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STUDY ON RISK FACTORS FOR RELAPSE IN CHILDHOOD NEPHROTIC SYNDROME PRESENTING IN RIMS, RANCHI
Dr. (Prof.) Rajeeva Mishra, Dr. Shiromani Kumari* and Dr. Jagrita Malakar
Background: Nephrotic syndrome (NS) is a disease characterised by heavy proteinuria, hypoalbuminemia (serum Albumin <2.5g/dl), hyperlipidemia (serum cholesterol >200mg/dl) & edema. Nephrotic range proteinuria is present if early morning urine protein is 3+/4+ (on dipstick or boiling test), urine albumin excretion >40 mg/m2 per hr (on a timed-sample) or spot urine protein/creatinine ratio > 2. The risk factors associated with frequent relapse of Nephrotic Syndrome are early age at onset, delayed time to achieve remission with steroid in 1st attack, presence of upper respiratory tract infection or any other associated infection during 1st episode or during relapse, more number of relapses in first six months after initial episode, shorter time interval between 1st episode and first relapse, inadequate/irregular initial therapy, history of hematuria, hypercholesterolemia and low serum albumin during initial diagnosis as shown in various studies.[2-5] In our country, inadequate health care facility, less organized referral system, lack of adequate knowledge about disease course among parents are great problems in early detection and treatment of relapse cases. Hence, prediction & prevention of risk factors is the key to successful management of childhood Nephrotic Syndrome. Objective: To evaluate different risk factors associated with the group of frequent relapsing Nephrotic Syndrome compared to the group of infrequent relapsers. To identify certain risk factors as predictors for frequently relapsing Nephrotic Syndrome, to address those risk factors and minimize frequency of relapses. Method: This hospital based cross-sectional observational study was conducted in the Department of Pediatrics, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, over a period of 1 year from June 2020-May 2021. A total of 100 children who met the inclusion criteria were enrolled into the study. Results: Mean age at onset was 6.5±3.374 years. Boys constituted 71% (71 out of 100 children) & girls 29% (29 out of 100) of total study population. Among 100 patients with SSNS, 39 patients were included in FRNS group, rest 61 patients were in IFRNS group. In this study, male to female ratio was 2.4:1. Mean age of onset in FRNS group in this study was lower in comparison to the IFRNS group but the difference was found to be statistically insignificant. Presence of infection during 1st episode played a statistically significant role for relapse (p<0.05). UTI was found to be the most common infection associated in FRNS. Massive edema was more in the FRNS group but the difference was found to be statistically insignificant. Time interval between remission in 1st attack & onset of 1st relapse was significantly lower in FRNS. Steroid free time interval between completion of treatment of 1st attack and onset of 1st relapse was also significantly lower in FRNS. H/o inadequate initial treatment was significantly more in FRNS. In FRNS group, remission occurred later than IFRNS group but there was no statistically significant association. Serum albumin concentration during disease onset was significantly less in FRNS. Serum cholesterol level was significantly higher in FRNS group. Hematuria, hypertension or presence of atopy at the onset of disease were not found as risk factor for increased relapse rate in this study. Conclusion: It was concluded that the following parameters were found to be associated with increased rate of relapse in children with SSNS and therefore may be considered as risk factor for relapse like Presence of infection during initial attack of NS, Presence of infection during 1st relapse of NS,Less time interval between remission in 1st episode of NS & onset of 1st relapse, Less steroid free time interval between completion of treatment of 1st attack & onset of 1st relapse, Inadequate period of treatment (duration in total <12 weeks i.e. daily doses @60mg/m2/day for <6 weeks, alternate day doses @40mg/m2/day for <6 weeks or irregular) of 1st episode of NS, Low serum albumin (with median value 1.6g/dl) and high serum cholesterol level ( with median value 430mg/dl ) at onset of disease. Finally, the hypothesis of the study was tested by chi-square test and found that the above mentioned risk factors for NS relapse were acceptable. But the result of this study may not be applicable for the total community as it was conducted in a single centre over a limited time period in small sample size. Further study with larger sample size in multicenter with longer follow up observations is required to evaluate the results of this study for universal acceptance.[Full Text Article]