zhihong, Zhang-yao
Department of Pediatrics, Guangzhou First People's Hospital, Affiliated
to Guangzhou Medical University, Guangdong, China
Dexamethasone (DEX) is an established treatment for glomerular disease
that, at least in part, protects podocyes fromapoptotic death. To reveal the
molecular mechanisms for renal protection, we examined the role of the
PI3K/Akt signal pathway in DEX-mediated inhibition of podocyte apo-
ptosis. A mouse podocyte cell line was treated with vehicle (DMSO), the
Pediatr Nephrol
apoptosis inducer puromycin (PAN), DEX + PAN, or DEX + PAN
following pretreatment with the PI3K inhibitor LY294002. Western blot-
ting, RT-PCR, and immunocytochemistry under laser confocal microsco-
py were adopted to measure the expression and subcellular distribution of
CD2AP, a major regulator of cytoskeletal dynamics and podocyte mor-
phology, at both the mRNA and protein levels, as well as the co-
localization of CD2AP protein with the PI3K regulatory subunit p85.
Western blotting was also used to detect changes in expression of Akt, p-
Akt, GSK3β, and p-GSK3β. Podocyte apoptosis was measured by flow
cytometry. The expression of CD2AP mRNA and protein decreased
significantly during PANtreatment (P<0.05). The subcellular distribution
of CD2AP protein changed from evenly distributed filaments in cyto-
plasmic foot processes and the nucleus to discontinuous rough granules in
the perinuclear region. In addition, CD2AP was aberrantly co-localization
with p85. Normal CD2AP mRNA expression and subcellular protein
distribution were maintained in the PAN + DEX group, and DEX co-
application also reduced CD2AP−p85 co-localization. PAN evoked a
concentration-dependent decrease in p-Akt and p-GSK3β expression
(P<0.05), with p-Akt expression reaching a nadir at 15 min and p-
GSK3β expression at 30 min. DEX treatment induced a concentration-
dependent reversal of PAN-induced p-Akt and p-GSK3βdownregulation
(P<0.05). The PI3K inhibitor LY294002 blocked p-Akt and p-GSK3β
expression in podocytes (P<0.01). Cells treated with PAN exhibited a
significantly higher apoptosis rate than untreated or vehicle-treated cells
(P<0.05). Furthermore, LY294002 exacerbated PAN-induced apoptosis
(P<0.01). DEX treatment caused a concentration dependent decrease in
PAN induced apoptosis (P<0.05). DEX protects podocytes by stabilizing
the expression and subcellular distribution of CD2AP and maintaining
expression of phosphor-activated Akt and GSK3β.
Registries
KNOW-Ped CKD (Korean Cohort Study for Outcome in patients
With Pediatric Chronic Kidney Disease): third-year follow-up report
H.G. Kang, H.Y. Cho, J.I Shin, M.H. Cho, J.H. Lee, H. Park, Y.S. Park, Y.
Choi, Il-Soo Ha, C. Ahn
Department of Pediatrics, Seoul National University Children's Hospital,
Seoul, Korea
Objectives: KNOW-CKD (KoreaNcohort study for Outcome in patients
With Chronic Kidney Disease) is a nation-wide, 10-yr longitudinal cohort
study collecting information of Korean chronic kidney disease (CKD)
patients, launched in 2011, to assess the characteristics and risk factors of
progression and complications of CKD. Pediatric sub-cohort of KNOW-
CKD is planned to enroll 400 children with CKD, stage I to V (pre-
dialysis), and collect information for >5 yr. Here we report the third-year
follow-up report of pediatric sub-cohort, KNOW-Ped CKD.
Methods: Five major pediatric nephrology centers of Korea enrolled
children with CKD. After informed consent, medical history taking,
questionnaire assessment of socio-economic status, anthropometric mea-
surement, and clinical assessment using laboratory and imaging tests
were done and recorded using web-based case report form.
Results: Total 300 patients (M: F 199:101) were enrolled by Feb. 2014.
Average age was 10.01 yr. Etiologies of CKD were congenital renal
dysplasia (48%), reflux nephropathy/chronic pyelonephritis (22%), pri-
mary glomerular diseases (16%), secondary glomerular diseases (5%),
and others. Stages of CKD were I for 16%, II 18%, III 34%, IV 18%, and
V 15%. Age groups were less than 2 yr for 10%, 2 to 5 yr for 15%, 6 to
11 yr 28%, and 12 to 19 yr 47%. One third had histories of UTI and 9%
had developmental delay. Growth delay was observed even in early stage
of CKD stage, with mean height and weight Z score of -0.98 and 0.99,
especially younger (<6 yr) with advanced CKD(IVand V). Hypertension
was observed in 16% and left ventricular hypertrophy in 9% of the
patients. One-year follow-up data were available in 230 patients; renal
replacement therapy was introduced in 33(14%) and other 5 (2 %)
experienced doubling of Cr.
Conclusion: This prospective, multicenter cohort study aiming to im-
prove CKD outcome revealed that our current management of pediatric
CKD in Korea had room for improvement. We expect to obtain more
information on pediatric CKD with this cohort study.
An on-line registry of hereditary kidney diseases in children in China
F. Wang, J. Ding, H.W Zhang, X.Y. Liu, Y.Q. Zhang, W. Li
Department of Pediatrics, Peking University First Hospital, Beijing, P. R.
China
A paper record of patients with rare hereditary renal diseases had been
kept and maintained for about 20 years in Department of Pediatrics,
Peking University First Hospital. However, this system was insufficient
as records for conducting research and for engaging more sites. An online
system will make any data extraction and analysis for research much
easier, and be convenient for a greater number of centres (other than
Peking First University) to start collecting information on patients with
rare kidney diseases. Supported by a grant from "Twelfth Five-Year"
Science and Technology Support Project in China, an online registry
was developed in 2012. Its language is Chinese. To design the registry,
well-established and successful registries such as ASTOR (Alport Syn-
drome Treatments and Outcomes Registry) were referred. All IT support
was provided by the IT company that developed the registry database.
The registry initially developed as a single-site registry at Peking First
Hospital, now has been expanded as part of a national collaboration with
6 centres in 6 cities in China (Beijing, Hangzhou, Changsha, Guangzhou,
Fuzhou and Chongqing). Training for using the registry in each centre
had been performed 10 months ago. Each centre accesses to the registry
via a unique Username and Password. Only those individuals who
involved in updating and checking the information in the registry can
access. Patients are identified by their physicians at each centre. The
patient’s information is recorded on paper, and then transcribed into the
database by a research nurse working with the registry. Ten physicians are
responsible for collecting, recording and checking the patient’s informa-
tion, 6 persons for transcribing the information into the registry,1 person
for coordination, and 1 person for the web service.Until now, more than
1000 patients, classified as 4 kinds of hereditary kidney diseases, were
registered.
Special issues
Inequalities in health care of children with ESRD – the case of Brazil
P.C. Koch-Nogueira, M.F. Camargo, L. Feltran, T. Konstantyner,
R.C. Sesso
Hospital Samaritano, Sao Paulo and UNIFESP, Brazil
Objectives: Regional discrepancies in health care are frequent among
countries and even among regions of the same country. We aimed to
determine the incidence and prevalence of ESRD in children (aged<18
years) in Brazil in 2012 and also to quantify regional inequalities.
Methods: Data collection fromboth: a) a sample of 239 (out of 708 total)
dialysis units randomly selected to represent geographic regions and b)
the national transplant waiting list coordinated by the Ministry of Health
from Brazil during the period 2010-2013.
Results: We collected data from 643-paediatric and 36401-adult dialysis
patients, yielding the estimation of a total of 1283 (95% CI 948 to 1618)
pediatric and 104577 (95% CI 94673 to 114482) adult ESRD cases on
dialysis throughout the country in 2012. This indicates pediatric preva-
lence of 20.0 (95%CI=14.8 to 25.3) cases per million (pm) and an adult
Pediatr Nephrol
prevalence of 539 (95%CI=488 to 590) cases pm in 2012. Prevalence in
children contrasted among regions, being 13.8 pm in the North/Midwest,
16.4 pmin the Northeast, 23.3 pmin Southeast and 27.7 pmin the South.
The main aetiologies of ESRD were indeterminate (38%), CAKUT
(28%), glomerulonephritis (16%), systemic diseases (6%), FSGS (5%),
congenital / hereditary diseases (5%) and other causes (2%). In addition,
1211 children were enrolled for renal transplantation in the study period.
From these, 769 were transplanted, being 657 (85%) performed with
deceased donor. The incidence of deceased donor paediatric transplant in
2012 was 4.1 cases pmand the hazard ratio for achieving a transplant after
2 years in the waiting list was significantly different among regions: a) 1.0
in the North/Midwest (reference), 2.8 in the Northeast, 4.4 in Southeast
and finally 4.5 pm in the South (P<0.001).
Conclusions: Existence of regions in Brazil with lower prevalence of
ESRD and inferior likelihood of transplantation suggests that patients do
not receive equitable health care in different areas of the country. There
are regions with good indicators alongside others with poor performance.
The implementation and evaluation of multicenter school urine
screening in China
Yi-nyu Gong
1
, Q. Shen
1
, Q. Yang
2
, J. Zhou
3
, X. Lei
4
, Jiang-jin Zhou
5
, Q.
Yuan-han
6
, Zhu-wen Yi
7
, Zhen-zhong Gao
8
, Shi-pin Feng
9
, Hai-ming
Liu
10
, Jian-hua Mao
10
, QiuLi
11
, Hong Xu
1
1
Children’s Hospital of Fudan University, Shanghai;
2
Yuying Children's
Hospital of Wenzhou Medical college, Wenzhou;
3
Tongji Hospital of
Central China University, Wuhan;
4
People's Hospital of Gansu, Lanzhou;
5
Ningbo Women and Children Hospital, Ningbo;
6
First affiliated hospital
of Guangxi Medical University, Nanning;
7
Xiangya Second Hospital of
Central South University, Changsha;
8
Weifang Maternity and Child Care
Hospital, Weifang;
9
Chengdu Women’s and Children’s Central Hospital,
Chengdu;
10
Children's Hospital of Medical School of Zhejiang Univer-
sity, Hangzhou;
11
Children's Hospital of Chongqing Medical university,
Chongqing, China
Objective: Understand asymptomatic urine abnormalities among prima-
ry & middle school students and effectiveness of the screening method.
Methods: During Jan 2013 to Dec 2013, urine screening of students of 6-
7 and 12-13 years of age in 11 provinces, municipalities and autonomous
regions were carried out. Urine samples were collected by unified method
and tested by unified urine dipsticks artificially by eyes. The observation
indices included urine occult blood and protein. Those who were positive
should be tested again in 2 weeks by the same method. The screening
method was assessed then.
Results: 1) Screening results: A total of 40,774 primary school students
and 43,394 middle school students completed the screening, the average
positive rate of first test was 8.76 (3.18-16.58%) and 3.18 (3.00-27.16%).
And isolated hematuria (IH) or occult blood, isolated proteinuria (IP),
hematuria associated with proteinuria (IH+IP) accounted 7.62% and
6.78%, 0.87% and 1.67%, 0.27% and 0.53%, respectively. Then the
average positive rate of secondary test was 2.92 (0.31-7.09%) and
0.31(0.34-14.79%). IH, IP and IH+IP accounted 2.56% and 2.56%,
0.26% and 0.80%, 0.11% and 0.38%, respectively. The proportion of IP
and IH+IP was significantly higher in middle school students (P< 0.05).
The positive rate in south cities was similar to foreign reports, while in
north-west, it was high (7.09%and 14.79%in primary and middle school
students), which was similar to the reported data of the large-scale urine
screening among children in the late 1980s in China. 2) Evaluation of
screening method: The school urine screening was conducted with phys-
ical examination of students. And two urine samples tested by dipstick,
the direct cost was <1.8 RMB per person. What’s more, it was easy to
operate, not restricted by device and specific sites and the results were
reliable. Meanwhile, false positives of double tests were significantly
lower than one-time test.
Conclusions: The prevalence of asymptomatic urine abnormalities
among primary and middle school students in China was about 3%,
implementation of school urine screening and follow-up of the positive
detection should be paid attention to. Two urine samples tested by
dipstick were cost-effective, suitable for different medical conditions.
Standard training and quality control were essential as well.
Prevalence and related factors of proteinuria in a primary school
children in Bali
M.A.K. Levina
1
, K. Suarta
1
, G. Nilawati
1
, R. Widiana
2
1
Department of Child Health;
2
Department Internal Medicine Udayana
University Medical School, Sanglah Hospital, Denpasar, Bali, Indonesia
Objectives: The prevalence of proteinuria in children in Indonesia is not
definitely known. The aim of the study is to determine the prevalence and
related factors of proteinuria in primary school children in Bali.
Methods: An analytic cross sectional study was conducted on elementary
schools students in Bali from July 2013 to December 2013. Data were
collected by examination & interviewed using questionnaire. Factors
associated with proteinuria were analyzed using Chi-square test. Multi-
variate analysis was performed to the related factors with P <0.25 on the
bivariate analysis.
Results: One thousand and twenty students participated in this study.
Prevalence of proteinuria was 2.6%. Male gender, 10-12 years age group,
hypertension and renal diseases in parents were related factors for the
occurrence of proteinuria with a significance value P<0.05. Multivariate
analysis showed hypertension was associated with frequency of protein-
uria [OR 4.5, 95% CI 1.2 to 16.9, P=0.02], and 10-12 years age group
also associated with frequency of proteinuria [OR 7.13, 95% CI 1.59 to
32.02, P=0.01].
Conclusion: The prevalence of proteinuria in primary school children in
Bali is 2.6%. Hypertension and 10-12 years age group are factors that
related to frequency of proteinuria in primary school children in Bali. The
prevalence of proteinuria depicts an increasing abnormalities and severity
of renal kidney disease. An early detection of proteinuria by dipstick test
is an important screening for an early marker for renal abnormalities.
Does malnutrition affect kidney size: Comparative study of size
between malnourished and healthy children
S. Gupta, P. Kumar, A. Mehta
Division of Nephrology, Department of Pediatric Medicine, SMS
Medical College, Jaipur, India
Background: Kidney size is an important parameter in the evaluation of
renal growth in children. Nutrition is one of the most important factors
that determines the growth and size of the human body. Poor renal growth
may have some long term consequences. This study planned to study
effect of malnutrition on kidney size in the children under 5-yr of age and
comparing them with healthy children.
Methods
Setting: Tertiary care, Department of Pediatrics and Radiodiagnosis, SMS
Medical College, Jaipur Sample size: With 80% study power and α-error
of 0.05 and assuming standard deviation of 10 mm
3
kidney volume and
minimum difference to be detected of 5 mm
3
, sample size comes to 68
patients in each group as final sample size. Subjects: Of 230 children,
between ages of 6 to 59 months, 137 had severe acute malnutrition (WHO
definition) and 93 were well nourished. Patients with anatomical abnor-
malities of kidneys (hydronephrosis, VUR, renal scars, nephrolithiasis)
and those born premature, small for gestational age or large for gestational
age were excluded. Renal size was measured by ultrasonography by
single observer. Kidney volume (cc) was: Volume = mean length x mean
width x mean depth x 0.523. Left and right kidney volumes were added
for combined kidney volume (cm
3
). Relative kidney volume was calcu-
lated as combined kidney volume/body weight (cm
3
/kg). Body surface
area (BSA) was estimated by Du Bois equation: BSA=body weight
0.425
x
Pediatr Nephrol
body height
0.725
x 0.007184. Kidney volume/body height and kidney
volume/BSA ratios were calculated.
Results: There were 77 (56.2%) males and 60(43.8%) females in mal-
nourished group while 68 (73.1%) males and 25(26.9%) females in
control group. Malnourished children had smaller kidneys than their
healthy controls, mainly affecting kidney length. However, relative renal
volume and renal volume/BSA ratio of children with energy deficiency
was higher than controls. These differences could be due to short stature
and decreased body weight. The strongest correlation was found between
height and kidney size in malnourished children.
Conclusion: Kidney size differences of marasmic children should be kept
in mind while assessing ultrasound imaging. Long-term consequences of
poor renal growth, such as increased risk of hypertension or tendency to
development of chronic renal insufficiency, need to be investigated.
Transplantation
Carotid intima-media thickness of pediatric kidney transplant
recipients
K. Sgambat, S. Clauss, M. Lasota, A. Moudgil
Children's National, Washington DC
Objectives: Increased carotid intima-media thickness (CIMT) is a known
predictor of increased cardiovascular risk in adults, but there are limited
data in pediatric transplant (TX) recipients. A prospective controlled
study was conducted to investigate CIMT of lean and obese children in
predominantly African American (AA) pediatric kidney TX cohort com-
pared to healthy controls as well as change in CIMT over time.
Methods: Pediatric TXrecipients had the following parameters measured
at baseline, 18 and 30 months post TX: CIMT, fasting glucose, HDL,
triglycerides (TG), HbA1c, waist circumference percentile (WC), and
blood pressure (BP). CIMT was measured using B-mode ultrasound
imaging of right and left common carotid arteries and carotid bulbs. TX
with metabolic syndrome (MS) were identified as those with ≥3 of the
following criteria: HbA1c >5.6% or fasting glucose >100, BP >90
th
percentile, central obesity (WC ≥95
th
percentile), HDL <5
th
percentile,
TG> 95
th
percentile. CIMTof Tx recipients were compared to 24 healthy
pediatric controls.
Results: Study group comprised of 28 pediatric kidney TX recipients (8
obese, 20 lean), age 13.1±0.75 yr, 59.2% AA. Controls were 24 healthy
children of similar age and race. CIMT of TX was greater compared to
healthy controls (0.47±0.002 vs. 0.46±0.001, P=0.05). CIMT of AATx
was greater than AA controls (0.49±0.002 vs. 0.47±0.002, P=0.000).
Mean CIMT of TX group improved over time from 0.47±0.002 mm at
baseline to 0.46±0.002 mm at 18 months (P=0.01) and 0.44±0.003 mm
(P=0.000) at 30 months post-tx. Obese TX had greater CIMT than lean
TX (0.48±0.004 vs. 0.46±0.002, P=0.001). TX with MS had greater
CIMT than those without MS (0.49±0.004 vs. 0.46±0.002 mm,
P=0.000). AA TX had greater CIMT vs. non-AA TX (0.49±0.002 vs.
0.43±0.001, P=0.000).
Conclusions: Pediatric kidney TX recipients carry increased CV risk,
particularly those with MS, obesity and AA race. This is the first study to
demonstrate that AAhave higher CIMTcompared with non-AApediatric
TX recipients. Further studies are needed to investigate strategies for
decreasing CIMTafter kidney TX, particularly in higher risk groups.
Prospective trial of attenuated live vaccines in children receiving
immunosuppressants
K. Kamei
1
, I. Miyairi
2
, M. Sato
1
, M. Ogura
1
, R. Ito
3
, T. Kudo
3
, K. Arai
4
,
S. Ito
1
Departments of
1
Nephrology and Rheumatology,
2
Infectious Diseases,
3
Hepatology and
4
Gastroenterology, National Center for Child Health
and Development, Japan
Background: Live vaccines are generally contraindicated in patients
receiving immunosuppressants. However, viral infections such as mea-
sles and chicken pox occasionally result in serious complications in
immunocompromised children, and are sometimes fatal. We have previ-
ously reported the results of a retrospective study of 50 live vaccinations
in children receiving immunosuppressants in ACPN2011. Thereafter, we
conducted a further prospective study.
Methods: Patients receiving immunosuppressants who showed negative
or borderline antibody titers against measles, rubella, chicken pox and/or
mumps, were enrolled. They had to show normal cellular and humoral
immunity (CD4 ≥500/mm
3
, normal lymphocyte blast transformation by
phytohemagglutinin and serumIgG≥300 mg/dl) for enrollment. The IgG
antibody titers against these viruses were measured by enzyme immuno-
assay, defined as <2.0, negative; 2.0–3.9, borderline; ≥4.0, positive. We
monitored the antibody titer at 2 months and 1 year after vaccination.
Adverse events were also monitored. This study was approved by the
ethical committee in our center and we obtained written informed consent
from all parents.
Results: A total of 107 vaccinations were given in 66 patients (41 boys;
47 with nephrotic syndrome, 9 inflammatory bowel disease, 5 collagen
disease, 3 kidney transplantation, and 1 each with IgA nephropathy &
autoimmune hepatitis). Calcineurin inhibitors were used in 29 patients
(27%), antimetabolic agents in 47 (44%) and both in 31 (29%) at
vaccination. Low doses of steroids were used in 18 patients (17%).
Measles–rubella, measles, varicella and mumps vaccines were adminis-
tered in 32, 2, 48 and 25 patients, respectively. The overall seropositivity
rate was 70% (measles 88%, rubella 100%, varicella 60%, and mumps
40%) 2 months after vaccination. In 57 patients who achieved seropos-
itivity, 41(72%) had positive antibody titers 1-yr after vaccination. 87%
patients with antibody titer ≥10 at 2-months had persistent positive
antibody titers at 1 year, compared with 42% of patients with titer
<10.0 (P=0.001). Eight patients (7%) showed vaccine-related adverse
events, including one with varicella–vaccine-related events, and two with
relapse of nephrotic syndrome. However, these adverse events were not
critical.
Conclusion: Immunization with attenuated live vaccines was relatively
safe even in children receiving immunosuppressants. However, more
clinical data are necessary to establish the efficacy and safety.
Preemptive rituximab therapy of Epstein-Barr virus (EBV) infection
to prevent post-transplant lymphoproliferative disease (PTLD)
after pediatric solid organ transplantation (SOT)
Y.H. Ahn
1
, J.M. Lee
1
, Nam-Joon Yi
2
, S.I. Min
2
, H.G. Kang
1
, Il-Soo Ha
1
,
H.I. Cheong
1
, Yong Choi
1
Departments of
1
Pediatrics and
2
Surgery, Seoul National University
College of Medicine, Seoul, Korea
Objectives: More than 90% of pediatric PTLD after solid organ trans-
plantation is associated with EBVinfection. EBVinfection often persists
despite immunosuppression reduction. Following stem cell transplanta-
tion, depletion of the EBV reservoir B cells using RTX is used as
preemptive strategy for PTLD in some centers. The aim of this study
was to assess the efficacy and safety of RTX in prevention of PTLD in
pediatric patients with SOT.
Methods: From September 2013 to July 2014, pediatric recipients of
SOT in Seoul National University Children’s Hospital were studied. We
evaluated EBV DNA load using quantitative PCR assay and if the EBV
load were greater than 10
5
copies/mL or over 10
4
copies/mL for consec-
utive 2 weeks, a single dose of RTX (375 mg/m
2
) was administered.
Results: Nine patients with SOT, 2 kidney, 6 liver, and one kidney-liver
recipient, received preemptive RTX therapy for uncontrolled EBVinfec-
tion. Median age at TPL was 1.2 years (0.3-5.5 years) and median age at
RTX treatment was 2.2 years (0.7-11.7 years). Before SOT, 6 patients
were EBV seronegative and 3 patients were EBV seropositive. Median
EBV viral loads before and after administration of RTX were 56214
Pediatr Nephrol
copies/mL (26464-275349 copies/mL) and 100 copies/mL (0-38082
copies/mL), respectively. In seven patients, EBVviral load was undetect-
able after RTX. After RTX therapy, five patients experienced neutropenia
and 5 patients were admitted for viral or bacterial infection. During
follow-up, rebound of EBV load along with recovery of B cells was
observed in 4 patients.
Conclusions: Preemptive RTXwas effective for reducing EBVviral load
in pediatric recipients of SOT. However, reduction of EBV viral load was
not persistent and side effect of RTX, infection and neutropenia, was
clinically significant.
Tubular disorders
NLRP3 inflammasome mediates albumin-induced renal tubular
injury through impaired mitochondrial function
Y. Zhuang
1,2
, G. Ding
1
, M. Zhao
2
, M. Bai
2
, L. Yang
2
, J. Ni
2
, R. Wang
2
, Z.
Jia
1,2
, S. Huang
1,2
, A. Zhang
1,2
1
Department of Nephrology, Nanjing Children's Hospital, Nanjing;
2
Institute of Pediatrics, Nanjing Medical University, Nanjing, China
Proteinuria serves as a direct causative factor of renal tubular cell injury
and is highly associated with the progression of chronic kidney disease
(CKD) via uncertain mechanisms. Recently, evidence demonstrated that
both NLRP3 inflammasome and mitochondria are involved in the CKD
progression. The present study was undertaken to examine the role of
NLRP3 inflammasome/mitochondria axis in albumin-induced renal tu-
bular injury. In patients with proteinuria, NLRP3 was significantly up-
regulated in tubular epithelial cells and was positively correlated with the
severity of proteinuria. In agreement with these results, albumin remark-
ably activated NLRP3 inflammasome in both in vitro renal tubular cells
and in vivo kidneys in parallel with significant epithelial cell phenotypic
alteration and cell apoptosis. Genetic disruption of NLRP3
inflammasome remarkably attenuated albumin-induced cell apoptosis
and phenotypic changes under both in vitro and in vivo conditions. In
addition, albumin treatment resulted in a significant mitochondrial abnor-
mality as evidenced by the impaired function and morphology, which was
markedly reversed by invalidation of NLRP3/caspase-1 signaling path-
way. Interestingly, protection of mitochondria function by MnTBAP or
CsA robustly attenuated albumin-induced injury in mPTCs. Collectively,
these findings demonstrated a pathogenic role of NLRP3 inflammasome/
caspase-1/mitochondria axis in mediating albumin-induced renal tubular
injury. The discovery of this novel axis provides some potential targets for
the treatment of proteinuria-associated renal injury.
Differential diagnosis of Bartter/Gitelman syndrome
and pseudo-disorder based on clinical characteristics
N. Matsunoshita
1
, K. Nozu
1
, N. Kamiyosh
1
, K. Nakanishi
2
, N.
Yoshikawa
2
, K. Iijima
1
1
Department of Pediatrics, Kobe University Graduate School of Medi-
cine, Kobe;
2
Department of Pediatrics, Wakayama Medical University,
Wakayama, Japan
Objectives: Bartter syndrome (BS) and Gitelman syndrome (GS) are
inherited autosomal recessive, salt-losing tubulopathies characterized by
hypokalemic metabolic alkalosis. Phenotypic overlap occurs between
type III BS and GS, which are difficult to distinguish based on clinical
features. Furthermore, some acquired cases of pseudo-BS/GS (p-BS/GS)
present clinical symptoms identical to BS/GS. Therefore, accurate diag-
noses of these diseases are important, but differences among their clinical
features have rarely been analyzed.
Methods: We retrospectively studied 163 patients (type III BS: 30; GS:
90; p-BS/GS: 43) to establish distinctions between these conditions.
Results: p-BS/GS patients were significantly older at diagnosis than type
III BS and GS patients (P <0.05). Adult patients with p-BS/GS included a
significantly higher percentage of women (P <0.05), and had a lower
body mass index (BMI) (P <0.05) and estimated glomerular filtration rate
(eGFR) (P <0.05) compared with adult GS patients. Furthermore, p-BS/
GS patients had significantly higher serum magnesium levels (P <0.05)
and urinary calcium/ creatinine ratio (P <0.05) than GS patients. Although
hypomagnesemia and hypocalciuria were leading biochemical findings in
patients with GS, five patients with type III BS (16.7%) and 10 with p-
BS/GS (23.3%) also showed hypomagnesemia and hypocalciuria and
only 41 (45.6%) GS patients presented with both hypomagnesemia and
hypocalciuria. Twelve patients with type III BS (40%) presented with
chronic kidney disease (CKD), compared with 11 patients with GS
(12%), and 27 with p-BS/GS (62.8%).
Conclusions: The results of the present study also confirmed the signif-
icant phenotypic overlap in serummagnesiumlevels and urinary calcium/
creatinine ratios and incidence of CKD between these three diseases. Our
results suggest that p-BS/GS usually occurs in adult women with lower
BMI and eGFR. These findings clarify the clinical distinctions among
type III BS, GS and p-BS/GS.
Clinical and genetic features of Chinese patients with Dent disease
Y. Zhang, F. Wang, J. Ding, H. Zhang, Y. Yao
Peking University First Hospital, Beijing, China
Objectives: Dent disease is an X-linked recessive renal tubulopathy,
associated with mutations in either CLCN5 (Dent disease 1) or OCRL
(Dent disease 2). The aim of this study was to analyze the clinical and
genetic features of patients with Dent disease in China.
Methods: We analyzed mutations in CLCN5 and OCRL genes and
clinical phenotype of 9 unrelated Chinese patients with Dent disease.
Results: Of 9 unrelated patients with Dent disease, 7 possessed mutations
in CLCN5 (Dent-1), of which 6 were novel mutations; 2 patients showed
mutations in OCRL (Dent-2), one of which were novel. Two patients had
de novo mutations. Low-molecular-weight (LMW) proteinuria and hy-
percalciuria were found in all the 9 patients. Six patients showed
nephrocalcinosis. In addition, three patients did renal biopsy and the
pathological changes were mesangial proliferative glomerulonephritis,
IgA nephropathy with thin basement membrane disease and minimal
change glomerulopathy, respectively. Two patients with mutations in
OCRL showed no mental retardation.
Conclusions: These results suggest that various renal pathologic changes
can be found in Dent disease. Gene analysis is critical for the diagnosis
and differential diagnosis of Dent-1 and Dent-2.
Urolithiasis in Asian children: evaluation of metabolic factors
M. Naseri
Dr Sheikh Children Hospital, Mashhad University of Medical Sciences,
Iran
Objective: This study was conducted to review urolithiasis in Asian
children with a focus on urinary metabolic factors.
Materials: A literature search of Pub Med and Google identified perti-
nent articles from 20 different Asian countries which were subsequently
reviewed. A totally of 12913 children (M/F ratio of 2.37:1) were enrolled
in the studies.
Results: Hypercalciuria, hyperuricosuria, hyperoxaluria, hypocitraturia
and decreased urinary magnesiumexcretion were reported in 652 of 4509
(14.45%), 276 of 3137 (8.8%), 1053 of 3973 (26.5%), 1940 of 2846
(68.2%), 32 of 240(13.3%) of subjects, respectively. Cystinuria was noted
in 112 of 4106 (2.7%) and mixed metabolic abnormalities were found in
175 of 724 (24.2%) patients. Association of urinary tract infection with
stone disease was common (2454 of 6430; 38.16%). Urologic abnormal-
ities were uncommon and recorded in only 447 of 9788 patients (4.5%).
Pediatr Nephrol
The etiology of stone formation was idiopathic in 731 of 2731 (26.8%)
patients. Analysis of 3977 stones indicated that 983 (24.9%) were pure
calcium; 1579 (40%), 411 (10.4%), 38 (0.95%) and 288 (7.35%) were
mixed calcium, uric acid, cystine and struvite, respectively. The study
showed that hypocitraturia and hyperoxaluria are the most common
metabolic abnormalities. Bladder stones were composed of urate or uric
acid alone or in combination with calcium. Uric acid stones were fre-
quently reported in Asian children.
Urology
Robo2 mutant mice with the inserted piggyback transposon: A new
model for study of VUR
J. Liu, L. Sun, H. Xu, Q. Shen
Department of Nephrology and Rheumatology, Children's Hospital of
Fudan University, Shanghai, China
Objectives: ROBO2 is shown to be important for the urinary develop-
ment process. Robo2 complete knockout mice die shortly after birth due
to severe CAKUT phenotypes and many human studies have found that
ROBO2 gene missense mutations are associated with VUR. So we have
studied a viable and fertile mouse model carrying a PB (PiggyBac)
insertion.
Methods: Robo2 mRNA and protein expressions were evaluated by
Real-time quantitative PCR and Western blot analysis. Noninvasive
ultrasonography was used as a screening method. VUR were tested by
injecting methylene blue into the bladder and observed whether the dye
refluxed up to the ureter. To test for urinary tract obstruction, the renal
pelvis was microinjected with dye and its passage along the urinary tract
was monitored to determine if there was evidence of impaired flowalong
the tract. The histology and ultrastructure of the kidney and ureter was
examined by light microscopy and transmission electron microscopy.
Results: The PBinsertion site in mutants was mapped to the first intron of
the Robo2 gene. The insertion reduces 50% of the Robo2 RNA expres-
sion. Using Vevo 770 micro-ultrasound, we found sever hydronephrosis
with hydroureter in 5.66% (6/106) new born Robo2
PB/PB
mice. Robo2
PB/PB
mice displayed a high frequency 29.56% (60/203) of VUR, com-
paring to 7.87% (10/127) in Robo2
PB/+
mice and 6.38% (6/94) in wild-
type mice. Only Robo2
PB/PB
mice (6.40%, 13/203) displayed sever
hydronephrosis. VUR were the most common cause in hydronephrotic
mice (46.15%, 6/13). HE staining exhibited cystic renal dysplasia in
hydronephrotic kidneys, some dilated tubules had cast. In dilated ureter
a thin layer of epithelium or mesenchymal cells or muscle were found.
Refluxing Robo2
PB/PB
ureters had disorganized smooth muscle fibers at
the level of bladder compared with littermate wild-type controls. Using
transmission electron microscopy, focal foot process effacement was
observed only in Robo2
PB/PB
mice. Large intercellular edematous areas
and intracytoplasmic vacuoles were found in ureters in Robo2
PB/PB
mice.
Conclusions: Robo2
PB/PB
mice simulate the clinical situation more
accurately, the ureters differ from normal ureters in having disorganized
smooth muscle fibers and altered smooth muscle cell structure.
Meta-analysis and clinical controlled trial of the alarm treatment
and desmopressin for children with primary nocturnal enuresis
W. Zhou
1,2
, X. Liu
2
, Y. Shen
2
1
Jinan Children's Hospital;
2
Beijing Children Hospital, Beijing, China
Objective: To find the best therapy for children with primary nocturnal
enuresis (PNE) by meta-analysis on the efficiency of alarm treatment
versus desmopressin and a clinical controlled trail of body-worn, bell,
alarm device and desmopressin treatment.
Methods: Pubmed, Central, Elesvier, CNKI and some other databases
were searched to get all randomized controlled trials comparing alarm
treatment and desmopressin. The results of short-term and long-term
efficacy, compliance were analyzed by Review Manager 5.0. A 6-
month clinical trial was performed with patients from our outpatient
department: patients 6-14 years old with PNE were divided to body-
worn, bell, alarm device and desmopressin treatment groups according to
the visiting sequence. Efficacy, compliance and safety were analyzed
after follow-up at 1, 3, 6 months of the treatments. Efficacy was evaluated
by the decrease of wetting nights. The relationship between efficacy and
compliance, family history, functional bladder capacity and other charac-
teristics were analyzed.
Results: 54 RCTs were retrieved and 11 RCTs were included in the
study. There were no significant differences between alarm treat-
ment and desmopressin when analyzing by no wetting episode,
wetting no more than 1 night per month, wetting nights decrease
more than 90% or wetting nights decrease more than 50%. At 3
months follow-up after treatment stopped, alarm treatment can sig-
nificantly reduce the wetting nights more than 50% or less than 1
night per month than desmopressin. At 6 months follow-up after
treatment stopped, there was no difference between alarm treatment
and desmopressin when analyzed by wetting no more than 1 night.
The relapse rate of desmopressin was higher than alarm treatment.
However, the withdrawal and loss rates of alarm treatment were
higher than desmopressin. Severe adverse effects were not found.
120 patients were included in the controlled trial. On intent-to-
treat analysis, the efficacy with alarm device was better than
body-worn and bell and the efficacy with desmopressin was better
than bell. The efficacy with alarm device was better than body-
worn and bell treatment at 3-months follow up. The efficacy of
alarm device was better than body-worn and bell and the efficacy
with desmopressin was better than bell at 6-months follow up.
Compliance: alarm device was the best and 90% can persist using
it. The compliance of bell was the worst with only 53.3%
persisting on it. The cure time of alarm device (2.6±1.5 months)
was shorter than desmopressin (3.2±2.2 months). The relationship
between clinical characteristics and the efficacy: compliance
(P=0.012, OR=17.7) was the protection factor of the cure and
family history (P=0.024, OR=0.317) was the risk factor.
Conclusion: The meta analysis shows no statistically significant
difference between alarm device and desmopressin in short-term
treatment. The efficiency of alarm device was better than
desmopressin in long-term treatment. The controlled trial shows
that both the alarm device and desmopressin have a high cure rate
and good compliance and safety. The alarm device and
desmopressin can be chosen as first-line treatments. The efficacy
and compliance of the alarm device was the best. The body-worn
and bell have certain effects on children with primary nocturnal
enuresis as the alternative treatments of the alarm device. Patients
and parents need to be counseled before making a treatment
decision.
Synergistic effect of mizoribine and a direct renin inhibitor, aliskiren,
on unilateral ureteral obstruction-induced renal fibrosis in rats
K. Sakuraya
1,2
, A. Endo
2
, T. Someya
2
, D. Hirano
3
, S. Fujinaga
1
, Y.
Ohtomo
2
, T. Shimizu
2
1
Division of Nephrology, Saitama Children’s Medical Center, Saitama;
2
Juntendo University Graduate School of Medicine, Tokyo;
3
The Jikei
University School of Medicine, Tokyo, Japan
Objectives: Renal fibrosis is the major histopathological change ob-
served in a variety of renal disorders and closely related to renal dysfunc-
tion. Unilateral ureteral obstruction (UUO) is a well-established model of
experimental renal disease, which results in tubulointerstitial fibrosis.
Previous studies have shown that both aliskiren and mizoribine (MZR)
Pediatr Nephrol
ameliorate UUO-induced renal fibrosis. However, the protective effect of
combination therapy with aliskiren and MZR against renal fibrosis is
unknown. In this study, we investigated the synergistic effects of combi-
nation therapy with aliskiren and MZR on UUO-induced fibrosis in rats.
Methods: Sprague-Dawley male rats underwent UUO, followed by
treatment with either aliskiren, MZR, or both drugs. Kidney samples
were fixed for histopathology and immunohistochemistry of
myofibroblasts (α-smooth muscle actin; α-SMA) and macrophages
(ED-1). Real-time quantitative reverse transcription polymerase chain
reaction (RT-PCR) was performed to measure the expression of α-
SMA, transforming growth factor-β1 (TGF-β1), osteopontin (OPN),
monocyte chemotactic protein-1 (MCP-1) and renin.
Results: The scores for tubular dilatation, interstitial volume, and α-SMA
expression following UUO were significantly reduced by combination
therapy compared with monotherapy with either aliskiren or MZR. Com-
bination therapy also caused a significant decrease in the number of ED-1
positive cells and expression of TGF-β1 gene compared with monother-
apy with either drug (both P<0.05). Combination therapy also decreased
the expression of OPN and MCP-1 gene (P<0.05).
Conclusion: Combination therapy with aliskiren and MZR provides
increased renal protection against renal fibrosis and UUO-induced in-
flammation. In view of this synergistic protective effect, we suggest that
combination therapy with aliskiren and MZR can be a clinical choice of
early intervention for progressive renal dysfunction.
Pediatr Nephrol