ORIGINAL ARTICLE

Predictors of remission and relapse in idiopathic nephrotic

syndrome: a prospective cohort study
Premala Sureshkumar & Elisabeth M. Hodson & Narelle S. Willis &
Federica Barzi & Jonathan C. Craig
Received: 16 October 2013 / Revised: 11 December 2013 / Accepted: 16 December 2013
#IPNA 2014
Abstract
Background Although most children with idiopathic nephrot-
ic syndrome will respond to corticosteroid therapy, 8090 %
suffer one or more relapses.
Methods Using Cox proportional hazard models, we analyzed
predictors of remission and relapse in 1-year follow-up data
on children aged below 15 years with new-onset nephrotic
syndrome.
Results Of 129 children, 107 achieved remission with corti-
costeroid therapy and 86 subsequently relapsed. Boys
achieved remission more often than girls (adjusted hazard
ratio [AHR] 1.52, 95 % confidence interval (CI) 1.022.3).
Boys relapsed significantly more frequently than girls (AHR
1.77, 95 % CI 1.112.83) and were more likely to have
frequently relapsing disease (AHR 3.3, 95 % CI 1.189.23).
The risk of first relapse increased with the number of days to
first remission (AHR 1.02, 95 % CI 1.011.04). The risk for a
frequently relapsing course increased with a shorter time from
remission to first relapse (AHR 0.92, 95 % CI 0.870.97).
Conclusions In idiopathic nephrotic syndrome, boys are more
likely to respond initially, more likely to relapse, and to be
classified as having frequently relapsing nephrotic syndrome.
Adecrease in time fromremission to first relapse predicts for a
frequently relapsing course.
Keywords Childhood nephrotic syndrome
.
Cohort study
.
Remission
.
Relapse
Introduction
Idiopathic nephrotic syndrome in children is characterized by
proteinuria, hypoalbuminaemia and edema with normal renal
function, and no evidence of secondary causes of nephrotic
syndrome. The incidence of idiopathic nephrotic syndrome is
reported to be 27 cases per 100,000 children aged below
16 years, with a prevalence of 16 cases per 100,000 [1].
Most children have steroid-sensitive nephrotic syndrome
(SSNS) and achieve remission with daily corticosteroid ther-
apy [2]. Although the long-term prognosis of SSNS is be-
lieved to be good with the condition resolving in adolescence
or early adult life in most children, 8090 % of children
experience one or more relapses [2, 3]. Of those who relapse,
50 % of children relapse frequently or become steroid depen-
dent and may suffer a number of adverse effects related to the
disease and its treatment [3].
Most studies to date have assessed the predictors for remis-
sion, relapse, and frequency of relapse from retrospective
analyses of cohorts of children with idiopathic nephrotic syn-
drome from selected populations managed by tertiary referral
services [4, 5]. In this prospective national cohort study of
children presenting with their first episode of idiopathic ne-
phrotic syndrome, we aimed to describe the predictors for
initial remission and for relapse, to inform patients, families,
and clinicians about the likely clinical course of the disease
P. Sureshkumar
:
E. M. Hodson (*)
:
N. S. Willis
:
J. C. Craig
Centre for Kidney Research, The Childrens Hospital
at Westmead, Locked Bag 4001, Westmead,
Sydney NSW 2145, Australia
e-mail: elisabeth.hodson@health.nsw.gov.au
P. Sureshkumar
Department of Psychology, Macquarie University,
Sydney, Australia
E. M. Hodson
:
N. S. Willis
:
J. C. Craig
Sydney School of Public Health, University of Sydney,
Sydney, Australia
F. Barzi
The George Institute for Global Health,
Sydney, Australia
Pediatr Nephrol
DOI 10.1007/s00467-013-2736-9
including the need for frequent courses of corticosteroids and
for corticosteroid sparing agents.
Materials and methods
Recruitment methods and study population
The study protocol was based on the Declaration of Helsinki
and was approved by The Royal Alexandra Hospital for
Children Ethics Committee. The study population included
all Australian children aged below15 years who were reported
to the Australian Paediatric Surveillance Unit with newly
diagnosed idiopathic nephrotic syndrome between July 1998
and June 2001. The Australian Paediatric Surveillance Unit
(APSU) is an active national surveillance mechanism for
identifying uncommon diseases of childhood and for short-
term follow-up. The APSU sends monthly reminders to over
1,000 pediatricians. Reminders list selected uncommon dis-
eases of childhood and request clinicians to notify any child
diagnosed with one of the listed conditions in the previous
month. Idiopathic nephrotic syndrome was listed for monthly
report for 3 years from July 1998 to June 2001. Notifications
were forwarded by the APSU to the investigators, who then
sent a baseline questionnaire to the reporting clinician
requesting further details of children. A follow-up question-
naire was sent to the reporting clinicians 12 months from the
date of diagnosis of nephrotic syndrome to ascertain details of
remission and relapse.
Definitions
Idiopathic nephrotic syndrome was defined as a child aged
more than 3 months and less than 15 years with edema,
proteinuria (urine protein/creatinine ratio 200 mg/mmol or
proteinuria 3+ on dipstick), hypoalbuminemia (serum albu-
min <25 g/l), and normal kidney function (creatinine in the
normal range for age after initial stabilization). Remission,
relapse, infrequent relapse, frequent relapse, and steroid de-
pendence were defined according to the definitions of the
International Study of Kidney Disease in Children [6] and
the Arbeitsgemeinschaft fr Pdiatrische Nephrologie [7, 8].
Children were considered to have SSNS if they achieved
remission (urine protein/creatinine ratio <20 mg/mmol or
proteinuria <1+ on dipstick for 3 or more consecutive days)
during the initial 4 weeks of prednisone therapy. Relapse was
defined as the reappearance of proteinuria (urine protein/
creatinine ratio 200 mg/mmol or proteinuria 3+ on dipstick)
for three consecutive days or more. Frequent relapsing ne-
phrotic syndrome was diagnosed if the child had two or more
relapses within 6 months of the initial response or four or more
relapses within any 12-month period. Steroid-dependent ne-
phrotic syndrome was defined as two consecutive relapses
during steroid therapy or within 14 days of its cessation.
Time to remission was measured as the time from commence-
ment of corticosteroid therapy until first remission. Time from
remission to first relapse was measured as the time from first
remission until first relapse. Because children with nephrotic
syndrome potentially have a concurrent risk factor for adverse
cardiovascular outcomes [9], children with diastolic and/or
systolic blood pressure greater than the 90th centile for age
and sex were considered to have hypertension [10].
Data collection
The baseline questionnaire recorded information on child fac-
tors (age at onset, gender, date of diagnosis), geographic loca-
tion (postcode), ethnicity, language spoken at home, and clin-
ical characteristics (blood pressure, hematuria, creatinine). The
follow-up questionnaire recorded information on regimens of
corticosteroid therapy, whether remission occurred, time to
remission, time to first relapse and the number of relapses.
Clinicians were also asked to classify children as having infre-
quent relapses, frequent relapses, or as being steroid dependent
according to the definitions above. For children who failed to
achieve remission, the results of renal biopsies were requested.
Information on socio-economic status was collected using
the Australian Bureau of Statistics Socio-Economic Indexes
for Areas 2001 (SEIFA) [11] for each participant based on
their postcode. This is a continuous score that summarizes
income, level of education, employment, and occupation. It
has been standardized to a mean of 1,000 and a standard
deviation of 100 across all collection districts in Australia so
that 95 % of scores are between 800 and 1,200. Lower scores
indicate relatively greater disadvantage and higher scores
indicate least disadvantage.
Ethnicity was classified using the major ethnic groupings
defined by the Australian Bureau of Statistics using the
mothers country of birth. These categories included Oceania
(Australia, New Zealand, New Zealand Maoris, Fiji, Samoa,
Indonesia, Solomon Islands), Non-Southern Asia (China,
Hong Kong, Cambodia, Vietnam, Malaysia, Philippines,
Thailand), Southern Asia (India, Pakistan, Sri Lanka, and
Bangladesh), Europe and other.
Data analysis
The outcomes of interest were remission, relapse, and fre-
quently relapsing or steroid-dependent nephrotic syndrome.
To estimate incidence, population-based estimates were ob-
tained from the Australian Bureau of Statistics (ABS) 2001
census [12]. Population denominators were obtained for males
and females. Age at onset, time to remission, and time from
remission to first relapse were analyzed as continuous vari-
ables. Baseline hematuria was analyzed as a dichotomous
variable. Creatinine, daily prednisone dosage, and
Pediatr Nephrol
socioeconomic status were categorized into quartiles. Univariate
and multivariate Cox proportional hazard models were used to
estimate the association between remission and relapse and the
variables of interest by deriving hazard ratios (HR) and 95 %
confidence intervals (CI). The KaplanMeier estimates of the
proportion of children experiencing relapse were compared
between sexes and age categories using the logrank test. Data
was analyzed using SAS version 9.2 and STATA 11.0.
Results
Of the 210 case notifications received by the Australian
Paediatric Surveillance Unit, 145 were confirmed to have
newly diagnosed idiopathic nephrotic syndrome (Fig. 1). Of
the 145 children with idiopathic nephrotic syndrome
(Table 1), 129 had follow-up questionnaires completed by
their clinician; 62 cases were reported by 55 general pediatri-
cians and 67 cases by 14 pediatric nephrologists.
Incidence
The incidence of idiopathic nephrotic syndrome in Australia
was 1.23 (95 % CI 1.031.4) per 100,000 children aged less
than 15 years. The incidence in males was 1.33 per 100,000
and in females was 1.13 per 100,000.
Patient characteristics
Patient characteristics at presentation are shown in Table 1.
Eighty (55 %) were boys and 91 (63 %) were aged less than
5 years at presentation. The majority of participants came
from Oceania, with 80 % of children being English speaking.
At presentation, 61 % of children had microscopic hematuria
and 23 and 21 % of children had systolic or diastolic blood
pressures respectively greater than the 90 % percentile for age
and sex. All children were treated initially with prednisolone
or prednisone at a dose of 60 mg/m
2
/day or 2 mg/kg/day.
Outcome at 12 months
Twelve-month follow-up data were available for 129 children
(89 %). Of these, 107 (83 %) achieved remission and 22
(17 %) had steroid-resistant nephrotic syndrome (SRNS).
Median time to achieve remission in children with SSNS
was 12 days (95 % CI 1014). Eighty-six (80 %) of 107
children experienced one or more relapses (median of two
relapses, range, 16) with the median time to relapse of
19 weeks (95 % CI 1323). Of 86 children with relapse,
clinicians classified 41 (48 %) children as having infrequent
relapses, 24 (28 %) as having frequent relapses, and 21 (24 %)
as being steroid dependent.
Of the 22 patients with SRNS, 11 were more than 7 years of
age and 15 were females. Histopathology revealed minimal
change disease in seven (32 %) children, focal and segmental
gl omerul oscl erosi s i n 10 (45. 5 %) chi l dren and
mesangioproliferative glomerulonephritis in five (23 %)
children.
Predictive factors for initial remission
Remission occurred in 64 (90 %) boys and 43 (74 %) girls.
Univariate analysis showed that younger age at diagnosis,
male gender, and absence of hematuria were significant pre-
dictors of remission (Table 2). We did not find a significant
association between achieving remission and ethnicity, socio-
economic status, blood pressure, or creatinine levels at pre-
sentation. Multivariate analysis showed that male gender
Fig. 1 Notification of cases of nephrotic syndrome and participant
follow-up and outcomes
Pediatr Nephrol
(adjusted HR 1.52, 95 % CI 1.022.30) was the only sig-
nificant predictive factor for achieving remission. Median
time to achieve remission was shorter in boys (10 days
[95 % CI 912]) than girls (14 days [95 % CI 1020]
logrank test p=0.008).
Predictive factors for first relapse
Relapse occurred in 55 (85.9 %) boys and 31 (72.1 %) girls.
Univariate analysis demonstrated that male gender, young age
at diagnosis and longer time to achieve initial remission were
significant predictors for first relapse (Table 3). In multivariate
analysis, male gender (adjusted HR 1.77, 95 % CI 1.112.83)
and longer time to achieve remission (adjusted HR1.02, 95 %
CI 1.011.04) remained statistically significant predictors for
first relapse. Boys relapsed earlier than girls (median time to
relapse 15 weeks [95 % CI 1020] versus 23 weeks [95 % CI
1433] logrank test p=0.04) (Fig. 2). We observed a signifi-
cant trend in age (trend p=0.02) with children older than
7 years of age having longer times to relapse compared with
younger children (Fig. 3). Although children with a shorter
time to remission (7 or fewer days) had a longer time to first
relapse (median time to relapse, 21 weeks) compared to chil-
dren who achieved remission after more than 14 days of
therapy (median time to relapse, 13 weeks), there was no
significant difference (trend p=0.43) when all children were
considered. There was no statistically significant association
between relapse of nephrotic syndrome and ethnicity, socio-
economic status, blood pressure, hematuria, or creatinine
levels at baseline or between relapse and the total duration
of prednisone therapy.
Predictive factors for frequent relapsing and steroid-dependent
nephrotic syndrome
Forty-five (52 %) children had frequently relapsing or steroid-
dependent nephrotic syndrome. In univariate analyses, male
gender, young age, and shorter time from remission to first
relapse but not time to first remission were predictors for
children to develop frequent relapsing or steroid-dependent
nephrotic syndrome (Table 3). In multivariate analysis, male
gender (adjusted HR 3.30; 95 % CI 1.189.23) and shorter
time from remission to first relapse (adjusted HR 0.92; 95 %
CI 0.870.97) remained independent predictors. Children
with frequently relapsing or steroid-dependent nephrotic syn-
drome experienced their first relapse earlier (9 weeks, 95 %CI
612) than children with infrequently relapsing nephrotic
syndrome (20 weeks, 95 % CI 1626, logrank p=0.02).
Discussion
The main findings of this national prospective cohort study of
childhood idiopathic nephrotic syndrome are that response to
treatment differs between boys and girls with male gender
predicting for remission during the initial course of cortico-
steroid therapy, for first relapse and for a frequently relapsing
or steroid-dependent course. Male gender is the only signifi-
cant independent predictor for remission. Male gender and a
Table 1 Characteristics of participating children (n=145)
Characteristic n (%)
Demographic
Gender
Male 80 (55.2)
Female 65 (44.8)
Age at onset (years)
3 months to 4.9 91 (63.2)
59 32 (22.2)
>9 21 (14.6)
Language spoken
English 115 (79.3)
Other 30 (20.7)
Ethnicity
a
European 7 (5.3)
Southern Asian 11 (8.4)
Non-Southern Asian 14 (10.7)
Oceanian 94 (71.8)
North/sub-Saharan African/Middle Eastern 5 (3.8)
Disadvantage category
b
Least disadvantage 37 (25.7)
Low-mid disadvantage 35 (24.3)
High-mid disadvantage 36 (25.0)
Highest disadvantage 36 (25.0)
Clinical
Blood pressure percentiles
Systolic BP
90th 108 (77.1)
>90th 32 (22.9)
Diastolic BP
90th 110 (78.6)
>90th 30 (21.4)
Creatinine (micromoles/l)
<31 57 (39.3)
>31 to <40 20 (13.8)
>40 to <4,933 (22.8) 33 (22.8)
>49 to <150 35 (24.1)
Hematuria 87 (60.8)
BP, blood pressure
a
Mothers country of birth classified using the major ethnic groupings
defined by the Australian Bureau of Statistics
b
SEIFA scores: Least disadvantage (10391138), Low-mid disadvantage
(9981039), High-mid disadvantage (955997), Highest disadvantage
(781954)
Pediatr Nephrol
longer time to first remission are independent risk factors for
the first relapse. Male gender and a shorter time from first
remission to first relapse but not time to first remission are
independent predictors for frequently relapsing and steroid-
dependent nephrotic syndrome. We speculate that evaluating
predictors in a population-based cohort could reveal different
predictors from retrospective studies of selected populations
so that in this study male gender proved to be the most
important predictor of remission, relapse, and of frequently
relapsing/steroid-sensitive disease.
In this study, the incidence of idiopathic nephrotic syn-
drome was 1.23 per 100,000 children below 15 years.
Previous prospective studies, which identified children
through Paediatric Surveillance Units, reported incidences of
1.52 and 1.9 per 100,000 children [13, 14].
We found that male gender was the only significant predictor
for steroid responsiveness. That children with SRNS are more
likely to be female has not been specifically mentioned in previ-
ous reports. Nevertheless, our results are consistent with data
from two studies, which showed that SRNS was slightly more
common in girls [2, 15]. A study evaluating children recruited to
a randomized controlled trial with newly diagnosed nephrotic
syndrome found no differences in gender between children with
SSNS or SRNS [16]. We could not confirm previous studies,
which identified older age as a predictor for steroid resistance
[1719]. Other reported risk factors for SRNS are African or
African American origin [19] and kidney histopathology
[1821]. Our population included few African children and
children did not undergo routine kidney biopsy so further infor-
mation on these predictors is not available in this study.
Table 2 Predictors for initial re-
mission with initial course of
corticosteroid therapy*
*Data from 129 children
a
Confidence intervals
b
Adjusted for gender
c
Data unavailable in two children
Variable Remission No remission Unadjusted hazard
ratio (95 % CI)
a
Adjusted hazard
ratio (95 % CI) n (%) n (%)
Gender
Females 43 (74.1) 15 (25.9) Referent 1.00
Males 64 (90.1) 7 (9.9) 1.65 (1.112.44) 1.52 (1.022.30)
Age at onset (years) 0.93 (0.880.99) 0.95 (0.891.01)
b
Hematuria
c
No 46 (93.9) 3 (6.1) Referent 1.00
Yes 59 (75.6) 19 (24.4) 0.62 (0.420.92) 0.68 (0.461.02)
b
Creatinine (micromoles/l)
31 48 (92.3) 4 Referent 1.00
>31 to 40 14 (73.7) 5 0.73 (0.401.35) 0.78 (0.421.44)
b
>40 to 49 24 (82.8) 5 0.88 (0.541.44) 0.88 (0.541.45)
>49 to 150 21 (72.4) 8 0.76 (0.451.27) 0.74 (0.441.23)
Table 3 Predictors for relapse
following remission after initial
course of corticosteroid therapy
a
First relapse following remission
after initial course of prednisone
therapy, data from 86 children
b
Child developing frequently re-
lapsing or steroid dependent ste-
roid-sensitive nephrotic syn-
drome, data from 45 children
c
Hazard Ratio with 95 %
confidence intervals
d
Adjusted for gender and time
to relapse
e
Adjusted for gender and time
to achieve remission
Variable First relapse
a
(86 children) Frequent relapses
b
(45 children)
Unadjusted HR
c
(95 % CI)
Adjusted HR
(95 % CI)
Unadjusted HR
(95 % CI)
Adjusted HR
(95 % CI)
Gender
Females Referent Referent Referent Referent
Males 1.59 (1.032.48) 1.77 (1.112.83) 3.67 (1.459.33) 3.30 (1.189.23)
Age at onset (years) 0.90 (0.830.98) 0.92 (0.851.01)
d
0.84 (0.710.99) 0.91 (0.771.09)
e
Time to achieve remission (days) 1.02 (1.011.03) 1.02 (1.011.04)
d
1.02 (0.991.04) 1.01 (0.981.04)
e
Hematuria
No Referent Referent Referent Referent
Yes 0.88 (0.571.36) 0.96 (0.611.49)
d
0.99 (0.422.34) 0.72 (0.252.07)
e
Total Prednisone (daily/alternate day therapy) (weeks)
09.4 Referent Referent
9.512.6 1.06 (0.581.92) 0.95 (0.501.79)
d
12.719.6 0.88 (0.491.56) 0.74 (0.401.35)
>19.6 0.68 (0.381.23) 0.67 (0.361.26)
Time to relapse (weeks) 0.91 (0.860.95) 0.92 (0.870.97)
Pediatr Nephrol
Most previous studies were retrospective and examined
predictive factors for developing frequently relapsing or
steroid-dependent nephrotic syndrome rather than predictive
factors for first relapse [4, 5] with only one study specifically
addressing predictors of the first relapse [22]. Other than one
study [23], the studies presented data from specialized pedi-
atric nephrology services. Eight studies determined indepen-
dent risk factors for frequent relapse and steroid dependence
using multivariate analysis [4, 5, 16, 22, 2427]. Our study
identified male gender as an independent risk factor for re-
lapse and for a frequently relapsing or steroid-dependent
course in keeping with some [23, 28] but not other studies
[4, 5, 16, 22, 2527, 2931]. This study did not identify young
age at onset as an independent risk factor in keeping with
some studies [4, 5, 16, 27, 2931] but not other studies
[2225, 28, 32]. Variability between studies may be related
to differences in patient selection since one study [22] identi-
fied young age as an independent risk factor for the first
relapse in a consecutive cohort of newly diagnosed patients
but did not find young age to be a risk factor for relapses
occurring in the second year of the disease in a group of
patients followed for at least 2 years [26]. We found that a
longer time to first remission predicted for first relapse but we
were unable to confirm previous retrospective studies [4, 5,
16, 24, 27, 30, 33], which found that time to first remission
was a significant predictor for frequently relapsing or steroid-
dependent, steroid-sensitive nephrotic syndrome but small
patient numbers in our study resulting in imprecision may
have masked a difference. We found that a shorter time from
remission to first relapse predicted for a frequently relapsing
course in common with some studies [3, 16, 26, 29, 31]. Other
factors reported to be associated with frequently relapsing or
steroid-dependent, steroid-sensitive nephrotic syndrome but
not examined in this study are the number of relapses in the
first 6 months after diagnosis [3, 16, 26, 29, 31, 33], infection
at presentation, or relapse [5, 31] and the need of pulse
methylprednisolone to achieve remission [27, 30].
The strength of this study is that it was a prospective
population-based cohort study with case ascertainment through
the Australian Paediatric Surveillance Unit (APSU), which has
developed effective processes for identifying unusual pediatric
disorders. The APSUreports a 96 %response rate to its monthly
requests to pediatricians for reports of listed conditions [34]. We
obtained 1-year follow-up data in 129 (89 %) of the children.
This study therefore had an adequate number of participants to
examine the predictors for remission and relapse using univar-
iate and multivariate analysis and to determine which factors
were independent risk factors for remission and relapse.
The main limitation of this study is that we had no separate
and independent way to assess whether we had identified all
new cases of idiopathic nephrotic syndrome during the study
period. It is possible that some older children, managed by
adult nephrologists, were not identified though a request
through the Australia and New Zealand Society of
Nephrology did not identify additional cases. Our study had
follow-up data only at 1 year so that the assessment of children
as having an infrequently relapsing, frequently relapsing or
steroid-dependent course by their pediatricians may not fully
reflect their subsequent course. Although the data were col-
lected between 1998 and 2001 with only 1 year of follow-up,
the data on predictors in idiopathic childhood nephrotic syn-
drome remain relevant to current practice since there is no
evidence that the time to remission and relapse rates following
corticosteroid therapy have changed in the past 10 years [23].
Although earlier consensus-based guidelines [35, 36] recom-
mended shorter courses of corticosteroids than current guide-
lines [37], this study and more recent studies [38, 39] have
demonstrated considerable variation in the duration and dose
of corticosteroid therapy between individual clinicians so
different guidelines for therapy 10 years ago are unlikely to
have influenced the results of this study.
Fig. 2 KaplanMeier estimates of the proportion of children with first
relapse in steroid-sensitive nephrotic syndrome stratified by gender
Fig. 3 KaplanMeier estimates of the proportion of children with first
relapse in steroid-sensitive nephrotic syndrome stratified by age at initial
presentation
Pediatr Nephrol
In conclusion, we have identified predictors for remission
and relapse in a national prospective cohort study of childhood
idiopathic nephrotic syndrome. These predictors can be used
in counseling families about the likely course of idiopathic
nephrotic syndrome in their child. They could also be used to
determine enrollment into randomized controlled trials to
customize corticosteroid regimens for children with new-
onset idiopathic nephrotic syndrome and thus potentially re-
duce exposure to corticosteroids in children destined not to
relapse or to relapse infrequently.
Acknowledgments This study was performed using case ascertain-
ment through the Australian Paediatric Surveillance Unit (APSU). The
activities of the APSU are supported by the National Health and Medical
Research Council of Australia (Enabling Grant no. 402784 and Practi-
tioner Fellowship No 1021480: E. Elliott); the Australian Government
Department of Health and Ageing; the Sydney Medical School, The
University of Sydney and the Royal Australasian College of Physicians.
The authors would like to thank all Australian pediatricians who partic-
ipated in APSU surveillance, reported cases, and completed question-
naires on their patients. The study was funded in part by Kidney Health
Australia. Kidney Health Australia had no involvement in the design, data
collection, data analysis or writing of the manuscript.
Parts of this study were presented at the 13th Congress of the Interna-
tional Pediatric Nephrology Association, August 29 to September 2 2004,
Adelaide, Australia, and were published in abstract form.
The authors would like to thank Mrs. Sandra Puckeridge and Dr.
Jeffrey Fletcher for their assistance with data collection and for the
preliminary analyses of the data. The authors would also like to thank
the Australian members of the Australia and New Zealand Paediatric
Nephrology Association, who reviewed the protocol and questionnaires
for this study.
Disclosures None.
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