Weeks Of Glucocorticoid Therapy Research Articles

Effects of a novel ANLN E841K mutation associated with SRNS on podocytes and its mechanism

BackgroundSteroid-resistant nephrotic syndrome (SRNS) is characterized by unrelieved proteinuria after an initial 4–8 weeks of glucocorticoid therapy. Genes in podocytes play an important role in causing SRNS.ObjectiveThis study aimed to report a pathogenic mutation in SRNS patients and investigate its effects on podocytes, as well as the pathogenic mechanism.MethodsWe screened out a novel mutation by using whole-exon sequencing in the SRNS cohort and verified it via Sanger sequencing. Conservative analysis and bioinformatic analysis were used to predict the pathogenicity of the mutation. In vitro, stable podocyte cell lines were constructed to detect the effect of the mutation on the function of the podocyte. Moreover, an in vivo mouse model of podocyte ANLN gene knockout (ANLNpodKO) was used to confirm clinical manifestations. Transcriptome analysis was performed to identify differential gene expression and related signaling pathways.ResultsANLN E841K was screened from three unrelated families. ANLN E841K occurred in the functional domain and was predicted to be harmful. The pathological type of A-II-1 renal biopsy was minimal change disease, and the expression of ANLN was decreased. Cells in the mutation group showed disordered cytoskeleton, faster cell migration, decreased adhesion, increased endocytosis, slower proliferation, increased apoptosis, and weakened interaction with CD2 association protein. ANLNpodKO mice exhibited more obvious proteinuria, more severe mesangial proliferation, glomerular atrophy, foot process fusion, and increased tissue apoptosis levels than ANLNflox/flox mice after tail vein injection of adriamycin. Upregulated differentially expressed genes in cells of the mutation group were mainly enriched in the PI3K-AKT pathway.ConclusionThe novel mutation known as ANLN E841K affected the function of the ANLN protein by activating the PI3K/AKT/mTOR/apoptosis pathway, thus resulting in structural and functional changes in podocytes. Our study indicated that ANLN played a vital role in maintaining the normal function of podocytes.CZoZEd4ExGAZZkosMrZTAEVideo

Limited Role of Antithrombin Deficiency in Hypercoagulopathy Associated with Nephrotic Syndrome

Background: Nephrotic syndrome (NS) is associated with an acquired hypercoagulopathy that drives venous thromboembolic comorbidities. The molecular mechanisms underlying NS-associated hypercoagulopathy are incompletely understood, however previous studies proposed marked urinary loss of antithrombin (AT) as a primary etiology. We have previously demonstrated, in rodent NS models, that there is no correlation between AT antigen and thrombin generation, which we have previously used to characterize the hypercoagulopathy. The objective of this study is to examine the association between AT antigen, AT activity, and hypercoagulopathy along with NS disease severity markers (proteinuria and plasma albumin) in 2 cohorts that include both pediatric and adult NS patients.Methods: Plasma samples were obtained from both cohorts as follows: (1) Samples were obtained on presentation from 147 adult and pediatric patients participating in the NEPTUNE prospective observational cohort study (2) Samples were obtained on presentation and after 7 weeks of glucocorticoid therapy (GC) in steroid sensitive and steroid resistant pediatric patients participating in the PNRC study. AT antigen and activity assays were performed using ELISA and chromogenic assays, respectively. Thrombin generation assay, plasma albumin, and urine protein-to-creatinine ratio were determined as previously described.Results: There was no significant relationship between AT antigen or AT activity and thrombin generation parameters. AT antigen and activity also did not correlate with NS severity markers (plasma albumin and proteinuria) in the NEPTUNE cohort (Figure1). In PNRC pediatric cohort, no significant correlation was found between AT antigen and thrombin generation or other disease severity markers. However, AT activity was significantly associated with both plasma albumin and endogenous thrombin potential at presentation (Figure 2) and at follow-up. Interestingly, GC therapy significantly improved AT activity in steroid-sensitive but not steroid-resistant NS patients (Figure 3). A comprehensive literature review and meta-analysis was also performed which revealed that clinically significant AT deficiency (<0.7 IU/mL) is uncommon in both pediatric and adult NS patients.Conclusion: AT antigen does not correlate with thrombin generation-defined hypercoagulopathy in adult or pediatric NS patients. AT activity does correlate with hypercoagulopathy in pediatric NS patients and improves significantly with successful remission inducing therapy. These data suggest that pediatric NS patients may have a qualitative, but not quantitative, AT deficiency that is responsive to therapy. The mechanism underlying this qualitative deficiency should be characterized in future studies. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Sulfatase 2 Is Associated with Steroid Resistance in Childhood Nephrotic Syndrome.

Glucocorticoid (GC) resistance complicates the treatment of ~10–20% of children with nephrotic syndrome (NS), yet the molecular basis for resistance remains unclear. We used RNAseq analysis and in silico algorithm-based approaches on peripheral blood leukocytes from 12 children both at initial NS presentation and after ~7 weeks of GC therapy to identify a 12-gene panel able to differentiate steroid resistant NS (SRNS) from steroid-sensitive NS (SSNS). Among this panel, subsequent validation and analyses of one biologically relevant candidate, sulfatase 2 (SULF2), in up to a total of 66 children, revealed that both SULF2 leukocyte expression and plasma arylsulfatase activity Post/Pre therapy ratios were greater in SSNS vs. SRNS. However, neither plasma SULF2 endosulfatase activity (measured by VEGF binding activity) nor plasma VEGF levels, distinguished SSNS from SRNS, despite VEGF’s reported role as a downstream mediator of SULF2’s effects in glomeruli. Experimental studies of NS-related injury in both rat glomeruli and cultured podocytes also revealed decreased SULF2 expression, which were partially reversible by GC treatment of podocytes. These findings together suggest that SULF2 levels and activity are associated with GC resistance in NS, and that SULF2 may play a protective role in NS via the modulation of downstream mediators distinct from VEGF.

Short-Term Versus 6-Week Prednisone In The Treatment Of Subacute Thyroiditis: A Randomized Controlled Trial

Moderate-to-severe subacute thyroiditis is clinically managed with 6 to 8 weeks of glucocorticoid therapy. However, no studies have evaluated short-term prednisone treatment for subacute thyroiditis. This 24-week, prospective, single-blind, randomized controlled study enrolled patients (aged 18 to 70 years) with subacute thyroiditis who were hospitalized between August, 2013, and December, 2014. Patients with moderate-to-severe symptoms were randomly assigned to receive either 30 mg/day prednisone for 1 week, followed by 1 week of nonsteroidal anti-inflammatory drugs, or the conventional 6-week prednisone therapy. The primary endpoint was intergroup differences in treatment efficacy at the end of the treatment course. Secondary endpoints included between-group differences in post-withdrawal adverse effect parameters and thyroid function at weeks 6, 12, and 24. We screened 96 patients, randomized 52 participants, and 50 participants completed the study. Efficacy and recurrence rates were not significantly different at withdrawal in both groups (P = .65). At treatment discontinuation, parathyroid hormone (28.8 versus 38.9 pg/mL; P = .011) and systolic blood pressure (113.9 versus 122.4mm Hg; P = .023) were significantly lower in the experimental group than in the control group. There were no significant intergroup differences in other secondary endpoints at withdrawal and in thyroid function at weeks 6, 12, and 24. Fewer side effects of glucocorticoids and similar efficacy and recurrence rates were observed with short-term prednisone compared with the 6-week treatment for subacute thyroiditis. Short-term prednisone, with a better safety profile, may be an alternative strategy for ameliorating moderate-to-severe symptoms of subacute thyroiditis. BPPG = breakfast postprandial plasma glucose; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; FPG = fasting plasma glucose; FT3 = free triiodothyronine; FT4 = free thyroxine; GA = glycated albumin; NSAIDs = nonsteroidal anti-inflammatory drugs; OC = osteocalcin; PINP = type I procollagen amino-terminal peptide; PTH = parathyroid hormone; RCT = randomized controlled trial; SAT = subacute thyroiditis; SBP = systolic blood pressure; TC = total cholesterol; TSH = thyroid-stimulating hormone; TBG = thyroid-binding globulin; TG = triglyceride; TGAb = antithyroglobulin antibody; TPOAb = antithyroid peroxidase antibody; TRAb = antithyroid-stimulating hormone receptor antibody.

Nephrotic syndrome-associated hypercoagulopathy is alleviated by both pioglitazone and glucocorticoid which target two different nuclear receptors.

BackgroundThrombosis is a potentially life‐threatening nephrotic syndrome (NS) complication. We have previously demonstrated that hypercoagulopathy is proportional to NS severity in rat models and that pioglitazone (Pio) reduces proteinuria both independently and in combination with methylprednisolone (MP), a glucocorticoid (GC). However, the effect of these treatments on NS‐associated hypercoagulopathy remains unknown. We thus sought to determine the ability of Pio and GC to alleviate NS‐associated hypercoagulopathy.MethodsPuromycin aminonucleoside‐induced rat NS was treated with sham, Low‐ or High‐dose MP, Pio, or combination (Pio + Low‐MP) and plasma was collected at day 11. Plasma samples were collected from children with steroid‐sensitive NS (SSNS) and steroid‐resistant NS (SRNS) upon presentation and after 7 weeks of GC therapy. Plasma endogenous thrombin potential (ETP), antithrombin (AT) activity, and albumin (Alb) were measured using thrombin generation, amidolytic, and colorimetric assays, respectively.ResultsIn a rat model of NS, both High‐MP and Pio improved proteinuria and corrected hypoalbuminemia, ETP and AT activity (p < .05). Proteinuria (p = .005) and hypoalbuminemia (p < .001) were correlated with ETP. In childhood NS, while ETP was not different at presentation, GC therapy improved proteinuria, hypoalbuminemia, and ETP in children with SSNS (p < .001) but not SRNS (p = .330).ConclusionsBoth Pio and GC diminish proteinuria and significantly alleviate hypercoagulopathy. Both Pio and MP improved hypercoagulopathy in rats, and successful GC therapy (SSNS) also improved hypercoagulopathy in childhood NS. These data suggest that even a partial reduction in proteinuria may reduce NS‐associated thrombotic risk.

Urinary calcium and bone mineral density in children with nephrotic syndrome treated with glucocorticoids

Background: Mainstay of therapy in the idiopathic nephrotic syndrome is glucocorticoids. Glucocorticoid induced osteoporosis is considered as most prevalent type of secondary osteoporosis. Only limited studies are conducted in tropical nations. Therefore our study is undertaken with objectives to evaluate Glucocorticoid therapy impact on bone health in Nephrotic Syndrome (NS) children by 2 different tools, namely urinary calcium and bone mineral density (BMD) by Quantitative ultrasound (QUS) and compare both the tools.Methods: Total 42 children with NS who completed minimum 12 weeks of Glucocorticoid therapy (6 weeks of daily regimen and minimum 6 weeks of alternate day regimen) were subjected to 24 hour Urinary calcium and Bone Mineral density by QUS at Tertiary health centre, Kalaburagi.Results: Out of 42 cases, 45.2 % had Osteopenia and 2.4% had osteoporosis, so 47.6% of them had BMD measured by QUS. Hypercalciurea was seen in 10 out of 42 cases (23.8%). In normal BMD group only 0.5% had hypercalciurea, Osteopenia group had 47.4% of cases and all osteoporosis group had hypercalciurea.Conclusions: Present study data concludes that children with NS treated with Glucocorticoids are at risk of Negative impact on bone health. Though both the tools detect impact of Glucocorticoids on bone health, BMD by QUS has better rate then urinary calcium in detecting negative effect of Glucocorticoid on bone health. As BMD by QUS decreases, Urinary calcium increases reflecting inverse relation between them.

Role of Aspergillus fumigatus-specific IgG in diagnosis and monitoring treatment response in allergic bronchopulmonary aspergillosis.

Few studies have evaluated the utility of Aspergillus fumigatus-specific IgG in allergic bronchopulmonary aspergillosis (ABPA). Herein, we evaluate the role of specific IgG in diagnosis and monitoring treatment response in ABPA. Forty-eight control subjects with A.fumigatus-associated asthma underwent A.fumigatus-specific IgG measurements at baseline, while specific IgG was assayed in 102 treatment-naïve subjects of ABPA at baseline, after eight weeks of glucocorticoid therapy, and during exacerbations. For determining the cut-off of A.fumigatus-specific IgG, we randomly classified two-thirds of the study subjects (cases and controls) as the derivation cohort, while the remaining one-thirds were labelled as the validation cohort. The best cut-off value of A.fumigatus-specific IgG in the derivation cohort was 26.9mgA /L (sensitivity: 88%; specificity: 100%). Using this limit, the sensitivity and specificity of A.fumigatus-specific IgG in diagnosis of ABPA was 89% and 100%, respectively, in the validation cohort. In contrast, the sensitivity of Aspergillus precipitins was only 27.4%. Following treatment, the A.fumigatus-specific IgG increased in 38 (37.2%) subjects, while it decreased in three (23.1%) of the 13 subjects experiencing an exacerbation. The A.fumigatus-specific IgG was found to be an extremely useful test in the diagnosis and differential diagnosis of ABPA but is unreliable in monitoring treatment response in this disorder.

Utility of IgE (total and Aspergillus fumigatus specific) in monitoring for response and exacerbations in allergic bronchopulmonary aspergillosis.

The role of total and specific IgE in monitoring treatment responses in allergic bronchopulmonary aspergillosis (ABPA) remains poorly studied. Here in, we evaluate the utility of total and Aspergillus fumigatus specific IgE in the follow-up of ABPA. Eighty-one consecutive treatment-naïve patients of ABPA (acute stage) with pulmonary infiltrates and bronchiectasis underwent measurement of total and A. fumigatus specific IgE at baseline, after 8 weeks of glucocorticoid therapy, and during exacerbations. There was clinical and radiological improvement after treatment with median decline of total IgE by 51.9%. The total IgE declined by at least 35%, 25% and 20% in 69 (85.2%), 76 (93.6%) and 78 (96.3%) patients, respectively. On the other hand, the A. fumigatus specific IgE increased in 42 (51.9%) subjects, and the mean increase was 1.4%, after 8 weeks. Among 13 patients with exacerbation, 12 (92.3%) had a rise of total IgE by >50%. The A. fumigatus specific IgE increased in only five (38.5%) subjects during exacerbation. Thus, the total IgE is a useful test in monitoring treatment responses in ABPA while A. fumigatus specific IgE has limited utility.

Synovial fluid total protein concentration as a possible marker for canine idiopathic polyarthritis.

Idiopathic polyarthritis (IPA) is a very common inflammatory arthropathy in the dog. Canine IPA is diagnosed mainly by detecting increased number of leukocytes in the synovial fluid (SF), which is easily influenced by glucocorticoid therapy. We obtained 31 SF samples from 24 IPA dogs prior to (n=19) and/or after (n=12) 1 to 10 weeks of glucocorticoid therapy. The SF total protein concentrations of IPA dogs were significantly higher than those of dogs with non-arthritis diseases (n=34) and healthy controls (n=10). Our data revealed that the SF total protein concentrations are not influenced by several weeks of glucocorticoid therapy. Hence, the SF total protein concentration is applicable as a diagnostic marker of canine IPA even when the patients are receiving glucocorticoid therapy.

Effects of allergen inhalation and oral glucocorticoid on serum soluble CTLA‐4 in allergic asthmatics

The serum soluble cytotoxic T lymphocyte associated antigen-4 (sCTLA-4) concentration is significantly elevated in patients with asthma, and sCTLA-4 concentration correlate with the severity of asthma. The aim of the present study was to investigate effects of allergen inhalation and oral glucocorticoid on concentration of serum sCTLA-4 in patients with allergic asthma. Allergen inhalation challenge was conducted in allergic asthmatics with isolated early asthma response and those with dual asthma response. In a randomized, double-blind, placebo-controlled, parallel group fashion, prednisolone or placebo was give orally once a day for 2 weeks. Venous blood samples were collected before and after allergen inhalation or prednisolone administration for obtaining sera. The serum sCTLA-4 concentrations were determined using enzyme-linked immunosorbent assay. The serum sCTLA-4 concentrations in the dual responder group increased from 29.0 (14.5-43.7) microg/l [median (25-75 percentiles)] before allergen inhalation to 44.0 (24.3-61.3) microg/l 24 h after allergen inhalation. In the isolated early responders, there were no significant increase in serum sCTLA-4 concentrations after allergen inhalation compared with baseline levels. There was a significant decrease in serum sCTLA-4 concentrations after 2 weeks of glucocorticoid therapy [22.0 (15.5-31.0) microg/l] compared with baseline values [37.0 (19.5-53.0) microg/l], whereas there was no significant difference in the placebo group. This study has demonstrated that serum sCTLA-4 concentrations increased after allergen inhalation in sensitized asthmatic subjects, and that serum sCTLA-4 concentrations were downregulated by prednisolone therapy.

Effects of allergen inhalation and oral glucocorticoid on concentrations of serum-soluble CD86 in allergic asthmatics

The aim of the present study was to investigate effects of allergen inhalation and oral glucocorticoid on concentration of serum soluble CD86 in patients with allergic asthma. Our results showed that the serum soluble CD86 concentrations in the dual responder group increased from 491.8 ± 15.4 IU/ml before allergen inhalation to 603.8 ± 19.3 IU/ml 24 h after allergen inhalation. In the isolated early responders, there was no significant increase in serum soluble CD86 concentrations after allergen inhalation compared with baseline levels. There was a significant decrease in serum soluble CD86 concentrations after 2 weeks of glucocorticoid therapy (448.3 ± 15.1 IU/ml) compared with baseline values (532.7 ± 12.3 IU/ml), whereas there was no significant difference in the placebo group. This study has demonstrated that serum soluble CD86 concentrations increased after allergen inhalation in sensitized asthmatic subjects, and that serum sCD86 concentrations were downregulated by prednisolone therapy.

Adrenal suppression versus clinical glucocorticoid deficiency in the premature infant: no simple answers.

In a recent issue of the journal, Karlsson et al. (1) reported their results of a study on the adrenal function of mostly premature infants by means of a low dose (1 mg/1.73 m) ACTH test and a standard, human (h) CRH (CRH) test (1 mg/kg). Infants studied varied in gestational age, exposure to antenatal glucocorticoid therapy, quantity of dexamethasone received postnatally, interval between the last dose of dexamethasone and the time of testing, and presence or not of concurrent hydrocortisone replacement. They concluded that the hCRH test was superior to the low dose ACTH test in detecting adrenal suppression on the basis of being abnormal more frequently than the latter in the same population of patients. By definition, adrenal suppression denotes sustained deficiency of hypothalamic-pituitary-adrenal (HPA) axis function ensuing exposure of the organism to excessive and prolonged administration of exogenous glucocorticoids (2). The mechanism is suprapituitary, and the condition has no real rodent model equivalent, as adrenal suppression in rats has a very limited duration of 1–2 days (3). Generally, clinically important adrenal suppression in children and adults occurs after 2 or more weeks of glucocorticoid therapy, depends on the type of and the schedule of glucocorticoid administration and lasts from days, to weeks, months or, rarely, infinity (2). The susceptibility of human beings to the development of adrenal suppression varies widely, as does the sensitivity of their different tissues to glucocorticoids (4). When one thinks of glucocorticoid suppression, one should clarify an important issue. The HPA axis, through several feedback control loops that influence its regulatory centers in the brain, is constantly attempting to maintain the day-to-day exposure of tissues to cortisol normal. This results in an intraindividual variability of HPA axis activity that is quite narrow, in contrast to the wide interindividual variability of this system. This means that decreased cortisol secretion a day or two after administration of a large dose of glucocorticoid is not but a corrective action of the organism. Such a change would not qualify as adrenal suppression, which is the sustained, risky glucocorticoid deficiency that ensues prolonged, excessive exposure to exogenous or endogenous glucocorticoids (2). The latter has significant morbidity, ranging from hypoglycemia to hypotension, as well as mortality, usually as a result of circulatory collapsus. The third trimester fetus and the premature and full-term infants have a functional HPA axis that responds to the negative feedback by glucocorticoids and can develop clinically significant adrenal suppression (5–7). Our ability to recognize adrenal suppression in infants is a prerequisite to decide whether or not to administer daily and stress-appropriate glucocorticoid coverage. In a full-term infant in which suppression is not complicated by concurrent systemic inflammation, one could employ the tests and criteria established for older children and adults. The rapid standard ACTH test (250 mg/1.75 m BSA) would be the procedure of choice in such an instance, and the criterion of a cortisol response greater than the value of 1.96 sd below the normal child/adult mean at 30 or 60 min would suggest no need for coverage. In the uncomplicated premature infant, a 40% lowering of these limits has been proposed because of a relative hypoactivity of the premie HPA axis when compared with that of full-term neonates (6). An insulin tolerance or a metyrapone test should not be used in these frail populations, as they provide no advantage over the standard ACTH test and might have serious complications. There is very little experience with the low dose ACTH test in infants and its clinical utility in children and adults remains controversial. Although, admittedly, it may be more sensitive than the standard ACTH test in detecting subtler abnormalities of the HPA axis, its true pertinence in helping treat patients that would not be treated on the basis of a standard ACTH test is uncertain. The same is true for the human or ovine CRH tests. Both appear to be more sensitive than the standard ACTH test in detecting subtle HPA axis abnormalities, but again, are such mild disturbances clinically relevant to dictate medical intervention? The study of Karlsson et al. (1) shows that the hCRH test is more sensitive than the low dose ACTH test but the question is: will such data change our approach to treatment? The usefulness of the standard ACTH test goes beyond detecting adrenal suppression in the premature infant after the remission of a disease for which glucocorticoid therapy was administered in the first place. Infants with the systemic inflammation that accompanies the respiratory distress synReceived October 30, 2000. Accepted October 30, 2000. Address correspondence and requests for reprints to: George Chrousos, M.D., National Institutes of Health, 10 Center Drive, Building 10, Room 9D42, Bethesda, Maryland 20892-1583. 0021-972X/01/$03.00/0 Vol. 86, No. 2 The Journal of Clinical Endocrinology & Metabolism Printed in U.S.A. Copyright © 2001 by The Endocrine Society

Glucocorticoid-induced hypertension in the elderly relation to serum calcium and family history of essential hypertension

To explore the syndrome of glucocorticoid-induced hypertension in the elderly, we analyzed the clinical findings from 35 patients aged more than 65 years (12 men, 23 women) who received glucocorticoid therapy. Resting blood pressures (BP) were less than 140/90 mm Hg before glucocorticoid therapy, and patients were apparently disease-free apart from the condition for which glucocorticoid therapy was prescribed. Glucocorticoid-induced hypertension is defined as systolic BP more than 160 mm Hg and/or diastolic BP more than 95 mm Hg after glucocorticoid administration. Glucocorticoid-induced hypertension was seen in 13 patients (37.1%); all patients with hypertension [steroid (glucocorticoid)-induced hypertension (SH(+)) group] received more than 20 mg of prednisolone daily, and BP rose rapidly within a week of commencing glucocorticoid administration. The SH(+) group did not differ significantly in terms of age, heart rate, blood count, plasma biochemistry, plasma renin activity, plasma aldosterone, routine urinalysis, or urinary electrolytes from patients who did not show hypertension [SH(-) group]. However, serum total calcium concentrations were significantly lower in the SH(+) group both before and after 2 weeks of glucocorticoid therapy than in the SH(-) group. Furthermore, the SH(+) group showed a significantly higher percentage of patients with a positive family history of essential hypertension than the SH(-) group. In conclusion, although the detailed mechanisms are as yet uncertain, glucocorticoid-induced hypertension occurs often in elderly patients, and is more common in patients with total serum calcium concentrations lower than the normal range, and/or in those with positive family history of essential hypertension.