PEDIATRICS Vol. 30 No. 3 September 1962, pp. 459-476
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PERCUTANEOUS RENAL BIOPSY IN CHILDREN

III. The Nephrotic Syndrome

W. F. Dodge M.D.1, C. W. Daeschner Jr. M.D.1, H. S. Rosenberg M.D.1, J. C. Brennan M.B., M.B.Ch.1, L. B. Travis M.D.1, and H. C. Hopps M.D.1

1 Department of Pediatrics (Division of Renology and Metabolism) and Pathology, University of Texas Medical Center, Galveston, Texas; William Scott McFarland Memorial Pediatric Renal and Metabolic Research Laboratory, John Sealy Hospital, Galveston, Texas; and the Departments of Pediatrics and Pathology, University of Baylor College of Medicine, Houston, Texas

Of the three views concerning the etiology of the idiopathic nephrotic syndrome, as summarized by Barnett et al. our data appear to best support the concept that this syndrome occurs as two distinct (histological) diseases, as suggested by Movat et al. Both, however, may be clinically similar at the time of onset.

The first histologic type is characterized by normal glomeruli (by light microscopy) or by thickening of the capillary basement membrane and at times also by lobulation of the glomerular tuft (Type II). Adequate intensive glucocorticoid therapy, when administered to patients with these histologic findings within the first 4 months after clinical recognition, is associated with rapid and complete cleaning of proteinuria and remission of other clinical and laboratory evidence of the syndrome in the majority of cases.

The second histologic type is characterized by axial stalk and glomenulam tuft scars and by crescents and adhesions (Type I). Other than for temporary remissions in some, patients with these histologic changes seem universally to have an unsuccessful response to glucocorticoid therapy, even when it is administered in adequate dosage and begun within the first 4 months after recognition. Although some investigators suggest that this lesion is "specific" for poststreptococcal glomerulonephritis, and while our data is at least not in opposition to their views, our experience with the occurrence of this lesion in association with the nephrotic syndrome is at present too limited to comment further.

The finding of histologic evidence of pyelonephritis in 4 of the 32 children with the nephrotic syndrome (all in association with Type II lesions), an incidence of greater than 10%, has not to our knowledge been reported previously to occur so frequently. This observation suggests that urine cultures, even in children who are in complete clinical and laboratory remission, should be obtained periodically. It is of note that in two of these four patients, the biopsy evidence of pyelonephritis was not noted until the time of the repeat examination, following interim glucocorticoid administration. This might indicate a lessening of resistance to bacterial invasion during steroid therapy.

Attention is drawn to the need for percutaneous biopsy of the kidney in children with the idiopathic nephrotic syndrome if early correct histologic diagnosis is to be made. The percentage of occurrence of unsuspected Type I lesions may be as great as 20% as demonstrated by this study.