Differential Protein Clearances in Indian Children with the Nephrotic Syndrome

Abstract

Differential clearances of five plasma proteins were studied in 37 north Indian children with the nephrotic syndrome, and these, and the serum β1c levels were related to steroid response and, in some, renal biopsy histology. 16 children (43%) did not respond completely to steroids and a majority of them had a poorly selective proteinuria. The differential protein clearances suggest that these patients are a heterogeneous group. The serum complement β1c levels in nephrotics were significantly lower than in control Indian and European children.

Full text

Archives
of
Disease
in
Childhood,
1970,
45,
491.
Differential
Protein
Clearances
in
Indian
Children
with
the
Nephrotic
Syndrome
R.
K.
CHANDRA,
S.
S.
MANCHANDA,
R.
N.
SRIVASTAVA,
and
J.
F.
SOOTHILL
From
the
Depariments
of
Pacdiatrics
of
the
All
India
Institute
of
Medical
Sciences,
New
Delhi,
and
the
Medical
College
Hospital,
Amritsar,
and
the
Department
of
Immunology,
Institute
of
Child
Health,
London
Chandra,
R.
K.,
Manchanda,
S.
S.,
Srivastava,
R.
N.,
and
Soothill,
J.
F.
(1970).
Archives
of
Disease
in
Childhood,
45,
491. Differential
protein
clearances
in
Indian
children
with
the
nephrotic
syndrome.
Differential
clearances
of
five
plasma
proteins
were
studied
in
37
north
Indian
children
with
the
nephrotic
syndrome,
and
these,
and
the
serum
P1c
levels
were
related
to
steroid
response
and,
in
some,
renal
biopsy
histology.
16
children
(43
%)
did
not
respond
completely
to
steroids
and
a
majority
of
them
had
a
poorly
selective
proteinuria.
The
differential
protein
clearances
suggest
that
these
patients
are
a
heterogeneous
group.
The
serum
complement
i,Bc
levels
in
nephrotics
were
significantly
lower
than
in
control
Indian
and
European
children.
In
most
communities
the
majority
of
children
with
the
nephrotic
syndrome
are
responsive
to
steroids
(93%o
in
the
series
reported
by
Arneil
and
Lam
(1966))
and
have
only
minimal
abnormality
of
renal
biopsy
histology
(Cameron
and
White,
1965;
Cameron,
1968),
though
there
is
always
a
minority
of
steroid
resistant
patients
who
often
show
abnorm-
ality
of
glomerular
structure.
In
Nigeria,
however,
the
situation
is
quite
different;
the
majority
of
patients
there
do
not
respond
to
steroids
and
have
abnormal
renal
biopsies,
and
there
is
epidemiological
evidence
that
this
difference
arises,
at
least
in
part,
from
the
high
incidence
of
a
form
of
nephritis
associated
with
P.
malariae
infection
(Gilles
and
Hendrickse,
1963;
Hendrickse
and
Gilles,
1963;
Soothill
and
Hendrickse,
1967).
Differential
protein
clearances,
a
quantitative
measurement
of
the
type
of
glomerular
damage
associated
with
heavy
proteinuria
(Hardwicke
and
Soothill,
1967),
provide
a
means
of
identifying
the
steroid
sensitive
minority
in
European
adult
patients
and
Nigerian
children
with
the
nephrotic
syndrome
(Blainey
et
al.,
1960;
Soothill
and
Hendrickse,
1967),
and
the
steroid
sensitive
majority
in
European
children
(Cameron
and
White,
1965),
all
of
whom
have
highly
selective
proteinuria,
i.e.
the
clearance
of
larger
proteins
is
very
much
less
than
the
clearance
of
small
proteins.
The
poorly
selective
group
in
European
adults
is
clearly
hetero-
Received
20
January
1970.
geneous,
both
in
terms
of
the
protein
clearance
measurements,
the
underlying
disease
process,
and
the
histology
of
the
kidney
(Hardwicke
and
Soothill,
1967),
but
it
is
difficult
to
study
this
in
European
nephrotic
children,
as
poorly
selective
proteinuria
is
relatively
rare,
while
the
findings
in
Nigerian
children
define
two
predominant,
remarkably
homogeneous
disease
processes-the
minority
highly
selective,
and
the
majority
with
a
characteristic
discontinuity
of
linearity
of
selectivity
of
proteinuria
(Soothill
and
Hendrickse,
1967).
For
this
reason,
studies
are
required
of
other
populations
of
nephrotic
children,
in
which
poor
response
to
steroids
occurs
fairly
frequently
and
in
which
P.
malariae
is
not
a
prominent
pathogen.
Children
in
Delhi
with
the
nephrotic
syndrome
represent
one
such,
and
we
report
findings
of
differential
protein
clearances,
renal
biopsy,
and
steroid
response
in
them.
Materials
and
Methods
Thirty-seven
children,
aged
between
2j
years
and
12
years,
who
attended
the
clinics
at
New
Delhi
or
Amritsar,
with
the
nephrotic
syndrome
(generalized
oedema
and
proteinuria
>0
1
g./kg.
per
day)
in
the
period
January
1968
to
November
1969
were
studied.
Five
of
these
children
had
previously
been
treated
with
steroids
without
significant
change
in
the
clinical
condition
or
proteinuria;
these
are
indicated
in
Table
I.
Since
both
the
clinics
are
in
teaching
hospitals,
it
is
possible
that
some
degree
of
selection
towards
more
severe
cases
may
occur,
particularly
at
the
New
Delhi
clinic,
but
we
are
not
aware
that
this
was
the
case,
or
491
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492
Chandra,
Manchanda,
indeed
how
it
could
be
done,
apart
from
the
initial
use
of
steroids
at
home,
which
was
done
in
only
the
5
mentioned
above.
9
patients
were
mildly
hypertensive
and
8
showed
a
moderate
increase
in
blood
urea.
A
past
history
suggestive
of
the
acute
nephritis
syndrome
was
elicited
in
2.
All
children
were
treated
with
prednisolone
2
mg./kg.
per
24
hours
and
supportive
measures.
Treatment
was
maintained
at
this
dose
for
4
weeks
if
a
response
occurred,
or
for
8
weeks,
if
proteinuria
persisted,
when
the
response
was
classified
as
'good'
if
random
specimens
of
urine
were
negative for
protein
by
the
heat
coagulation
test,
'poor'
if
the
test
was
still
strongly
positive
(+
+
+),
and
'fair'
if
small
amounts
of
proteinuria
(tr,
-,
+
+)
were
detected.
Percutaneous
renal
biopsy
was
performed
in
15
children.
The
slides
were
classified
as
normal,
'minimal
change',
proliferative
glomerulonephritis,
or
membranous
glom-
erulonephritis
by
one
of
us
(R.N.S.)
who
had
no
knowledge
of
the
therapeutic
outcome.
Srivastava,
and
Soothill
Differential
protein
clearances
and
serum
/lc
were
estimated
by
the
double
diffusion
method
described
by
Soothill
(1962).
Urine
and
serum
samples,
collected
before
treatment
was
started,
were
preserved
with
1
drop
of
0-10%
sodium
azide
and
stored
at
-20
'C.
The
specific
antisera
to
albumin
(A),
siderophilin
(S),
IgG,
Plc,
and
a-macroglobulin
(aM)
were
raised
in
rabbits
or
sheep.
The
estimations
were
made
after
the
patients
had
been
classified
therapeutically
and
histologically.
Reactions
of
identity
were
shown
between
each
of
the
proteins
studied
in
the
urine
and
the
serum,
by
the
double
gel
diffusion
technique.
Serum
fllc
concentra-
tions
are
expressed
as
a
percentage
of
the
M.R.C.
Research
Standard
Serum
for
immunoglobulins
G,
A,
and
M,
and
values
for
15
healthy
Indian
children
aged
2
to
12
years,
estimated
by
the
same
technique,
and
for
19
European
children
(Ngu
and
Soothill,
1969)
using
a
single
diffusion
technique,
but
the
same
standard,
are
also
shown.
Differential
Protein
Clearances
TABLE
I
Expressed
as
Percentage
of
Albumin
Response
Groups
Clearance
in
Different
Treatment
CS/CA
CIgGA
CX1C/CA
COCM1CA
Serum
Previous
Response
Biopsy
CsA
ic
Steroid
(
%o)
(
%!
(0°/O
)
(
%)
(0/o
)
Treatment
Good
(21)
Normal
85
16
9
<0*20
112
Normal
95
11
4-5
<0-12
75
Minimal
change
90
20
12
0-25
87
Normal
85
8
4
<0
20
87
Minimal
change
95
16
12
<0*20
112
-
105
12
8
0
12
87
-
75
30
23
<0-24
75
-
88
16
7
<0-21
137
-
96
33
12
0
4
87
-
98
6
7
<0
05
25
-
105
11
9
0*15
62
-
97
30
12
<0
04
87
-
73
87
0
10
75
-
92
7
11
<0-20
62
-
90
5
5
0
05
125
I
_
110
16
4
0
15
37
_
85
9
5
0-12
87
-_
93
5
2
<0-20
62
_
90
10
5
0
16
87
_
102
13
7
<0
20 62
-
102
6
3
0
14
112
Fair
(8)
Prolif.
95
23
12
0
9
25
Prolif.
90
18
12
0*2S
62
+
Minimal
change
95
23
17
0
4
75
Normal
80
20
7
0-4
62
Membranous
90
40
12
0
8
87
+
65
45
12
0
9 112
-
103
33
12
0
4 37
95
33
7
0
9
87
Poor
(8)
Membranous
80
50
20
0
9
87
92
55
16
2
0
50
+
Prolif.
105
50
14
0
7
50
Minimal
change
95
40
14
0
8
150
+
F
Prolif.
92
42
29
1
4
37
70
50
28
0
8
62
95
50
14
0
23
37
105
33
4-5
115
62
-
Not
done.
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Differential
Protein
Clearances
in
Indian
Children
with
the
Nephrotic
Syndrome
Results
Of
the
37
children,
21
(57%)
responded
fully
to
4-8
weeks
of
prednisolone
treatment.
If
the
5
patients
who
were
referred
after
some
steroid
treatment
are
excluded,
this
incidence
rises
to
21
out
of
32-66%.
These
figures
confirm
previous
impressions
that
steroid
response
is
less
frequent
in
Indian
nephrotic
children
than
in
some
populations.
In
Table
I
the
renal
biopsy
findings,
differential
protein
clearance
results,
and
serum
Plc
levels
are
given
for
the
patients,
classified
according
to
their
response
to
steroid
treatment
as
good,
fair,
or
poor.
The
mean
value
for
each
group
of
the
clearances
of
each
protein
expressed
as
a
percentage
of
the
clearance
of
albumin
is
plotted
against
the
molecular
weight
of
each
protein
in
Fig.
1.
For
all
proteins,
50;
10
U
<0
2
S
1
IqG/31c
Mol.
Wt.x
K)5
_M
10
FIG.
1.-Mean
value
of
clearances
of
siderophilin
(S),
IgG,
Plc,
and
a
macroglobulin
(aM)
expressed
as
percentage
of
clearance
of
albumin
(A),
and
plotted
against
the
mole-
cular
weight of
the
protein,
for
Indian
children
with
nephrotic
syndrome,
classified
by
steroid
response
as
good
(A),
fair
(@),
and
poor
(0).
except
siderophilin,
which
is
passed
nearly
as
readily
as
albumin,
the
selectivity
is
greatest
in
the
good
re-
sponders,
and
least
in
the
poor
responders.
Each
of
these
distinctions
is
significant
by
t
test
analysis
of
log
CAgG
I
(Table
II).
Similar
separations
are
achiev-
ed
by
Plc
and
oCM,
but
analysis
for
oM
is
difficult
because
of
threshold
values,
though
the
differences
are
obvious,
and
perhaps
achieve
the
clearest
separation,
since
all
the
good
responders
had
Ca/CA
TABLE
II
CIgGICA
in
Indian
Nephrotic
Children
Classified
by
Steroid
Response
and
by
Renal
Biopsy
Histology
Group
No.
Log
Men
t
Good
response
21
11
10-55
<0
001
Fair
response
8
27}}
Poor
response
8
46
3-21
<0
01
Minimal
change
8
16]
Histological
7
37
k
4-04
<0*01
abnormality
J
of
0
*4
or
less,
and
all
the
rest
had
C,m/CA
of
0*4
or
greater.
This
difference
of
discrimination
by
the
different
proteins
arises
from
the
heterogeneity
of
linearity
on
these
plots
for
different
individuals,
which
is
illustrated
in
Fig.
2,
in
which
the
results
of
5
patients
selected
to
illustrate
this
point
are
plotted.
3
give
essentially
linear
plots,
of
different
selectivities,
whereas
2
others
were
poorly
selective
for
IgG
but
highly
selective
for
OCm.
We
do
not
have
evidence
for
the
reproducibility
of
this
in
these
children,
though
such
evidence
has
been
reported
previously
(Hardwicke
et
al.,
1970).
0
0
CL
S
i
I9G
#IC
Moc
lO
MoI.Wt.
x
105
FIG.
2.-Differential
protein
clearance
results,
plotted
as
in
Fig.
1,
for
5
selected
Indian
children
with
the
nephrotic
syndrome,
3
of
whom
showed
proteinuria
of
a
range
of
selectivities
which
resulted
in
approximately
linear
plots,
and
2
of
whom
show
marked
discontinuity
of
linearity.
493
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Chandra,
Manchanda,
Srivastava,
and
Soothill
Similar
relations
are
shown
between
differential
protein
clearances
and
renal
biopsy
histology.
The
histology
also
clearly
was
related
to
treatment
response,
since
all
the
5
patients
with
good
response
who
were
biopsied
had
essentially
normal
renal
histology,
whereas
this
was
true
of
only
3
of
the
10
who
did
not
respond
fully.
The
numbers
were
small,
so
comparison
between
those
classified
as
membranous
nephritis,
and
those
classified
as
proliferative
cannot
be
made
statistically,
but
CI11f/CA
is
significantly
higher
for
them
together
than
it
is
for
the
patients
with
minimal
renal
histological
abnormality
(Table
II),
and
similar
trends
are
shown
for
the
other
proteins.
The
serum
f1lc
values
in
the
healthy
Indian
children
(log
mean
110°%)
were
remarkably
similar
to
those
of
healthy
English
children
(log
mean
108%)
(Fig.
3),
and
the
Indian
nephrotic
children
200-
150*
w100
70
S-
50
E
S
30-
2n
20
AAA
A
A
A&AAAAAMAO
AAAA
A
AS
Healthy
Healthy
Indian
children
European
Indian
with
nephrotic
children
children
syndrome
FIG.
3.-Serum
Plc
concentration
in
Indian
children
with
the
nephrotic
syndrome
(A
=
good
steroid
response,
*
=
fair
or
poor
steroid
response),
in
healthy
Indian
children,
and
in
healthy
European
children
(from
Ngu
and
Soothill,
1969)
expressed
as
percentage
of
M.R.C.
standard
serum
for
immunoglobulins
G,
A,
and
M.
The
log
mean
of
each
group
is
indicated.
gave
values
(log
mean
74%)
which
were
significantly
lower
than
the
healthy
Indian
children
(t
=
61
-2;
P
=
<0-001).
There
were
trends
for
the
good
responders,
and
for
the
patients
with
minimal
renal
histological
abnormality
to
give
higher
values,
but
these
were
not
significant.
Discussion
Nephrotic
syndrome
is
the
clinical
manifestation
of
glomerular
damage,
resulting
in
a
large
leak
of
protein,
and
there
are
many
causes
of
it
(Hardwicke
and
Soothill,
1967).
The
prognosis
and
treatment
response
of
any
particular
patient
are
related
to
the
underlying
renal
lesion
rather
than
to
the
apparent
severity
of
the
presenting
symptoms.
A
good
correlation
between
the
short-term
steroid
response
and
the
selectivity
of
differential
protein
clearances
has
been
shown
for
European
adults
(Blainey
et
al.,
1960),
European
children
(Cameron
and
White,
1965;
Cameron,
1968),
and
Nigerian
children
(Soothill
and
Hendrickse,
1967).
Our
observations
confirm
this
for
another
population
group-Indian
children.
Probably
good
response
to
steroids
is
rarer
in
this
population
than
in
nephrotic
children
in
Europe,
and
more
common
than
in
nephrotic
children
in
Nigeria,
and
this
is
reflected
in
the
proportion
with
highly
selective
proteinuria,
and
by
the
renal
biopsy
histology,
though
the
correlation
between
these
different
findings
is
not
perfect.
It
is
likely
that
the
difference
in
the
proportion
of
nephrotic
children
with
poor
response
and
a
poorly
selective
protein
excretion
would
differ
from
one
population
group
to
another,
depending
upon
the
incidence
of
different
causes
of
the
glomerular
damage
in
the
different
populations.
In
Nigeria,
epidemiological
evidence
suggests
that
infection
with
P.
malariae
is
an
important
cause
of
the
childhood
nephrotic
syndrome
(Gilles
and
Hendrickse,
1963;
Hendrickse
and
Gilles,
1963),
and
this
accounts
for
the
fact
that
the
steroid
responsive
group
are
a
minority
with
another
common
illness
superimposed.
In
Delhi,
malaria
has
been
almost
unknown
for
the
past
5
years,
and
it
is
most
unlikely
that
malarial
infection
is
a
significant
contributory
cause
for
the
relatively
large
number
of
poor
and
fair
responders
among
Delhi
nephrotic
children.
It
is
possible
that
this
incidence
represents
an
allergic
reaction
to
one
of
the
other
infectious
diseases,
still
endemic
in
India,
though
we
do
not
know
what.
The
use
of
different
means
of
expression
of
the
differential
protein
clearance
data
has
been
debated
(Hardwicke
et
al.,
1970).
Where
a
line
can
be
drawn
through
a
series
of
points,
slope
statistics
are
attractive
(Joachim
et
al.,
1964),
but
clearly
this
is
possible
in
only
some
of
our
patients
(Fig.
2),
though
probably
in
a
higher
proportion
than
in
the
Nigerian
children.
As
approximations
to
this,
implicitly
assuming
such
linearity,
Cig0/C8
(Cameron
and
Blandford,
1966),
or
Cm/CA
(MacLean
and
Robson,
1967)
have
been
advocated,
and
our
data
are
probably
consistent
with
the
view
of
the
latter
workers,
that
theirs
is
the
best
single
predictor
of
steroid
response,
though
the
former
has
practical
advantages,
and
both
eliminate
some
potentially
useful
information.
The
discontinuity
of
linearity
(or
dog's
leg
proteinuria)
leading
to
this
complexity
provides
evidence
of
heterogeneity
in
the
poor
494
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Differential
Protein
Clearances
in
Indian
Children
with
the
Nephrotic
Syndrome
495
steroid
responders,
which
is
apparently
greater
in
our
patients
than
that
in
Nigerian
nephrotic
children
(Soothill
and
Hendrickse,
1967).
This
perhaps
points
to
multiple
aetiology
in
our
patients.
The
serum
complement
component
Plc
levels
in
normal
Indian
children
are
remarkably
similar
to
those
in
a
European
population.
In
our
patients
with
the
nephrotic
syndrome,
there
was
a
significant
depression
of
serum
fBlc
concentration
which
involved
both
those
with
good
and
poor
steroid
response
since,
though
there
was
a
tendency
for
those
with
histological
abnormality
and
for
the
poor
responders
to
give
lower
values,
this
small
trend
was
not
significant.
Though
there
has
been
debate
about
serum
complement
levels
in
steroid
sensitive
nephrotic
syndrome,
and
there
is
evidence
that
it
may
be
an
immunological
disease
(Lange
et
al.,
1957;
Ngu,
Barratt,
and
Soothill,
1970),
the
latter
found
no
difference
between
the
serum
lc
levels
in
European
steroid
sensitive
relapsing
nephrotic
syn-
drome,
and
in
the
healthy
European
children
whose
data
are
plotted
in
Fig.
3. It
is
possible
that
there
is
a
regional
difference
even
in
the
steroid
sensitive
group,
though
the
concentration
of
a
plasma
protein
in
the
face
of
heavy
proteinuria
may
well
be
influenced
by
many
non-specific
variables
which
may
differ
from
place
to
place.
We
are
grateful
to
Drs.
D.
Myekar
and
K.
K.
Khanna
for
collection
of
some
of
the
samples,
and
to
Professor
0.
P.
Ghai
for
permission
to
publish
this
paper.
The
study
was
done
during
the
tenure
of
a
Commonwealth
Medical
Fellowship
to
one
of
us
(R.K.C.).
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Chandra,
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of
Paediatrics,
All
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New
Delhi
16,
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group.bmj.com on July 15, 2011 - Published by adc.bmj.comDownloaded from

doi: 10.1136/adc.45.242.491
1970 45: 491-495Arch Dis Child
et al.
R. K. Chandra, S. S. Manchanda, R. N. Srivastava,
Nephrotic Syndrome
in Indian Children with the
Differential Protein Clearances
http://adc.bmj.com/content/45/242/491
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