Randomized clinical trial to compare efficacy and safety of repeated courses of rituximab to single-course rituximab followed by maintenance mycophenolate-mofetil in children with steroid dependent nephrotic syndrome.

BACKGROUND: Approximately 30% of children with idiopathic nephrotic syndrome develop a complicated course with frequent relapses or steroid dependency. Rituximab, a B cell depleting monoclonal antibody, is a safe and effective alternative to steroids or other immunosuppressants for achieving and maintaining remission in this population at short term. Despite the good initial response relapses inevitably occur after regeneration of B lymphocytes, necessitating either repeat courses of rituximab or addition of another steroid-sparing immunosuppressant. METHODS: This is a prospective, single-center, open-label, two-parallel-arm randomized controlled phase III study among children with steroid dependent nephrotic syndrome who are maintained in remission with oral steroids. One hundred children will be randomized to either Rituximab and maintenance Mycophenolate mofetil (A) or repeated courses of prophylactic Rituximab only (B). In arm A, mycophenolate mofetil (1200 mg/m2 per day) will be started 3 months after Rituximab administration. In arm B, Rituximab infusions will be administered at 0, 8 and 16 months if B cell count normalize at the given time points. Prednisolone will be discontinued in both groups 2 weeks following first course of rituximab. Primary aim is to evaluate the difference in 24-month relapse-free survival. Main secondary endpoints are cumulative prednisolone dose, frequency of relapses and changes in anthropometry. Circulating B lymphocyte populations will be studied as biomarkers or predictors of rituximab responsiveness and adverse events will be analysed. DISCUSSION: The study will provide evidence as to the comparative safety and efficacy of two alternative steroid-sparing therapeutic options in children suffering from steroid dependent nephrotic syndrome. The two-year study design will address the long-term results obtained with the alternative treatment protocols. TRIAL REGISTRATION: This trial was prospectively registered to the Clinicaltrial.gov ( NCT03899103 dated 02/04/2019; https://clinicaltrials.gov/ ) and Clinical Trials Registry of India ( CTRI/2019/04/018517 dated 09/04/2019).

Efficacy of Rituximab vs Tacrolimus in Pediatric Corticosteroid-Dependent Nephrotic Syndrome: A Randomized Clinical Trial.

Importance: Calcineurin inhibitors are an established first-line corticosteroid-sparing therapy for patients with corticosteroid-dependent nephrotic syndrome (CDNS), whereas B-lymphocyte-depleting therapy is mostly used as a rescue for calcineurin inhibitor-resistant cases. The positive efficacy and safety profile of rituximab raises the question of whether it could be used as a first-line alternative to calcineurin inhibitor therapy. Objective: To compare the efficacy of rituximab and tacrolimus in maintaining relapse-free survival among children with CDNS. Design, Setting, and Participants: A parallel-arm, open-label, randomized clinical trial was performed from May 8, 2015, to September 20, 2016, with 1-year follow-up in a single-center, tertiary care unit. A total of 176 consecutive children aged 3 to 16 years with CDNS not previously treated with corticosteroid-sparing agents were screened for eligibility. Interventions: The children received either tacrolimus (along with tapering alternate-day prednisolone) for 12 months or a single course of rituximab (2 infusions of 375 mg/m2). Main Outcomes and Measures: Twelve-month relapse-free survival in the intention-to-treat population. Results: Of the 176 children screened for eligibility, 120 were randomized and all but 3 patients completed 1 year of follow-up. The groups were comparable, with mean (SD) age of 7.2 (2.8) years, 32 boys (53.3%) in each group, mean (SD) disease duration of 2.5 (1.5) years and 2.3 (1.7) in the tacrolimus and rituximab groups, respectively, disease duration less than 1 year among 15 children (25.0%) in each group, median (interquartile range) of 4 (3-5) relapses in each group, and mean (SD) cumulative prednisolone dose of 246 (48) mg/kg and 239 (52) mg/kg in the prestudy year in the tacrolimus and rituximab groups, respectively. Rituximab therapy was associated with a higher 12-month relapse-free survival rate than tacrolimus (54 [90.0%] vs 38 [63.3%] children; P < .001; odds ratio, 5.21; 95% CI, 1.93-14.07). Among the patients who experienced relapse, median time to first relapse was 40 weeks in the rituximab group and 29 weeks in the tacrolimus group. Only 2 patients in the rituximab group had more than 1 relapse during the study period compared with 10 patients in the tacrolimus group. The cumulative corticosteroid dose during the 12-month study period was lower with rituximab compared with tacrolimus (mean [SD], 25.8 [27.8] vs 86.3 [58.0] mg/kg). Although both treatments were well tolerated, mild to moderate infections were twice as common in the tacrolimus group (26 [43.3%] vs 13 [21.7%] events). Conclusions and Relevance: In children with CDNS, rituximab appears to be more effective than tacrolimus in maintaining disease remission and minimizing corticosteroid exposure and, given its good tolerability and lack of nephrotoxic effects, may be considered as first-line corticosteroid-sparing therapy. Trial Registration: ClinicalTrials.gov Identifier: NCT02438982; Clinical Trial Registry of India: CTRI/2014/01/004355.

Long-term efficacy and safety of common steroid-sparing agents in idiopathic nephrotic children.

BACKGROUND: Calcineurin inhibitors (CNI), mycophenolate mofetil (MMF), and levamisole are common treatment choices for patients with frequently relapsing (FRNS) and steroid-dependent nephrotic syndrome (SDNS). METHODS: In this retrospective cohort study, we analyzed the relative efficacy and safety of tacrolimus, MMF, and levamisole over a period of 30 months, in treating 340 children with idiopathic FRNS/SDNS. The children received either MMF 1200 mg/m2 daily, or levamisole 2.5 mg/kg on alternate days, or tacrolimus 0.1-0.2 mg/kg daily along with tapering doses of alternate-day prednisolone. RESULTS: Tacrolimus was associated with a higher rate of 30-month relapse-free survival when compared to MMF (61.7 vs. 38.5 %, p < 0.001), or levamisole (61.7 vs. 24 %, p < 0.001). However, relapse rate increased almost threefold once tacrolimus was stopped, resulting in a higher relapse rate per patient-year when compared to the MMF group (2.0 vs. 1.5, p = 0.013). The cumulative prednisolone dose per patient during the last year of the study period was also increased among tacrolimus group in comparison with MMF group (96.4 vs. 74.4 mg/kg/year, p = 0.004). Independent of the impact of drug choice, the relapse risk was higher in patients with steroid dependency at baseline (HR 2.14, 95 %CI 1.79-2.96, p < 0.0001). In comparison with few minor adverse events in other two cohorts, several serious adverse events were documented in the tacrolimus group. CONCLUSIONS: Although there are serious safety concerns regarding tacrolimus, it is more effective than MMF or levamisole in maintaining relapse-free survival. However, unlike MMF, the relative efficacy of tacrolimus in preventing further relapses is seen only when the patient is on the drug. Taking together the long-term efficacy and safety data observed, MMF appears as a safe and effective alternative to tacrolimus in managing pediatric FRNS/SDNS.

Mycophenolate Mofetil Following Rituximab in Children With Steroid-Resistant Nephrotic Syndrome.

BACKGROUND: Rituximab is being increasingly used in children with idiopathic nephrotic syndrome resistant to standard treatments. In spite of good initial response, rituximab responders always remain prone to further relapse, necessitating either repeat course of rituximab or addition of another steroid-sparing immunosuppressant. METHODS: A retrospective analysis of baseline clinico-pathologic presentation and treatment outcome (complete remission, partial remission, or no response) was performed among 24 children with refractory-idiopathic SRNS over a follow-up period of 24 months. Children received 2 to 4 rituximab infusions (375 mg/m(2) weekly) depending on circulating B-cell level. At 3-month follow-up, a second course of rituximab was administered (if >5 B cells/mm(3)) along with MMF (1200 mg/m(2) per day) maintenance therapy. RESULTS: Of 24 patients, 54% (13/24) and 46% (11/24) had minimal change disease and focal segmental glomerulosclerosis, respectively, on renal histopathology. After the first course of rituximab, 21% (5/24) of children achieved complete remission; however, most (4/5) of them relapsed again at a median interval of 53 (interquartile range 46-72) days. Depending on response to the first course of rituximab, MMF was started on 15 children at 3 months. After 6 months, 67% (10/15) of children on MMF achieved complete remission and 33% (5/15) remained at partial remission. At 24 months overall, 25% (6/24) and 42% (10/24) of children were in complete remission and partial remission, respectively; 33% (5/15) of children continued sustained complete remission after postrituximab-MMF maintenance therapy in comparison with no sustained complete remission with rituximab alone at 24 months (P < .001). CONCLUSIONS: MMF may be an effective and safe maintenance therapy to consider as an additive immunosuppressant after induction with rituximab in maintaining remission among children with refractory SRNS.

WITHDRAWN: Efficacy and Safety of Mycophenolate Mofetil Versus Levamisole in Children and Adolescents With Idiopathic Nephrotic Syndrome: Results of a Randomized Clinical Trial.

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Favourable renal survival in paediatric microscopic polyangiitis: efficacy of a novel treatment algorithm.

BACKGROUND: Microscopic polyangiitis (MPA) is one of the most common forms of antineutrophil cytoplasm autoantibodies (ANCA)-associated vasculitis in children. Cyclophospamide and glucocorticoid-based treatment protocols are still considered gold standard in managing this multi-system disorder. But treatment-related toxicity is a major cause of chronic morbidity and early mortality in MPA. Hence, the search for an effective and safe alternative immunosuppressant is essential. METHODS: A retrospective analysis of baseline clinico-pathological presentation and treatment-outcome was performed among 11 paediatric MPA patients. All of whom were treated with a pre-specified cyclophosphamide free, rituximab- and mycophenolate mofetil (MMF)-based management protocol as per centre practice. RESULTS: We describe the clinical course of 11 children with MPA over a median follow-up period of 20.9 months. Both patient survival and renal survival at 1 year follow-up were 100%. In spite of the varying degree of renal involvement at presentation, kidney function was recovered in all patients with a median estimated glomerular filtration rate (eGFR) of 79.5 mL/min/1.73 m(2). At last follow-up, 91% (10/11) of patients were in complete remission and one (9%) child continued partial remission state. There was no treatment failure. In total, 73% (8/11) of patients were off steroids at last follow-up and 82% (9/11) of patients never relapsed during follow-up period. CONCLUSIONS: Efficacy and medium-term safety of rituximab- and MMF-based protocol in managing children with MPA was evident in this study.

Factors predicting mortality in newborn ventilation.

OBJECTIVE: Prediction of mortality among newborns on mechanical ventilation is difficult. Our aim was to develop a scoring system for predicting mortality among such neonates. METHODS: This multi centre prospective study was performed to develop and validate a scoring system among two equal cohorts of ventilated newborns in India. Mechanical ventilator was used in pressure-limited time-cycled mode. Arterial blood gas, initial pulmonary pressures, septicemia screen along with other basic parameters were recorded in a pre-structured proforma. Blood samples were analyzed for malondialdehyde to determine the possible role and predictive validity of free radical injury. Multiple logistic regression analysis was done to find out independent predictors of mortality for the variables those were significantly associated with outcome after univariate analysis. RESULTS: On univariate analysis, birth-weight, oxygenation-index, septicaemia, malondialdehyde level, and inotropic support were significantly associated with mortality. However, after multiple regression analysis gestational-age, pH and FiO2 lost their significance as predictors. According to cut-off values of ROC-curve, a scoring system ranging from 0 to 20 and four mortality risk groups were developed. Area under ROC-curve was 0.94, compared to 0.90 for both APACHE-III and CRIB-scores; and 0.92 for PRISM-score. CONCLUSIONS: Birth-weight, oxygenation-index, malondialdehyde level, inotropic support, and septicemia are independent mortality predictors of neonatal ventilation. Increase in malondialdehyde level is associated with higher mortality rate, indicating possible role of free radical injury. Pediatr Pulmonol. 2015; 50:271-275. © 2014 Wiley Periodicals, Inc.

Ellis van Creveld syndrome with unusual association of essential infantile esotropia.

Ellis-van Creveld syndrome is a rare short-limbed disproportionate dwarfism characterized by postaxial polydactyly, several skeletal, oral mucosal and dental anomalies, nail dysplasia and in 50-60% cases of congenital cardiac defects. It is an autosomal recessive disorder with mutations of the EVC1 and EVC2 genes located on chromosome 4p16. Patients with this syndrome usually have a high mortality in early life due to cardiorespiratory problems. We present the case of a six- month-old female infant with Ellis-van Creveld syndrome - essential infantile esotropia, which has been infrequently documented in the literature.

Lipomodelling of the breast: a review.

BACKGROUND: Autologous fat transplantation has been used to correct cosmetic deformities in almost all areas of the body. In recent years, there has been a resurgence of interest in the use of fatty tissue to fill defects resulting from breast conserving surgery (BCS) and asymmetries after reconstructive breast surgery. METHODS: A Medline database search was performed, and the published evidence was reviewed. RESULTS & CONCLUSION: We describe and discuss the technique and indications, advantages, disadvantages and future direction of fat transfer to the breast. SEARCH METHODOLOGY: A Medline database search was used to retrieve relevant literature. Key search words used were: breast fat transfer, fat auto-transplantation, adipose tissue injection and lipomodelling. As a number of original articles are in French these were translated and used in addition to the English publications.

Early results of inguinal hernia repair by the 'mesh plug' technique--first 200 cases.

INTRODUCTION: Inguinal hernia repair is the most common surgical procedure performed in the UK. Evidence from several earlier studies suggests that primary inguinal hernia repair has a high recurrence rate of 10-15%. The Royal College of Surgeons of England guidelines suggested the use of layered suture (Shouldice) or prosthetic (Lichtenstein) repair. Per-fix plugs have been used in the US for more than a decade with excellent results. This study was a series of 200 consecutive cases. The aim was to evaluate the mesh plug technique in the repair of all types of inguinal hernias and its results in one consultant practice within a district general hospital. PATIENTS AND METHODS: In a 15-month period between 1997 and 1998, all patients with inguinal hernias presenting to the general surgical clinic of one consultant were recruited to the study. All had mesh plug repair under local (n = 40), regional (n = 50) or general (n = 110) anaesthesia either by the consultant, associate specialist or specialist registrar (following initial training), using the same standard technique. The majority 80% (n = 160) were done as day cases. The results were evaluated by questionnaire and personal outpatient review initially at 3 weeks, then at 1 year (9-13 months). RESULTS: 200 consecutive patients with inguinal hernias underwent mesh plug repair; mean age was 54 years (95% CI, 46-61). The majority of patients had primary (n = 180) and others had recurrent (n = 20) hernia. All types of hernia (Gilbert's I-VII) were included. Median follow-up was 1 year (9-15 months). Groin pain, which was the leading symptom at presentation, was relieved in 96% of the patients; 79% returned to previous jobs within 4 weeks (95% CI, 0.71-0.87). All retired patients resumed normal life activities within 2 days. Postoperative pain was minimal; 28 patients did not require any postoperative analgesia. There were very few minor (n = 6) and no major complications. During the follow-up, one recurrence occurred. CONCLUSIONS: Mesh plug repair is associated with minimal postoperative pain, quick recovery and return to work. It is an ideal technique for day-case surgery. Although longer follow-up will be required to assess true recurrence rate, so far the recurrence rate at 0.5% is acceptable, particularly in the light of other published series.