1. Steriods: A good thing in Childhood MPGN ?By
Brent Lee Lechner
CPT, MC, USA

2. History 10 year old White Female presents to PCP:
Periorbital edema during trip to Netherlands, which started 15 days prior visit
Dark red urine the day of the visit along with ankle edema
Dipstick of Urine: Protein 3+, Large Blood
No Hypertension, Creatinine at 0.7 mg/dl
Sent to Peds Nephrology within 2 days

3. History No rashes, no joint pain, and no fevers
No sore throat, no skin infections
Strep. culture taken negative
Fatigue and decreased appetite
URI symptoms prior to trip to Netherlands
Runny nose, cough and congestion
Zithromax given for sinusitis

4. Past History PMHx: PSHx: FHx: Imm: UTD All: NKDA Few otitis media
No UTI
No renal stones
No admission to hospital
PSHx:
None
FHx:
No ESRD
No Renal Stones
No Hematuria
No Autoimmune Disease
Imm: UTD
All: NKDA

5. Physical Examination T: 37.1 C P:81 BP: 132/82 R:18 PO2:100%
Head: NC, 0 lesions
Eyes: PERRLA, EOMI,
B Fundo:Nml
B eyelid Edema 2+/4
Ears: B Clear TM
Nose: Non-swollen turbinates
Throat: Non-red, clear,
0 exudate
Neck: Supple, 0 mass, 0 JVD
0 Stiffness
Chest: RRR, S1, S2, 0 murmur
Lungs: B CTA
good air movement
0 Wheezing
0 lymph nodes
Abdomen: ND/NT, Soft, BS(+)
0 HSM
Ext: 0 c/c; From; Cap Refill<2s
Edema
Ankles: 2+ pitting edema B
No edema in UE
Skin: 0 Rashes; 0 Impetigo

6. LABS
CBC
CHEM 10
11.9
6.7
339
133
108 15
36.9
3.7
21.0
0.8

7. LABS Urinanalysis Urine Micro pH 6.0 SG 1.030 Ketones (-) Glucose (-)
Nitrates (-)
LE (-)
Protein 3+
Blood Large
Urine Micro
TNTC RBCs
10-20 RBC cast/ hpf
50+ Dysmorphic RBCs/hpf
5-7 Granular Casts/hpf

8. Labs C3: 16 C4: 29 ANA < 1:40 Strep Serologies: Negative
Albumin 1.9 mg/dl
Hepatitis Screen (-)
HIV screen (-)
Urine Protein to Creatinine ratio: 8.8

9. Army Air Ambulance

10. History One Month: Daily journal and school nurse recording BP
increasing BP, more edema, weight gain and some ascites
Slightly elevated creatinine to 1.4 mg/dl
Repeat C3 showed low C3 at 20
Anemia worsening at Hct: 24.4%
Admitted to the Hospital
BP control with medication
Renal Biopsy

11. Army CSH

12. Follow Up History
Started on Prednisone 60 mg qd after IV Solumedrol pulse in the hospital
Developed Shingles
Treated with Valcyclovir
Attempt to reduce Prednisone to qod
Unsuccessful
Creatinine increased to 2.2 mg/dl

13. Follow Up History Two weeks after steriod reduction:
Creatinine rose to 2.8mg/dl and 3.1 mg/dl
Admission to hospital
Massive Ascites developed
Creatinine rose to 4.7 mg/dl, despite pulse steriods
Patient started on Peritoneal Dialysis
Prednisone 60 mg qd

14. Continued History One week of peritoneal dialysis
Patient responded to Steroids and creatinine reduced to 1.7 mg/dl
Several more attempts to reduce to Prednisone qod: unsuccessful
Bump in her creatinine with return to baseline after Prednisone dose resumed
Occasional readmission to hospital due to massive ascites and uncontrolled HTN

15. Humanitarian Relief

16. MPGN Type II Children > 5 years of age, Male=Female
Caucasians and reports of familial clusters
95% low plasma C3
50% Anemic
50 % 10-year renal survival (Cameron et al)
1983
West CD Alternate day 60 mg/m2 Prednisone
Retrospective study
71 patients: Renal Survival at 10 year mark 82, 56% after 20 years

17. Do steroids aid in the regression of MPGN ?
“Regression of Membranoproliferative GN Type II (DDD): Observations in Six Children” McEnery and Adams AJKD 1988

18. Do steroids aid in the regression of MPGN ?
“Regression of Membranoproliferative GN Type II (DDD): Observations in Six Children” McEnery and Adams AJKD 1988

19. More Humanitarian Relief

20. Do steroids aid in the regression of MPGN ?
“Treatment of MPGN with qod prednisone – a report of The International Study of Kidney Disease in Children” Tarish (1992) Ped Nephrology
Controlled, double-blinded Study
Years:
Ages: 5-17
80 Children
End Point: Increase in creatinine 0.4 mg.dl

21. Do steroids aid in the regression of MPGN ?
“Treatment of MPGN with qod prednisone – a report of The International Study of Kidney Disease in Children” Tarish (1992) Ped Nephrology

22. Do steroids aid in the regression of MPGN ?
“Treatment of MPGN with qod prednisone – a report of The International Study of Kidney Disease in Children” Tarish (1992) Ped Nephrology

23. Do steroids aid in the regression of MPGN ?
“Treatment of MPGN with qod prednisone – a report of The International Study of Kidney Disease in Children” Tarish (1992) Ped Nephrology

24. Cadets At Yankee Stadium