NS in Childhood.pdf

Management of Childhood Onset Nephrotic Syndrome

abstractThe therapeutic approach to childhood nephrotic syndrome is basedon a series of studies that began with an international collaborativeeffort sponsored by the International Study of Kidney Disease in Chil-dren in 1967. The characteristics of children presenting with nephroticsyndrome have changed over recent decades with greater frequencyof the challenging condition focal segmental glomerulosclerosis and agreater prevalence of obesity and diabetes mellitus, which may beresistant to glucocorticoids in the former and exacerbated by long-term glucocorticoid therapy in the latter 2 conditions. The ChildrensNephrotic Syndrome Consensus Conference was formed to systemati-cally review the published literature and generate a childrens primarynephrotic syndrome guideline for use in educational, therapeutic, andresearch venues. Pediatrics 2009;124:747757

Idiopathic nephrotic syndrome affects 16 in 100 000 children, makingthis condition one of the more common childhood kidney diseases. Thetherapeutic approach to childhood nephrotic syndrome is based onstudies that began with the International Study of Kidney Disease inChildren (ISKDC). Between 1967 and 1974, 521 children with nephroticsyndrome entered into this study with a histologic classification ofminimal change (MCNS) (77.1%), focal segmental glomerulosclerosis(FSGS) (7.9%), membranoproliferative glomerulonephritis (6.2%), andothers (8.8%).1,2 Normalization of urine protein levels with 8 weeks ofglucocorticoid therapy was predictive of MCNS with a sensitivity of93.1% and specificity of 72.2%.2 Consequently, pediatricians began us-ing therapeutic response to glucocorticoids for evaluation and therapyfor incident patients.

The sentinel work of the ISKDC followed by a series of studies by theArbeitsgemeinschaft fur Padiatrische Nephrologie (APN) formed thefoundation for management of children with nephrotic syndrome.35

The characteristics of children presenting with nephrotic syndromehave changed over recent decades. Contemporary literature has doc-umented an increasing incidence of FSGS-induced nephrotic syndromein the 1990s compared with that of the 1970s.6 FSGS is less responsiveto glucocorticoids and has greater risk for progressive kidney failurecompared with the MCNS that dominated the ISKDC cohort.2,7 Fur-thermore, children in the United States have a greater prevalence ofobesity and diabetes mellitus compared with children of previous de-cades, which may be exacerbated by long-term glucocorticoid thera-py.8,9 The Childrens Nephrotic Syndrome Consensus Conference wasformed to assess current evaluation and management practices forchildren with nephrotic syndrome among North American Pediatric

CONTRIBUTORS: Debbie S. Gipson, MD, MS,a Susan F. Massengill,MD,b Lynne Yao, MD,c Shashi Nagaraj, MD,d William E. Smoyer,MD,e,f John D. Mahan, MD,f Delbert Wigfall, MD,g Paul Miles, MD,h

Leslie Powell, RN, CPNP,a Jen-Jar Lin, MD, PhD,d,i HowardTrachtman, MD,j and Larry A. Greenbaum, MD, PhDk

aDivision of Nephrology and Hypertension, Department ofMedicine and Pediatrics, University of North Carolina, ChapelHill, North Carolina; bPediatric Nephrology, Levine ChildrensHospital at Carolinas Medical Center, Charlotte, North Carolina;cDepartment of Pediatric Nephrology, Inova Fairfax Hospital forChildren, Falls Church, Virginia; dDepartment of PediatricNephrology, Wake Forest University Medical Center, Winston-Salem, North Carolina; eDepartment of Pediatric Nephrology,University of Michigan, Ann Arbor, Michigan; fDepartment ofPediatric Nephrology, Nationwide Childrens Hospital, Columbus,Ohio; gDivision of Nephrology, Department of Pediatrics, DukeUniversity Medical Center, Durham, North Carolina; hAmericanBoard of Pediatrics, Chapel Hill, North Carolina; iDepartment ofPediatric Nephrology, East Carolina University, Greenville, NorthCarolina; jDepartment of Pediatric Nephrology, SchneiderChildrens Hospital, New Hyde Park, New York; and kDepartmentof Pediatric Nephrology, Emory University and ChildrensHealthcare of Atlanta, Atlanta, Georgia

KEY WORDSproteinuria, pediatric, nephrosis, kidney disease

ABBREVIATIONSISKDCInternational Study of Kidney Disease in ChildrenMCNSminimal-change nephrotic syndromeFSGSfocal segmental glomerulosclerosisUp/curine protein/creatinine ratioBIDtwice dailyACE-Iangiotensin-converting enzyme inhibitorARBangiotensin receptor blockerHMG-CoA3-hydroxy-3-methylglutaryl coenzyme A

www.pediatrics.org/cgi/doi/10.1542/peds.2008-1559

doi:10.1542/peds.2008-1559

Accepted for publication Nov 26, 2008

Address correspondence to Debbie S. Gipson, MD, MS, Universityof North Carolina, Division of Nephrology and Hypertension, 7012Burnett Womack Building, CB 7155, Chapel Hill, NC 27599-7155.E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2009 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

SPECIAL ARTICLES

PEDIATRICS Volume 124, Number 2, August 2009 747 at Indonesia:AAP Sponsored on February 7, 2015pediatrics.aappublications.orgDownloaded from

http://pediatrics.aappublications.org/

Nephrologists,10 systematically reviewthe published literature, and generatea childrens primary nephrotic syn-drome guideline for use in educa-tional, therapeutic, and researchvenues.

METHODS

Participating sites were gatheredfrom the Southeast and Midwest Pedi-atric Nephrology study groups. Onerepresentative from each center wasasked to represent the institution forthe consensus conference and subse-quent meetings by conference call.Participants (along with their institu-tions) are listed as authors.

A literature search was conducted byusing the PubMed search engine.English-language literature generatedfrom North America, Europe, and Asiawas identified by using the key wordsnephrotic syndrome, proteinuria,and child. A total of 709 articles wereidentified. Simultaneously, membersof the consensus group were asked tosubmit a list of key articles relevant tothe topic of childhood nephrotic syn-drome that were used to validate andaugment the PubMed search. Articleswith original scientific investigation,clinical trials, cohorts, and case-control studies were retained for a to-tal of 344 articles.

The consensus study group was di-vided into working groups to reviewthe literature and present guidelinerecommendations to the full studygroup for discussion at the June 21,2007, Childrens Nephrotic SyndromeStudy Group Consensus Conferenceheld in Chapel Hill, North Carolina, andduring subsequent conference callsthrough July 30, 2007. The charge tothe consensus participants was to cre-ate a consensus document and educa-tional module for childhood nephroticsyndrome on the basis of literaturewhen available andwith expert opinion

when the literature was insufficient.All recommendations were generatedby the physician participants and werenot subject to previous review by thefunding agency.

This document was designed for physi-cians who manage children 1 to 18years old with:

a urine protein/creatinine ratio(Up/c) of 211; and

a serum albumin level of 2.5mg/dL.

On presentation, the evaluation of achild with proteinuria includes a thor-ough review for signs and symptomsthat may suggest that the nephroticsyndrome is a secondary condition.Malar rash, adenopathy, arthritis, fe-vers and weight loss may be signs ofsystemic lupus erythematosus, anddiffuse lymphadenopathy and hepato-splenomegaly may suggest lymphoma.These disorders require a differentevaluation andmanagement approachand will not be considered within thisdocument.

EVALUATION OF CHILDREN WITHNEPHROTIC SYNDROME

Recommendations for initial evalua-tion include:

urinalysis;

first morning Up/c;

serum electrolytes, serum urea ni-trogen, creatinine, and glucose;

cholesterol level;

serum albumin level;

complement 3 level;

antinuclear antibody level (forchildren aged 10 years or withany other signs of systemic lupuserythematosus);

hepatitis B, hepatitis C, and HIV se-rology in high-risk populations;

purified protein derivative level; and

kidney biopsy for children aged12 years.

A urinalysis with microscopy is recom-mended for identifying hematuria, cellu-lar casts, or other evidence of nephritis,which should precipitate evaluation forglomerulonephritis rather than primarynephrotic syndrome. First morning Up/cwill establish the degree of proteinuriawithout the contribution of benign ortho-static increases in urinary protein excre-tion. Complement 3 and antinuclear anti-body screen for proteinuric diseasesassociated with hypocomplementemia,including membranoproliferative glo-merulonephritis and systemic lupus ery-thematosus, which require additional in-vestigation with laboratory tests andkidney biopsy.

A kidney biopsy for children over theage of 12 is recommended because ofthe frequency of diagnoses other thanminimal-change disease. Figure 1 pre-sents a summary of 223 kidney biop-sies obtained between 2001 and 2006from a southeast regional referralcenter showing that FSGS accounts forthe majority of kidney diseases in chil-dren undergoing biopsy for protein-uria in this region.

DEFINITIONS

The following are terms commonly usedfor nephrotic syndromemanagement.Remission: Up/c 0.2 or Albustix-negative (Albustix, Miles, Inc, Diagnos-tics Division, Elkhart, IN) or trace for3 days.Relapse: After remission, an increasein the first morning Up/c to 2 or Al-bustix reading of 2 for 3 of 5 consec-utive days.Frequently relapsing: 2 or more re-lapses within 6 months after initialtherapy or 4 relapses in any 12-month period.Steroid dependent: Relapse duringtaper or within 2 weeks of discontinu-ation of steroid therapy.Steroid resistant: Inability to induce aremission with 4 weeks of daily steroidtherapy.

748 GIPSON et al at Indonesia:AAP Sponsored on February 7, 2015pediatrics.aappublications.orgDownloaded from


Discrepancies in the definition ofsteroid-resistant nephrotic syndromecreate difficulties for comparing out-comes for reported treatment strate-gies.2,12,13 On the basis of the ISKDCstudy, 95% of children with steroid-responsive nephrotic syndrome willdemonstrate resolution of proteinuriawith 4 weeks of daily glucocorticoidtherapy and 100% after an additional 3weeks of alternate-day therapy.2 Thisconsensus guideline uses a 4-weekoral glucocorticoid limit to define ste-roid resistance; however, therapy maybe continued during the subsequentevaluation for steroid-resistant ne-phrotic syndrome, allowing the cap-ture of late responders. Glucocorticoiddosing is presented as mg/kg and mg/m2. Published studies in childhood ne-phrotic syndrome have included glu-cocorticoid dosing with either mg/kgor mg/m2 regimens. Actual prescribeddose will vary on the basis of the stan-dard used, especially at the extremesof weight, but no literature exists toprove that 1 scheme is more effectivethan the other.

THERAPY

Initial Therapy for ChildhoodNephrotic Syndrome

prednisone 2 mg/kg per day for 6weeks (maximum: 60 mg);

thenprednisone1.5mg/kgonalternatedays for 6weeks (maximum: 40mg);

no steroid taper is required at theconclusion of this initial therapy.5

The initial therapy for nephrotic syndromeinchildren isbasedonthestudiessumma-

rized in Fig 2. This series of studies evalu-ated initial prednisone exposure rangingfrom 4 to 28 weeks.25,14,15 The 12-weektreatment regimen including 6 weeksof prednisone at 60 mg/m2 per day (2mg/kg per day) plus 6 weeks at 40mg/m2 (1.5mg/kg) on alternate days isrecommended by this consensuspanel because of maximum effect andminimization of glucocorticoid-relatedadverse effects.5,1518 Results of severalstudies in India, Europe, and Japanhave challenged this course of therapywith a long treatment taper, additionof cyclosporine, and lower initial dailyprednisone doses of 40 mg/m2 per daybut have not demonstrated significantimprovements in sustained remissionover the traditional 12-week regi-men.14,16,18,19 Cessation of prednisone after12weekswithout a taperhasnodisadvan-tage and may limit the negative effects ofprolonged courses of prednisone. A 24-month sustained remission rate of 49%and frequent-relapse rate of 29% is ex-pectedwith this regimen.

Initial or Infrequent-RelapseTherapy

prednisone 2 mg/kg per day untilurine protein test results are nega-tive or trace for 3 consecutive days;

then prednisone 1.5 mg/kg on alter-nate days for 4 weeks.

FIGURE 1Kidney biopsy results from 223 children with proteinuria referred for diagnostic kidney biopsy (Glo-merular Disease Collaborative Network, J. Charles Jennette, MD, Hyunsook Chin, MS, and D. S. Gipson,2007). n number of patients. MPGN indicates membranoproliferative glomerulonephritis; C1Q,nephropathy.

FIGURE 2Summary of early published trials of initial therapy studies for primary nephrotic syndrome inchildren. APN indicates Arbeitsgemeinschaft fur Padiatrische. CyA indicates cyclosporine A and Predindicates prednisone.

SPECIAL ARTICLES



Treatment of the nephrotic syndromeinitial or infrequent relapse requiresconsiderably less glucocorticoids thaninitial therapy. Glucocorticoids (2 mg/kgper day prednisone equivalent) continueuntil urine protein levels normalize for 3days. The dose is then reduced to alter-nate days for 4 weeks.20

Frequently Relapsing NephroticSyndrome Therapy Options

prednisone 2 mg/kg per day untilproteinuria normalizes for 3 days,1.5 mg/kg on alternate days for 4weeks, and then taper over 2months by 0.5 mg/kg on alternatedays (total: 34 months);

oral cyclophosphamide 2 mg/kg perday for 12 weeks (cumulative dose:168 mg/kg) based on ideal bodyweight started during prednisone(2 mg/kg per day) induced remis-sion, decrease prednisone dose to1.5 mg/kg on alternate days for 4weeks, and then taper over 4 weeks;

mycophenolate mofetil 25 to 36 mg/kgper day (maximum: 2 g/day) dividedtwice daily (BID) for 1 to 2 years with atapering dose of prednisone; and

cyclosporine A 3 to 5 mg/kg per day di-vided BID for an average of 2 to 5 years.

Patients with frequently relapsing ne-phrotic syndrome have treatment op-tions that include extended dosing ofglucocorticoids, cytotoxic agents, myco-phenolate mofetil, or calcineurin inhibi-tors. When glucocorticoids have not pro-duced signs of toxicity, this therapy maybe continued with an extended dosingregimen. Clear data regarding the opti-mal extended course of prednisone or,indeed, any other of the therapeutic op-tions for frequently relapsing nephroticsyndrome have not been published; con-sequently, these recommendations arelargely based on opinion.

Cytotoxic agents, including cyclophos-phamide or chlorambucil, used in com-bination with glucocorticoids have beendemonstrated to induce a sustained

remission of 72% at 2 years and 36% at5 years in frequently relapsingnephroticsyndrome.21 On the basis of a meta-analysis from pediatric nephrotic syn-drome studies, cytotoxic agents have asignificant toxicity profile including 1%fatality, 1.5% severe bacterial infections,and 0.2% to 0.6% late malignancy. Up to3% of patients receiving chlorambucilhave reported seizures. Reduced fertilityafter cytotoxic therapy has been de-scribed. Compared with cyclophospha-mide, chlorambucil is associated with aslightly greater toxicity profileandno im-provement in efficacy.21

A 6-month course of mycophenolatemofetil with a tapering dose of alternate-day prednisone induced remission in75% of 33 patients during therapy andmaintained in 25%after therapywasdis-continued.22 The relapse rate in thesepa-tients improved from 1 episode every 2monthsbeforemycophenolatemofetil to1 every 14.7 months during therapy.22

Cyclosporine for 2 to 5 years has re-sulted in60%remissionduring the initialyear of therapy.23,24 Remissionwasmain-tained in only 28% of children duringthe second year of cyclosporine.25 Up to40% of patients may need additionalalternate-day prednisone to maintainremission. There is a high rate of re-lapse after cyclosporine withdrawal.25

The nephrotoxic effects of cyclosporinewarrant careful monitoring of kidneyfunction and blood drug levels. Tacro-limus, an alternative calcineurin in-hibitor, provides no advantage re-garding nephrotoxicity profile. The riskfor nephrotoxicity attributable to cal-cineurin inhibitors makes this a third-line option for frequently relapsing ne-phrotic syndrome.23,25,26

Steroid-Dependent NephroticSyndrome Therapy

glucocorticoids are preferred in the ab-sence of significant steroid toxicity;

secondary alternatives should be cho-sen on the basis of risk/benefit ratio;

cyclosporine A 3 to 5 mg/kg per daydivided BID;

tacrolimus 0.05 to 0.1mg/kg per daydivided BID; and

mycophenolate mofetil 24 to 36mg/kg per day or 1200 mg/m2 perday divided BID (maximum: 2 g/day).

Steroid-dependent nephrotic syndromeoccurs in 24% of children with ne-phrotic syndrome.27 Some childrencan maintain a remission with low-dose glucocorticoids given daily or onalternate days, but many continue torelapse. Steroid-induced adverse ef-fects, such as obesity, hypertension, andcataracts, develop in a significant pro-portionofpatientsandpromptcliniciansto search for steroid-sparing therapies.

There have been no randomized, con-trolled trials reported in the English-language literature that addresssteroid-free protocols for steroid-dependent nephrotic syndrome. For 1European study an improved outcome-with the glucocorticoid deflazacortcompared with prednisone in 40 chil-dren was reported.28 Deflazacort is notavailable in the United States. Use ofcyclosporine, levamisole, mycopheno-latemofetil,mizoribine(notavailable in theUnited States), cyclophosphamide, orchlorambucil may reduce the risk of re-lapses without glucocorticoids.21,2932 Oralcyclophosphamide2to3mg/kgperdayfor8 to 12 weeks in steroid-dependent chil-dren induces remission in 40% at 2 years,24% at 5 years, and 17% in long-termfollow-up.21,32 Given the severity ofcyclophosphamide-associated adverse ev-ents, cytotoxic agents are considered athird-line choice for steroid-dependent ne-phrotic syndrome therapy.

Steroid-Resistant NephroticSyndrome Management

kidney biopsy;

tailor therapeutic regimen accord-ing to kidney histology; and

provide optimal supportive therapy.



Steroid resistance places a patient at in-creased risk for both the development ofcomplications of nephrotic syndromeand progression to end-stage kidney dis-ease.33,34 The goal of therapy for steroid-resistant nephrotic syndrome is com-plete resolution of proteinuria andpreservation of kidney function. How-ever, pediatric and adult studies havedocumented an improved kidney sur-vival rate for patients with a partial re-mission, defined as 50% reduction inproteinuria from baseline, comparedwith those without control of protein-uria.33,34 Because of this risk for end-stage kidney disease and the potentialutility of histology for therapeuticdecision-making, nephrologists performa kidney biopsy before initiation of ther-apy for patients with steroid resistance.

The optimal therapy for steroid-resistant nephrotic syndrome remainspoorly defined but requires a completeunderstandingof thearmamentariumoftherapeutic options and a fully engagedpediatric nephrologist to promote an op-timal outcome. Clear evidence-basedguidelines for the treatment of steroid-resistant nephrotic syndrome are notpossible on the basis of a lack of suffi-cient randomized, controlled trials.

There are 3 major categories of ther-apy for steroid-resistant nephroticsyndrome: (1) immunosuppressive;(2) immunostimulatory; and (3) non-immunosuppressive. The more com-monly used immunosuppressive ther-apies include calcineurin inhibitors,mycophenolate mofetil, pulse intrave-nous methylprednisolone, and cyto-toxic agents.3541 Other less commonlyused or controversial treatments in-clude plasma exchange and immuno-absorption.42 Novel agents are underinvestigation, but their safety and effi-cacy have not yet been determined.4345

The only reported immunostimulatoryagent in use is levamisole. However,this agent is not universally available.Last, nonimmunosuppressive treat-

ments are commonly considered to beconservative therapy and includeangiotensin-converting enzyme inhibi-tors (ACE-Is), angiotensin receptorblockers (ARBs), and vitamin E.33,46

Disease-based therapeutic recommen-dations are beyond the scope of theseguidelines.

ACE-I and ARB Therapy

ACE-I or ARB therapy is recom-mended for steroid-resistant ne-phrotic syndrome;

consider use of ACE-Is or ARBs withsteroid-dependent or frequently re-lapsing nephrotic syndrome; and

counsel regarding contraindications ofACE-I or ARB therapy during pregnancy.

Blockade of the renin-angiotensin sys-tem has been shown to blunt the evo-lution of kidney disease, especiallythose associated with marked protein-uria.4749 Several studies have demon-strated a reduction in proteinuria withACE-I or ARB therapy.33,4850 These drugsare generally well tolerated but alsohave documented adverse effects in-cluding hyperkalemia, angioedema,cough (ACE-Is), and, rarely, acute renalfailure. Combination therapy withACE-Is plus ARBs may simultaneouslyincrease efficacy and adverse-effectpotential.51,52 Women of childbearingage must be counseled regarding theteratogenic effects of ACE-I and ARBtherapy.53

Hypertension Management

control blood pressure to 90thpercentile of normal54;

recommend low-salt diet, exercise,and weight reduction if obesity ispresent; and

ACE-Is and/or ARBs for chronicpharmacologic management.

Hypertension is present in 13% to51% of children with nephrotic syn-drome.55,56 Blood pressure generallyimproves with remission of nephrotic

syndrome.56 When antihypertensivetherapy is indicated, the expected re-duction in proteinuria and blood pres-sure with ACE-I or ARB agents makethem first-line agents.57

Edema Management

counsel caregivers regarding po-tential complications of edema; and

consider treatment with low-sodiumdiet, modest fluid restriction, diuretics,and albumin infusions.

Edema is one of the cardinal symp-toms of nephrotic syndrome. Immedi-ate physician involvement is war-ranted if the patient developsrespiratory distress, which may besecondary to pleural effusions or pul-monary edema. Sodium restriction toa level of 1500 to 2000 mg daily is com-monly recommended. Severe edemaassociated with weeping tissuesshould be monitored for secondary in-fection. Severe edema may requirepharmacologic intervention includingloop diuretics, thiazide diuretics, and25%albumin infusion. At a high dose orwith chronic administration, diureticsmay cause hypokalemia, exacerbatehyponatremia, cause intravascularvolume depletion, and increase therisk for acute renal failure. Althoughonly a temporizing measure, treat-ment with 25% albumin infusions anddiuretics may be prescribed for chil-dren with severe edema. Albumin infu-sion may produce acute expansion ofintravascular volume leading to hyper-tension, pulmonary edema, and con-gestive heart failure.58

COMPLICATIONS

The complications of childhood ne-phrotic syndrome are associated withdisease activity and therapy. Active ne-phrotic syndrome increases the riskfor therapy-associated growth compli-cations, dyslipidemia, infections, andthromboembolism.

SPECIAL ARTICLES



Obesity and Growth

monitor BMI and linear growth;

provide counseling on weight con-trol; and

consider glucocorticoid alterna-tives when short stature or obesityis present.

Glucocorticoids may impair growthand increase BMI, with these effectsproportional to dose and duration ofthe disease and therapy.5963 Steroid-sparing treatment strategies may im-prove linear growth.59,64,65 Glucocorti-coid therapy may increase BMI.59,66,67

Children who are overweight at initia-tion of steroid therapy are more likelyto remain overweight after treatmentfor nephrotic syndrome.62,67 Steroid-sparing strategies have been associ-ated with a lower BMI.59,65 Anticipatorydietary counseling is recommendedfor children with nephrotic syndrome.

Dyslipidemia

low-fat diet;

consider low-density lipoproteincholesterol-lowering drug therapywhen fasting low-density lipopro-tein cholesterol levels are persis-tently 160 to 190 mg/dL; and

counsel regarding contraindica-tions of 3-hydroxy-3-methylglutarylcoenzyme A (HMG-CoA) reductaseinhibitors during pregnancy.

Dyslipidemia is an expected finding inchildren with nephrotic syndrome andmay resolve when patients are in re-mission. Children who have refractorynephrosis often have persistent dyslip-idemia. In adult studies, persistent ne-phrotic syndrome is associated withatherosclerosis and an increased riskof coronary artery disease. One retro-spective study, however, suggestedthat relapsing nephrotic syndrome inchildhooddoes not lead to increase in riskfor cardiovascular disease.68 Treatmentincludes dietary counseling to limit di-etary fat to 30% of calories, satu-

rated fat to 10% of calories, and300 mg/day dietary cholesterol.

Treatment with HMG-CoA reductaseinhibitors in adults with nephroticsyndrome have demonstrated a ben-eficial effect on dyslipidemia andmay impact the progression ofchronic kidney disease.69,70 Treat-ment of children with steroid-resistant nephrotic syndrome andpersistent dyslipidemia with HMG-CoA reductase inhibitors has beenproposed in childhood dyslipidemiacare guidelines, but randomizedstudies are lacking.71

Infection

counsel regarding signs and symp-toms of infections such as cellulitis,peritonitis, and bacteremia; and

provide empiric therapy for peritonitisuntil culture results are available.

Infection is a common complication inchildren with nephrotic syndrome andan important cause of mortality.72

Edema associated with weeping tis-sues should bemonitored carefully fordevelopment of secondary infectiouscomplications including cellulitis.Spontaneous bacterial peritonitis, pre-senting with fever, severe abdominalpain, peritoneal signs, and, occasion-ally, signs of sepsis, is a well-describedcomplication associated with morbid-ity and mortality.7375 The predisposi-tion to peritonitis is felt to be multifac-torial, including the presence of lowserum albumin, ascites, and an im-paired immune system.74,76 Definitivediagnosis of peritonitis requires cul-ture of peritoneal fluid. A Gram-stainand cell count should also be obtained.Bacteremia may be concurrent.

Although Streptococcus pneumoniae isthemost common organism that causesperitonitis in childhood nephrotic syn-drome, Gram-negative organisms causea significant percentage of spontaneousbacterial peritonitis cases.72,73,75,77 Thereare no data supporting the efficacy of

prophylactic penicillin in preventingperitonitis in childhood nephrotic syn-drome.78 The potential benefit must bebalanced against the risk of allergicreactions and the development of re-sistant organisms.77 Administration of23-valent and heptavalent conjugatedpneumococcal vaccines is recom-mended to provide immunity against abroad range of pneumococcal strains.

Thromboembolism

evaluate children with a thrombo-embolism for an underlying hyper-coagulopathy; and

provide anticoagulation therapy forchildren with nephrotic syndromeand thromboembolism.

Two percent to 5% of children with ne-phrotic syndrome develop thrombo-embolism.7981 The risk seems higherin children with steroid-resistant com-pared with steroid-sensitive disease.81

Potential sites for thromboembolisminclude deep vein, central sinus, andrenal vein thrombosis, pulmonary em-bolism, and arterial sites.

Multiple factors are postulated tocause the increased risk of thrombo-embolism in nephrotic syndrome.There are urinary losses of factorsthat inhibit clot formation (eg, anti-thrombin III) and increased levels offactors that promote clot formation(eg, fibrinogen).80 Thrombocytosis andplatelet hyperaggregability are com-mon with nephrotic syndrome.82 More-over, volume depletion caused by dehy-dration or diuretic therapy mayincrease the risk of clot formation.81

Although there have been no placebo-controlled studies, anticoagulationseems to be effective in childrenwith ne-phrotic syndrome. Heparin, low molecu-larweight heparin, andoral anticoagula-tion with warfarin are therapeuticoptions.81,8385 Fibrinolytic therapy hasbeen effectively used in some children,but its use must be balanced by the in-creased risk of complications.81,86,87



During periods of disease activity andincreased thromboembolic risk, chil-dren should be encouraged to continuephysical activity and avoid prolongedbed rest. The role of prophylactic antico-agulation medication such as low-doseaspirin isunclear. Prophylacticanticoag-ulation may be indicated in the settingof thromboembolism history, an under-lying hypercoagulable condition beyondnephrotic syndrome, steroid-resistantnephrotic syndrome, and the presenceof a central venous catheter.88 Thepoten-tial benefits and risks of such therapymust be evaluated individually.

Vaccinations

immunize with the 23-valent andheptavalent conjugated pneumo-coccal vaccines;

immunize the immunosuppressedor actively nephrotic patient andhousehold contacts with inactivatedinfluenza vaccine yearly;

defer immunization with livevaccines:

until prednisone dose is 2 mg/kgper day (maximum: 20mg);

for 3 months from completion oftherapy with cytotoxic agents; or

for 1 month from completion ofother daily immunosuppression;

provide varicella immunization ifnonimmune, on the basis of immu-nization history, disease history, orserologic evaluation;

provide postexposure immunoglob-ulin for nonimmune immunocom-promised patients; and

consider intravenous acyclovir forimmunosuppressed children at theonset of chicken pox lesions.

Vaccination is especially important forchildren with nephrotic syndrome. Theyare at risk formore severe infections be-cause of the impact of nephrotic syn-drome and the effects of immunosup-pression.89 Moreover, children withnephrotic syndrome are especially sus-ceptible to pneumococcal disease.75

Varicella infection may lead to life-threatening disease in children receiv-ing immunosuppressive medications.89

Varicella vaccination, proven to be safeand effective in children with nephroticsyndrome, should be administered onthe basis of the recommended guide-lines for live vaccines.9093

Monitoring

Table 1 sets forth a summary of moni-toring recommendations accordingto nephrotic syndrome severity andtreatment regimen.

CONCLUSIONS

Childhood nephrotic syndrome is achronic health condition that, opti-mally, is managed by a team preparedto provide ongoing care. Pediatric pa-tients and their caregivers require ed-ucation regarding the complex treat-ment of this chronic condition,including proper administration ofmedications, adherence to dietary re-strictions, and necessity for medicalmonitoring. An initial 12-week glu-cocorticoid therapeutic regimen hasbeen shown to decrease subsequentnephrotic syndrome relapse rates insteroid-responsive children.2,3 How-ever, to avoid many of the adverse ef-fects associated with this treatmentcourse, careful anticipatory guidanceand support of families should be pro-vided by a multidisciplinary team.

Complications of nephrotic syndromethatariseduringdiseaseactivityaswell asthe treatment itself also require an antici-patory approach. Commonly occurringcomplications related to chronic steroidadministration include hypertension, obe-sity, and linear growth retardation. Abnor-malities in bone density may also develop.Steroid-sparing regimens warrant agent-specific monitoring. Adverse effects arevaried and range from hypertension andacute renal failure with calcineurin inhibi-

TABLE 1 Monitoring Recommendations for Children With Nephrotic Syndrome

HomeUrineProtein

Weight,Growth,BMI

BloodPressure

Creatinine Electrolytes SerumGlucose

CBC LipidProfile

DrugLevels

LiverFunction

Urinalysis CPK

DiseaseMild (steroid responsive) Moderate (frequentrelapsing, steroiddependent)

Severe (steroid resistant) TherapyCorticosteroids Cyclophosphamide Mycophenolate mofetil Calcineurin inhibitors ACE-Is/ARBs HMG-CoA reductaseinhibitors

CBC indicates complete blood count; CPK, creatine kinase.

SPECIAL ARTICLES



tors to infertility and potential for futuremalignancywith cytotoxic agents.

Patients with steroid-resistant ne-phrotic syndrome are at greatest riskfor progressive kidney injury, compli-cations of chronic nephrotic syn-drome, and complications associatedwith pharmaceutical therapy. An indi-vidualized treatment plan based onkidney histology and response will re-quire the involvement of a pediatric

nephrologist to optimize control of ne-phrotic syndrome and minimize mor-bidity and mortality rates.

These guidelines are based on the bestsummary of available published dataand opinion when data were insuffi-cient. In addition to the development ofthese guidelines, the panel has identi-fied opportunities for validation andimprovement of this consensus docu-ment through collaborative research.

ACKNOWLEDGMENTSThis research was supported in partby the University of North CarolinaCenter for Education and Research onTherapeutics (Alan Stiles, MD, princi-pal investigator), funded by the Agencyfor Healthcare Research and Quality,award 2 U18HS10397-08.

We thank Sara Massie, Sue Tolleson-Rinehart, Jackie MacHardy, and MollieColeman.

REFERENCES

1. Churg J, Habib R, White RH. Pathology of the nephrotic syndrome in children: a report for theInternational Study of Kidney Disease in Children. Lancet. 1970;760(1):12991302

2. The primary nephrotic syndrome in children: identification of patients with minimal changenephrotic syndrome from initial response to prednisonea report of the International Study ofKidney Disease in Children. J Pediatr. 1981;98(4):561564

3. Alternate-day versus intermittent prednisone in frequently relapsing nephrotic syndrome: a re-port of Arbeitsgemeinschaft fur Padiatrische Nephrologie. Lancet. 1979;1(8113):401403

4. Short versus standard prednisone therapy for initial treatment of idiopathic nephrotic syndromein children. Arbeitsgemeinschaft fur Padiatrische Nephrologie. Lancet. 1988;1(8582):380383

5. Ehrich JH, Brodehl J. Long versus standard prednisone therapy for initial treatment of idiopathicnephrotic syndrome in children. Arbeitsgemeinschaft fur Padiatrische Nephrologie. Eur J Pediatr.1993;152(4):357361

6. Srivastava T, Simon SD, Alon US. High incidence of focal segmental glomerulosclerosis in ne-phrotic syndrome of childhood. Pediatr Nephrol. 1999;13(1):1318

7. Lichtig C, Ben-Izhak O, On A, Levy J, Allon U. Childhoodminimal change disease and focal segmentalglomerulosclerosis: a continuous spectrum of disease? Pathologic study of 33 cases with long-term follow-up. Am J Nephrol. 1991;11(4):325331

8. Harris KM, Gordon-Larsen P, Chantala K, Udry JR. Longitudinal trends in race/ethnic disparities inleading health indicators from adolescence to young adulthood. Arch Pediatr Adolesc Med. 2006;160(1):7481

9. Fagot-Campagna A, Pettitt DJ, EngelgauMM, et al. Type 2 diabetes among North American childrenand adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136(5):664672

10. Gipson DS, MacHardy N, Massengill S, et al. Variability in childhood onset nephrotic syndromemanagement in North America. 2009 In press

11. Hogg RJ, Furth S, Lemley KV, et al. National Kidney Foundations Kidney Disease Outcomes QualityInitiative clinical practice guidelines for chronic kidney disease in children and adolescents:evaluation, classification, and stratification. Pediatrics. 2003;111(6 pt 1):14161421

12. Clarkson MR, Meara YM, Murphy B, Rennke HG, Brady HR. Collapsing glomerulopathy: recurrencein a renal allograft. Nephrol Dial Transplant. 1998;13(2):503506

13. Niaudet P, GagnadouxMF, BroyerM. Treatment of childhood steroid-resistant idiopathic nephroticsyndrome. Adv Nephrol Necker Hosp. 1998;28:4361

14. Bagga A, Hari P, Srivastava RN. Prolonged versus standard prednisolone therapy for initial epi-sode of nephrotic syndrome. Pediatr Nephrol. 1999;13(9):824827

15. Hodson EM, Knight JF, Willis NS, Craig JC. Corticosteroid therapy for nephrotic syndrome inchildren. Cochrane Database Syst Rev. 2005;(1):CD001533

16. Hiraoka M, Tsukahara H, Matsubara K, et al. A randomized study of two long-course prednisoloneregimens for nephrotic syndrome in children. Am J Kidney Dis. 2003;41(6):11551162

17. Ksiazek J, Wyszynska T. Short versus long initial prednisone treatment in steroid-sensitive ne-phrotic syndrome in children. Acta Paediatr. 1995;84(8):889893

18. Hoyer PF, Brodehl J. Initial treatment of idiopathic nephrotic syndrome in children: prednisoneversus prednisone plus cyclosporine Aa prospective, randomized trial. J Am Soc Nephrol.2006;17(4):11511157



19. Hiraoka M, Tsukahara H, Haruki S, et al. Older boys benefit from higher initial prednisolonetherapy for nephrotic syndrome. Kidney Int. 2000;58(3):12471252

20. Nephrotic syndrome in children: a randomized trial comparing two prednisone regimens insteroid-responsive patients who relapse earlyreport of the international study of kidney dis-ease in children. J Pediatr. 1979;95(2):239243

21. Latta K, von S, Ehrich JH. A meta-analysis of cytotoxic treatment for frequently relapsing nephroticsyndrome in children. Pediatr Nephrol. 2001;16(3):271282

22. Hogg RJ, Fitzgibbons L, Bruick J, et al. Mycophenolate mofetil in children with frequently relapsingnephrotic syndrome: a report from the Southwest Pediatric Nephrology Study Group. Clin J AmSoc Nephrol. 2006;1(6):11731178

23. Gregory MJ, Smoyer WE, Sedman A, et al. Long-term cyclosporine therapy for pediatric nephroticsyndrome: a clinical and histologic analysis. J Am Soc Nephrol. 1996;7(4):543549

24. Kitano Y, Yoshikawa N, Tanaka R, Nakamura H, NinomiyaM, Ito H. Ciclosporin treatment in childrenwith steroid-dependent nephrotic syndrome. Pediatr Nephrol. 1990;4(5):474477

25. Abeyagunawardena AS, Dillon MJ, Rees L, vant Hoff W, Trompeter RS. The use of steroid-sparingagents in steroid-sensitive nephrotic syndrome. Pediatr Nephrol. 2003;18(9):919924

26. Hulton SA, Jadresic L, Shah V, Trompeter RS, Dillon MJ, Barratt TM. Effect of cyclosporin A onglomerular filtration rate in children with minimal change nephrotic syndrome. Pediatr Nephrol.1994;8(4):404407

27. Wong W. Idiopathic nephrotic syndrome in New Zealand children, demographic, clinical features,initial management and outcome after twelve-month follow-up: results of a three-year nationalsurveillance study. J Paediatr Child Health. 2007;43(5):337341

28. Broyer M, Terzi F, Lehnert A, Gagnadoux MF, Guest G, Niaudet P. A controlled study of deflazacort inthe treatment of idiopathic nephrotic syndrome. Pediatr Nephrol. 1997;11(4):418422

29. Fujieda M, Ishihara M, Morita T, et al. Effect of oral mizoribine pulse therapy for frequentlyrelapsing steroid-dependent nephrotic syndrome. Clin Nephrol. 2008;69(3):179184

30. Niaudet P. Treatment of childhood steroid-resistant idiopathic nephrosis with a combination ofcyclosporine and prednisone. French Society of Pediatric Nephrology. J Pediatr. 1994;125(6 pt 1):981986

31. Gellermann J, Querfeld U. Frequently relapsing nephrotic syndrome: treatment with mycopheno-late mofetil. Pediatr Nephrol. 2004;19(1):101104

32. Vester U, Kranz B, Zimmermann S, Hoyer PF. Cyclophosphamide in steroid-sensitive nephroticsyndrome: outcome and outlook. Pediatr Nephrol. 2003;18(7):661664

33. Gipson DS, Chin H, Presler TP, et al. Differential risk of remission and ESRD in childhood FSGS.Pediatr Nephrol. 2006;21(3):344349

34. Troyanov S, Wall CA, Miller JA, Scholey JW, Cattran DC. Focal and segmental glomerulosclerosis:definition and relevance of a partial remission. J Am Soc Nephrol. 2005;16(4):10611068

35. Prospective, controlled trial of cyclophosphamide therapy in children with nephrotic syndrome.Report of the International study of Kidney Disease in Children. Lancet. 1974;2(7878):423427

36. Garin EH, Orak JK, Hiott KL, Sutherland SE. Cyclosporine therapy for steroid-resistant nephroticsyndrome: a controlled study. Am J Dis Child. 1988;142(9):985988

37. Hymes LC. Steroid-resistant, cyclosporine-responsive, relapsing nephrotic syndrome. PediatrNephrol. 1995;9(2):137139

38. Lieberman KV, Tejani A. A randomized double-blind placebo-controlled trial of cyclosporine insteroid-resistant idiopathic focal segmental glomerulosclerosis in children. J Am Soc Nephrol.1996;7(1):5663

39. Ponticelli C, Rizzoni G, Edefonti A, et al. A randomized trial of cyclosporine in steroid-resistantidiopathic nephrotic syndrome. Kidney Int. 1993;43(6):13771384

40. Elhence R, Gulati S, Kher V, Gupta A, Sharma RK. Intravenous pulse cyclophosphamide: a newregime for steroid-resistant minimal change nephrotic syndrome. Pediatr Nephrol. 1994;8(1):13

41. Tarshish P, Tobin JN, Bernstein J, Edelmann CM. Cyclophosphamide does not benefit patients withfocal segmental glomerulosclerosis: a report of the International Study of Kidney Disease inChildren. Pediatr Nephrol. 1996;10(5):590593

42. Feld SM, Figueroa P, Savin V, et al. Plasmapheresis in the treatment of steroid-resistant focalsegmental glomerulosclerosis in native kidneys. Am J Kidney Dis. 1998;32(2):230237

43. Cho ME, Smith DC, Branton MH, Penzak SR, Kopp JB. Pirfenidone slows renal function decline inpatients with focal segmental glomerulosclerosis. Clin J Am Soc Nephrol. 2007;2(5):906913

44. Letavernier E, Bruneval P, Mandet C, et al. High sirolimus levels may induce focal segmentalglomerulosclerosis de novo. Clin J Am Soc Nephrol. 2007;2(2):326333

SPECIAL ARTICLES



45. NakayamaM, Kamei K, Nozu K, et al. Rituximab for refractory focal segmental glomerulosclerosis.Pediatr Nephrol. 2008;23(3):481485

46. Tahzib M, Frank R, Gauthier B, Valderrama E, Trachtman H. Vitamin E treatment of focal segmentalglomerulosclerosis: results of an open-label study. Pediatr Nephrol. 1999;13(8):649652

47. Gansevoort RT, Sluiter WJ, Hemmelder MH, de Zeeuw D, de Jong PE. Antiproteinuric effect ofblood-pressure-lowering agents: a meta-analysis of comparative trials. Nephrol Dial Transplant.1995;10(11):19631974

48. Ellis D, Vats A, Moritz ML, Reitz S, Grosso MJ, Janosky JE. Long-term antiproteinuric and renopro-tective efficacy and safety of losartan in children with proteinuria. J Pediatr. 2003;143(1):8997

49. Bagga A, Mudigoudar BD, Hari P, Vasudev V. Enalapril dosage in steroid-resistant nephroticsyndrome. Pediatr Nephrol. 2004;19(1):4550

50. Yi Z, Li Z, Wu XC, He QN, Dang XQ, He XJ. Effect of fosinopril in children with steroid-resistantidiopathic nephrotic syndrome. Pediatr Nephrol. 2006;21(7):967972

51. Wolf G, Ritz E. Combination therapy with ACE inhibitors and angiotensin II receptor blockers to haltprogression of chronic renal disease: pathophysiology and indications. Kidney Int. 2005;67(3):799812

52. Hanevold CD. Acute renal failure during lisinopril and losartan therapy for proteinuria. Pharma-cotherapy. 2006;26(9):13481351

53. Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med. 2006;354(23):24432451

54. National High Blood Pressure Education Program Working Group on High Blood Pressure inChildren and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of highblood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl 4th report):555576

55. Nephrotic syndrome in children: prediction of histopathology from clinical and laboratory char-acteristics at time of diagnosis: a report of the International Study of Kidney Disease in Children.Kidney Int. 1978;13(2):159165

56. Kuster S, Mehls O, Seidel C, Ritz E. Blood pressure in minimal change and other types of nephroticsyndrome. Am J Nephrol. 1990;10(suppl 1):7680

57. Chiurchiu C, Remuzzi G, Ruggenenti P. Angiotensin-converting enzyme inhibition and renal protec-tion in nondiabetic patients: the data of the meta-analyses. J Am Soc Nephrol. 2005;16(suppl 1):S58S63

58. Haws RM, BaumM. Efficacy of albumin and diuretic therapy in children with nephrotic syndrome.Pediatrics. 1993;91(6):11421146

59. Tanaka R, Yoshikawa N, Kitano Y, Ito H, Nakamura H. Long-term ciclosporin treatment in childrenwith steroid-dependent nephrotic syndrome. Pediatr Nephrol. 1993;7(3):249252

60. Donatti TL, Koch VH, Fujimura MD, Okay Y. Growth in steroid-responsive nephrotic syndrome: astudy of 85 pediatric patients. Pediatr Nephrol. 2003;18(8):789795

61. Emma F, Sesto A, Rizzoni G. Long-term linear growth of children with severe steroid-responsivenephrotic syndrome. Pediatr Nephrol. 2003;18(8):783788

62. Hegarty J, Mughal MZ, Adams J, Webb NJ. Reduced bone mineral density in adults treated withhigh-dose corticosteroids for childhood nephrotic syndrome. Kidney Int. 2005;68(5):23042309

63. Ruth EM, KemperMJ, Leumann EP, Laube GF, Neuhaus TJ. Childrenwith steroid-sensitive nephroticsyndrome come of age: long-term outcome. J Pediatr. 2005;147(2):202207

64. Berns JS, Gaudio KM, Krassner LS, et al. Steroid-responsive nephrotic syndrome of childhood: along-term study of clinical course, histopathology, efficacy of cyclophosphamide therapy, andeffects on growth. Am J Kidney Dis. 1987;9(2):108114

65. Elzouki AY, Jaiswal OP. Long-term, small dose prednisone therapy in frequently relapsing ne-phrotic syndrome of childhood: effect on remission, statural growth, obesity, and infection rate.Clin Pediatr (Phila). 1988;27(8):387392

66. Foster BJ, Shults J, Zemel BS, Leonard MB. Risk factors for glucocorticoid-induced obesity inchildren with steroid-sensitive nephrotic syndrome. Pediatr Nephrol. 2006;21(7):973980

67. Merritt RJ, Hack SL, Kalsch M, Olson D. Corticosteroid therapy-induced obesity in children. ClinPediatr (Phila). 1986;25(3):149152

68. Lechner BL, Bockenhauer D, Iragorri S, Kennedy TL, Siegel NJ. The risk of cardiovascular diseasein adults who have had childhood nephrotic syndrome. Pediatr Nephrol. 2004;19(7):744748

69. Olbricht CJ, Wanner C, Thiery J, Basten A. Simvastatin in nephrotic syndrome. Simvastatin inNephrotic Syndrome Study Group. Kidney Int Suppl. 1999;71:S113S116

70. Valdivielso P, Moliz M, Valera A, Corrales MA, Sanchez-Chaparro MA, Gonzalez-Santos P. Atorvasta-tin in dyslipidaemia of the nephrotic syndrome. Nephrology (Carlton). 2003;8(2):6164



71. Holmes KW, Kwiterovich PO Jr. Treatment of dyslipidemia in children and adolescents. CurrCardiol Rep. 2005;7(6):445456

72. Tain YL, Lin G, Cher TW. Microbiological spectrum of septicemia and peritonitis in nephroticchildren. Pediatr Nephrol. 1999;13(9):835837

73. Krensky AM, Ingelfinger JR, Grupe WE. Peritonitis in childhood nephrotic syndrome: 19701980.Am J Dis Child. 1982;136(8):732736

74. Hingorani SR, Weiss NS, Watkins SL. Predictors of peritonitis in children with nephrotic syndrome.Pediatr Nephrol. 2002;17(8):678682

75. Gorensek MJ, Lebel MH, Nelson JD. Peritonitis in children with nephrotic syndrome. Pediatrics.1988;81(6):849856

76. Matsell DG, Wyatt RJ. The role of I and B in peritonitis associated with the nephrotic syndrome ofchildhood. Pediatr Res. 1993;34(1):8488

77. Milner LS, Berkowitz FE, Ngwenya E, Kala U, Jacobs D. Penicillin resistant pneumococcal peritonitisin nephrotic syndrome. Arch Dis Child. 1987;62(9):964965

78. McIntyre P, Craig JC. Prevention of serious bacterial infection in children with nephrotic syn-drome. J Paediatr Child Health. 1998;34(4):314317

79. Mehls O, Andrassy K, Koderisch J, Herzog U, Ritz E. Hemostasis and thromboembolism in childrenwith nephrotic syndrome: differences from adults. J Pediatr. 1987;110(6):862867

80. Citak A, Emre S, Sairin A, Bilge I, Nayir A. Hemostatic problems and thromboembolic complicationsin nephrotic children. Pediatr Nephrol. 2000;14(2):138142

81. Lilova MI, Velkovski IG, Topalov IB. Thromboembolic complications in children with nephroticsyndrome in Bulgaria (19741996). Pediatr Nephrol. 2000;15(12):7478

82. Zwaginga JJ, Koomans HA, Sixma JJ, Rabelink TJ. Thrombus formation and platelet-vessel wallinteraction in the nephrotic syndrome under flow conditions. J Clin Invest. 1994;93(1):204211

83. Deshpande PV, Griffiths M. Pulmonary thrombosis in steroid-sensitive nephrotic syndrome.Pediatr Nephrol. 2005;20(5):665669

84. Gangakhedkar A, Wong W, Pitcher LA. Cerebral thrombosis in childhood nephrosis. J PaediatrChild Health. 2005;41(4):221224

85. Papachristou FT, Petridou SH, Printza NG, Zafeiriou DI, Gompakis NP. Superior sagittal sinusthrombosis in steroid-resistant nephrotic syndrome. Pediatr Neurol. 2005;32(4):282284

86. Jones CL, Hebert D. Pulmonary thrombo-embolism in the nephrotic syndrome. Pediatr Nephrol.1991;5(1):5658

87. Share A, Uzun O, Blackburn ME, Gibbs JL. Prolonged local infusion of streptokinase in pulmonaryartery thrombosis with nephrotic syndrome. Pediatr Nephrol. 1996;10(6):734736

88. AndrewM, Michelson AD, Bovill E, Leaker M, Massicotte MP. Guidelines for antithrombotic therapyin pediatric patients. J Pediatr. 1998;132(4):575588

89. Dowell SF, Bresee JS. Severe varicella associated with steroid use. Pediatrics. 1993;92(2):223228

90. Quien RM, Kaiser BA, Deforest A, Polinsky MS, Fisher M, Baluarte HJ. Response to the varicellavaccine in children with nephrotic syndrome. J Pediatr. 1997;131(5):688690

91. Alpay H, Yildiz N, Onar A, Temizer H, Ozcay S. Varicella vaccination in children with steroid-sensitivenephrotic syndrome. Pediatr Nephrol. 2002;17(3):181183

92. Furth SL, Arbus GS, Hogg R, Tarver J, Chan C, Fivush BA. Varicella vaccination in children withnephrotic syndrome: a report of the Southwest Pediatric Nephrology Study Group. J Pediatr.2003;142(2):145148

93. American Academy of Pediatrics. Active and passive immunization. In: Pickering LK, Baker CJ,Long SS, McMillan JA, eds. Red Book. 27th ed. Elk Grove Village: American Academy of Pediatrics.2006:940

SPECIAL ARTICLES



DOI: 10.1542/peds.2008-1559; originally published online July 27, 2009; 2009;124;747Pediatrics

Howard Trachtman and Larry A. GreenbaumSmoyer, John D. Mahan, Delbert Wigfall, Paul Miles, Leslie Powell, Jen-Jar Lin, Debbie S. Gipson, Susan F. Massengill, Lynne Yao, Shashi Nagaraj, William E.


ServicesUpdated Information &

mlhttp://pediatrics.aappublications.org/content/124/2/747.full.htincluding high resolution figures, can be found at:

References

ml#ref-list-1http://pediatrics.aappublications.org/content/124/2/747.full.htat:This article cites 91 articles, 17 of which can be accessed free

Citations

ml#related-urlshttp://pediatrics.aappublications.org/content/124/2/747.full.htThis article has been cited by 13 HighWire-hosted articles:

Subspecialty Collections

ary_disorders_subhttp://pediatrics.aappublications.org/cgi/collection/genitourinGenitourinary Disorders

bhttp://pediatrics.aappublications.org/cgi/collection/urology_suUrology

y_subhttp://pediatrics.aappublications.org/cgi/collection/nephrologNephrologythe following collection(s):This article, along with others on similar topics, appears in

Permissions & Licensing

mlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhttables) or in its entirety can be found online at: Information about reproducing this article in parts (figures,

Reprints http://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright 2009 by the American Academy of Pediatrics. All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elkpublication, it has been published continuously since 1948. PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on February 7, 2015pediatrics.aappublications.orgDownloaded from

http://pediatrics.aappublications.org/content/124/2/747.full.htmlhttp://pediatrics.aappublications.org/content/124/2/747.full.htmlhttp://pediatrics.aappublications.org/content/124/2/747.full.html#ref-list-1http://pediatrics.aappublications.org/content/124/2/747.full.html#ref-list-1http://pediatrics.aappublications.org/content/124/2/747.full.html#related-urlshttp://pediatrics.aappublications.org/content/124/2/747.full.html#related-urlshttp://pediatrics.aappublications.org/cgi/collection/nephrology_subhttp://pediatrics.aappublications.org/cgi/collection/nephrology_subhttp://pediatrics.aappublications.org/cgi/collection/urology_subhttp://pediatrics.aappublications.org/cgi/collection/urology_subhttp://pediatrics.aappublications.org/cgi/collection/genitourinary_disorders_subhttp://pediatrics.aappublications.org/cgi/collection/genitourinary_disorders_subhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/

DOI: 10.1542/peds.2008-1559; originally published online July 27, 2009; 2009;124;747Pediatrics

Howard Trachtman and Larry A. GreenbaumSmoyer, John D. Mahan, Delbert Wigfall, Paul Miles, Leslie Powell, Jen-Jar Lin, Debbie S. Gipson, Susan F. Massengill, Lynne Yao, Shashi Nagaraj, William E.


http://pediatrics.aappublications.org/content/124/2/747.full.html

located on the World Wide Web at: The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2009 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on February 7, 2015pediatrics.aappublications.orgDownloaded from

http://pediatrics.aappublications.org/content/124/2/747.full.htmlhttp://pediatrics.aappublications.org/

Documents

NS in Childhood.pdf