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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the field of nephrology&#44; treatment options have been very limited until the early <span class="elsevierStyleSmallCaps">xxi</span> century&#44; when the pathophysiological mechanisms of numerous renal diseases started to be elucidated&#44; leading to the identification of potential therapeutic targets&#46; It was not until 2007&#44; when the European Union Paediatric Regulation was introduced&#44; mandating performance of paediatric clinical trials in the drug development process&#44; that research advances started to translate into treatments in paediatric nephrology&#46; Since 2007&#44; the European Medicines Agency &#40;EMA&#41; and the Food and Drug Administration &#40;FDA&#41; have collaborated closely in paediatric development plans and paediatric strategies&#44; allowing the pursuit of a single&#44; aligned paediatric investigation plan &#40;PIP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Conducting a literature search for clinical trials in paediatric nephrology yields at least 77 hits just from the past year&#46; Autoimmune diseases with heterogeneous presentations&#44; such as lupus nephritis&#44; require a more personalised approach with identification of individual risk factors and characterization of the immune profile of patients&#44; and there are now clinical trials of drugs that target specific biological pathways and may achieve better response rates&#46; Currently underway are 3 phase I trials &#40;anifrolumab&#44; tocilizumab and eculizumab&#41;&#44; 3 phase II trials &#40;obinutuzumab&#44; dapirolizumab and atacicept&#41; and 1 phase III trial &#40;abatacept&#41; that accept paediatric patients who do not achieve complete remission with conventional treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients with primary glomerulonephritis have also benefitted from recent advances in pharmacology and genetics&#46; For instance&#44; in the case of nephrotic syndrome&#44; the most frequent form of chronic glomerulonephritis in children&#44; there has been an exponential increase in the detection of genetic changes that cause the disease&#44; to the point that in some series the proportion of monogenic cases is as low as 30&#37;&#44; and the number of patients assessed by means of whole-genome exome sequencing has been increasing&#46; These findings are important to avoid treatments that could have severe side effects&#46; Patients with steroid-resistant nephrotic syndrome with negative genetic test results that progress to end-stage renal disease in childhood are at high risk of recurrence after renal transplantation&#44; so treatment efforts should be maximised&#44; while patients with genetic mutations do not experience relapse in the graft&#44; which calls for reducing the number of drugs that have frequent or severe adverse effects especially given that&#44; on the other hand&#44; the likelihood of a response is minimal no nonexistent&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Eighty percent of patients with nephrotic syndrome respond to first-line treatment &#40;steroid therapy&#41;&#44; but 50&#37; of them experience a course of disease with numerous relapses &#40;frequently relapsing nephrotic syndrome&#44; FRNS&#41; or become steroid-dependent &#40;steroid-dependent nephrotic syndrome&#44; SDNS&#41;&#46; The treatment options for nephrotic syndrome in the late XX century were limited to steroids&#44; alkylating agents and ciclosporin&#44; all of which have significant and frequent adverse effects&#44; including Cushing syndrome&#44; osteoporosis&#44; delayed growth&#44; sterility&#44; and an increased risk of cardiovascular disease&#44; tumours&#44; infection and kidney failure&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The new therapeutic armamentarium includes tacrolimus&#44; mycophenolate mofetil&#44; rituximab and levamisole&#44; as well as their combinations and their combination with conventional treatment&#44; chiefly steroids&#46; Rituximab is a chimeric anti-CD20 monoclonal antibody that inhibits B cell proliferation and differentiation mediated by CD20&#46; It was originally developed to treat patients with B-cell non-Hodgkin lymphoma&#46; This monoclonal antibody is currently used to treat various autoimmune diseases&#44; such as rheumatoid arthritis&#44; Wegener granulomatosis and microscopic polyangiitis&#46; Benz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> were the first to report that a 4-dose course of rituximab induced long-term remission in CDNS complicated by idiopathic thrombocytopenic purpura in a male patient aged 16 years&#46; This was the first report that hinted at the efficacy of rituximab for treatment of complicated FRNS or SDNS&#46; Later on&#44; Gilbert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> reported that 4 cycles of rituximab were effective for maintaining remission in patients with complicated childhood-onset FRNS or SDNS&#46; Ravani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> carried out the first clinical trial of rituximab for children with steroid and calcineurin inhibitor-dependent nephrotic syndrome &#40;complicated SDNS&#41; and found urine protein levels that were 70&#37; lower in the rituximab group compared to the group that received conventional treatment&#44; as well as a lower relapse rate&#46; However&#44; there are also drawbacks of treatment with rituximab&#44; as the drug has been associated with severe adverse events&#44; including fatal hepatitis due to reactivation of the hepatitis B virus and progressive multifocal leukoencephalopathy&#46; In children with FRNS or SDNS&#44; the most frequently described adverse events are pulmonary fibrosis&#44; fulminant myocarditis&#44; <span class="elsevierStyleItalic">Pneumocystis</span> pneumonia&#44; immune-mediated ulcerative colitis and agranulocytosis&#46; Following treatment with rituximab&#44; hypogammaglobulinemia persist in most patients who had low immunoglobulin G &#40;IgG&#41; levels before treatment&#44; so it is important to conduct a long follow-up in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Different rituximab protocols are used in Europe for management of steroid-dependent or frequent-relapsing patients in clinical practice&#44; which do not modify the established dose of 375&#8239;mg&#47;m<span class="elsevierStyleSup">2</span> per infusion&#44; but rather the number of doses&#44; as it was observed that some patients maintained low or undetectable CD19&#43; cell counts without relapsing for a long time after only 1 or 2 doses&#44; which also minimised the adverse effects of rituximab&#46; Guzm&#225;n et al&#46; published their experience supporting this approach&#44; as only 1 of their patients received 4 cycles&#44; while 6 received 2 and 1 a single dose&#46; The authors observed a decrease in the number of relapses per year after treatment&#44; which allowed a reduction in the dosage of steroid and immunosuppressant drugs and offered their patients&#44; who had undergone chronic treatment for years&#44; a treatment option that maintained them free of disease and without treatment for a long time&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinical trials for nephrotic syndrome currently underway focus on finding combinations of drugs that would allow reducing their dosage to prevent adverse events&#44; and genetics studies on establishing the predisposition to develop disease and predicting the response to drugs&#46; As paediatricians&#44; we must never forget that our duty is not limited to protecting child health in the present&#44; but also to work towards future health and wellbeing&#44; which requires that we stay up to date and promote advances in science&#46;</p></span>"
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Editorial
The horizon of the 21st century in pediatric nephrology: Clinical trials and personalized medicine
El horizonte del siglo XXI en nefrología pediátrica: ensayos clínicos y medicina personalizada
Mar Espino Hernández
Asociación Española de Nefrología Pediátrica, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the field of nephrology&#44; treatment options have been very limited until the early <span class="elsevierStyleSmallCaps">xxi</span> century&#44; when the pathophysiological mechanisms of numerous renal diseases started to be elucidated&#44; leading to the identification of potential therapeutic targets&#46; It was not until 2007&#44; when the European Union Paediatric Regulation was introduced&#44; mandating performance of paediatric clinical trials in the drug development process&#44; that research advances started to translate into treatments in paediatric nephrology&#46; Since 2007&#44; the European Medicines Agency &#40;EMA&#41; and the Food and Drug Administration &#40;FDA&#41; have collaborated closely in paediatric development plans and paediatric strategies&#44; allowing the pursuit of a single&#44; aligned paediatric investigation plan &#40;PIP&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Conducting a literature search for clinical trials in paediatric nephrology yields at least 77 hits just from the past year&#46; Autoimmune diseases with heterogeneous presentations&#44; such as lupus nephritis&#44; require a more personalised approach with identification of individual risk factors and characterization of the immune profile of patients&#44; and there are now clinical trials of drugs that target specific biological pathways and may achieve better response rates&#46; Currently underway are 3 phase I trials &#40;anifrolumab&#44; tocilizumab and eculizumab&#41;&#44; 3 phase II trials &#40;obinutuzumab&#44; dapirolizumab and atacicept&#41; and 1 phase III trial &#40;abatacept&#41; that accept paediatric patients who do not achieve complete remission with conventional treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Patients with primary glomerulonephritis have also benefitted from recent advances in pharmacology and genetics&#46; For instance&#44; in the case of nephrotic syndrome&#44; the most frequent form of chronic glomerulonephritis in children&#44; there has been an exponential increase in the detection of genetic changes that cause the disease&#44; to the point that in some series the proportion of monogenic cases is as low as 30&#37;&#44; and the number of patients assessed by means of whole-genome exome sequencing has been increasing&#46; These findings are important to avoid treatments that could have severe side effects&#46; Patients with steroid-resistant nephrotic syndrome with negative genetic test results that progress to end-stage renal disease in childhood are at high risk of recurrence after renal transplantation&#44; so treatment efforts should be maximised&#44; while patients with genetic mutations do not experience relapse in the graft&#44; which calls for reducing the number of drugs that have frequent or severe adverse effects especially given that&#44; on the other hand&#44; the likelihood of a response is minimal no nonexistent&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Eighty percent of patients with nephrotic syndrome respond to first-line treatment &#40;steroid therapy&#41;&#44; but 50&#37; of them experience a course of disease with numerous relapses &#40;frequently relapsing nephrotic syndrome&#44; FRNS&#41; or become steroid-dependent &#40;steroid-dependent nephrotic syndrome&#44; SDNS&#41;&#46; The treatment options for nephrotic syndrome in the late XX century were limited to steroids&#44; alkylating agents and ciclosporin&#44; all of which have significant and frequent adverse effects&#44; including Cushing syndrome&#44; osteoporosis&#44; delayed growth&#44; sterility&#44; and an increased risk of cardiovascular disease&#44; tumours&#44; infection and kidney failure&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The new therapeutic armamentarium includes tacrolimus&#44; mycophenolate mofetil&#44; rituximab and levamisole&#44; as well as their combinations and their combination with conventional treatment&#44; chiefly steroids&#46; Rituximab is a chimeric anti-CD20 monoclonal antibody that inhibits B cell proliferation and differentiation mediated by CD20&#46; It was originally developed to treat patients with B-cell non-Hodgkin lymphoma&#46; This monoclonal antibody is currently used to treat various autoimmune diseases&#44; such as rheumatoid arthritis&#44; Wegener granulomatosis and microscopic polyangiitis&#46; Benz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> were the first to report that a 4-dose course of rituximab induced long-term remission in CDNS complicated by idiopathic thrombocytopenic purpura in a male patient aged 16 years&#46; This was the first report that hinted at the efficacy of rituximab for treatment of complicated FRNS or SDNS&#46; Later on&#44; Gilbert et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> reported that 4 cycles of rituximab were effective for maintaining remission in patients with complicated childhood-onset FRNS or SDNS&#46; Ravani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> carried out the first clinical trial of rituximab for children with steroid and calcineurin inhibitor-dependent nephrotic syndrome &#40;complicated SDNS&#41; and found urine protein levels that were 70&#37; lower in the rituximab group compared to the group that received conventional treatment&#44; as well as a lower relapse rate&#46; However&#44; there are also drawbacks of treatment with rituximab&#44; as the drug has been associated with severe adverse events&#44; including fatal hepatitis due to reactivation of the hepatitis B virus and progressive multifocal leukoencephalopathy&#46; In children with FRNS or SDNS&#44; the most frequently described adverse events are pulmonary fibrosis&#44; fulminant myocarditis&#44; <span class="elsevierStyleItalic">Pneumocystis</span> pneumonia&#44; immune-mediated ulcerative colitis and agranulocytosis&#46; Following treatment with rituximab&#44; hypogammaglobulinemia persist in most patients who had low immunoglobulin G &#40;IgG&#41; levels before treatment&#44; so it is important to conduct a long follow-up in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Different rituximab protocols are used in Europe for management of steroid-dependent or frequent-relapsing patients in clinical practice&#44; which do not modify the established dose of 375&#8239;mg&#47;m<span class="elsevierStyleSup">2</span> per infusion&#44; but rather the number of doses&#44; as it was observed that some patients maintained low or undetectable CD19&#43; cell counts without relapsing for a long time after only 1 or 2 doses&#44; which also minimised the adverse effects of rituximab&#46; Guzm&#225;n et al&#46; published their experience supporting this approach&#44; as only 1 of their patients received 4 cycles&#44; while 6 received 2 and 1 a single dose&#46; The authors observed a decrease in the number of relapses per year after treatment&#44; which allowed a reduction in the dosage of steroid and immunosuppressant drugs and offered their patients&#44; who had undergone chronic treatment for years&#44; a treatment option that maintained them free of disease and without treatment for a long time&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Clinical trials for nephrotic syndrome currently underway focus on finding combinations of drugs that would allow reducing their dosage to prevent adverse events&#44; and genetics studies on establishing the predisposition to develop disease and predicting the response to drugs&#46; As paediatricians&#44; we must never forget that our duty is not limited to protecting child health in the present&#44; but also to work towards future health and wellbeing&#44; which requires that we stay up to date and promote advances in science&#46;</p></span>"
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Article information
ISSN: 23412879
Original language: English
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