Long-term prognostic analysis of IgA nephropathy with focal segmental glomerulosclerosis in children / 中华肾脏病杂志

Objective:To analyze the long-term prognosis of IgA nephropathy (IgAN) with focal segmental glomerulosclerosis (FSGS) and the risk factors related to renal prognosis in children with IgAN-FSGS.Methods:A retrospective study was concluded in IgAN-FSGS children who were followed up for more than 5 years and diagnosed by renal biopsy for the first time in the Eastern Theater General Hospital from January, 2004 to December, 2018. The end-point events of the study were entering end-stage kidney disease (ESKD) or estimated glomerular filtration rate (eGFR) decreased by ≥50% from baseline, which were defined as poor renal prognosis. Baseline clinicopathologic data of IgAN-FSGS children were compared between the end-point event group and the non-end-point event group. The cumulative renal survival rate of IgAN-FSGS children was calculated by Kaplan-Meier survival analysis. The influencing factors of poor renal prognosis in IgAN-FSGS children were analyzed by Cox proportional hazards model, and the diagnostic value was evaluated by the receiver operating characteristic curve (ROC curve) and area under the curve (AUC). The diagnostic value was verified by time dependent-ROC and time dependent-AUC.Results:A total of 204 IgAN-FSGS children were enrolled in this study, of whom 132 cases were males (64.7%). The median age of renal biopsy was 16 (14, 17) years old. During a median follow-up time of 90.7 (71.7, 114.8) months, 57 cases (27.9%) reached the end-point events. Compared with the non-end-point event group ( n=147), the end-point event group ( n=57) had higher proportions of males and hypertension, higher levels of 24-hour urinary protein, serum creatinine, serum uric acid, urinary N-acetyl-β- D-glucosaminidase, urinary retinol binding protein, higher proportions of glomerular segmental sclerosis (S1) ≥25% and tubular atrophy/interstitial fibrosis (T1/T2), and lower levels of serum albumin, serum IgA, and serum IgG (all P<0.05). There was no statistical difference between the two groups in treatment (all P>0.05). Kaplan-Meier survival analysis showed that with entry of ESKD or eGFR decreased by ≥50% from baseline as the end-point events, the 5-year, 10-year, and 15-year cumulative renal survival rates in IgAN-FSGS children were 88.7%, 67.6%, and 50.7%, respectively. Multivariate Cox regression analysis showed that proteinuria >1 g/24 h ( HR=3.702, 95% CI 1.657-8.272, P=0.001), hyperuricemia ( HR=3.066, 95% CI 1.793-5.245, P<0.001), S1≥25% ( HR=2.017, 95% CI 1.050-3.874, P=0.035), T1/T2 ( HR=1.863, 95% CI 1.021-3.158, P=0.016) were the independent related factors for poor renal prognosis. ROC curve analysis showed that S1≥25% ( AUC=0.605, P=0.021, sensitivity 26.3%, specificity 94.6%), T1/T2 ( AUC=0.624, P=0.006, sensitivity 43.9%, specificity 81.0%), hyperuricemia ( AUC=0.658, P<0.001, sensitivity 52.6%, specificity 78.9%), proteinuria>1 g/24 h ( AUC=0.670, P<0.001, sensitivity 87.7%, specificity 46.3%) could accurately predict the renal outcome of IgAN-FSGS. Time dependent-ROC curve validation showed that the combined diagnosis of S1≥25%, T1/T2, hyperuricemia and proteinuria>1 g/24 h had a good predictive value for renal prognosis (3-year AUC=0.846 and 5-year AUC=0.777, respectively). Conclusions:During a median follow-up of 90.7 months, 27.9% of IgAN-FSGS children have poor renal prognosis, and the 5-year, 10-year, and 15-year cumulative renal survival rates are 88.7%, 67.6%, and 50.7%, respectively. Urinary protein >1 g/24 h, hyperuricemia, T1/T2, and S1 ≥25% are the risk factors for renal prognosis in IgAN-FSGS children.

Effect of tonsillectomy combined with glucocorticoids in the treatment of IgA nephropathy children on long-term clinical remission and renal prognosis / 中华肾脏病杂志

Objective:To investigate the effect of tonsillectomy combined with glucocorticoids therapy on long-term clinical remission and renal prognosis in IgA nephropathy (IgAN) children with recurrent acute onset history of tonsillitis.Methods:The clinical data of children who were diagnosed with primary IgAN from January 2000 to December 2017 in Jinling Hospital were retrospectively analyzed. All participants were treated with long course therapy of glucocorticoids. The children with recurrent acute onset history of tonsillitis were divided into tonsillectomy group and non-tonsillectomy group according to whether to perform tonsillectomy, followed up until the patients' serum creatinine doubled, the estimated glomerular filtration rate decreased by more than 50%, progression to end-stage renal disease, renal replacement therapy or death. The renal survival rate was calculated and compared by Kaplan-Meier method. Univariate and multivariate Cox regression models were used to analyze the effect of tonsillectomy on the renal prognosis of IgAN children.Results:A total of 120 children with IgAN were enrolled in this study, including 40 cases in tonsillectomy group and 80 cases in non-tonsillectomy group. The median follow-up time was 97.5(57.3, 132.0) months. The clinical remission rate in the tonsillectomy group was higher than that in the non-tonsillectomy group (72.5% vs 45.0%, χ2=8.123, P=0.004). The Kaplan-Meier survival curve showed that there was no significant difference in renal survival rate between the two groups (Log-rank test χ2=0.070, P=0.791). Multivariate Cox regression analysis showed that tonsillectomy was not an independent risk factor affecting renal end-point events in IgAN children ( HR=0.986, 95% CI 0.499-1.948, P=0.967). Conclusions:The clinical remission rate of IgAN children undergoing tonsillectomy is higher than that of children without tonsillectomy. Tonsillectomy is not an independent factor affecting renal end-point events in IgAN children. Tonsillectomy does not delay the time of entry into end-stage renal disease for children with IgAN.

Comparison of tacrolimus and mycophenolate mofetil in the treatment of refractory IgA nephropathy children / 中华肾脏病杂志

Objective:To observe the clinical efficacy of tacrolimus (TAC) and mycophenolate mofetil (MMF) in children with refractory IgA nephropathy (IgAN).Methods:The diagnosis of refractory IgAN was defined as urinary protein level ≥ 50 mg·kg -1·d -1 after treatment with renin-angiotensin system (RAS) blocker and prednisone. Following the case-control matching method, 76 children with renal biopsy diagnosed as refractory IgAN in the Jinling Hospital from January 1, 2012 to December 31, 2016 were retrospectively selected, and the children were divided into TAC group (38 cases) and MMF group (38 cases). The 24 h urinary protein quantity (24hUP), serum albumin (Alb), serum creatinine (Scr), serum uric acid (UA), serum glucose (Glu), adverse reactions and treatment effects were compared between the two groups. Results:There were no significant differences in the age, sex ratio, blood pressure, estimated glomerular filtration rate (eGFR), 24hUP, urine red blood cell count (U-RBC), Scr, Alb, BUN, aspartate transarninase (AST), alanine transarninase (ALT), Glu, pathological Oxford classification, and the proportions of big-dose methylprednisolone treatment before using immunosuppressants between the two groups (all P>0.05), and they were comparable. From 3 months after treatment, the 24hUP levels of the two groups were significantly lower than those of the baseline (all P<0.05), and the 24hUP levels of TAC group were lower than those of MMF group at 3, 6 and 12 months (all P<0.05). The Alb level of TAC group was significantly higher than the baseline value from 1 month of treatment ( P<0.05), while the Alb level in the MMF group was significantly higher from 3 months of treatment ( P<0.05). The Alb levels in the TAC group were higher than those in MMF group after 1, 3, and 6 month of treatment (all P<0.05), and there was no significant difference in Alb level at 12 months between the two groups. The total effective rate, complete remission rate and ineffectiveness rate of the TAC group all showed significant differences with the MMF group from 3 month of treatment (all P<0.05), but there was no difference between the two groups during the follow-up period of partial remission rate, point recurrence rate and cumulative recurrence rate (all P>0.05). The TAC group achieved the maximum effective rate at 6 months (94.7%), while the MMF group achieved the maximum effective rate at 12 months (68.4%), and the difference was statistically significant ( χ2=8.756, P=0.003). The incidence of adverse reactions in two groups had not significant difference (15.8% vs 21.1%, χ2=0.350, P=0.554). However, the blood glucose of TAC group was higher than that of MMF group in the third month of treatment, and the difference was statistically significant [5.02(4.72, 5.22) mmol/L vs 4.42 (4.19, 5.07) mmol/L, Z=-2.745, P=0.006]. Conclusion:Both TAC and MMF in the treatment of refractory IgAN result in a good treatment effect in children, but the TAC reaches the response level faster and the response rate is higher.

Progress in pathogenic genes of focal segmental glomerulosclerosis / 中华实用儿科临床杂志

Focal segmental glomerulosclerosis (FSGS) is characterized by the fusion of foot processes of podocytes, and can lead to end-stage kidney disease in children.The pathogenesis of FSGS has not been fully clarified, but more than 30 pathogenic genes have been identified in FSGS patients in recent years with the development of molecular genetics.These findings prove that the destruction of the structure and function of podocytes plays a role in the pathogenesis of FSGS.In this paper, the research progress of common pathogenic genes of FSGS was reviewed.

Clinicopathological and prognostic analysis of children with primary IgA nephropathy with C1q deposition / 中华肾脏病杂志

Objective@#To investigate the clinical and pathological features and prognosis of children with IgA nephropathy with C1q deposition.@*Methods@#The children with IgA nephropathy diagnosed by renal biopsy from January 1, 2000 to December 30, 2017 were retrospectively analyzed and divided into C1q deposit group and C1q negative group according to glomerular immunofluorescence examination. Follow-up until the patient's serum creatinine doubled, glomerular filtration rate decreased by more than 50%, entering end-stage kidney disease, renal replacement therapy or death. Kaplan-Meier survival analysis was used to evaluate the renal survival rate in two groups. Univariate and multivariate Cox proportional hazard regression models were used to analyze the effect of C1q deposition on the prognosis of patients with IgA nephropathy.@*Results@#There were 60 cases in C1q deposition group and 60 cases in C1q negative group. (1) the initial eGFR and plasma albumin in C1q deposition group were lower than those in C1q negative group, while the levels of serum creatinine, serum cholesterol and 24 hour urinary protein in C1q group were higher than those in C1q negative group (all P<0.05). (2) pathological indexes: Mesangial cell proliferation, tubular atrophy/interstitial fibrosis, and cell/fibrocytic crescein score in C1q negative group were significantly higher than those in C1q negative group (all P<0.0.5). (3) Kaplan-Meier analysis showed that there was significant difference in renal cumulative survival rate between the two groups (Log-rank test: χ2=6.801, P=0.009). Cox proportional hazard regression model showed that the risk of renal end-point events in IgAN children with C1q deposition group was 5.772 times higher than that in C1q negative group (HR=5.772, 95%CI: 1.353-24.6211, P=0.018).@*Conclusion@#C1q deposition is an independent risk factor for the progress of renal function in IgA nephropathy children.

Clinicopathological and prognostic analysis of children with primary IgA nephropathy with C1q deposition / 中华肾脏病杂志

Objective To investigate the clinical and pathological features and prognosis of children with IgA nephropathy with C1q deposition. Methods The children with IgA nephropathy diagnosed by renal biopsy from January 1, 2000 to December 30, 2017 were retrospectively analyzed and divided into C1q deposit group and C1q negative group according to glomerular immunofluorescence examination. Follow-up until the patient's serum creatinine doubled, glomerular filtration rate decreased by more than 50％, entering end-stage kidney disease, renal replacement therapy or death. Kaplan-Meier survival analysis was used to evaluate the renal survival rate in two groups. Univariate and multivariate Cox proportional hazard regression models were used to analyze the effect of C1q deposition on the prognosis of patients with IgA nephropathy. Results There were 60 cases in C1q deposition group and 60 cases in C1q negative group. (1) the initial eGFR and plasma albumin in C1q deposition group were lower than those in C1q negative group, while the levels of serum creatinine, serum cholesterol and 24 hour urinary protein in C1q group were higher than those in C1q negative group (all P<0.05). (2) pathological indexes:Mesangial cell proliferation, tubular atrophy/interstitial fibrosis, and cell/fibrocytic crescein score in C1q negative group were significantly higher than those in C1q negative group (all P<0.0.5). (3) Kaplan-Meier analysis showed that there was significant difference in renal cumulative survival rate between the two groups (Log-rank test:χ2=6.801, P=0.009). Cox proportional hazard regression model showed that the risk of renal end-point events in IgAN children with C1q deposition group was 5.772 times higher than that in C1q negative group (HR=5.772, 95％CI: 1.353-24.6211, P=0.018). Conclusion C1q deposition is an independent risk factor for the progress of renal function in IgA nephropathy children.

Long－term observation of RituXimab therapy for children with frequently relapsing nephrotic syndrome / 中华实用儿科临床杂志

Objective To observe the long_term efficacy and adverse reactions of Rituximab( RTX)in the treatment of children with frequently relapsing nephrotic syndrome(PRNS),and to explore the feasible treatment plan of RTX in children with PRNS. Methods PRNS children with RTX[375 mg∕(m2·time),2_3 times]from Depart_ment of Dediatrics,Jinling Hospital,Nanjing Clinical School of Southern Medical University between Pebruary 2011 and December 2017 were retrospectively reviewed,and followed up for 12 _36 months. Age,gender,number of relapses, dose of steroids and immunosuppressants,adverse reactions and laboratory indicators(peripheral blood CD20 ﹢B lympho_cyte count,24_hour urine protein quantification,etc)were observed. Results Thirty_four patients(23 males and 11 females)with PRNS were included in the present study,and the median age for the first RTX treatment was 6 years (2_12 years). After the first treatment,there was complete remission in 34 patients(100%,34∕34 cases),and 12 pa_tients(35%,12∕34 cases)relapsed during follow_up. The number of relapse after treatment[(0. 27 ± 0. 45)times] significantly decreased compared with that before treatment[(2. 94 ± 1. 08)times;t﹦11. 9,P〈0. 05]. After the second treatment,3 children relapsed due to ＂infection＂ and no discomfort was found in the first 6 months;5 of 23 cases (21. 7%,5∕23 cases)relapsed once and 11 were unclear in the following 6 months. There was a difference between the 2 treatment intervals 〈12 months(12. 5%,2∕16 cases)and ≥12 months(55. 5%,10∕18 cases). After the third treatment,with an interval of 6 to 15 months,1 of 15 patients(6. 67%)relapsed and the rest were stable. In addition, there was a significant difference in the mean accumulated steroid dose of 20 patients between 6 months before treatment [(2. 50 ± 0. 87)g ]and 6 months after treatment[(1. 30 ± 0. 97)g;t﹦6. 05,P﹦0. 001]. Of the 15 patients after RTX treatment for 6_12 months Tacrolimus was reduced from[(1. 62 ± 0. 77)mg∕24 h ]to[(0. 62 ± 0. 96)mg∕24 h;t﹦6. 80,P﹦0. 000]. Two patients after RTX first infusion had chest tightness,palpitations,nausea,vomiting,dizzi_ness,and headache,3 cases had mild upper respiratory tract infection and 1 case had severe pulmonary infection. Conclusion Long_term follow_up of PRNS children treated with RTX turns out to be safe and effective.

The early toxic effect sensitive index of short-term-repeated exposure to cadmium chloride in male rats / 中国职业医学

OBJECTIVE: To observe the early adverse effect index caused by short-term-repeated exposure to cadmium chloride via oral perfusion in male rats. METHODS: Forty specific pathogen free healthy male SD rats were randomly divided into four groups: control group,low-,middle-and high-dose groups. The rats of low-,middle-and high-dose groups were treated with cadmium chloride 1. 11,3. 51 and 11. 06 mg/kg body weight,respectively,and the control group rats was treated with the same volume of ultra pure water,by gavage once a day for four weeks. During the experimental duration,the body weights of the rats were taken and activity status of the rats was observed. After the experiment,the rats were executed,and some indicators of main organ coefficients,blood routine,serum biochemical indexes,urine related effect indexes and bone mineral density were measured. RESULTS: During the experimental duration,rats of high-dose group showed the symptoms such as decreased activity,increase repose,move slowly and skin duller. Comparing with control group at the same time points,the body masses of the high-dose group of the 1-4 weeks were lower(P < 0. 05).After the experiment,comparing with control group,the weights of kidney and spleen of the high-dose group decreased significantly(P < 0. 05) and the liver coefficient increased significantly(P < 0. 05). The cadmium levels in blood,urine,liver,kidney and thighbone of the middle-and high-dose groups were higher than those of the control group(P < 0. 05).The red blood cell counts of the low-and middle-dose groups increased significantly(P < 0. 05). The level of hemoglobin of middle-and high-dose groups decreased(P < 0. 05),and the activity of alanine aminotransferase in high-dose groups increased significantly(P < 0. 05). Comparing with control group,the levels of urine α_1-microglobulin and urine β_2-microglobulin in urine of the middle-dose group were decreased(P < 0. 05) and the level of urine urea nitrogen increased(P < 0. 05),but there were no significantly changes of the above three indexes in the high-dose group(P >0. 05). There were no significant difference of the levels of N-acetyl-beta-D glucosaminidase in urine between control and treatment groups(P > 0. 05). Simultaneously,in high-dose group,the weight of thighbone,the bone calcium content and bone mineral density reduced significantly than those of the control group(P < 0. 05). CONCLUSION: Skeletal effects can be used as an early toxic effect sensitive index of short-term-repeated experiments exposure to cadmium chloride via oral perfusion in male rats.

Study on Growth and Toxin Production of Microcystis aeraginosa Strain Under Different Conditions / 环境与健康杂志

Objective To study the impact of temperature, light, nitrogen and phosphorus on growth and microcystin-LR production of Microcystis aeraginosa strain under laboratory conditions. Methods M.aeraginosa strain was cultivated in BG-11 medium. Growth was determined by counting cell, while microcystin-LR was analyzed by high-performance liquid chromatography. Results M.aeraginosa strain had a biggest growth rate at temperature of 25 ℃ and light intensity of 3 000 lx, while microcystin-LR production contents reached maximum at 20 ℃ and 5 000 lx respectively. Under the phosphorus-fixed condition, M. aeraginosa amount and mircrocystin-LR content increased by nitrogen concentration and reached the peak when the nitrogen concentration was 650.0 ?mol/L. But higher concentration of nitrogen could probably restrain the cell growth and toxin production. Under the nitrogen-fixed condition, M. aeraginosa strain grew slowly at phosphorus concentration of 1.43 ?mol/L, but had a higher growth rate when phosphorus concentration was 6.50 ?mol/L. No significant change was found with the increase of phosphorus concentration. And almost similar contents of microcystin-LR produced by M. aeraginosa were observed at different phosphorus concentrations. Positive correlations between total microcystin-LR concentrations and chlorophyll-a contents and M. aeraginosa cell densities were found. Conclusion The optimum conditions for growth and toxin production of M. aeraginosa are not the same. Phosphorus is a probable limitation nutrient factor, and a low concentration will satisfy the growth and toxin production of M. aeraginos. The N∶P atomic ratio at 100∶1 was determined as the optimum for growth and toxin production. The total microcystin-LR concentration can be forecasted by M. aeraginosa cell density or chlorophyll-a content.