Incidence and risk factors for major infections in hospitalized children with nephrotic syndrome

Abstract

Introduction: Children with nephrotic syndrome are at increased risk of infections because of disease status itself and use of various immunosuppressive agents. In majority, infections trigger relapses requiring hospitalization with increased risk of morbidity and mortality. This study aimed to determine the incidence, spectrum, and risk factors for major infections in hospitalized children with nephrotic syndrome. Methods: All consecutive hospitalized children between 1-12 years of age with nephrotic syndrome were enrolled in the study. Children with acute nephritis, secondary nephrotic syndrome as well as those admitted for diagnostic renal biopsy and intravenous cyclophosphamide or rituximab infusion were excluded. Results: A total of 148 children with 162 admissions were enrolled. Incidence of major infections in hospitalized children with nephrotic syndrome was 43.8%. Peritonitis was the commonest infection (24%), followed by pneumonia (18%), urinary tract infection (15%), and cellulitis (14%), contributing with two thirds of major infections. Streptococcus pneumoniae (n = 9) was the predominant organism isolated in children with peritonitis and pneumonia. On logistic regression analysis, serum albumin < 1.5gm/dL was the only independent risk factor for all infections (OR 2.6; 95% CI, 1.2-6; p = 0.01), especially for peritonitis (OR 29; 95% CI, 3-270; p = 0.003). There were four deaths (2.5%) in our study, all due to sepsis and multiorgan failure. Conclusions: Infection remains an important cause of morbidity and mortality in children with nephrotic syndrome. As Pneumococcus was the most prevalent cause of infection in those children, attention should be paid to the pneumococcal immunization in children with nephrotic syndrome.

Infections in Children With Nephrotic Syndrome: Twenty Years of Experience

“…While no randomized controlled trial has investigated the efficacy of antibiotic prophylaxis in preventing SBI in children with NS, SBI in patients on prophylaxis and SBI caused by penicillin-resistant Streptococcus pneumoniae have been reported. 13,17,32 Our study showed no benefit for antibiotic prophylaxis or pneumococcal vaccination in preventing SBI in nephrotic children who were admitted for fever, but due the selection bias, which was mentioned above, it cannot rule out an overall benefit of these measures in SBI prevention.…”

“…This is in contrast to previous studies in which the incidence of peritonitis was higher: up to 16% of infections and 50% of SBI. [19][20][21][22]32 The relatively low incidence of peritonitis in our study could plausibly be due to the widespread use in our population of pneumococcal vaccination and prophylactic antibiotic therapy, which are directed against Streptococcus pneumoniae, the major causative pathogen of peritonitis in children with NS. The use of these measures was not associated with a lower risk of SBI in our study, but since it included only febrile patients who were admitted to hospital it is possible that these measures have prevented febrile infections including SBI in the general NS population (selection bias).…”

Early diagnosis and successful treatment of cytomegalovirus peritonitis in children with primary nephrotic syndrome: case series and literature review

“…The infectious complications, especially primary peritonitis, are well-known alarming situation in children with NS. Studies have shown incidence of peritonitis in childhood NS ranging from 2.6% to 26.0% [7][8][9][10]. Patients with NS have a defective immune response due to increased urinary losses of complement factor B, low IgG levels, inadequate opsonization and impaired T-cell function [11][12][13].…”

Steroid Sensitive Nephrotic Syndrome: Revised Guidelines

“…Infections are the chief complication in patients with SSNS, accounting for 19-44% of hospitalizations [115][116][117][118][119][120].…”

“…Contributing factors include the use of immunosuppressive agents, anasarca, and urinary losses of IgG and complement factors, that predispose to infection with encapsulated organisms [121]. Peritonitis is the most common severe infection, followed by pneumonia and cellulitis [115][116][117][118][119].…”