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Enalapril and prednisone in children with nephrotic-range proteinuria
A Delucchi1, F Cano, E Rodriguez
1Division of Pediatric Nephrology, Hospital Luis Calvo Mackenná, Universidad de Chile, Santiago. delucchi@cmet.net
Insights
Enalapril significantly reduced proteinuria and shifted the pattern to albumin-selective in pediatric nephrotic syndrome patients. Prednisone offered no additional benefit, but enalapril improved edema and hypertension.
Area of Science:
- Nephrology
- Pediatric Nephrology
- Pharmacology
Background:
- Steroid-resistant nephrotic syndrome (SRNS) in children presents a therapeutic challenge.
- Urinary protein electrophoretic patterns help characterize the selectivity of proteinuria.
Purpose of the Study:
- To evaluate the effect of enalapril and low-dose prednisone on urinary protein electrophoretic patterns in pediatric patients with glomerular diseases and SRNS.
- To assess the impact on proteinuria, plasma proteins, edema, and renal function.
Main Methods:
- 13 pediatric patients with glomerular diseases and SRNS were treated with enalapril (0.2-0.6 mg/kg/day) for 24-84 months.
- Prednisone (30 mg/m2 on alternate days) was added in 11 patients after 2 months.
- Urinary protein electrophoresis, total protein, albumin, and renal function parameters were monitored.
Main Results:
- Enalapril reduced total urinary protein by 80% and albumin by 70%, decreasing total protein from 5.46 to 1.1 g/m2/day (P<0.001).
- A shift from non-selective to albumin-selective proteinuria was observed, with mean total plasma proteins increasing from 4.7 to 5.43 g/dl (P<0.001).
- Four patients achieved complete remission of proteinuria at 24 months, but only 2 at 48 months; prednisone did not enhance the effect. Clinical improvement in edema and hypertension was noted in all patients.
Conclusions:
- Enalapril monotherapy effectively reduces proteinuria and promotes selective albuminuria in pediatric SRNS patients.
- While enalapril improves clinical symptoms like edema and hypertension, its long-term efficacy in achieving complete remission is limited.
- Low-dose prednisone does not appear to add significant benefit to enalapril in this cohort.
Abstract:
The effect of enalapril and low prednisone doses on the urinary protein electrophoretic pattern was studied in 13 pediatric patients with glomerular diseases and steroid-resistant nephrotic syndrome. Enalapril was administered at doses of 0.2-0.6 mg/kg per day for 24-84 months, and prednisone was introduced 2 months later in 11 patients at doses of 30 mg/m2 on alternate days. The urine protein electrophoretic pattern showed a reduction of 80% and 70% in the total protein and albumin, respectively, after enalapril. Total urinary protein decreased from 5.46 to 1.1 g/m2 per day (P<0.001). A marked change from a pattern of non-selective urinary protein loss to an albumin-selective proteinuria was observed. Mean total plasma proteins increased from 4.7 to 5.43 g/dl (P<0.001). Four patients became free of proteinuria 24 months after enalapril was started, but only 2 remained free of proteinuria at 48 months of follow-up. The other 11 patients had persistent albuminuria of between 0.5 and 2.6 g/m2 per day with a selective urinary electrophoretic pattern. No additional decrease was observed after steroids were introduced. A clinical improvement in edema was observed in all children. Three patients developed transient acute renal failure, during the course of an infectious disease; 2 developed peritonitis and 1 pneumopathy. In these patients withdrawal of enalapril was necessary until a complete recovery of renal function was observed. Four patients were hypertensive on admission, achieving normal blood pressure 1 month after enalapril was started. No episodes of systemic arterial hypotension were seen. Creatinine clearance and serum potassium showed no statistically significant change.