Effective therapy for severe Henoch-Schonlein purpura nephritis with prednisone and azathioprine: a clinical and histopathologic study

[Henoch-Schönlein purpura : most frequent form of vasculitis in childhood and adolescence]

Henoch-Schönlein purpura is the most common form of vasculitis in childhood and adolescence. It is manifested as palpable purpuras in the region of position-dependent extremities with otherwise good clinical general condition. The expression on the skin can, however, be variable so that sometimes other differential diagnoses must be included. In typical cases an extensive diagnostic procedure is unnecessary but the short-term complications of abdominal symptoms as well as the long-term complications of nephritis should be pursued. If musculoskeletal symptoms occur paracetamol or non-steroidal anti-inflammatory drugs are effective as are steroids for reducing the duration of abdominal pain. The effectiveness of steroid prophylaxis of renal damage is still controversial.

T cell immunoglobulin and mucin-domain containing molecule 1 in peripheral blood mononuclear cells in Henoch Schonlein purpura

The T cell immunoglobulin- and mucin domain-containing molecules (Tim) have been implicated in the pathogenesis of immune diseases. In this study, we used quantitative real time reverse transcription polymerase chain reaction to examine the Tim 1 mRNA expression in peripheral blood mononuclear cells from Henoch Schonlein purpura patients. The results showed that Tim1 mRNA expression was significantly higher in patients, which was closely correlated with serum TNFa, IL4 levels, IgA1 levels.

Early treatment with methylprednisolone pulse therapy combined with tonsillectomy for heavy proteinuric henoch-schönlein purpura nephritis in children

Background

There is no clear consensus as to which patients with Henoch-Schönlein purpura nephritis (HSPN) at risk of a poor outcome should be treated and what therapeutic regimen should be used.

Methods

Nine children with heavy proteinuric HSPN received prompt initiation of methylprednisolone pulse therapy (MPT) combined with tonsillectomy in a prospective study.

Results

At presentation, the mean values for the patients’ urine protein excretion (early-morning urinary protein/creatinine ratio), serum IgA, activity index (AI), and chronicity index (CI) were 5.0 ± 5.6 g/g Cr, 135.6 ± 56.5 mg/dl, 4.0 ± 0.7, and 1.7 ± 1.3, respectively. At the second biopsy, conducted approximately 24 months after initiation of therapy, the patients’ serum albumin had significantly increased (4.4 ± 0.2, p < 0.01), and the serum IgA and AI had significantly decreased (88.1 ± 30.8 mg/dl, p < 0.05; 2.0 ± 1.2, p < 0.01, respectively), whereas the CI remained unchanged. Proteinuria disappeared within 24 months in all but 1 patient, and hematuria disappeared within 38 months in all patients. No patient showed renal impairment or experienced a recurrence and/or exacerbation of HSP/HSPN.

Conclusions

Early treatment with MPT combined with tonsillectomy is effective in ameliorating the histopathological progression and improving the clinical course of children with heavy proteinuric HSPN.

Methylprednisolone pulse plus mizoribine in children with Henoch-Schoenlein purpura nephritis

We evaluated whether methylprednisolone and urokinase pulse therapy combined with mizoribine (MUPM) was effective in children with severe Henoch-Schoenlein purpura nephritis (HSPN). We studied 12 patients who had been diagnosed with HSPN of at least ISKDC type III. All patients were treated with MUPM. Clinical features, pathological findings, and prognosis were prospectively investigated. Ten patients (responders; nine with ISKDC grade IIIb and one with grade IVb) were treated with MUPM, whereas MUPM was discontinued due to the lack of response in two patients (non-responders; two with grade IVb). Among responders, urinary protein excretion had decreased significantly from 99.7 ± 37.8 to 25.9 ± 33.4 mg/m(2) per hour after 3 months of therapy. The acute index and tubulointerstitial scores decreased significantly from 5.8 ± 1.5 and 3.8 ± 0.6 at the first biopsy to 2.3 ± 1.3 and 1.0 ± 0.8 at the second biopsy, respectively. At the most recent follow-up, eight of the responders had normal urine, and two had minor urinary abnormalities. Non-responders demonstrated continued high levels of urinary protein excretion after 3 months of therapy, and MUPM was discontinued. Our study suggests that MUPM is effective in ameliorating the proteinuria and the histological severity of HSPN in patients with <50% crescents but is not so effective for HSPN in patients with >50% crescents.

Effects of cyclosporin A therapy combined with steroids and angiotensin converting enzyme inhibitors on childhood IgA nephropathy

To evaluate the effects of cyclosporin A (CyA) on clinical outcome and pathologic changes in children with IgA nephropathy (IgAN), we retrospectively evaluated 14 children (mean age 8.9+/-2.9 yr; eight males, six females) who were treated with CyA and steroids. The starting dose of CyA was 5 mg/kg per day, and the drug level was maintained at 100-200 ng/mL. The mean CyA level was 183.8+/-48.3 ng/mL (range 120.7-276.0 ng/mL) and the mean duration of CyA therapy was 10.9+/-1.9 months (range 8-12 months). After CyA therapy the mean 24 hr urinary protein excretion declined from 107.1+/-35.1 mg/m(2)/hr to 7.4+/-2.4 mg/m(2)/hr (P<0.001) and serum albumin increased from 3.3+/-0.6 g/dL to 4.3+/-0.3 g/dL (P<0.001). At a follow-up biopsy the histological grade of IgAN was improved in seven (50%) of the 14 patients, remained the same in three (21%), and was aggravated in four (29%). Serum creatinine, creatinine clearance, and blood pressure did not differ before and after CyA therapy. Two patients (14%) showed CyA-induced nephrotoxicity at the second biopsy. Our findings indicate that CyA therapy may be effective in reducing proteinuria and regressing renal pathology in a subset of children with IgAN.

Henoch-Schönlein purpura nephritis in children: risk factors, prevention and treatment

AIM

To identify risk factors for a child with Henoch-Schönlein purpura (HSP) either to develop nephritis (HSPN) or to contract progressive course and to obtain the currently available evidence on the efficacy of treatment options in both preventing and treating the established renal disease.

METHOD

Review of the literature published over the last two decades.

RESULTS

Persistent or recurrent purpura, severe abdominal symptoms and an older age proved as the most significant risk factors for later HSPN. The risks of long-term renal impairment are the highest in children having at presentation nephritic/nephrotic syndrome and/or more than 50% of glomeruli occupied by large crescents or sclerosing lesions. Randomized controlled trials (RCT) do not support short course prednisone at presentation of HSP in preventing persistent renal disease. Many uncontrolled studies using various treatment regimens have reported outcomes considered better than expected. However, the data from RCTs are sparse and no treatment options for the established renal disease can be currently recommended based on RCTs.

CONCLUSION

Severity and/or duration of extrarenal HSP symptoms and an older age are the most significant risk factors for developing HSPN, whereas clinical and histological severity at HSPN onset are in general predictive of a long-term renal impairment. The existing evidence does not support of short course prednisone in preventing persistent renal disease. A well-designed RCTs are needed in children with moderately severe or rapidly progressive (crescentic) HSPN.

Treatment-based literature of Henoch-Schönlein purpura nephritis in childhood

Considerable concern has been expressed on the importance of identifying an improved therapeutic protocol for use in the treatment of childhood Henoch-Schönlein purpura nephritis, primarily due to the unpredictable success shown to date in improving long-term renal outcome. This review focuses on published reports describing the outcomes of therapeutic approaches currently being used in the treatment of pediatric Henoch-Schönlein purpura nephritis, with the aim of providing information that will facilitate a treatment-based approach in children presenting with varying degrees of kidney disease. The conclusions of the authors of this review are that currently prescribed treatments of children affected by Henoch-Schönlein purpura nephritis are not adequately guided by evidence obtained in properly designed, randomized, placebo-controlled trials with outcome markers related to the progression to end stage renal disease (level I evidence). Moreover, firm evidence supporting the best practice to be applied with the aim of delaying the progression of kidney disease is still lacking.

Interventions for preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP)

BACKGROUND

To determine the benefits and harms of therapies used to prevent or treat kidney disease in Henoch-Schönlein Purpura (HSP).

OBJECTIVES

To evaluate the benefits and harms of different agents (used singularly or in combination) compared with placebo or no treatment or another agent for the prevention or treatment of kidney disease in patients with HSP.

SEARCH STRATEGY

Randomised controlled trials (RCTs) and quasi-RCTs were identified from the Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE using optimally sensitive search strategies combined with search terms for HSP.

SELECTION CRITERIA

RCTs comparing any intervention used to prevent or treat kidney disease in HSP compared with placebo, no treatment or other agents were included.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality and extracted data from each study. Statistical analyses were performed using the random effects model and the results were expressed as risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).

MAIN RESULTS

Ten studies (1230 children) were identified. There was no significant difference in the risk of persistent kidney disease at six months (3 studies, 379 children: RR 0.51, 95% CI 0.24 to 1.11) and 12 months (3 studies, 498 children: RR 1.02, 95% CI 0.40 to 2.62) in children given prednisone for 14 to 28 days at presentation of HSP compared with placebo or supportive treatment. In children with severe kidney disease, there was no significant difference in the risk of persistent kidney disease with cyclophosphamide compared with supportive treatment (1 study, 56 children: RR 1.07, 95% CI 0.65 to 1.78) and with cyclosporin compared with methylprednisolone (1 study, 19 children: RR 0.39, 95% CI 0.14 to 1.06).

AUTHORS' CONCLUSIONS

Data from RCTs for any intervention used in improve kidney outcomes in children with HSP are very sparse except for short-term prednisone. There was no evidence of benefit of prednisone in preventing serious long-term kidney disease in HSP.

Serial renal biopsies in three girls with tubulointerstitial nephritis and uveitis syndrome

Tubulointerstitial nephritis and uveitis (TINU) syndrome is considered to have a good prognosis even without any immunosuppressive therapy, although there is no histological evidence to support this. The objective of this study was to evaluate, retrospectively, serial renal biopsy findings in three girls with TINU syndrome who were treated with prednisolone. At presentation, all patients had significantly elevated urinary beta(2)-microglobulin levels (7583-19,313 microg/l) and high serum creatinine levels (0.93-1.3 mg/dl). The elevated beta(2)-MG and creatinine levels persisted for 1 month, and renal biopsies were performed to establish a definitive diagnosis. The initial biopsy specimens of all patients revealed marked interstitial enlargement consisting of infiltration of lymphocytes; there was also notable tubulitis and infiltration of eosinophils. All patients received prednisolone therapy following the diagnosis. A second renal biopsy was performed 9 months after the first biopsy for two of three patients, and 2 years later for the third patient. The biopsy specimens taken at 9 months still showed histological changes of acute inflammation; in contrast, that taken at 2 years showed a lower degree of acute inflammation, but scar formation was observed in some regions. Based on these results, we conclude that selected TINU syndrome patients require some immunosuppressive therapy.

[Henoch-Shönlein purpura]

Henoch-Shönlein purpura (HSP) is an immunoglobulin A (IgA) vasculitis that affects the small vessels. It is a multi-organ system disease that may include cutaneous purpura, arthralgia, acute enteritis and nephritis. Nephritis is characterized by mesangial proliferation with IgA deposits. Neurological, pulmonary, cardiac or genitourinary complications occur rarely. The acute stage progresses by successive flare-ups of limited duration. Although the cause is unknown, it is clear that IgA plays a central role in the immunopathogenesis of HSP. The syndrome usually affects children in which evolution is generally favourable. In adults the disease is rare and seems different from children with much more severe manifestations and prognosis. Short-term outcome, in children as in adults, depends on the severity of gastrointestinal manifestations. Long-term outcome depends on renal involvement. In studies with enough observation time, as much as one third of the patients will progress to end stage renal failure. The benign manifestations of the disease are managed by appropriate symptomatic measures. In case of severe involvement, including severe gastrointestinal complications or proliferative glomerulonephritis, immunosuppressive drugs may be required including steroids. These specific treatments are still controversial and their efficacy has to be evaluated.

Treatment of severe Henoch-Schönlein and immunoglobulin A nephritis. A single center experience

Our aim was to report the effect of two treatment regimens in 43 cases of severe Henoch-Schönlein nephritis (HSN) and immunoglobulin A nephritis (IgAN) (24 HSN, 19 IgAN). Group A, 11 HSN and 7 IgAN, 88% with an International Study of Kidney Disease in Children (ISKDC) biopsy grade > or = III and severe clinical features, were treated with corticosteroids, cyclophosphamide (CYC-P) and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB). Group B, 12 HSN and 13 IgAN, 72% with biopsy findings as above and 52% with severe clinical features, were treated with ACEi/ARB +/- corticosteroids. The outcome classification was: (a) healthy; (b) mild proteinuria, normal glomerular filtration rate (GFR); (c) active renal disease; (d) chronic renal failure. Twenty-six patients had a good outcome (a + b). The 17 children with poor outcome (c + d) had lower GFR at onset and at follow-up, higher albumin excretion at follow-up, and higher percentage of segmental glomerulosclerosis in the renal biopsy, than those with good outcome. Treatment with corticosteroids, CYC-P and ACEi/ARB was effective in increasing GFR, reducing proteinuria and decreasing the disease activity index. The proteinuria had decreased at follow-up in both groups. In group A, GFR increased and histopathological activity index declined after treatment. The outcome did not differ between groups A and B. The effects of treatment did not differ between HSN and IgAN.

Expression of mRNA for functional molecules in urinary sediment in glomerulonephritis

Recent studies have suggested that gene expression studies using urinary sediment might be a non-invasive approach to assessing activity and pathogenesis in glomerulonephritis. However, little information is available regarding the mRNA expression patterns of functional molecules, such as T-bet, GATA-3, FOXP3, and retinoic acid-inducible gene-I (RIG-I), in urinary sediment, from patients with immunocomplex-mediated glomerulonephritis. Fourteen lupus nephritis (LN) patients, 13 IgA nephropathy (IgAN) patients, and 12 healthy controls were enrolled in the study. The mRNA expressions of T-bet, GATA-3, FOXP3 and RIG-I in urinary sediment were measured using real time quantitative polymerase chain reaction. We also studied the expression of RIG-I in kidney tissue specimens obtained from LN and IgAN patients. Significant differences in the expression patterns of GATA-3, FOXP3 and RIG-I, and marginal differences in T-bet expression, were observed between the three study groups. Immunofluorescent staining for RIG-I was observed in the tissue specimens from the LN patients, but not in those from the IgAN patients. The mRNA expression patterns of T-bet, GATA-3, FOXP3 and RIG-I in urinary sediment differ according to diagnostic category. These results suggest that the measurement of these target gene expressions might be a useful, non-invasive method for clinical monitoring and studying of pathogenesis in glomerulonephritis.

[Henoch-Schönlein purpura. Study of factors associated with the development and course of the disease]

INTRODUCTION

Henoch-Schönlein purpura (HSP) is the most common form of pediatric vasculitis. The objective of this study was to determine the factors associated with the development and course of this disease.

PATIENTS AND METHODS

A case-control study was performed. The case group included patients with HSP followed-up at the pediatric rheumatology and nephrology units of a tertiary university hospital over a 2-year period. The control group included children followed-up at the pediatric rheumatology unit for mechanical or non-inflammatory conditions. A medical history including data on infectious conditions and previous medication was taken. A throat culture was performed and antistreptolysin 0 levels were quantified. The seroprevalence of different viruses was investigated. Subsequently, the patients were prospectively followed-up and disease manifestations were compared with reported epidemiological factors.

RESULTS

Seventy patients and 58 controls were studied. A history of a recent upper respiratory infection (URI) and antibiotic intake were independently associated with development of HSP. Palpable purpura was present in 100 % of the patients. Gastrointestinal manifestations were recorded in 63 %, articular in 50 %, and renal in 18.6 %. Arthralgias were more frequent in girls and purpura duration was longer when disease onset occurred in spring or summer. Other factors studied were not associated with disease development or with a worse clinical course.

CONCLUSIONS

Factors associated with the development of HSP were a history of URI and antibiotic administration. Other epidemiological factors studied were not associated with either the development or the course of the disease.

Clinicopathology of childhood-onset renal systemic lupus erythematosus

AIMS

To determine the clinicolaboratory renal manifestations; glomerular, extra-glomerular histopathologic lesions; renal tubular dysfunction (RTD) frequency and outcome of a short-term renal follow up in Nigerian children with systemic lupus erythematosus (SLE).

METHODS

A non-randomized prospective study of consecutive cases of childhood-onset SLE with nephropathy was conducted. Baseline/follow-up clinicolaboratory data were collected. Each patient was followed up for 12 months.

RESULTS

Seven of the 11 children studied were girls. The median age at diagnosis was 11.0 years. Median diagnosis time interval (1.9 years) and median time of renal disease onset (1.0 year) were similar. Hypertension, nephrotic syndrome and acute renal failure (ARF) occurred in 45.5%, 54.5% and 63.7% of the patients, respectively. The glomerular lesions were non-proliferative lupus nephritis (LN) in 9.0% (class II LN); focal (class III LN) and diffuse (class IV LN) proliferative LN (PLN) in 27.0% and 64.0%, respectively. Tubulointerstitial nephritis (TIN, 91.0%) and RTD (64.0%) were common. ARF (P = 0.033) and RTD (P = 0.015) were significantly associated with severe TIN. Complete renal remission rate at end-point was 71.4%. Relapse and renal survival rates were 14.3% and 86.0%, respectively. RTD was persistent in 43.0%.

CONCLUSION

Renal function disorders, diffuse PLN and extra-glomerular lesions were frequent. Significant association of ARF and RTD with severe TIN in this series suggests the need for early renal tubular function (RTF) assessment in our SLE patients. Deranged RTF may be marker of severe TIN in SLE warranting early confirmatory renal biopsy and aggressive interventional treatment.

Outcome of Henoch-Schönlein purpura nephritis treated with long-term immunosuppression

This retrospective study investigated the outcome of 27 children (19 male) with Henoch-Schönlein purpura nephritis (HSN) of International Study of Kidney Disease in Children (ISKDC) grade 3b or higher treated with long-term immunosuppressive therapy in a single centre over a 10-year period. The mean age at presentation was 9.7 years. The median estimated glomerular filtration rate (eGFR) was 91.3 ml/min per 1.73 m(2), with the median urine protein creatinine ratio (UP:UC) 556 mg/mmol. The treatment protocol comprised daily steroids and cyclophosphamide for 8-12 weeks followed by azathioprine and a reducing regimen of alternate-day steroids for 8-12 months. After a mean follow-up period of 7 years following presentation, 37% made a complete recovery, 40.7% had persistent proteinuria, 7.4% had persistent proteinuria and were on antihypertensive therapy and 14.8% had progressed to end-stage kidney failure (ESKF). Children with poor outcome were older at presentation (p 0.005), had more crescents (p 0.015) and had heavier proteinuria 6 months post initial biopsy (p 0.023). All of the four children with ESKF had nephrotic range proteinuria and greater than 50% crescents on initial biopsy. Despite long-term immunosuppression, the majority of children with HSN grade 3b or higher will have persistent renal abnormalities on long-term follow-up.

Efficacy of tonsillectomy plus methylprednisolone pulse therapy for a child with Henoch-Schoenlein purpura nephritis

Henoch-Schoenlein purpura (HSP) is a systemic disorder characterized by a leukocytoplastic vasculitis involving small vessels with the deposition of immunoglobulin A (IgA) immune complexes. Renal involvement is the principal cause of morbidity and mortality in children with HSP. We report here an 11-year-old boy with Henoch-Schoenlein purpura nephritis (HSPN) accompanied by recurrent purpura and persistent nephropathy despite conventional therapy such as prednisolone, methylprednisolone pulse therapy and immunosuppressive agent (Mizoribine). The patient was treated with tonsillectomy plus methylprednisolone pulse therapy. This treatment decreased proteinuria, induced disappearance of microscopic hematuria, and improved renal pathological findings. Tonsillectomy plus methylprednisolone pulse is effective and useful therapy for some children with recurrent purpura and persistent nephropathy.

Development of acute Henoch-Schönlein purpura subsequent to endodontic treatment

BACKGROUND

Henoch-Schönlein purpura (HSP) is an inflammatory disorder of unknown origin that is characterized by IgA-dominant immune complexes in smaller blood vessels. It results in a triad of symptoms, including a purpuric rash on the lower extremities, abdominal pain or renal involvement, and arthritis. Any of the triad may be absent, however, which often leads to confusion in diagnosing the condition. Cases of acute HSP developing subsequent to dental treatment have not been previously reported in the dental literature.

CASE REPORT

This study reports the unusual case of a 14-year-old female who developed acute HSP following endodontic treatment.

CONCLUSION

Treatment for this condition is supportive and children affected by this disorder need close follow-up of their renal status.

Lupus nephropathy and cardiopulmonary and hepatic dysfunctions in a child

Systemic lupus erythematosus (SLE) is a potentially fatal autoimmune multi-systemic rheumatologic disorder. An unusual case is reported of an 11.9-year-old Nigerian girl who was diagnosed after 2.8 years of non-specific symptoms and six episodes of recurrent haemolysis and pancytopaenia warranting blood transfusions. At diagnosis, she had hepatitis, polyarthritis, nephropathy, and cardiopulmonary and bone-marrow dysfunctions. Lymphopaenia, thrombocytopaenia, and direct antiglobulin-test positive haemolytic anaemia were present. Rapid resolution of disease activity followed exchange blood transfusion after an initial poor response to corticosteroid and cyclophosphamide therapy. Any child with recurrent haemolysis and pancytopaenia of unknown aetiology should be investigated for SLE.

Role of mesangial fibrinogen deposition in the pathogenesis of crescentic Henoch-Schonlein nephritis in children

AIMS

To clarify the role of mesangial fibrinogen deposition in crescentic Henoch-Schönlein nephritis (HSN).

METHODS

A retrospective analysis of 21 children with HSN treated with immunosuppressants. Serial renal biopsies were performed before and after treatment. They were divided into two groups according to the immunofluorescent course of fibrinogen deposition: group I (n = 9), no or decreased deposition; group II (n = 12), persistent or increased deposition.

RESULTS

There were no differences between the two groups in renal manifestations or laboratory and histological findings at presentation. However, the activity index after immunosuppressive treatment was significantly decreased in group I (mean, 7.9 (SEM, 0.7) v 2.9 (0.4); p = 0.008) and unchanged in group II (mean, 6.8 (SEM, 0.3) v 6.0 (2.1)). The chronicity index was unchanged in group I, but increased in group II (mean, 0.8 (SEM, 0.3) v 1.8 (0.3); p = 0.02). Univariate analysis revealed that the only factor significantly related to persistent or increased fibrinogen deposition was age more than 9 years (p = 0.03). Furthermore, the intensity of fibrinogen deposition at the second biopsy correlated positively with the age at onset (R2= 0.306; p = 0.009) and changes in the percentage of crescents (post-treatment crescents (%) minus pretreatment crescents (%)) correlated positively with the intensity of fibrinogen deposition at the second biopsy (R2= 0.193; p = 0.046).

CONCLUSIONS

This study indicates that fibrinogen deposition has an important role to play in renal injury of crescentic HSN and reflects persistent severe histological activity.

Factors affecting histological regression of crescentic Henoch-Schönlein nephritis in children

To identify the factors affecting histological regression of crescentic Henoch-Schönlein nephritis (HSN), we retrospectively analyzed serially biopsied 20 children with crescentic HSN treated with immunosuppressants. They were classified into two groups according to the histological changes between the first and second biopsy: group I (n=10) with histological regression and group II (n=10) with no change or histological progression. Of the 20 patients, 19 showed a favorable outcome at the end of follow-up. Initial laboratory and histological findings did not differ between the two groups. Histological regression was associated with a younger age at onset (P=0.003), early treatment with immunosuppressants (P=0.044) and absent or decreased fibrinogen deposits at the second biopsy (P<0.0001) in a univariate analysis. Mesangial IgA and fibrinogen depositions at the second biopsy were reduced significantly in group I (P<0.05). In the multivariate analysis, a younger age was an independent determinant of histological regression (OR 1.44; 95% CI 1.03-2.02). The intensity of fibrinogen deposits at the second biopsy correlated positively with the age at onset (r=0.503, P=0.024), and the chronicity index at the second biopsy correlated positively with the time that immunosuppressive therapy was started (r=0.619, P=0.004).

Henoch-Schönlein purpura nephritis with nephrotic-range proteinuria: histological regression possibly associated with cyclosporin A and steroid treatment

OBJECTIVE

To clarify the therapeutic role of cyclosporin A (CyA) for patients with Henoch-Schönlein purpura nephritis (HSPN) showing nephrotic-range proteinuria.

METHODS

The clinical and histological findings of eight children (7.7+/-3.8 years), who were treated with CyA and prednisolone, were evaluated retrospectively. All underwent a renal biopsy before therapy, and six of the eight patients received a follow-up biopsy after therapy.

RESULTS

The histological grade of the International Study of Kidney Disease in Children (ISKDC) was improved in all six patients who received a follow-up biopsy (pre-therapy, four grade IIIa and two grade IIIb; post-therapy, one grade I and five grade II) and it was statistically significant (p = 0.031). The activity index was significantly decreased after therapy (8.3+/-1.6 vs. 3.5+/-1.5, p = 0.031), and the chronicity index (0.5+/-0.5 vs. 0.7+/-1.0) and tubulointerstitial (TI) scores (1.5+/-1.3 vs. 0.8+/-1.6) did not change. There was a reduction in proteinuria from 3.2+/-2.3 to 0.1+/-0.1 g/m2/day (p = 0.008) and renal function remained normal in all patients after therapy. However, one patient showed CyA-induced nephrotoxicity at a second biopsy. After an average follow-up period of 3.8 years, six patients showed normal urine and renal function, and two showed minor urinary abnormalities.

CONCLUSION

This study suggests that CyA therapy is effective in reducing proteinuria, which is a known risk factor for the development of renal insufficiency in HSPN and may regress the renal pathology in patients with nephrotic-range proteinuria.

Multisystemic leukocytoclastic vasculitis affecting the central nervous system

Leukocytoclastic vasculitis is a self-limiting disease with rare systemic complications in the majority of patients. This report describes a 10-year-old male with leukocytoclastic vasculitis caused by an insect bite who presented with central nervous system, lung, kidney, and gastrointestinal involvement in addition to cutaneous findings. The diagnosis was confirmed by histopathologic examination of cerebral hematoma material. Initially, his symptoms improved with a treatment protocol including steroid, cyclophosphamide, intravenous immunoglobulin, and plasmapheresis, but the patient succumbed because of nosocomial sepsis.

Can azathioprine and steroids alter the progression of severe Henoch-Schönlein nephritis in children?

To evaluate the effect of azathioprine with steroids on the clinical course and histologic parameters of severe Henoch-Schönlein nephritis (HSN), 20 patients with a median age of 9.3 years (range 4.4-17 years) and a follow-up period of 4.8 years (range 1-14 years) were included in this study. The patients were divided into two groups. Ten patients received azathioprine with steroids for 8 months (group A), and the other ten received steroids alone (group B). All patients underwent renal biopsy at presentation, and ten of them who were treated with azathioprine underwent follow-up biopsy after therapy. Six patients in group A achieved clinical remission, and the remaining four showed minor urinary abnormalities at the latest observation. The histological grades of the International Study of Kidney Disease in Children (ISKDC) improved in four of the ten patients, and the activity index decreased significantly from 6.8+/-2.0 to 4.3+/-2.3 (p=0.016). In group B, however, four patients had normal urine and renal function; two had minor urinary abnormalities; one had active renal disease, and three had chronic renal insufficiency, at the latest observation. The combination treatment of azathioprine and steroids may be beneficial in ameliorating histopathological features and improving the clinical course of severe HSN.

Cyclosporin A therapy for severe Henoch-Schönlein nephritis with nephrotic syndrome

To evaluate the efficacy of cyclosporin A (CyA) for treating severe Henoch-Schönlein nephritis (HSN), seven patients with nephrotic syndrome, aged 3.9-13.8 years (mean 6.5 years), were analyzed retrospectively. Mean follow-up times were 5.5 years (range 2-9 years). All underwent renal biopsy before treatment, and follow-up renal biopsy was performed in six of the seven patients. All patients improved, with 24-h protein declining from a mean of 9.2 g/m(2)/day (range 1.5-16 g/m(2)/day) to 0.3 g/m(2)/day (range 0.03-1.2 g/m(2)/day) (p=0.016) and serum albumin increasing from a mean of 2.1 g/dl (range 1.5-2.4 g/dl) to 4.6 g/dl (range 3.5-5.3 g/dl) (p=0.016) after CyA therapy. The activity index decreased significantly at the second renal biopsies obtained at a mean interval of 11.7 months after the first (6.4+/-3.3 vs 3.5+/-1.2, p=0.042, respectively), while the chronicity index and the tubulointerstitial scores did not change. On the immunofluorescent findings at the second biopsies, the degree of deposits of immunoglobulins such as IgA, IgM, C3, and fibrinogen decreased in five of the six patients. Although this case series is without controls, our study suggests that CyA may be beneficial to a subset of HSN patients with nephrotic syndrome.

Serum IgA/C3 Ratio May Be a Useful Marker of Disease Activity in Severe Henoch-Schönlein Nephritis

BACKGROUND/AIMS

This study was designed to investigate whether the serum IgA/C3 ratio can be a serologic marker of disease activity in children with severe Henoch-Schönlein nephritis (HSN).

METHODS

Twelve HSN patients who were treated with steroids and cyclosporine were examined. The levels of serum IgA and C3 were measured using an international reference preparation (IFCC/CRM470) and a renal biopsy was performed in all patients before and after therapy. After therapy, patients were divided into 3 groups: complete remission (n = 6, group I), mild urinary abnormalities (n = 3, group II), and active renal disease (n = 3, group III).

RESULTS

The serum IgA/C3 ratio decreased significantly in groups I and II after therapy (2.62 +/- 0.82 vs. 2.02 +/- 0.52, p = 0.02), whereas the ratio in group III increased, although it was not statistically significant (2.13 +/- 0.93 vs. 4.67 +/- 1.71, p = 0.25). A follow-up renal biopsy revealed that the activity index was reduced in groups I and II (7.0 +/- 2.4 vs. 3.6 +/- 1.6, p = 0.016), and not changed in group III (7.3 +/- 2.1 vs. 9.3 +/- 2.5, p = 0.25). The activity index at a follow-up renal biopsy correlated positively with the changes of the serum IgA/C3 ratio: posttherapy activity index = 1.20 x DeltaIgA/C3 + 4.78 (r = 0.635, p = 0.027); where DeltaIgA/C3 is posttherapy IgA/C3--pretherapy IgA/C3.

CONCLUSION

These findings suggest that the serum IgA/C3 ratio may be a useful marker to predict disease activity and histologic severity in HSN.

Life-threatening purpura and vasculitis

Palpable purpura, the inflammation of blood vessels is the hallmark of vasculitis. It can be observed in a variety of settings, where vessels can be affected primarily or as a secondary event. Every patient with vasculitis should be considered to have a systemic disease unless proven otherwise. One or more systemic symptoms occur in at least 50% of patients and there is no way to predict systemic involvement. Patients may demonstrate mild systemic involvement like arthralgia and arthritis, fever and malaise or more severe symptoms such as massive proteinuria and raised creatinine leading to chronic renal failure, severe intestinal bleeding or perforation with a fatal outcome. In this article we will review the life-threatening aspects of purpura and vasculitis.

Efficacy of methylprednisolone and urokinase pulse therapy combined with or without cyclophosphamide in severe Henoch-Schoenlein nephritis: a clinical and histopathological study

BACKGROUND

There have been few controlled studies of combined therapy with multiple drugs, including immunosuppressives, for severe Henoch-Schoenlein nephritis (HSPN). We evaluated the efficacy of methylprednisolone and urokinase pulse therapy combined with cyclophosphamide for patients with HSPN of at least grade IVb.

METHODS

We studied 37 patients who had been diagnosed with HSPN of at least grade IVb. Of them, 20 (Group A) were treated with methylprednisolone and urokinase pulse therapy, and 17 (Group B) were treated with methylprednisolone and urokinase pulse therapy combined with cyclophophamide. We analysed the clinical features, laboratory and pathological findings of the two groups retrospectively.

RESULTS

After 6 months of treatment, mean urinary protein excretion in Group B had significantly decreased compared with Group A, and the activity index of both groups at the second biopsy was lower than that at the first. Furthermore, at the second biopsy, the chronicity index of Group B was lower than that of Group A. Four patients of Group A but none of Group B had persistent nephropathy (P<0.05).

CONCLUSIONS

Our study suggests that methylprednisolone and urokinase pulse therapy combined with cyclophosphamide is useful for patients with severe HSPN.

Combined therapy of enalapril and losartan attenuates histologic progression in immunoglobulin A nephropathy

BACKGROUND

It has been reported that combined therapy of angiotensin converting enzyme inhibitor and angiotensin receptor blocker significantly decreases proteinuria in immunoglobulin A (IgA) nephropathy. However, histologic alterations following the therapy have not been reported.

METHODS

A total of nine Japanese children with severe proteinuric IgA nephropathy who received a prompt immunosuppressive therapy were enrolled the study, four of whom received a combined therapy of angiotensin converting enzyme inhibitor, enalapril and angiotensin receptor blocker, losartan (Group A), while the remaining five did not (Group B). All underwent renal biopsy before and approximately 12 months after the first renal biopsy.

RESULTS

At presentation, urine protein excretion and the histologic indices of mean activity index, mean chronicity index and tubulointerstitial scores did not show a statistical difference between the two groups: Group A (2.6 +/- 0.6 g/day; mean activity index, 5.0 +/- 1.0; mean chronicity index, 5.0 +/- 1.0; tubulointerstitial scores, 4.3 +/- 1.0) and Group B (2.2 +/- 0.6 g/day; mean activity index, 4.8 +/- 0.8; mean chronicity index, 4.8 +/- 1.3; tubulointerstitial scores, 3.6 +/- 0.5, respectively). All had normal blood pressure and renal function. Urine protein excretion and the activity index decreased at the second renal biopsy, while the chronicity index and the tubulointerstitial scores slightly increased or remained unchanged. In comparison with Group B, a significant suppression in increasing the chronicity index and the tubulointerstitial scores obtained at the second renal biopsy were observed in Group A [Group A: 4.3 +/- 1.2 and 3.0 +/- 0.0, respectively, vs Group B: 6.0 +/- 0.7 and 4.4 +/- 0.9, respectively (P < 0.05)]. One patient in Group B developed chronic renal insufficiency thereafter.

CONCLUSIONS

Although only a small number of patients were examined, these clinical findings suggest that a combined therapy of enalapril and losartan may attenuate histologic progression in at least a proportion of patients with severe proteinuric IgA nephropathy.

Pediatric IgA nephropathies: clinical aspects and therapeutic approaches

The pediatric IgA nephropathies are IgA nephrothapy (Berger's Disease) and Henoch-Schönlein purpura nephritis. Both conditions are reviewed in detail with respect to epidemiology, clinical features, outcome, prognostic markers, and therapeutic approaches. For both conditions variable disease severity and outcome along with the lack of conclusive evidence for efficacy of treatment based on randomized clinical trials makes it difficult to make strong recommendations regarding therapy.

Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is a multisystem immunoglobulin A-mediated vasculitis with a self-limited course affecting the skin, joints, gastrointestinal tract, and kidneys. HSP occurs most often in children between the ages of 3 and 10 years, and presents classically with a unique distribution of the rash to the lower extremities and the buttocks area. For this reason, a skin biopsy in children is rarely necessary for diagnosis. However, in the very young age children and adults, the rash is not classically distributed, and therefore a skin biopsy is often needed. Although there are currently no prospective controlled studies on the treatment of the different manifestations of HSP, there are several retrospectively designed studies and other physicians' personal experiences supporting the use of steroids in patients with severe gastrointestinal, severe renal, central nervous system, and testicular involvements. Severe renal and central nervous system disease may lead to life-threatening conditions, and immunosuppressive agents and plasmapheresis may be needed. The overall prognosis in HSP is excellent, but the long-term morbidity depends on the renal and neurologic involvement. One third to one half of these patients will have one or more recurrences of symptoms, usually within 6 weeks, but may occur as late as 3 to 7 years later.

Palpable purpura, polyarthritis and abdominal pain

We report a patient who presented with a purpuric rash and polyarthritis, but IgA deposits were not found in the skin. Abdominal pain and renal disease first emerged 1 and 2 weeks, respectively, after presentation, to reveal the classic tetrad of Henoch-Schönlein purpura. Our patient emphasises the need for careful follow-up in patients with cutaneous vasculitis, as they may develop systemic manifestations, of which renal involvement, particularly, may be asymptomatic.

Repeat renal biopsy in children with severe idiopathic tubulointerstitial nephritis

Idiopathic (primary) tubulointerstitial nephritis (TIN) of childhood is relatively rare. Four children, two with concomitant uveitis, aged 8-14 years, with idiopathic TIN who underwent repeat renal biopsy were retrospectively evaluated. At presentation, all had a significant elevation of the urinary beta(2)-microglobulin/creatinine ratio (beta2MG ratio), ranging from 10100 to 44550, with increased histological indices of tubulointerstitial scores (TI scores) in excess of 6 points. Three of the children received prednisolone (PSL) therapy following diagnosis, while the remaining child received the therapy 30 months after the first renal biopsy. In the children that received prompt PSL therapy, a rapid decrease in urinary beta2MG ratio was observed and the TI scores obtained at a mean interval of 16 months after the first biopsy decreased to less than 5, while preserving renal function. In the remaining child that received delayed PSL therapy, persistent elevations of urinary beta2MG ratio and TI scores were observed. He subsequently progressed to chronic renal insufficiency. These clinical findings suggest that persistent elevations of urinary beta2MG ratio and TI scores are indicators of progression of renal failure in TIN. For successful treatment, early therapeutic intervention should be deployed in selected patients with severe idiopathic TIN.

Cyclosporin A for the treatment of severe Henoch-Schönlein glomerulonephritis

We evaluated the efficacy of cyclosporin A (CyA) for treating pediatric patients with severe Henoch-Schönlein glomerulonephritis (HSP-GN) and nephrotic-range proteinuria. Seven pediatric HSP-GN patients (5 boys, 2 girls) were treated with CyA, with a mean age of 10.6 years at diagnosis (range 7.2-15.2 years) and mean follow-up times of 6.0 years (range 4.4-8.9 years) from diagnosis and 5.2 years (range 3.4-7.7 years) from the beginning of the CyA treatment. All had developed nephrotic-range proteinuria within 1-3 months of the HSP diagnosis. A renal biopsy was performed on all the patients, and two showed rapidly progressive glomerulonephritis. They all received additional angiotensin converting enzyme inhibitor medication and one to three types of immunosuppressive treatment had been tried in five of the seven patients before CyA was initiated at a mean interval of 0.7 years after diagnosis (range 0.1-2.0 years). All the patients responded to the CyA treatment within a mean of 1.4 months (range 1 week to 4 months). Four patients achieved a stable remission and had been without CyA treatment for a mean of 3.7 years (range 2.9-5.3 years) by the end of the follow-up. Three patients seemed to become CyA dependent, since they developed proteinuria when the treatment was stopped. CyA treatment had been started significantly earlier ( P=0.045) in the former group (mean 0.2 years, range 0.1-0.3 years) than in the latter (mean 1.5 years, range 1.2-2.0 years). Renal function was preserved in all patients, the glomerular filtration rate, plasma cystatin C, serum albumin, and serum creatinine being within normal limits at the end of the follow-up. We conclude that CyA treatment for severe treatment-resistant HSP-GN is promising, since four of the seven patients enjoy stable remission and all have retained their renal function after a mean follow-up of 6.0 years. However, some patients seem to develop CyA-dependent nephritis.

Efficacy of methylprednisolone and urokinase pulse therapy for severe Henoch-Schönlein nephritis

OBJECTIVE

To evaluate the efficacy of methylprednisolone and urokinase pulse therapy (MUPT) for severe Henoch-Schönlein nephritis, we examined the clinical manifestation and prognosis of patients with MUPT on long-term observation.

METHODS

We enrolled 56 patients with Henoch-schönlein nephritis who had been diagnosed with at least type IIIb from 1980 to 1998 on long-term observation and had been treated with MUPT. The clinical features, laboratory data, and pathologic findings between "pre-MUPT" and "post-MUPT," and the prognosis of these patients on long-term observation were retrospectively investigated.

RESULTS

The mean urinary protein excretion after 6 months of treatment had decreased significantly compared with "pre-MUPT." Hypercoagulant state in "after the completion of urokinase pulse therapy" improved compared with "pre-MUPT." First renal biopsies were performed in all patients and second biopsies were performed in 27 patients. The activity index decreased significantly from 4.1 +/- 1.9 at first biopsy to 2.5 +/- 1.7 at second biopsy, while the chronicity index did not differ between first and second biopsy. None had renal insufficiency and renal survival rate was 100% for the decade.

CONCLUSIONS

Although uncontrolled, our study suggested that MUPT is effective for those patients with the risk of progression of their nephropathy, especially if started early during the course of the disease before the crescents become fibrous.

Early treatment with oral immunosuppressants in severe proteinuric purpura nephritis

Nine Japanese children with severe proteinuric Henoch-Schönlein purpura nephritis (HSPN) received prompt initiation of oral prednisolone (1.5 mg/kg/day) combined with an 8-week course of cyclophosphamide (2 mg/kg/day) therapy. All underwent renal biopsy before and after treatment. At presentation, urine protein excretion and histologic indices of the mean activity index, the mean chronicity index and the tubulointerstitial (TI) scores in the patients were 5.0+/-1.4, 4.7+/-1.0, 3.9+/-1.6 and 3.7+/-0.5 g/day, respectively. Urine protein excretion, the activity index and the TI scores decreased significantly at the second renal biopsies obtained at a mean interval of 23 months after the first [0.3+/-0.3, 2.4+/-0.5 and 1.4+/-0.7 g/day ( P<0.01), respectively], while the chronicity index did not change. At the latest observation (mean interval 78 months), all except two showed negative proteinuria while no patient showed renal impairment. Although this case series is without controls, our experience suggests that early treatment with oral prednisolone and cyclophosphamide may be beneficial to a proportion of patients with severe proteinuric HSPN.

Vasculitis in childhood

Vasculitis is an important diagnostic consideration in the child with prolonged fever, unexplained pains, new neurologic findings, or other persistent and troubling signs of inflammation. As long as the etiology of vasculitis remains unknown, reliance upon imperfect diagnostic criteria is likely to remain the state of the art. Nonetheless, anti-inflammatory and immunosuppressive therapy is highly effective in speeding resolution of systemic inflammation and reducing long-term complications. The care, experience, and acumen of the treating physician thus remain the gold standard for diagnosing and treating pediatric vasculitides. In all cases this begins with a high level of suspicion in the primary care physician.