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Oxidant Stress in Primary Nephrotic Syndrome: Does It Modulate The Response To Corticosteroids?
Oxidant Stress in Primary Nephrotic Syndrome: Does It Modulate The Response To Corticosteroids?
DOI 10.1007/s00467-009-1246-2
ORIGINAL ARTICLE
Received: 18 April 2009 / Revised: 24 May 2009 / Accepted: 8 June 2009 / Published online: 31 July 2009
# IPNA 2009
Abstract In order to assess the oxidative stress in newly the response to corticosteroids. Further prospective
diagnosed children with primary nephrotic syndrome studies using larger numbers of patients are needed to
(PNS), we serially measured serum total antioxidant validate these results.
capacity (TAC) and malondialdehyde (MDA) in 33 children
with PNS and ten healthy matched controls. Patients were Keywords Children . Corticosteroid response .
classified into two groups: those who had steroid-sensitive Oxidant stress . Primary nephrotic syndrome
nephrotic syndrome (SSNS; n = 26) and those who had
steroid-resistant nephrotic syndrome (SRNS; n = 7). Of the
patients with SSNS, 15 were non-relapsers and 11 were Introduction
relapsers. At the proteinuric phase, all patients had
significantly higher MDA levels and lower TAC than the The generation of reactive oxygen species (ROS) is a normal
controls. These changes were more marked in patients with steady state process in cells, although uncontrolled production
SRNS than in those with SSNS. During remission and results in damage to cellular molecules. Malondialdehyde
still on corticosteroids, patients had higher TAC and (MDA), the main indicator of lipid peroxidation, causes the
similar MDA levels as in the proteinuric phase, but the cross linking and polymerization of membrane components
TAC and MDA levels still significantly differed from and also reacts with DNA nitrogenous bases [1]. Cellular
those of the controls. More improvement in TAC and defense mechanisms against ROS include enzyme systems
MDA levels occurred in patients following the weaning that directly remove these species (superoxide dismutase,
of corticosteroids, but TAC was still lower in the patients catalase and glutathione peroxidase) and non-enzymatic
than in the controls. Moreover, TAC was higher in non- scavengers that are either endogenous molecules (albumin,
relapsers than in relapsers. Using a receiver operating glutathione and uric acid) or derived from the diet (vitamin
characteristic curve, the initial response to corticosteroids C, vitamin E, carotenoids, selenium and zinc). The cumulative
could be predicted at serum TAC level ≥0.73 mM/L effect of endogenous and food-derived antioxidants represents
(sensitivity 89%, specificity 86%), while serum TAC the total antioxidant capacity (TAC) of the system. An
levels ≤1.14 mM/L after the weaning of corticosteroids imbalance between the production and elimination of ROS
could predict that the patient would not relapse (sensitivity is referred to oxidative stress [2].
91%, specificity 80%). In conclusion, based on our results, The study of oxidant/antioxidant balance in primary
PNS can be considered to be associated with oxidative nephrotic syndrome (PNS) in both animal [3, 4] and human
stress even during remission. This stress may modulate [5–7] models has gained the attention of many researchers in
recent years. However, the results of these studies have been
conflicting. Almost all of the human studies were carried out
A. Bakr (*) : S. Abul Hassan : M. Shoker : M. Zaki : R. Hassan on patients with steroid-sensitive nephrotic syndrome. More-
Pediatric Nephrology, Mansoura Faculty of Medicine,
over, whether the studied patients were relapsers or non-
Mansoura University Children’s Hospital,
Mansoura, Egypt relapsers was not taken into account. The longitudinal study
e-mail: ashbakr@mans.edu.eg reported here was carried out to assess the serial changes in
2376 Pediatr Nephrol (2009) 24:2375–2380
serum TAC and MDA levels in newly diagnosed PNS patients revealed focal segmental glomerularsclerosis in
children. We also evaluated the prognostic value of TAC and three patients, minimal change nephrotic syndrome in two
MDA levels in predicting the response to corticosteroids. patients and diffuse mesangial proliferation in two
patients.
SSNS, steroid-sensitive nephrotic syndrome; SRNS, steroid-resistant nephrotic syndrome; BP, blood pressure
Data are presented as mean ± standard deviation (SD)
patients enrolled in the study had significantly lower TAC TAC levels in stages II (P=0.004) and III (P=0.001) than
serum levels during the three stages of the disease. In relapsers.
comparison, serum MDA levels were significantly higher in There were no significant differences in MDA levels
the patient group in stage I and II only, and no significant between stage I and II in both relapsers and non-relapsers,
difference was observed in stage III. but MDA levels were significantly lower in stage III than
In stage I, SRNS patients had significantly lower TAC stage II in both non-relapsers (P=0.001) and relapsers
levels (P=0.001) and higher MDA levels (P=0.003) than (0.004). No significant differences were observed in MDA
SSNS patients (Table 3). levels between non-relapsers and relapsers in the three
Figure 1a demonstrates that TAC levels significantly stages of PNS (Fig. 1b).
increased in both non-relapsers (P=0.001) and relapsers Figure 2 shows that it is possible to predict the
(P=0.005) in stage II compared to stage I. A further response to corticosteroids in the proteinuric stage of
significant increase was observed in stage III in non- PNS by using TAC levels at the cut-off point ≥0.73 mM/L
relapsers (P=0.001) and relapsers (P=0.003). No significant (sensitivity 89%, specificity 86%, predictability 93%).
difference in TAC levels was observed between non-relapsers Alternatively, TAC levels after the weaning of cortico-
and relapsers in stage I. However, non-relapsers had higher steroids at a cut-off point ≤1.14 mmol/L could be used to
Table 2 Comparison of serum total antioxidant capacity and malondialdehyde levels between the studied patients and controls at different stages of primary
nephrotic syndrome
SSNS SRNS
TAC (mM/L) 0.86 (0.72–0.91) 0.82 (0.68–0.91) 0.66 (0.59–0.81) 0.97 (0.87–1.14) 0.88 (0.72–0.96) 1.43 (0.97–1.6) 1.05 (0.87–1.16) 1.78 (0.99–2.0)
MDA (nmol/mL) 12.5 (8.72–20.5) 14.4 (9.24–23) 17.5 (14.3–29) 10.8 (4.3–22.43) 13.2 (6.6–19.2) 4.8 (2.47–7.5) 6.4 (2.5–15.5) 6.6 (4.5–7.5)
a
P1 <0.0001 <0.0001 0.001 <0.0001 <0.0001 0.007 0.001
P2b <0.0001 <0.0001 0.001 0.006 <0.0001 0.08 0.86
0.00
0.00 0.25 0.50 0.75 1.00
0.4 To the best of our knowledge, this is the first study to assess
Non relapser
0.2 Relapser serial changes in oxidants and antioxidants in a cohort of
0 newly diagnosed children with PNS with different
Stage I Stage II Stage III
responses to corticosteroids.
P1= Stage I vs. stage II (non relapsers: 0.001, relapsers: 0.005) All of the newly diagnosed patients with PNS in the
P2= Stage II vs. stage III (non relapsers: 0.00, relapsers: 0.003)
P3= Stage I vs. stage III (non relapsers: 0.001, relapsers: 0.003)
proteinuric phase of the disease prior to starting corticoste-
P4=non relapsers vs. relapsers (stage I: 0.49, stage II: 0.004, stage III: 0.001) roid therapy had oxidative stress in the form of high serum
MDA with low TAC concentrations. This condition of
b MDA (nmol/mL)
oxidative stress was similar whether the patients were
16
proved later to have SRNS or SSNS (either non-relapsers or
14
12 1.00
10
8
0.75
Median level of controls
6
Non relapser
0.50
2 Relapser
0
Stage I Stage II Stage III
0.25
P1= Stage I vs. stage II (non relapsers: 0.45, relapsers: 0.37)
P2= Stage II vs. stage III (non relapsers: 0.001, relapsers: 0.004)
P3= Stage I vs. stage III (non relapsers: 0.001, relapsers: 0.003)
P4=non relapsers vs. relapsers (stage I: 0.07, stage II: 0.15, stage III: 0.06) 0.00
0.25 0.50 0.75 1.00
Fig. 1 Serial changes in serum total antioxidant capacity (TAC) (a)
and malondialdehyde (MDA) level (b) in relapsers and non-relapsers Fig. 3 The ROC curve to differentiate between non-relapsers and
at different stages of primary nephrotic syndrome (PNS) relapsers using serum TAC after the weaning of corticosteroids
Pediatr Nephrol (2009) 24:2375–2380 2379
relapsers). Interestingly, this pattern was more evident in TAC [12] and MDA [13, 24] concentrations in patients with
SRNS than in SSNS, while it was similar in non-relapsers SSNS during the remission stage. High serum MDA levels
and relapsers. were more common among the relapsers than in another
Low TAC concentrations have been reported in the group of patients during remission [24], but none of these
proteinuric phase of SSNS during the first episode [12, 13] earlier studies took the differences between non-relapsers
or at relapse [13]. In contrast, Karthikeyan et al. reported and relapsers into account.
significantly increased ferric-reducing antioxidant power in The normalization of serum albumin and the improvement
nephrotic syndrome in the active disease state and that this in a patient’s appetite as well as intestinal absorption of
remained high during remission when compared to the antioxidants may be responsible for the increase in TAC levels
controls [14]. While many studies have documented high during the remission of the disease. The use of corticosteroids
serum MDA levels [15–17], Ginveri et al. [6] reported high may be another explanation for the improvement of TAC
intra-erythrocyte concentrations of MDA and reduced levels. In an experimental rat model, the administration of
concentrations of the antioxidant glutathione in both SSNS corticosteroids increased glomerular antioxidant enzymes,
and SRNS. However, Gusmano et al. [18] and Kinra et al. which in turn reduced the proteinuria caused by hydrogen
[19] observed an insignificant rise of serum MDA, which peroxide infusion [25].
they explained as being due to factors associated with the There was a further improvement in serum TAC levels in
study design, including small sample size and bias resulting both non-responders and responders following weaning of
from their selection of hospital controls, as well as to the the corticosteroids, in comparison to the previous two
possibility that the much higher concentrations of membrane stages of the disease, but the levels were still lower than
cholesterol found in the acute phase provided a protective those found in the controls. Interestingly, relapsers still had
effect. lower TAC levels than non-relapsers. In contrast, the MDA
The low TAC concentration in the proteinuric phase of level decreased significantly in both groups and reached the
PNS could be attributable to many mechanisms. Hypo- level found in the controls; no significant difference was
albuminemia may be a contributory factor as albumin is the observed between non-relapsers and relapsers.
leading preventive antioxidant of the serum due to its role The persistence of oxidative stress in patients with SSNS
as a metal binding protein [20]. Other contributory factors after long-term remission has been reported by a number of
are the impaired intestinal absorption of some antioxidant investigators [26, 27]. These changes in the studied
components and/or the low antioxidant content of the diet parameters suggest that although there is clinical remission,
in patients with PNS as most have a poor appetite [21]. as indicated by the absence of proteinuria and the
There are some data in the literature showing that a diet normalization of serum albumin, ongoing oxidative stress
deficient in selenium and vitamin E may lead to renal injury still remains, even during remission. This indicates that the
characterized by proteinuria [22]. The low TAC during the body can withstand a certain degree of stress, only beyond
acute stage may also result from the increased consumption which do proteinuria and the clinical picture of nephrotic
of certain antioxidant components, such as vitamin C, syndrome occur [15].
which is significantly lower in the acute phase of nephrotic It is difficult to interpret why patients with SRNS had more
syndrome [7]. The impaired antioxidant status enhances oxidative stress than SSNS patients at the time of diagnosis
lipid peroxidation. There is some evidence available and why the oxidative stress was more evident in relapsers
showing that during the proteinuric stage of PNS circulating than in non-relapsers during the remission of the disease. It
lipids bind to and become trapped by extracellular matrix can be speculated that the oxidant/antioxidant imbalance
molecules where they undergo oxidation, thereby increasing partly modulates the response of newly diagnosed PNS
the formation of ROS [23]. Enhanced lipid peroxidation is patients to corticosteroids. Since our study cohort was
known to be manifested by increased serum MDA levels [1]. insufficient in terms of the number of enrolled patients,
During remission when patients were still receiving further studies with larger numbers of patients are required to
corticosteroids, serum TAC improved in both non-relapsers prove/disprove this hypothesis. However, our results are
and relapsers compared to the proteinuric stage; however, encouraging in terms of suggesting the use of serum TAC
the levels were still significantly lower than those found in and MDA levels as potential predictors of the response of
the controls. This improvement was more marked in newly diagnosed patients to corticosteroid therapy. At the time
non-relapsers than in relapsers. In comparison, although of diagnosis, we found that the response to corticosteroids
serum MDA levels were still significantly higher in patients could be predicted at serum TAC level ≥0.73 mM/L
during remission than in controls, they did not significantly (sensitivity 89%, specificity 86%), while serum TAC levels
differ from levels in the proteinuric stage, and there was no ≤1.14 mM/L after the weaning of corticosteroids could
significant difference between non-relapsers and relapsers. predict that the patient would be a relapser (sensitivity 91%,
Previous studies have reported similar changes in serum specificity 80%).
2380 Pediatr Nephrol (2009) 24:2375–2380
In conclusion, newly diagnosed patients with PNS 13. Ece A, Atamer Y, Gurkan F, Davutoglu M, Kocyigit Y, Tutanc M
(2005) Paraoxonase, total antioxidant response, and peroxide
persistently have oxidant stress even during remission of
levels in children with steroid-sensitive nephrotic syndrome.
the disease. This stress may modulate the response to Pediatr Nephrol 20:1279–1284
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diagnosis could predict the response to corticosteroids (2008) Plasma protein thiols and total antioxidant power in
pediatric nephrotic syndrome. Nephron Clin Pract 110:c10–
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c14
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prospective studies using larger numbers of patients are steroid responsive nephrotic syndrome in indian children. J
needed to validate these results. Paediatr Child Health 38:450–454
16. Balamurgan R, Bobby Z, Selvaraj N, Nalini P, Koner BC, Sen SK
(2003) Increased protein glycation in non-diabetic pediatric
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