Coronavirus Disease-2019 in Children with Nephrotic Syndrome.

Abstract

To the Editor, Coronavirus disease-2019 (COVID-19) started in late December 2019 in Wuhan, China, and declared as a pandemic by the World Health Organization by mid-March due to increase mortality worldwide.[1] As of 19 August 2020, there has been more than 22 million of confirmed cases, causing more than 780,000 deaths with mortality rate of 3.5%.[2] So far, a total of 83,606 laboratory-confirmed COVID-19 cases reported in Oman with mortality rate of 0.7%.[3] COVID-19 in children generally tends to have a milder disease and better prognosis compared to adults.[4] There is limited literature on the severity of COVID-19 in children with nephrotic syndrome. In this letter, we report a 10-year-old boy with steroid-sensitive nephrotic syndrome admitted to our hospital with mild COVID-19 which provoked a nephrotic relapse end of July 2020. He presented with 5-day history of rhinorrhea, facial edema, abdominal distension, and proteinuria. Earlier on, he got exposed to a family member with confirmed COVID-19. He was initially managed at home with prednisone 60 mg/m2 daily, but his edema worsened requiring admission for albumin infusions. He was admitted for 48 h after which he was discharge home on oral prednisolone of 60 mg/m2 daily. He had a mild course at home, and once the proteinuria had resolved, the prednisone was tapered down to 40 mg/m2 given on alternate days. To the best of our knowledge, this is the first reported case of COVID-19 among Omani children with nephrotic syndrome. A global survey conducted by the European Rare Kidney Disease Reference Network early in the start of the pandemic reported 18 children with kidney diseases on immunosuppressive medications who all have mild COVID-19 of whom three have nephrotic syndrome. Eleven children required hospitalization but none required intensive care.[5] Angeletti et al reported that none of the 159 children with nephrotic syndrome receiving anti-CD20 in combination of other immunosuppressive medications they followed up in Italy during the peak of the pandemic developed COVID-19 including the children who got exposed to confirmed cases of COVID-19 at home. Melgosa et al reported 16 children with chronic kidney disease who all got mild COVID-19 without significant complications from Spain. Four children with nephrotic syndrome; two were asymptomatic and they were continued on maintenance immunosuppression without any modifications and two children had COVID-19 provoked a nephrotic relapse. They were managed with prednisolone without any complications.[2] From these findings, it seems that COVID-19 does not cause severe disease in children with nephrotic syndrome and children on chronic immunosuppressive medication may not be at increased risk of getting COVID-19 provided; they follow optimal preventive measures. They suggested keeping the same immunosuppressive regimen for children with nephrotic syndrome even after exposure to confirmed cases.[6] From our experience in Oman over the last five months, COVID-19 has not been a major problem among children with nephrotic syndrome. The available literature suggests that children with nephrotic syndrome tend to have mild course of COVID-19. It is recommended to treat relapses of nephrotic syndrome promptly with the standard dose of prednisolone to avoid complications associated with anasarca and bacterial infections. Conflict of interest: None declared.