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Lin J, Selkirk EK, Siqueira I, Beaucage M, Carriere C, Dart A, De Angelis M, Erickson RL, Ghent E, Goldberg A, Hartell D, Henderson R, Matsuda-Abedini M, McKay A, Prestidge C, Toulouse C, Urschel S, Weiss MJ, Anthony SJ. Access to and Health Outcomes of Pediatric Solid Organ Transplantation for Indigenous Children in 4 Settler-colonial Countries: A Scoping Review. Transplantation 2024:00007890-990000000-00777. [PMID: 38776228 DOI: 10.1097/tp.0000000000005071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
Solid organ transplantation (SOT) is considered the optimal treatment for children with end-stage organ failure; however, increased efforts are needed to understand the gap surrounding equitable access to and health outcomes of SOT for Indigenous children. This scoping review summarizes the literature on the characteristics of access to and health outcomes of pediatric SOT among Indigenous children in the settler-colonial states of Canada, Aotearoa New Zealand, Australia, and the United States. A search was performed on MEDLINE, EMBASE, PsycINFO, and CINAHL for studies matching preestablished eligibility criteria from inception to November 2021. A preliminary gray literature search was also conducted. Twenty-four studies published between 1996 and 2021 were included. Studies addressed Indigenous pediatric populations within the United States (n = 7), Canada (n = 6), Aotearoa New Zealand (n = 5), Australia (n = 5), and Aotearoa New Zealand and Australia combined (n = 1). Findings showed that Indigenous children experienced longer time on dialysis, lower rates of preemptive and living donor kidney transplantation, and disparities in patient and graft outcomes after kidney transplantation. There were mixed findings about access to liver transplantation for Indigenous children and comparable findings for graft and patient outcomes after liver transplantation. Social determinants of health, such as geographic remoteness, lack of living donors, and traditional spiritual beliefs, may affect SOT access and outcomes for Indigenous children. Evidence gaps emphasize the need for action-based initiatives within SOT that prioritize research with and for Indigenous pediatric populations. Future research should include community-engaged methodologies, situated within local community contexts, to inform culturally safe care for Indigenous children.
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Affiliation(s)
- Jia Lin
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Enid K Selkirk
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Izabelle Siqueira
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Mary Beaucage
- Patient, Family and Donor Partnership Platform, Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Indigenous Peoples' Engagement and Research Council, Can-SOLVE CKD Network, Vancouver, BC, Canada
| | - Carmen Carriere
- Patient, Family and Donor Partnership Platform, Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Allison Dart
- Section of Pediatric Nephrology, Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Maria De Angelis
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robin L Erickson
- Paediatric Kidney Service, Starship Children's Hospital, Auckland, New Zealand
| | - Emily Ghent
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Social Work, The Hospital for Sick Children, Toronto, ON, Canada
| | - Aviva Goldberg
- Section of Pediatric Nephrology, Department of Pediatrics and Child Health, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Randi Henderson
- Patient, Family and Donor Partnership Platform, Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Mina Matsuda-Abedini
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Nephrology, BC Children's Hospital, Vancouver, BC, Canada
| | - Ashlene McKay
- Division of Nephrology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Chanel Prestidge
- Paediatric Kidney Service, Starship Children's Hospital, Auckland, New Zealand
| | - Crystal Toulouse
- Patient, Family and Donor Partnership Platform, Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Simon Urschel
- Department of Pediatrics, University of Alberta/Stollery Children's Hospital, Edmonton, AB, Canada
| | - Matthew J Weiss
- Division of Critical Care, Department of Pediatrics, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
| | - Samantha J Anthony
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Social Work, The Hospital for Sick Children, Toronto, ON, Canada
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON, Canada
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Garg S, Sweet N, Boderman B, Montes D, Walunas T, Ramsey-Goldman R, Khosroshahi A, Astor BC, Lim SS, Bartels CM. Multiplicative Impact of Adverse Social Determinants of Health on Outcomes in Lupus Nephritis: A Meta-analysis and Systematic Review. Arthritis Care Res (Hoboken) 2024. [PMID: 38693617 DOI: 10.1002/acr.25359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/15/2024] [Accepted: 04/19/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Social determinants of health (SDoH) likely contribute to outcome disparities in lupus nephritis (LN). Understanding the overall burden and contribution of each domain could guide future health equity-focused interventions to improve outcomes and reduce disparities in LN. Objectives of this meta-analysis were to 1) determine the association of overall SDoH and specific SDoH domains on LN outcomes and 2) develop a framework for the multidimensional impact of SDoH on LN outcomes. METHODS We performed a comprehensive search of studies measuring associations between SDoH and LN outcomes. We examined pooled odds of poor LN outcomes including death, end-stage kidney disease, or cardiovascular disease in patients with and without adverse SDoH. Additionally, we calculated the pooled odds ratios of outcomes by four SDoH domains: individual (eg, insurance), health care (eg, fragmented care), community (eg, neighborhood socioeconomic status), and health behaviors (eg, smoking). RESULTS Among 531 screened studies, 31 meeting inclusion criteria and 13 with raw data were included in meta-analysis. Pooled odds of poor outcomes were 1.47-fold higher in patients with any adverse SDoH. Patients with adverse SDoH in individual and health care domains had 1.64-fold and 1.77-fold higher odds of poor outcomes. We found a multiplicative impact of having two or more adverse SDoH on LN outcomes. Black patients with public insurance and fragmented care had 12-fold higher odds of poor LN outcomes. CONCLUSION Adverse SDoH is associated with poor LN outcomes. Having two or more adverse SDoH, specifically in different SDoH domains, had a multiplicative impact leading to worse LN outcomes, widening disparities.
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Affiliation(s)
- Shivani Garg
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Nadia Sweet
- University of Wisconsin School of Medicine and Public Health, Madison
| | - Brianna Boderman
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | | | | | | | - Brad C Astor
- University of Wisconsin School of Medicine and Public Health, Madison
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Andrist E, Clarke RG, Phelps KB, Dews AL, Rodenbough A, Rose JA, Zurca AD, Lawal N, Maratta C, Slain KN. Understanding Disparities in the Pediatric ICU: A Scoping Review. Pediatrics 2024; 153:e2023063415. [PMID: 38639640 DOI: 10.1542/peds.2023-063415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Health disparities are pervasive in pediatrics. We aimed to describe disparities among patients who are likely to be cared for in the PICU and delineate how sociodemographic data are collected and categorized. METHODS Using MEDLINE as a data source, we identified studies which included an objective to assess sociodemographic disparities among PICU patients in the United States. We created a review rubric, which included methods of sociodemographic data collection and analysis, outcome and exposure variables assessed, and study findings. Two authors reviewed every study. We used the National Institute on Minority Health and Health Disparities Research Framework to organize outcome and exposure variables. RESULTS The 136 studies included used variable methods of sociodemographic data collection and analysis. A total of 30 of 124 studies (24%) assessing racial disparities used self- or parent-identified race. More than half of the studies (52%) dichotomized race as white and "nonwhite" or "other" in some analyses. Socioeconomic status (SES) indicators also varied; only insurance status was used in a majority of studies (72%) evaluating SES. Consistent, although not uniform, disadvantages existed for racial minority populations and patients with indicators of lower SES. The authors of only 1 study evaluated an intervention intended to mitigate health disparities. Requiring a stated objective to evaluate disparities aimed to increase the methodologic rigor of included studies but excluded some available literature. CONCLUSIONS Variable, flawed methodologies diminish our understanding of disparities in the PICU. Meaningfully understanding and addressing health inequity requires refining how we collect, analyze, and interpret relevant data.
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Affiliation(s)
- Erica Andrist
- Division of Pediatric Critical Care Medicine
- Departments of Pediatrics
| | - Rachel G Clarke
- Division of Pediatric Critical Care Medicine, Upstate University Hospital, Syracuse, New York
- Center for Bioethics and Humanities, SUNY Upstate Medical University, Syracuse, New York
| | - Kayla B Phelps
- Division of Pediatric Critical Care Medicine, Louisiana State University Health Sciences Center, Children's Hospital of New Orleans, New Orleans, Louisiana
| | - Alyssa L Dews
- Human Genetics, University of Michigan Medical School, Ann Arbor, Michigan
- Susan B. Meister Child Health and Adolescent Research Center, University of Michigan, Ann Arbor, Michigan
| | - Anna Rodenbough
- Division of Pediatric Critical Care Medicine, Children's Hospital of Atlanta, Atlanta, Georgia
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jerri A Rose
- Pediatric Emergency Medicine
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adrian D Zurca
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Nurah Lawal
- Stepping Stones Pediatric Palliative Care Program, C.S. Mott Children's Hospital, Ann Arbor, Michigan
- Departments of Pediatrics
| | - Christina Maratta
- Department of Critical Care, The Hospital for Sick Children, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katherine N Slain
- Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Wenderfer SE, Cooper JC. Do we really need cyclophosphamide for lupus nephritis? Pediatr Nephrol 2024:10.1007/s00467-024-06367-9. [PMID: 38607424 DOI: 10.1007/s00467-024-06367-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
A 14-year-old patient presents with hematuria and proteinuria. Clinical evaluation reveals a positive anti-nuclear antibody titer, positive anti-double stranded DNA antibody and hypocomplementemia. Systemic lupus erythematosus (SLE) is diagnosed based on the 2019 EULAR/ACR (European League Against Rheumatism/American College of Rheumatology) classification criteria (Aringer et al. Arthritis Rheumatol 71:1400-1412, 2019). A kidney biopsy is performed that confirms the presence of immune complex glomerulonephritis, ISN-RPS (International Society of Nephrology/Renal Pathology Society) class IV (Bajema et al. Kidney Int 93:789-796, 2018). According to the latest clinical practice guidelines (Rovin et al. Kidney Int 100:753-779, 2021; Fanouriakis et al. Ann Rheum Dis 83:15-29, 2023), there are alternatives to treating this patient with cyclophosphamide. But what if this patient also presented with oliguria and volume overload requiring intensive care and dialysis? What if this patient also presented with altered mental status and seizures, and was diagnosed with neuropsychiatric lupus? What if this patient was also diagnosed with a pulmonary hemorrhage and respiratory failure? The clinical practice guidelines do not address these scenarios that are not uncommon in patients with SLE. Moreover, in some countries worldwide, patients do not have the privilege of access to biologics or more expensive alternatives. The purpose of this review is to evaluate the contemporary options for initial treatment of nephritis in patients with SLE.
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Affiliation(s)
- Scott E Wenderfer
- Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada.
- Pediatric Nephrology, BC Children's Hospital, Vancouver, BC, Canada.
| | - Jennifer C Cooper
- Department of Pediatrics, University of Colorado, Denver, CO, USA
- Pediatric Rheumatology, Children's Hospital Colorado, Aurora, CO, USA
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5
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Wang CS, Sadun RE, Zhou W, Miller KR, Pyle L, Ardoin SP, Bacha C, Hause E, Hui-Yuen J, Ling N, Pereira M, Riebschleger M, Rouster-Stevens K, Sarkissian A, Shalen J, Soulsby W, Twilt M, Wu EY, Lewandowski LB, Wenderfer SE, Cooper JC. Renal Response Outcomes of the EuroLupus and National Institutes of Health Cyclophosphamide Dosing Regimens in Childhood-Onset Proliferative Lupus Nephritis. Arthritis Rheumatol 2024; 76:469-478. [PMID: 37800549 DOI: 10.1002/art.42725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 09/07/2023] [Accepted: 09/27/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE We compared clinical characteristics and renal response in patients with childhood-onset proliferative lupus nephritis (LN) treated with the EuroLupus versus National Institutes of Health (NIH) cyclophosphamide (CYC) regimen. METHODS A retrospective cohort study was conducted at 11 pediatric centers in North America that reported using both CYC regimens. Data were extracted from the electronic medical record at baseline and 3, 6, and 12 months after treatment initiation with CYC. To evaluate the adjusted association between CYC regimen (EuroLupus vs NIH) and renal response over time, generalized estimating equations with a logit link were used. An interaction between time and CYC regimen was included, and a contrast between CYC regimens at 12 months was used to evaluate the primary outcome. RESULTS One hundred forty-five patients (58 EuroLupus, 87 NIH) were included. EuroLupus patients were on average older at the start of current CYC therapy, had longer disease duration, and more commonly had relapsed or refractory LN compared with the NIH group. After multivariable adjustment, there was no significant association between CYC regimen and achieving complete renal response at 12 months (odds ratio [OR] of response for the EuroLupus regimen, reference NIH regimen: 0.76; 95% confidence interval [CI] 0.29-1.98). There was also no significant association between CYC regimen and achieving at least a partial renal response at 12 months (OR 1.35, 95% CI 0.57-3.19). CONCLUSION Our study failed to demonstrate a benefit of the NIH regimen over the EuroLupus CYC regimen in childhood-onset proliferative LN. However, future prospective outcome studies are needed.
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Affiliation(s)
| | | | - Wenru Zhou
- University of Colorado Anschutz Medical Campus, Aurora
| | | | - Laura Pyle
- University of Colorado Anschutz Medical Campus, Aurora
| | | | | | - Emily Hause
- University of Minnesota Masonic Children's Hospital, Minneapolis
| | - Joyce Hui-Yuen
- Cohen Children's Medical Center, New Hyde Park, New York
| | | | - Maria Pereira
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | | | - Kelly Rouster-Stevens
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | | | - Julia Shalen
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Marinka Twilt
- Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Laura B Lewandowski
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
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Pennesi M, Benvenuto S. Lupus Nephritis in Children: Novel Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1841. [PMID: 37893559 PMCID: PMC10607957 DOI: 10.3390/medicina59101841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Childhood-onset systemic lupus erythematosus is an inflammatory and autoimmune condition characterized by heterogeneous multisystem involvement and a chronic course with unpredictable flares. Kidney involvement, commonly called lupus nephritis, mainly presents with immune complex-mediated glomerulonephritis and is more frequent and severe in adults. Despite a considerable improvement in long-term renal prognosis, children and adolescents with lupus nephritis still experience significant morbidity and mortality. Moreover, current literature often lacks pediatric-specific data, leading clinicians to rely exclusively on adult therapeutic approaches. This review aims to describe pediatric lupus nephritis and provide an overview of the novel perspectives on the pathogenetic mechanisms, histopathological classification, therapeutic approach, novel biomarkers, and follow-up targets in children and adolescents with lupus nephritis.
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Affiliation(s)
- Marco Pennesi
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Simone Benvenuto
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
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7
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Chen HG, Chen JS, Chen YS, Yin CH, Chen HC, Chiou YH. Comparison of mycophenolic acid with cyclophosphamide for the treatment of pediatric lupus nephritis: A retrospective study from a tertiary center hospital in Taiwan. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:1105-1113. [PMID: 37586916 DOI: 10.1016/j.jmii.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 07/23/2023] [Accepted: 08/04/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND This study aimed to compare the efficacy of mycophenolic acid (MPA) and cyclophosphamide (CYC) for treating pediatric lupus nephritis (pLN). METHODS Data on patients with pLN class III, IV, and V, diagnosed by renal biopsy, were collected from the Databank of Kaohsiung Veterans General Hospital between February 2005 and December 2020. The study included 31 pLN patients. Of these, 15 received MPA (MPA group) and 16 received CYC (CYC group). Systemic lupus erythematosus disease activity index score, laboratory findings, complete remission (CR), and partial remission (PR) were assessed at 6, 12, and 24 months. RESULTS In the MPA group, CR occurred in 7/15 (47%) patients at month 6 and in 11/15 (73%) at months 12 and 24. In the CYC group, CR was reached in 5/16 (31%) patients at month 6, in 8/16 (50%) at month 12, and in 9/16 (56%) at month 24. PR was seen in 3/15 (20%) patients in the MPA group and in 3/16 (19%) in the CYC group at month 24. The cumulative probability of CR and PR showed no statistically significant difference between the two groups. However, the estimated glomerular filtration rate (eGFR) improved significantly in the MPA group at months 6, 12 and 24 compared to that in the CYC group (p < 0.05). CONCLUSION The efficacy of MPA is similar to that of CYC for pLN treatment, with MPA providing a significant improvement in eGFR after pLN induction therapy at months 6,12 and 24.
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Affiliation(s)
- Huei-Geng Chen
- Division of Pediatric Allergy Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Pediatrics, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
| | - Jin-Shuen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yao-Shen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Institute of Health Care Management, National Sun Yat-sen University, Taiwan
| | - Hsiao-Ching Chen
- Division of Pediatric Allergy Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yee-Hsuan Chiou
- Division of Pediatric Allergy Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Division of Pediatric Nephrology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Medical Laboratory Science and Biotechnology, Fooyin University, Kaohsiung, Taiwan.
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8
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Keskinyan VS, Lattanza B, Reid-Adam J. Glomerulonephritis. Pediatr Rev 2023; 44:498-512. [PMID: 37653138 DOI: 10.1542/pir.2021-005259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Glomerulonephritis (GN) encompasses several disorders that cause glomerular inflammation and injury through an interplay of immune-mediated mechanisms, host characteristics, and environmental triggers, such as infections. GN can manifest solely in the kidney or in the setting of a systemic illness, and presentation can range from chronic and relatively asymptomatic hematuria to fulminant renal failure. Classic acute GN is characterized by hematuria, edema, and hypertension, the latter 2 of which are the consequence of sodium and water retention in the setting of renal impairment. Although presenting signs and symptoms and a compatible clinical history can suggest GN, serologic and urinary testing can further refine the differential diagnosis, and renal biopsy can be used for definitive diagnosis. Treatment of GN can include supportive care, renin-angiotensin-aldosterone system blockade, immunomodulatory therapy, and renal transplant. Prognosis is largely dependent on the underlying cause of GN and can vary from a self-limited course to chronic kidney disease. This review focuses on lupus nephritis, IgA nephropathy, IgA vasculitis, and postinfectious GN.
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Cody EM, Wenderfer SE, Sullivan KE, Kim AHJ, Figg W, Ghumman H, Qiu T, Huang B, Devarajan P, Brunner HI. Urine biomarker score captures response to induction therapy with lupus nephritis. Pediatr Nephrol 2023; 38:2679-2688. [PMID: 36715772 PMCID: PMC10393841 DOI: 10.1007/s00467-023-05888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Renal Activity Index for Lupus (RAIL) consists of urine protein assessment of neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, monocyte chemotactic protein 1, adiponectin, hemopexin, and ceruloplasmin, which non-invasively identifies lupus nephritis (LN). We aimed to delineate RAIL scores with inactive versus active LN and changes over time with response to LN induction therapy. METHODS There were 128 pediatric patients with systemic lupus erythematosus (SLE) and age-matched healthy controls recruited in a prospective case control study, with kidney biopsy confirmation of LN. Laboratory and clinical information was recorded and urine collected at diagnosis and end of induction and during maintenance therapy. Response to therapy was assessed by repeat kidney biopsy or laboratory parameters. Urine was assayed for RAIL biomarkers and the RAIL score calculated. RESULTS Pediatric RAIL (pRAIL) scores from 128 children and young adults with SLE (with/without LN: 70/38) including 25 during LN induction therapy, differentiated clinically active LN from inactive LN or without LN, and controls (all p < 0.0017). pRAIL scores significantly decreased with complete LN remission by 1.07 ± 1.7 (p = 0.03). CONCLUSIONS The RAIL biomarkers differentiate LN patients based on activity of kidney disease, with decreases of ≥ 1 in pRAIL scores indicating complete response to induction therapy. Significantly lower RAIL scores in healthy controls and in SLE patients without known LN raise the possibility of subclinical kidney disease. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Ellen M Cody
- Division of Nephrology, Hypertension and Pheresis, Department of Pediatrics, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, Campus, Box 8116, St. Louis, MO, 63110, USA.
| | - Scott E Wenderfer
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Nephrology, B.C. Children's Hospital, Vancouver, BC, Canada
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alfred H J Kim
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Wesley Figg
- Medical School, Baylor College of Medicine, Houston, TX, USA
| | - Harneet Ghumman
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tingting Qiu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Hermine I Brunner
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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10
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Smitherman EA, Chahine RA, Beukelman T, Lewandowski LB, Rahman AKMF, Wenderfer SE, Curtis JR, Hersh AO. Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care. Arthritis Care Res (Hoboken) 2023; 75:1553-1562. [PMID: 36775844 PMCID: PMC10500561 DOI: 10.1002/acr.25002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 07/14/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis. METHODS We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded. RESULTS We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers. CONCLUSION In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.
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11
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Khandelwal P, Govindarajan S, Bagga A. Management and outcomes in children with lupus nephritis in the developing countries. Pediatr Nephrol 2023; 38:987-1000. [PMID: 36255555 DOI: 10.1007/s00467-022-05769-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/14/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lupus nephritis (LN) has variable prevalence, severity, and outcomes across the world. OBJECTIVES This review compares the outcomes of childhood LN in low- and middle-income countries (LMICs) and high-income countries (HICs) and aims to summarize long-term outcomes of pediatric LN from LMICs. DATA SOURCES A systematic literature search, conducted in PubMed, EMBASE, and Cochrane database in the last 30-years from January 1992, published in the English language, identified 113 studies including 52 from lower (n = 1336) and upper MICs (n = 3014). STUDY ELIGIBILITY CRITERIA Cohort studies or randomized controlled trials, of patients ≤ 18 years of age (or where such data can be separately extracted), with > 10 patients with clinically or histologically diagnosed LN and outcomes reported beyond 12 months were included. PARTICIPANTS AND INTERVENTIONS Patients ≤ 18 years of age with clinically or histologically diagnosed LN; effect of an intervention was not measured. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently extracted data. We separately analyzed studies from developed countries (high income countries; HIC) and developing countries (LMICs). Middle-income countries were further classified as lower and upper MICs. Meta-analyses of data were performed by calculating a pooled estimate utilizing the random-effects model. Test for heterogeneity was applied using I2 statistics. Publication bias was assessed using funnel plots. RESULTS Kidney remission was similar across MICs and HICs with 1-year pooled complete remission rates of 59% (95% CI 51-67%); one third of patients had kidney flares. The pooled 5-year survival free of stage 5 chronic kidney disease (CKD5) was lower in MICs, especially in lower MICs compared to HICs (83% vs. 93%; P = 0.002). The pooled 5-year patient survival was significantly lower in MICs than HICs (85% vs. 94%; P < 0.001). In patients with class IV LN, the 5-and 10-year respective risk of CKD5 was 14% and 30% in MICs; corresponding risks in HICs were 8% and 17%. Long-term data from developing countries was limited. Sepsis (48.8%), kidney failure (14%), lupus activity (18.1%), and intracranial hemorrhage/infarct (5.4%) were chief causes of death; mortality due to complications of kidney failure was more common in lower MICs (25.6%) than HICs (6.4%). LIMITATIONS The review is limited by heterogenous approach to diagnosis and management that has changed over the period spanning the review. World Bank classification based on income might not correlate with the standards of medical care. The overall quality of evidence is low since included studies were chiefly retrospective and single center. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Challenges in LMICs include limited access to pediatric nephrology care, dialysis, increased risk of infection-induced mortality, lack of frequent monitoring, and non-compliance due to cost of therapy. Attention to these issues might update the existing data and improve patient follow-up and outcomes. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO 2022 number: CRD42022359002, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022359002.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Srinivasavaradan Govindarajan
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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12
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Rea KE, West KB, Dorste A, Christofferson ES, Lefkowitz D, Mudd E, Schneider L, Smith C, Triplett KN, McKenna K. A systematic review of social determinants of health in pediatric organ transplant outcomes. Pediatr Transplant 2023; 27:e14418. [PMID: 36321186 DOI: 10.1111/petr.14418] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/27/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Equitable access to pediatric organ transplantation is critical, although risk factors negatively impacting pre- and post-transplant outcomes remain. No synthesis of the literature on SDoH within the pediatric organ transplant population has been conducted; thus, the current systematic review summarizes findings to date assessing SDoH in the evaluation, listing, and post-transplant periods. METHODS Literature searches were conducted in Web of Science, Embase, PubMed, and Cumulative Index to Nursing and Allied Health Literature databases. RESULTS Ninety-three studies were included based on pre-established criteria and were reviewed for main findings and study quality. Findings consistently demonstrated disparities in key transplant outcomes based on racial or ethnic identity, including timing and likelihood of transplant, and rates of rejection, graft failure, and mortality. Although less frequently assessed, variations in outcomes based on geography were also noted, while findings related to insurance or SES were inconsistent. CONCLUSION This review underscores the persistence of SDoH and disparity in equitable transplant outcomes and discusses the importance of individual and systems-level change to reduce such disparities.
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Affiliation(s)
- Kelly E Rea
- Department of Psychology, University of Georgia, Athens, Georgia, USA
| | - Kara B West
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna Dorste
- Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Debra Lefkowitz
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Mudd
- Cleveland Clinic Children's, Center for Pediatric Behavioral Health, Wilmington, North Carolina, USA
| | - Lauren Schneider
- Stanford University School of Medicine, Palo Alto, California, USA
| | - Courtney Smith
- Norton Children's, University of Louisville, Louisville, Kentucky, USA
| | - Kelli N Triplett
- Children's Health, Children's Medical Center Dallas, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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13
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Davis A, Faerber J, Ardalan K, Katcoff H, Klein-Gitelman M, Rubinstein TB, Cidav Z, Mandell DS, Knight A. The Effect of Psychiatric Comorbidity on Healthcare Utilization for Youth With Newly Diagnosed Systemic Lupus Erythematosus. J Rheumatol 2023; 50:204-212. [PMID: 36109077 DOI: 10.3899/jrheum.220052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine the effect of psychiatric diagnoses on healthcare use in youth with systemic lupus erythematosus (SLE) during their first year of SLE care. METHODS We conducted a retrospective cohort study using claims from 2000 to 2013 from Clinformatics Data Mart (OptumInsight). Youth aged 10 years to 24 years with an incident diagnosis of SLE (≥ 3 International Classification of Diseases, 9th revision, codes for SLE 710.0, > 30 days apart) were categorized as having: (1) a preceding psychiatric diagnosis in the year before SLE diagnosis, (2) an incident psychiatric diagnosis in the year after SLE diagnosis, or (3) no psychiatric diagnosis. We compared ambulatory, emergency, and inpatient visits in the year after SLE diagnosis, stratified by nonpsychiatric and psychiatric visits. We examined the effect of childhood-onset vs adult-onset SLE by testing for an interaction between age and psychiatric exposure on outcome. RESULTS We identified 650 youth with an incident diagnosis of SLE, of which 122 (19%) had a preceding psychiatric diagnosis and 105 (16%) had an incident psychiatric diagnosis. Compared with those without a psychiatric diagnosis, youth with SLE and a preceding or incident psychiatric diagnosis had more healthcare use across both ambulatory and emergency settings for both nonpsychiatric and psychiatric-related care. These associations were minimally affected by age at time of SLE diagnosis. CONCLUSION Psychiatric comorbidity is common among youth with newly diagnosed SLE and is associated with greater healthcare use. Interventions to address preceding and incident psychiatric comorbidity may decrease healthcare burden for youth with SLE.
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Affiliation(s)
- Alaina Davis
- A. Davis, MD, MPH, Department of Pediatrics, Division of Pediatric Rheumatology, Monroe Carell Junior Children's Hospital at Vanderbilt, Nashville, Tennessee, USA;
| | - Jennifer Faerber
- J. Faerber, PhD, Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kaveh Ardalan
- K. Ardalan, MD, MS, Department of Pediatrics (Division of Pediatric Rheumatology), Duke University School of Medicine, Durham, North Carolina, and Departments of Pediatrics and Medical Social Sciences, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Hannah Katcoff
- H. Katcoff, MPH, Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Marisa Klein-Gitelman
- M. Klein-Gitelman, MD, MPH, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tamar B Rubinstein
- T.B. Rubinstein, MD, Department of Pediatrics, Division of Pediatric Rheumatology, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Zuleyha Cidav
- Z. Cidav, PhD, Leonard Davis Institute of Health Economics, University of Pennsylvania, and Center for Mental Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Mandell
- D.S. Mandell, ScD, Center for Mental Health, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrea Knight
- A. Knight, MD, MSCE, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, and PolicyLab, Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania, USA, and Division of Rheumatology, Hospital for Sick Children, Toronto, Ontario, Canada
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14
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Mannemuddhu SS, Shoemaker LR, Bozorgmehri S, Borgia RE, Gupta N, Clapp WL, Zeng X, Modica RF. Does kidney biopsy in pediatric lupus patients "complement" the management and outcomes of silent lupus nephritis? Lessons learned from a pediatric cohort. Pediatr Nephrol 2023:10.1007/s00467-022-05859-w. [PMID: 36688943 PMCID: PMC10393877 DOI: 10.1007/s00467-022-05859-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 12/10/2022] [Accepted: 12/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Silent lupus nephritis (SLN) is systemic lupus erythematosus (SLE) without clinical and laboratory features of kidney involvement but with biopsy-proven nephritis. This study aims to describe and compare the baseline characteristics and outcomes of pediatric SLN with overt LN (OLN) and to identify associated risk factors and biochemical markers. METHODS In this retrospective, observational study, multivariate logistic regression and receiver operating characteristic (ROC) analyses studied age, sex, race, serum complements, anti-double-stranded-DNA antibody, anti-Smith antibody, eGFR, and proliferative nephritis. RESULTS In our cohort of 69 patients, 47 were OLN, and 22 were SLN. OLN (OR = 4.9, p = 0.03) and non-African Americans (AA) (OR = 13.0, p < 0.01) had higher odds, and increasing C3 and C4 were associated with lower odds of proliferative nephritis (OR 0.95 and 0.65 per one unit increase in C3 and C4, respectively, p < 0.01). They demonstrated a good discriminative ability to detect proliferative nephritis as assessed by the area under the ROC curve (C3 = 0.78, C4 = 0.78). C3 and C4 in proliferative SLN and OLN were comparable and significantly lower than their non-proliferative counterparts. No association was observed between age, sex, anti-double-stranded-DNA antibody, anti-Smith antibody, eGFR, and proliferative nephritis. Proliferative SLN and OLN patients received similar treatments. Adverse events were identified in the proliferative OLN only. CONCLUSIONS Lower complement levels are associated with proliferative lesions in pediatric LN-both SLN and OLN. The non-AA population had higher odds of having proliferative nephritis than the AA. Prospective, randomized, long-term follow-up of proliferative SLN patients is needed to ascertain the beneficial effect of early diagnosis and treatment. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sai Sudha Mannemuddhu
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA. .,Pediatric Nephrology, East Tennessee Children's Hospital, 2100 Clinch Avenue, MOB, Suite 310, Knoxville, TN, 37916, USA. .,Department of Medicine, University of Tennessee, Knoxville, TN, USA.
| | - Lawrence R Shoemaker
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Shahab Bozorgmehri
- Department of Medicine, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA
| | - R Ezequiel Borgia
- Department of Pediatrics, Division of Rheumatology, University of Florida-School of Medicine, Gainesville, FL, USA.,Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Nirupama Gupta
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA.,Blue Jay Pediatrics, Leesburg, VA, USA
| | - William L Clapp
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Xu Zeng
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Renee F Modica
- Department of Pediatrics, Division of Rheumatology, University of Florida-School of Medicine, Gainesville, FL, USA
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15
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Acute kidney injury requiring kidney replacement therapy in childhood lupus nephritis: a cohort study of the Pediatric Nephrology Research Consortium and Childhood Arthritis and Rheumatology Research Alliance. Pediatr Nephrol 2022; 38:1653-1665. [PMID: 36251074 DOI: 10.1007/s00467-022-05775-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/21/2022] [Accepted: 09/25/2022] [Indexed: 10/24/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in lupus nephritis (LN) and a risk factor for development of chronic kidney disease. In adults with LN, AKI severity correlates with the incidence of kidney failure and patient survival. Data on AKI outcomes in children with LN, particularly those requiring kidney replacement therapy (KRT), are limited. METHODS A multicenter, retrospective cohort study was performed in children diagnosed between 2010 and 2019 with LN and AKI stage 3 treated with dialysis (AKI stage 3D). Descriptive statistics were used to characterize demographics, clinical data, and kidney biopsy findings; treatment data for LN were not included. Logistic regression was used to examine the association of these variables with kidney failure. RESULTS Fifty-nine patients (mean age 14.3 years, 84.7% female) were identified. The most common KRT indications were fluid overload (86.4%) and elevated blood urea nitrogen/creatinine (74.6%). Mean follow-up duration was 3.9 ± 2.9 years. AKI recovery without progression to kidney failure occurred in 37.3% of patients. AKI recovery with later progression to kidney failure occurred in 25.4% of patients, and there was no kidney recovery from AKI in 35.6% of patients. Older age, severe (> 50%) tubular atrophy and interstitial fibrosis, and National Institutes of Health (NIH) chronicity index score > 4 on kidney biopsy were associated with kidney failure. CONCLUSIONS Children with LN and AKI stage 3D have a high long-term risk of kidney failure. Severe tubular atrophy and interstitial fibrosis at the time of AKI, but not AKI duration, are predictive of kidney disease progression. A higher resolution version of the Graphical abstract is available as Supplementary information.
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16
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Roberts JE, Berbert L, Chang J, Son MBF. Association of Race and Ethnicity With Medication Use for Pediatric Lupus in the Childhood Arthritis and Rheumatology Research Alliance Registry. ACR Open Rheumatol 2022; 4:954-963. [DOI: 10.1002/acr2.11494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/06/2022] [Accepted: 07/19/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jordan E. Roberts
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Laura Berbert
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Joyce Chang
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
| | - Mary Beth F. Son
- Boston Children's Hospital and Harvard Medical School Boston Massachusetts
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17
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Cannon LA, Wenderfer SE, Lewandowski LB, Cooper JC, Goilav B, Knight AM, Hersh AO, Ardoin SP, Sadun RE. Use of EuroLupus Cyclophosphamide Dosing for the Treatment of Lupus Nephritis in Childhood-onset Systemic Lupus Erythematosus in North America. J Rheumatol 2022; 49:607-614. [PMID: 35169053 PMCID: PMC10464387 DOI: 10.3899/jrheum.210428] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Childhood-onset systemic lupus erythematosus (cSLE) has higher rates of lupus nephritis (LN) than adult-onset SLE, often requiring intensive immunosuppression. This study examined North American practices and preferences for the low-dose EuroLupus cyclophosphamide (CYC) protocol, as compared to the high-dose National Institutes of Health (NIH) CYC protocol, to treat LN in cSLE. METHODS A 35-item Web-based survey was distributed to Childhood Arthritis and Rheumatology Research Alliance (CARRA) and Pediatric Nephrology Research Consortium (PNRC) providers. The survey assessed participant demographics, CYC prescribing practices, perceptions of EuroLupus protocol, and LN vignette treatment decisions; 1 vignette was taken from a 2009 CARRA survey and responses were compared. Multivariable logistic regression analyzed provider factors associated with use of low- vs high-dose CYC. RESULTS Responses were provided by 185/421 (44%) pediatric rheumatologists (CARRA) and 40/354 (11%) pediatric nephrologists (PNRC). Among respondents who prescribed CYC for pediatric LN over the past year (n = 135), half reported using EuroLupus. When presented with the same vignette about an adolescent with class IV LN, 32% of pediatric rheumatologists chose EuroLupus dosing in 2020, vs 6% in 2009. Provider factors associated with choosing the low-dose regimen were familiarity with the protocol (OR 4.2, P = 0.006) and greater perceived benefit (OR 1.6, P < 0.0001). Pediatric nephrologists had similar responses to the pediatric rheumatology providers. Overall, 78% of respondents perceived EuroLupus protocol efficacy to be equivalent to the high-dose protocol in cSLE LN. CONCLUSION Pediatric specialists are currently more likely to use low-dose CYC to treat cSLE LN than they were a decade ago. Nevertheless, familiarity with EuroLupus dosing remains low.
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Affiliation(s)
- Laura A Cannon
- L.A. Cannon, MD, Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, Durham, and Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA;
| | - Scott E Wenderfer
- S.E. Wenderfer, MD, Department of Pediatrics, Baylor College of Medicine; Renal Section, Texas Children's Hospital, Houston, Texas, USA
| | - Laura B Lewandowski
- L.B. Lewandowski, MD, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jennifer C Cooper
- J.C. Cooper, MD, Division of Pediatric Rheumatology, Department of Pediatrics, University of Colorado, Denver, Colorado, USA
| | - Beatrice Goilav
- B. Goilav, MD, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Andrea M Knight
- A.M. Knight, MD, Division of Pediatric Rheumatology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Aimee O Hersh
- A.O. Hersh, MD, Division of Pediatric Rheumatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Stacy P Ardoin
- S.P. Ardoin, MD, Division of Pediatric Rheumatology, Department of Pediatrics, and Division of Rheumatology, Department of Medicine, The Ohio State University, Columbus, Ohio, USA
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18
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Wenderfer SE, Orjuela A, Bekheirnia MR, Pereira M, Muscal E, Braun MC, De Guzman M. Lupus Nephritis, Autoantibody Production and Kidney Outcomes in Males with Childhood-Onset Systemic Lupus Erythematosus. Pediatr Rep 2022; 14:220-232. [PMID: 35645367 PMCID: PMC9149811 DOI: 10.3390/pediatric14020030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 02/04/2023] Open
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) only represents 20% of all SLE patients, and males with SLE only represent 10%. To study this rare SLE subset, males diagnosed with cSLE over a 30-year period were identified. Organ involvement, autoantibody production, hypocomplementemia, and kidney biopsy findings were compared to cSLE females. Outcomes were assessed using SLE Disease Activity Index scores, Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, and Childhood Arthritis and Rheumatology Research Alliance definitions for nephritis responsiveness. Of 95 males and 545 females with cSLE, 62% and 57% developed nephritis, respectively. Median age of cSLE onset was 14 years in both genders. Among males, 80% of non-Hispanic whites, 64% of blacks, 59% of Hispanics, and 50% of Asians developed nephritis. The prevalence of pure and mixed class V membranous nephritis was 33%. Median follow-up was 3.2 years (range 0.1-18). Complete kidney responses were seen in 70% after a median 24 months; however, relapse rates were 46%. Kidney disease flares were 56% nephritic and 44% proteinuric. Males and females with cSLE present with comparable rates and nephritis class. While overall and kidney response rates are favorable, kidney disease relapses are common among males.
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Affiliation(s)
- Scott E. Wenderfer
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- British Columbia Children’s Hospital, Vancouver, BC V6H 3V4, Canada
| | - Alvaro Orjuela
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Mir Reza Bekheirnia
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Maria Pereira
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Eyal Muscal
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Michael C. Braun
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Marietta De Guzman
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
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Chang JC, Sears C, Torres V, Son MB. Racial Disparities in Renal Outcomes over Time among Hospitalized Children with Systemic Lupus Erythematosus. Arthritis Rheumatol 2022; 74:1430-1439. [PMID: 35384383 PMCID: PMC9339464 DOI: 10.1002/art.42127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/19/2022] [Accepted: 03/22/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Racial and ethnic minority groups have excess morbidity related to renal disease in pediatric-onset systemic lupus erythematosus (SLE). We evaluated temporal trends in renal outcomes and racial disparities among hospitalized children with SLE over 14 years. METHODS We identified patients ≤21 years-old with discharge diagnoses of SLE in the Pediatric Health Information System® inpatient database (2006-2019). Adverse renal outcomes included end-stage renal disease (ESRD), dialysis, or transplant, analyzed as a composite and separately. We estimated the odds of adverse renal outcomes at any hospitalization, or the first occurrence of an adverse renal outcome, adjusted for calendar period, patient characteristics, and clustering by hospital. We tested whether racial disparities differed by calendar period. RESULTS There were 20,893 admissions for 7,434 SLE patients, of which 32%, 16%, 12% and 8% were Black, Hispanic White, Hispanic Other and Asian, respectively. Proportions of admissions with adverse renal outcomes decreased over time (p<0.01). Black children remained at highest risk of adverse renal outcomes at any admission (OR 2.5, 95% CI [1.8-3.5] vs. non-Hispanic White). Black and Asian children remained at higher risk of incident adverse renal outcomes, driven by ESRD among Black children (OR 1.6 [1.2-2.1]) and dialysis among Asians (OR 1.7 [1.1-2.7]). Relative disparities did not change significantly over time. CONCLUSION Significant reductions in ESRD and dialysis occurred over time for children with SLE across all racial and ethnic groups. The lack of corresponding reductions in racial disparities highlights the need for targeted interventions to achieve greater treatment benefit among higher risk groups.
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Affiliation(s)
- Joyce C Chang
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia Research Institute.,Division of Immunology, Boston Children's Hospital and Harvard Medical School.,Division of Rheumatology, Children's Hospital of Philadelphia
| | - Cora Sears
- Division of Rheumatology, Children's Hospital of Philadelphia
| | | | - Mary Beth Son
- Division of Immunology, Boston Children's Hospital and Harvard Medical School
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20
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Cody E, Hooper DK. Kidney transplantation in pediatric patients with rheumatologic disorders. Curr Opin Pediatr 2022; 34:234-240. [PMID: 34954727 DOI: 10.1097/mop.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Providers caring for children with end-stage kidney disease from rheumatologic conditions face questions such as when to proceed with kidney transplantation, how common is disease recurrence posttransplant, how does recurrent disease impact patient and allograft outcomes, and what approaches are available to prevent and treat recurrent disease. We discuss recent developments and relevant literature that address these questions for the most common rheumatologic disorders that lead to end-stage kidney disease in childhood namely, systemic lupus erythematosus, IgA nephropathy, IgA Vasculitis/Henoch Schoenlein Purpura, and Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis. RECENT FINDINGS Recent data suggest that children with IgA nephropathy, IgA vasculitis, and ANCA-associated vasculitis have similar patient and allograft survival to other conditions despite the risk of recurrent disease, yet those with lupus have worse posttransplant patient and allograft outcomes. A period of disease quiescence may be prudent prior to transplantation to decrease the risk of recurrence, which is associated with decreased allograft survival. Data on preventive strategies and treatment options are limited. SUMMARY It is recommended that patients with systemic rheumatologic conditions not be excluded from kidney transplantation but that patients be counseled on the risk of potential recurrent disease with its impact on transplant outcomes.
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Affiliation(s)
- Ellen Cody
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center
| | - David K Hooper
- Division of Nephrology and Hypertension, Department of Pediatrics, Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Autoantibody cluster analysis in juvenile lupus nephritis. Clin Rheumatol 2022; 41:2375-2381. [DOI: 10.1007/s10067-022-06146-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 11/03/2022]
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22
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Rovin BH. Kidney Failure in Systemic Lupus Erythematosus: A Fraught Complication in a Fraught Disease. Am J Kidney Dis 2022; 79:617-619. [PMID: 35125262 DOI: 10.1053/j.ajkd.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Brad H Rovin
- Department of Internal Medicine, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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23
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Rangoonwala S, Marks SD. Kidney transplantation outcomes for children and young people with lupus nephritis. Pediatr Transplant 2022; 26:e14193. [PMID: 34820978 DOI: 10.1111/petr.14193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 10/16/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Sana Rangoonwala
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Stephen D Marks
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK.,Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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24
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Mai K, Singer P, Fahmy AE, Teperman LW, Molmenti EP, Grodstein EI, Castellanos L, Sethna CB. Kidney transplant outcomes in children and adolescents with systemic lupus erythematosus. Pediatr Transplant 2022; 26:e14178. [PMID: 34687584 DOI: 10.1111/petr.14178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/17/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Literature supports equivalent kidney transplant outcomes in adults with systemic lupus erythematosus (SLE) compared with those without SLE. However, there are conflicting and scant data on kidney transplant outcomes, as well as controversy over optimal timing of transplantation, in children and adolescents with SLE. METHODS Analysis included kidney-only transplant recipients aged 2-21 years from 2000 to 2017 enrolled in the Organ Procurement and Transplant Network (OPTN). The relationship between diagnosis (SLE n = 457, non-SLE glomerular disease n = 4492, and non-SLE non-glomerular disease n = 5605) and transplant outcomes was evaluated. The association between dialysis time and outcomes was analyzed in the SLE group only. RESULTS In adjusted models, SLE had higher mortality compared with non-SLE glomerular recipients (HR 1.24 CI 1.07-1.44) and non-glomerular recipients (HR 1.42 CI 1.20-1.70). SLE was associated with higher graft failure compared with non-SLE glomerular (HR 1.42 CI 1.20-1.69) and non-glomerular disease (HR 1.67 CI 1.22-2.28). SLE had a higher risk of acute rejection at 1 year compared with non-glomerular disease (HR 1.39 CI 1.03-1.88). There was a decreased risk of delayed graft function compared with non-SLE glomerular disease (HR 0.54, CI 0.36-0.82). There were no significant associations between dialysis time and transplant outcomes in the SLE group. CONCLUSION SLE in children and adolescents is associated with worse patient and graft survival compared with non-SLE diagnoses. Outcomes in children and adolescents with SLE are not associated with dialysis time. Further studies are needed to assess implications of potential earlier transplantation and shorter time on dialysis prior to transplantation.
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Affiliation(s)
- Katherine Mai
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA
| | - Pamela Singer
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Ahmed E Fahmy
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Lewis W Teperman
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Ernesto P Molmenti
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Elliot I Grodstein
- Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Laura Castellanos
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
| | - Christine B Sethna
- Department of Pediatrics, Division of Nephrology, Cohen Children's Medical Center of New York, New Hyde Park, New York, USA.,Department of Transplantation, Northwell Health, Great Neck, New York, USA
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25
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Smitherman EA, Goh I, Pooni R, Vora SS, Yildirim-Toruner C, von Scheven E. Implementation Science in Pediatric Rheumatology: A Path to Health Equity. Rheum Dis Clin North Am 2021; 48:331-342. [PMID: 34798956 DOI: 10.1016/j.rdc.2021.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Implementation science is the study of processes that promote reliable uptake of evidence-based practices into clinical care. The integration of implementation science and health disparities research approaches has been proposed as a method to reduce health inequity through detection, understanding, and implementation of health equity-focused interventions. In this review, we provide an argument for the study of implementation science in pediatric rheumatology in light of previously observed health disparities, present a framework for the study of health equity and implementation science in pediatric rheumatology, and propose next steps to accelerate action.
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Affiliation(s)
- Emily A Smitherman
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, 1601 4th Avenue South, Park Place North Suite G10, Birmingham, AL 35233, USA.
| | - Ingrid Goh
- Division of Rheumatology, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M5G 0A4, Canada; Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
| | - Rajdeep Pooni
- Division of Allergy, Immunology, and Rheumatology, Stanford University School of Medicine, Stanford Children's Health, 700 Welch Road, Suite 301, Palo Alto, CA 94304, USA
| | - Sheetal S Vora
- Department of Pediatrics, Atrium Health Levine Children's Hospital, 1000 Blythe Boulevard, 4th Floor, Charlotte, NC 28203, USA
| | - Cagri Yildirim-Toruner
- Department of Pediatrics, Baylor College of Medicine, 6701 Fannin Street, 11th Floor, Houston, TX 77030, USA
| | - Emily von Scheven
- Division of Pediatric Rheumatology, University of California San Francisco, 550 16th Street, 5th Floor, #5453, San Francisco, CA, USA
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26
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Plott C, Gracie T, Alvis C, Schlefman A, Dudas R. A 4-year old presenting with fever and achiness. SAGE Open Med Case Rep 2021; 9:2050313X211056416. [PMID: 34733521 PMCID: PMC8558788 DOI: 10.1177/2050313x211056416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/12/2021] [Indexed: 11/15/2022] Open
Abstract
In children under the age of 5 who have abnormalities in history, physical examination, and laboratory studies indicating multi-system disease, uncovering the correct diagnosis is challenging. Here, we report the course of a 4-year-old girl who presented with a change in behavior, fever, arthralgia, arthritis, and hematuria following three recent hospitalizations for pneumonia and impetigo. Serologic findings were suggestive of a rheumatologic etiology and a renal biopsy was consistent with Membranous Lupus Nephritis Class V which helped secure the diagnosis of pediatric systemic lupus erythematosus. We review the clinical features and diagnostic criteria of early-onset systemic lupus erythematosus and discuss diagnostic considerations and prognosis.
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Affiliation(s)
| | - Thomas Gracie
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Courtney Alvis
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Amanda Schlefman
- Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Robert Dudas
- Johns Hopkins School of Medicine, Baltimore, MD, USA.,Department of Pediatrics, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
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27
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Burnham JM, Cecere L, Ukaigwe J, Knight A, Peterson R, Chang JC. Factors Associated With Variation in Pediatric Systemic Lupus Erythematosus Care Delivery. ACR Open Rheumatol 2021; 3:708-714. [PMID: 34551217 PMCID: PMC8516107 DOI: 10.1002/acr2.11314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Patients with pediatric systemic lupus erythematosus (pSLE) and mixed connective tissue disease (MCTD) receive only a fraction of recommended care. Using published quality indicators and guidelines, we developed a 13‐item pediatric lupus care index (p‐LuCI) to quantify the proportion of recommended clinical evaluations and comorbidity prevention interventions completed and the timeliness of follow‐up. Our objective was to assess baseline index performance and identify sources of p‐LuCI variation. Methods We performed a cross‐sectional study in patients with pSLE or MCTD and analyzed the performance of individual p‐LuCI process metrics and calculated the overall p‐LuCI score. We identified factors associated with the p‐LuCI using multivariable linear regression with clustering by provider. Results For 110 patients (99 with pSLE and 11 with MCTD), the median p‐LuCI was 65.2% (interquartile range: 9.1‐92.3%). Component performance ranged from 27.3% (on‐time scheduling) to 95.4% (steroid‐sparing treatment). Patients with p‐LuCI scores above the median had higher scores across all 13 components. Higher p‐LuCI scores were independently associated with disease‐modifying antirheumatic drug use (β = 14.3 [95% confidence interval (CI), 1.5‐27.2]), nephritis (β = 10.4 [95% CI, 5.1‐15.8]), higher provider pSLE/MCTD volume (β = 3.1 [95% CI, 1.9‐4.2] per patient), assignment to rheumatology fellow trainee (β = 36.3 [95% CI, 17.3‐55.2]), and disease duration of less than 1 year (β = 12.6 [95% CI, 0.7‐24.5]). Differences by race, ethnicity, and/or insurance were not observed. Conclusion Using an index of recommended pSLE care metrics, we identified significant variation in performance by disease, treatment, and provider characteristics. The p‐LuCI may be useful to assess care quality at the patient, provider, and practice levels and to identify areas in need of greater standardization.
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Affiliation(s)
- Jon M Burnham
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lynsey Cecere
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joy Ukaigwe
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrea Knight
- Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Joyce C Chang
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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28
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Vazzana KM, Daga A, Goilav B, Ogbu EA, Okamura DM, Park C, Sadun RE, Smitherman EA, Stotter BR, Dasgupta A, Knight AM, Hersh AO, Wenderfer SE, Lewandowski LB. Principles of pediatric lupus nephritis in a prospective contemporary multi-center cohort. Lupus 2021; 30:1660-1670. [PMID: 34219529 PMCID: PMC10461610 DOI: 10.1177/09612033211028658] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Lupus nephritis (LN) is a life-threatening manifestation of systemic lupus erythematosus (SLE) and is more common in children than adults. The epidemiology and management of childhood-onset SLE (cSLE) have changed over time, prompting the need to reassess expected outcomes. The purpose of this study is to use the Childhood Arthritis and Rheumatology Research Alliance (CARRA) prospective registry to validate historical principles of LN in a contemporary, real-world cohort. After an extensive literature review, six principles of LN in cSLE were identified. The CARRA registry was queried to evaluate these principles in determining the rate of LN in cSLE, median time from cSLE diagnosis to LN, short-term renal outcomes, and frequency of rituximab as an induction therapy. Of the 677 cSLE patients in the CARRA registry, 32% had documented LN. Decline in kidney function was more common in Black cSLE patients than non-Black patients (p = 0.04). Black race was associated with worse short-term renal outcomes. In short-term follow up, most children with LN had unchanged or improved kidney function, and end stage kidney disease (ESKD) was rare. Ongoing follow-up of cSLE patients in the CARRA registry will be necessary to evaluate long-term outcomes to inform risk, management, and prognosis of LN in cSLE.
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Affiliation(s)
- Kathleen M Vazzana
- Lupus Genomics and Global Disparities Unit, Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Ankana Daga
- Division of Nephrology, Boston Children's Hospital, Boston, MA, USA
| | - Beatrice Goilav
- Division of Nephrology, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ekemini A Ogbu
- Department of Pediatrics, 1466Johns Hopkins University, Division of Pediatric Allergy, Immunology and Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Daryl M Okamura
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA, USA
| | - Catherine Park
- Division of Nephrology, Children's National Hospital, Washington, DC, USA
| | | | - Emily A Smitherman
- Division of Rheumatology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brian R Stotter
- Division of Pediatric Nephrology, Hypertension & Pheresis, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Andrea M Knight
- Division of Pediatric Rheumatology, 7979Hospital for Sick Children, Hospital for Sick Children, Toronto, Canada
| | - Aimee O Hersh
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Scott E Wenderfer
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Laura B Lewandowski
- Lupus Genomics and Global Disparities Unit, Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
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29
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Wasik H, Chadha V, Galbiati S, Warady B, Atkinson M. Dialysis Outcomes for Children With Lupus Nephritis Compared to Children With Other Forms of Nephritis: A Retrospective Cohort Study. Am J Kidney Dis 2021; 79:626-634. [PMID: 34461164 DOI: 10.1053/j.ajkd.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/16/2021] [Indexed: 01/12/2023]
Abstract
RATIONALE & OBJECTIVE Children with lupus nephritis (LN) are at high risk of developing kidney failure requiring initiation of kidney replacement therapy. This study compared outcomes among children with LN on dialysis with children with non-lupus glomerular disease and investigated risk factors for adverse outcomes among children with LN on dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Children and adolescents aged 6-20 years with LN (n = 231) and non-lupus glomerular disease (n = 1,726) who initiated maintenance dialysis 1991-2018 and were enrolled in the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry. EXPOSURE Lupus nephritis. OUTCOME Hospitalization, mortality, and time to transplant. ANALYTICAL APPROACH Contingency tables were used to compare hospitalizations, and multivariable cause-specific hazards models were used to compare rates of death and transplantation in children with LN compared with those with non-lupus glomerular disease. Using data from children with LN, multivariable logistic regression models were fit to evaluate the risk factors for hospitalization, and multivariable Cox regression models were fit to evaluate factors associated with kidney transplantation. RESULTS Children with LN were more likely to be hospitalized in the first year after dialysis initiation (63.3% vs 48.6%, P < 0.001) and were less likely to receive a kidney transplant in the first 3 years after dialysis initiation (year 0-1: adjusted hazard ratio [AHR], 0.36 [95% CI, 0.23-0.57], P < 0.001; year 1-3: AHR, 0.73 [95% CI, 0.54-0.98], P = 0.04). Anemia was associated with hospitalization after dialysis initiation (adjusted OR, 4.44 [95% CI, 1.44-13.66], P = 0.01). Non-White race was associated with a lower rate of kidney transplantation (AHR, 0.47 [95% CI, 0.27-0.82], P = 0.01). LN was not associated with death while on dialysis (AHR, 1.21 [95% CI, 0.47-3.11], P = 0.7). LIMITATIONS The NAPRTCS registry does not collect information on lupus disease activity or medication doses and has limited data on medication use. CONCLUSIONS Children and adolescents with LN on dialysis are at higher risk for adverse outcomes including hospitalization and lower rates of kidney transplantation compared with children with non-lupus glomerular disease receiving maintenance dialysis.
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Affiliation(s)
- Heather Wasik
- Division of Pediatric Nephrology, SUNY Upstate Medical University, Syracuse, New York.
| | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | | | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Meredith Atkinson
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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30
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Mok CC, Hamijoyo L, Kasitanon N, Chen DY, Chen S, Yamaoka K, Oku K, Li MT, Zamora L, Bae SC, Navarra S, Morand EF, Tanaka Y. The Asia-Pacific League of Associations for Rheumatology consensus statements on the management of systemic lupus erythematosus. THE LANCET. RHEUMATOLOGY 2021; 3:e517-e531. [PMID: 38279404 DOI: 10.1016/s2665-9913(21)00009-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is prevalent in Asia and carries a variable prognosis among patients across the Asia-Pacific region, which could relate to access to health care, tolerability of medications, and adherence to therapies. Because many aspects of SLE are unique among patients from this region, the Asia-Pacific League of Associations for Rheumatology developed the first set of consensus recommendations on the management of SLE. A core panel of 13 rheumatologists drafted a set of statements through face-to-face meeting and teleconferences. A literature review was done for each statement to grade the quality of evidence and strength of recommendation. 29 independent specialists and three patients with SLE were then recruited for a modified Delphi process to establish consensus on the statements through an online voting platform. A total of 34 consensus recommendations were developed. Panellists agreed that patients with SLE should be referred to a specialist for the formulation of a treatment plan through shared decision making between patients and physicians. Remission was agreed to be the goal of therapy, but when it cannot be achieved, a low disease activity state should be aimed for. Patients should be screened for renal disease, and hydroxychloroquine is recommended for all Asian people with SLE. Major organ manifestations of SLE should be treated with induction immunosuppression and subsequently maintenance; options include cyclophosphamide, mycophenolate mofetil, azathioprine, and calcineurin inhibitors, in combination with glucocorticoids. Biologics, combination regimens, plasma exchange, and intravenous immunoglobulins should be reserved for cases of refractory or life-threatening disease. Anticoagulation therapy with warfarin is preferred to the direct oral anticoagulants for thromboembolic SLE manifestations associated with a high-risk antiphospholipid antibody profile.
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Affiliation(s)
- Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong Special Administrative Region, China.
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Jawa Barat, Indonesia
| | - Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Thailand
| | - Der Yuan Chen
- Rheumatology and Immunology Centre, China Medical University, Taichung, Taiwan
| | - Sheng Chen
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China; Chinese Academy of Medical Science, National Clinical Research Centre for Dermatological and Immunological Diseases, Beijing, China
| | - Leonid Zamora
- Section of Rheumatology, University of Santo Tomas, Manila, Philippines
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas, Manila, Philippines
| | - Eric F Morand
- Centre for Inflammatory Diseases, Monash University School of Clinical Sciences, Monash Medical Centre, Melbourne, Australia
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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31
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Basu K, Karmakar S, Sengupta M, Roychowdhury A, Ghosh A, Bandopadhyay M. Pediatric lupus nephritis - An evil cousin of its adult counterpart: A single-center based experience from a tertiary care hospital of Eastern India. INDIAN J PATHOL MICR 2021; 63:397-404. [PMID: 32769328 DOI: 10.4103/ijpm.ijpm_995_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Context Systemic lupus erythematosus is an autoimmune multisystem disease with a high predilection for renal involvement. Lupus nephritis develops in 20% to 75% within the first two years. Presentation varies from subnephrotic proteinuria to end-stage renal disease. Aims To study clinical features, biochemical, and serological parameters and correlate with histological activity and chronicity score [modified National Institute of Health (NIH) score]. Settings and Design Retrospective, cross-sectional, single-center based study in a tertiary care hospital of Eastern India. Subjects and Methods We incuded 36 children with lupus nephritis diagnosed from February 2018 to March 2019. Laboratory data included were complete blood count (CBC), blood glucose, urine analysis, serum urea, creatinine, blood urea nitrogen (BUN), albumin, cholesterol, HBsAg, antihepatitis C virus (HCV) antibody, antistreptolysin O (ASO) titer, antinuclear antibody (ANA), myeloperoxidase antineutrophil cytoplasmic antibody (MPO ANCA), proteinase 3 antineutrophil cytoplasmic antibody (PR3 ANCA), double-stranded DNA (dsDNA), C3, and C4. Clinical parameters were age, sex, blood pressure (BP), skin lesions, arthralgia, edema, obesity. Renal biopsies examined with light microscopy, hematoxylin and eosin (H and E), periodic acid-Schiff (PAS), silver methanamine, Masson's trichrome (MT) stains. Immunofluorescence microscopy done with IgG, IgM, IgA, C3c, C1q, kappa, lambda antibodies. Statistical Analysis Used Kruskal-Wallis and χ2 tests. Results Mean age was 15.12 ± 3.49 and 12.5 ± 1.73 years for lupus nephritis (LN) with activity and LN without activity, respectively. Mean dsDNA was higher and mean C3 was lower (52.35 ± 22.21 mg/dl) in active LN. Mean 24-hour urinary protein was higher in LN without activity. Serum creatinine was raised in active LN. LN class III and IV showed higher activity than chronicity. Conclusions Pediatric LN is proliferative and more active as compared with adult counterparts. Activity scores are much higher than chronicity scores.
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Affiliation(s)
- Keya Basu
- Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Subhrajyoti Karmakar
- Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Moumita Sengupta
- Department of Pathology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Arpita Roychowdhury
- Department of Nephrology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Alakendu Ghosh
- Department of Rheumatology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Manimoy Bandopadhyay
- Director, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
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32
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Mosaad YM, Hammad A, AlHarrass MF, Sallam R, Shouma A, Hammad E, Ahmed EO, Abdel-Azeem HA, Sherif D, Fawzy I, Elbahnasawy A, Abdel Twab H. ARID5B rs10821936 and rs10994982 gene polymorphism and susceptibility to juvenile systemic lupus erythematosus and lupus nephritis. Lupus 2021; 30:1226-1232. [PMID: 33888010 DOI: 10.1177/09612033211010338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The prevalence of SLE and the spectrum of clinical manifestations vary widely in different races and geographical populations. OBJECTIVE To investigate the possible role of ARID5B rs10821936 and rs10994982 polymorphism as a risk factor for the development of SLE in children (jSLE) and to evaluate their role in relation to clinical manifestations especially lupus nephritis (LN). METHODS DNA extraction and Real-time PCR genotyping of ARID5B rs10821936 and rs10994982 were done for 104 jSLE and 282 healthy controls. RESULTS The C allele and C containing genotypes (CC, CT and CC+CT) of ARID5B rs10821936 were higher in children with SLE (p = 0.009, OR = 1.56, 0.037, OR = 2.35, 0.016, OR = 1.81 and 0.008 OR = 1.88 respectively). ARID5B rs10994982 alleles, genotypes and haplotypes are not associated with jSLE (p > 0.05). The ARID5B rs10821936 and rs10994982 genotypes showed non-significant associations with LN, proliferative versus non proliferative and biopsy grades (p > 0.05). CONCLUSION ARID5B rs10821936 SNP may be a susceptibility risk factor for juvenile SLE in the studied cohort of Egyptian children.
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Affiliation(s)
- Youssef M Mosaad
- Clinical Immunology Unit, Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ayman Hammad
- Pediatric Nephrology Unit, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed F AlHarrass
- Clinical Immunology Unit, Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Rehab Sallam
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Amany Shouma
- Pediatric Cardiology Unit, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Enas Hammad
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Engy Osman Ahmed
- Pediatric Pulmonology and Allergy Unit, Department of Pediatrics, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Heba A Abdel-Azeem
- Dermatology, Andrology & STDs, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Doaa Sherif
- Microbiology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Iman Fawzy
- Laboratory Medicine Department, Mansoura Fever Hospital, Ministry of Health, Mansoura, Egypt
| | - Amany Elbahnasawy
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Hosam Abdel Twab
- Clinical Immunology Unit, Clinical Pathology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Mok CC, Mohan C. Urinary Biomarkers in Lupus Nephritis: Are We There Yet? Arthritis Rheumatol 2021; 73:194-196. [PMID: 32892509 DOI: 10.1002/art.41508] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/13/2020] [Indexed: 02/02/2023]
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Arora S, Yazdany J. Use of Quality Measures to Identify Disparities in Health Care for Systemic Lupus Erythematosus. Rheum Dis Clin North Am 2020; 46:623-638. [PMID: 32981640 DOI: 10.1016/j.rdc.2020.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Assessment of quality of care for people with systemic lupus erythematosus (SLE) provides opportunities to identify gaps in health care and address disparities. Poor access to specialty care has been shown to negatively impact care in SLE and is associated with poor disease outcomes. Racial/ethnic minorities and those with low socioeconomic status are at higher risk for poor access and lower quality of care. Quality measures evaluating processes of care have shown significant deficiencies in care of SLE patients across studies. High SLE patient volume correlates with better quality of care for providers in hospital and ambulatory settings.
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Affiliation(s)
- Shilpa Arora
- Division of Rheumatology, Rush University Medical Center, 1611 West Harrison Street, Suite 510, Chicago, IL 60612, USA
| | - Jinoos Yazdany
- Division of Rheumatology, University of California, San Francisco, 1001 Potrero Avenue, Suite 3300, San Francisco, CA 94110, USA.
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Abstract
Disparities in prevalence, disease severity, physical and mental morbidity, and mortality exist in childhood-onset systemic lupus (cSLE) that lead to worse outcomes in children with systemic lupus erythematosus from socially disadvantaged backgrounds. Important gaps exist in knowledge regarding many individual race/ethnicities across the globe, the interaction between race/ethnicity and poverty, and drivers for identified disparities. Large cSLE registries will facilitate investigating disparities in groups of patients that have yet to be identified. Social-ecological models can inform approaches to investigate, monitor, and address disparities in cSLE.
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Haridasan S, Rathi M, Sharma A, Nada R, Kumar S, Ramachandran R, Kohli HS. Outcome of biopsy-proven lupus nephritis with low glomerular filtration rate at presentation. Int J Rheum Dis 2020; 23:1201-1209. [PMID: 32677761 DOI: 10.1111/1756-185x.13907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/24/2020] [Accepted: 06/16/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Currently, there is limited data regarding the outcomes of lupus nephritis (LN) with moderate to severe renal failure at presentation (defined by low glomerular filtration rate; GFR <30 mL/min). METHODS Sixty-four patients with biopsy-proven LN and estimated GFR (eGFR) <30 mL/min were prospectively analyzed. Outcome measure of persistently low eGFR, end-stage renal disease (ESRD) or death at 365 days were grouped as Major Adverse Kidney Events (MAKE365). RESULTS Diagnosis of lupus was simultaneous with onset of renal disease in 60% of cases. Histologically, 82.3% (n = 51) were class IV, the median serum creatinine was 4 mg/dL (interquartile range [IQR] 3.1-5.9 mg/dL), median eGFR was 13.75 mL/min (IQR 9.25-19 mL/min) and 42.2% (n = 27) required dialysis at presentation. Induction regimens included National Institute of Health (68.2%), Eurolupus protocol (10.9%) and mycophenolate mofetil (8%). Over 365 days, 23 (37.5%) subjects died, while 41 (62.5%) survived. The majority of deaths were due to infection and sepsis (14/23). Among the survivors, 70.7% had good renal outcome, 12.1% had persistently low GFR (<30 mL/min), while 17% developed ESRD. In this group, treatment response rate was 84.6% (complete response 25.6%, partial response 59%). Those with a better renal function at presentation had a good treatment response (100% vs. 40%). Altogether, n = 35 (54.6%) were included in the MAKE365 category. Between the renal survival group (n = 29) versus the MAKE365 group (n = 35) there was no difference in clinical or histological parameters. CONCLUSION The current treatment protocols had a good response rate in patients with LN even with severe kidney injury at presentation. However, the risk of serious infections and subsequent mortality was high.
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Affiliation(s)
- Satish Haridasan
- Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Aman Sharma
- Department of Rheumatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sachin Kumar
- Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Harbir Singh Kohli
- Department of Nephrology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Miguel DF, Terreri MT, Pereira RMR, Bonfá E, Silva CAA, Corrente JE, Magalhaes CS. Comparison of urinary parameters, biomarkers, and outcome of childhood systemic lupus erythematosus early onset-lupus nephritis. Adv Rheumatol 2020; 60:10. [PMID: 32005292 DOI: 10.1186/s42358-020-0114-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 01/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Urinary parameters, anti-dsDNA antibodies and complement tests were explored in patients with childhood-Systemic Lupus Erythematosus (cSLE) early-onset lupus nephritis (ELN) from a large multicenter cohort study. METHODS Clinical and laboratory features of cSLE cases with kidney involvement at presentation, were reviewed. Disease activity parameters including SLEDAI-2 K scores and major organ involvement at onset and follow up, with accrued damage scored by SLICC-DI, during last follow up, were compared with those without kidney involvement. Autoantibodies, renal function and complement tests were determined by standard methods. Subjects were grouped by presence or absence of ELN. RESULTS Out of the 846 subjects enrolled, mean age 11.6 (SD 3.6) years; 427 (50.5%) had ELN. There was no significant difference in the ELN proportion, according to onset age, but ELN frequency was significantly higher in non-Caucasians (p = 0.03). Hematuria, pyuria, urine casts, 24-h proteinuria and arterial hypertension at baseline, all had significant association with ELN outcome (p < 0.001). With a similar follow up time, there were significantly higher SLICC-DI damage scores during last follow up visit (p = 0.004) and also higher death rates (p < 0.0001) in those with ELN. Low C3 (chi-square test, p = 0.01), but not C3 levels associated significantly with ELN. High anti-dsDNA antibody levels were associated with ELN (p < 0.0001), but anti-Sm, anti-RNP, anti-Ro, anti-La antibodies were not associated. Low C4, C4 levels, low CH50 and CH50 values had no significant association. High erythrocyte sedimentation rate (ESR) was associated with the absence of ELN (p = 0.02). CONCLUSION The frequency of ELN was 50%, resulting in higher morbidity and mortality compared to those without ELN. The urinary parameters, positive anti-dsDNA and low C3 are reliable for discriminating ELN.
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Affiliation(s)
- Daniele Faria Miguel
- Universidade Estadual Paulista (UNESP) Faculdade de Medicina de Botucatu, Botucatu, Brazil
| | - Maria Teresa Terreri
- Pediatric Rheumatology Division, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), São Paulo, Brazil
| | - Rosa Maria Rodrigues Pereira
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eloisa Bonfá
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Clovis Artur Almeida Silva
- Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - José Eduardo Corrente
- Biostatistic Department, Instituto de Biociencias, Universidade Estadual Paulista (UNESP), Botucatu, Brazil
| | - Claudia Saad Magalhaes
- Pediatric Rheumatology Division, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP), Botucatu, Brazil.
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Wong T, Goral S. Lupus Nephritis and Kidney Transplantation: Where Are We Today? Adv Chronic Kidney Dis 2019; 26:313-322. [PMID: 31733715 DOI: 10.1053/j.ackd.2019.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/03/2019] [Accepted: 08/09/2019] [Indexed: 12/12/2022]
Abstract
Lupus nephritis (LN) is the cause of end-stage kidney disease (ESKD) for 1.9% of the ESKD population in the United States. Although the incidence rates of ESKD from LN stopped rising in recent years, racial disparities in waiting time, pre-emptive kidney transplant, and transplant outcomes still exist. Patients with LN who progress to ESKD tend to be female, of African ancestry, and young. Kidney transplantation is safe in this population and associated with a substantial survival benefit, primarily due to reduced deaths from cardiovascular disease and infection. Transplant outcomes for patients with ESKD due to LN are similar to those without LN.
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Aljaberi N, Bennett M, Brunner HI, Devarajan P. Proteomic profiling of urine: implications for lupus nephritis. Expert Rev Proteomics 2019; 16:303-313. [PMID: 30855196 DOI: 10.1080/14789450.2019.1592681] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Lupus nephritis (LN) is a common and significant manifestation, affecting 60% of adults and 80% of children with systemic lupus erythematosus, with up to 30% of patients progressing to end stage renal disease. There remains an unmet need for non-invasive markers of disease activity, damage, and response to therapy. In addition, non-invasive biomarkers that predict therapeutic efficacy are needed to enable cost-effective clinical trials of novel agents. Areas covered: This review examines the methodological aspects of urinary proteomics, the role of proteome profiling in identifying promising urinary biomarkers in LN, and the translation of research findings into clinically useful tools in the management of LN. Expert opinion: Targeted and unbiased proteomics have identified several promising urinary biomarkers that predict LN activity, damage (chronicity), and response to therapy. In particular, a combination of biologically plausible urinary biomarkers termed as RAIL (Renal Activity Index for Lupus) has emerged as an excellent predictor of LN activity as well as response to therapy, being able to predict efficacy within 3 months of therapy. If validated in additional large prospective studies, the RAIL biomarkers will transform the care of patients with LN, allowing for a personalized and predictive approach and improved outcomes.
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Affiliation(s)
- Najla Aljaberi
- a Divisions of Rheumatology, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Michael Bennett
- b Division of Nephrology & Hypertension, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Hermine I Brunner
- a Divisions of Rheumatology, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Prasad Devarajan
- b Division of Nephrology & Hypertension, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
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Broder A, Mowrey WB, Golestaneh L, Putterman C, Costenbader KH, Kim M. Methodological considerations in comparing access to Pre-emptive renal transplantation between SLE and other ESRD causes in the USRDS. Semin Arthritis Rheum 2019; 48:678-685. [PMID: 30064728 PMCID: PMC6291358 DOI: 10.1016/j.semarthrit.2018.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/17/2018] [Accepted: 05/30/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND We compared pre-emptive transplant rates between SLE and non-SLE end-stage renal disease (ESRD) from the U.S. Renal Data System (USRDS) and investigated the potential influence of frequency matching and primary ESRD causes in the non-SLE group. METHODS 4830 adult SLE patients with incident ESRD from USRDS 2005-2009 were frequency matched by age, sex and race to 4830 patients with incident non-SLE ESRD. Multivariable logistic regression models were used to estimate the odds of pre-emptive transplantation in SLE and non-SLE, and with the non-SLE subgroups by primary ESRD cause. RESULTS The odds ratios (OR) of receiving a pre-emptive transplant were similar among non-SLE and SLE (referent group): OR = 1.18 (95% CI: 0.92, 1.50; p = 0.20). However, the ORs for receiving a pre-emptive transplant were 0.19 (95% CI: 0.08, 0.42) in type 2 diabetes ESRD, 0.42 (95% CI: 0.23, 0.75) for hypertension-associated ESRD, 1.67 (95% CI: 1.10, 2.54) in type 1 diabetes ESRD, and 2.06 (95% CI: 1.55, 2.73) for "other" ESRD. In contrast to non-SLE, younger SLE patients were less likely to receive a pre-emptive transplant than older SLE patients. CONCLUSION The results of this study provide compelling evidence that major improvements need to be made in optimizing access to pre-emptive transplantation in SLE by addressing sociodemographic disparities and the unique challenges faced by SLE patients. Applying careful matching and selecting appropriate comparison groups in future studies may facilitate the development of effective strategies to address these barriers and to increase the number of pre-emptive renal transplants among SLE patients.
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Affiliation(s)
- Anna Broder
- Division of Rheumatology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, United States.
| | - Wenzhu B Mowrey
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States.
| | - Ladan Golestaneh
- Division of Nephrology, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, United States.
| | - Chaim Putterman
- Division of Rheumatology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States.
| | - Karen H Costenbader
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, United States.
| | - Mimi Kim
- Division of Biostatistics, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, United States.
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Abstract
Childhood-onset systemic lupus erythematosus (SLE) is a subset of SLE with an onset before 18 years of age. Patients with early onset SLE tend to have a greater genetic component to their disease cause, more multisystemic involvement, and a more severe disease course, which includes greater risks for developing nephritis and end-stage kidney disease. Five- and 10-year mortality is lower than in adult-onset SLE. Although patient and renal survival have improved with advances in induction and maintenance immunosuppression, accumulation of irreversible damage is common. Cardiovascular and infectious complications are frequent, as are relapses during adolescence and the transition to adulthood.
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Smith EMD, Eleuteri A, Goilav B, Lewandowski L, Phuti A, Rubinstein T, Wahezi D, Jones CA, Marks SD, Corkhill R, Pilkington C, Tullus K, Putterman C, Scott C, Fisher AC, Beresford MW. A Markov Multi-State model of lupus nephritis urine biomarker panel dynamics in children: Predicting changes in disease activity. Clin Immunol 2018; 198:71-78. [PMID: 30391651 DOI: 10.1016/j.clim.2018.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/28/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND A urine 'biomarker panel' comprising alpha-1-acid-glycoprotein, ceruloplasmin, transferrin and lipocalin-like-prostaglandin-D synthase performs to an 'excellent' level for lupus nephritis identification in children cross-sectionally. The aim of this study was to assess if this biomarker panel predicts lupus nephritis flare/remission longitudinally. METHODS The novel urinary biomarker panel was quantified by enzyme linked immunoabsorbant assay in participants of the United Kingdom Juvenile Systemic Lupus Erythematosus (UK JSLE) Cohort Study, the Einstein Lupus Cohort, and the South African Paediatric Lupus Cohort. Monocyte chemoattractant protein-1 and vascular cell adhesion molecule-1 were also quantified in view of evidence from other longitudinal studies. Serial urine samples were collected during routine care with detailed clinical and demographic data. A Markov Multi-State model of state transitions was fitted, with predictive clinical/biomarker factors assessed by a corrected Akaike Information Criterion (AICc) score (the better the model, the lower the AICc score). RESULTS The study included 184 longitudinal observations from 80 patients. The homogeneous multi-state Markov model of lupus nephritis activity AICc score was 147.85. Alpha-1-acid-glycoprotein and ceruloplasmin were identified to be the best predictive factors, reducing the AICc score to 139.81 and 141.40 respectively. Ceruloplasmin was associated with the active-to-inactive transition (hazard ratio 0.60 (95% confidence interval [0.39, 0.93])), and alpha-1-acid-glycoprotein with the inactive-to-active transition (hazard ratio 1.49 (95% confidence interval [1.10, 2.02])). Inputting individual alpha-1-acid-glycoprotein/ceruloplasmin values provides 3, 6 and 12 months probabilities of state transition. CONCLUSIONS Alpha-1-acid-glycoprotein was predictive of active lupus nephritis flare, whereas ceruloplasmin was predictive of remission. The Markov state-space model warrants testing in a prospective clinical trial of lupus nephritis biomarker led monitoring.
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Affiliation(s)
- E M D Smith
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - A Eleuteri
- Medical Physics and Clinical Engineering, and Department of Physics, University of Liverpool, Liverpool, UK.
| | - B Goilav
- Department of Paediatric Nephrology, Albert Einstein College of Medicine, New York, USA.
| | | | - A Phuti
- Paediatric Rheumatology, University of Cape Town, Cape Town, South Africa.
| | - T Rubinstein
- Department of Paediatric Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - D Wahezi
- Department of Paediatric Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - C A Jones
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - S D Marks
- Paediatric Nephrology, Great Ormond Street Hospital, London, UK.
| | - R Corkhill
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK.
| | - C Pilkington
- Paediatric Rheumatology, Great Ormond Street Hospital, London, UK.
| | - K Tullus
- Paediatric Nephrology, Great Ormond Street Hospital, London, UK.
| | - C Putterman
- Department of Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - C Scott
- Paediatric Rheumatology, University of Cape Town, Cape Town, South Africa.
| | - A C Fisher
- Medical Physics and Clinical Engineering, and Department of Physics, University of Liverpool, Liverpool, UK.
| | - M W Beresford
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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Smith EMD, Yin P, Jorgensen AL, Beresford MW. Clinical predictors of active LN development in children – evidence from the UK JSLE Cohort Study. Lupus 2018; 27:2020-2028. [DOI: 10.1177/0961203318801526] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Juvenile-onset systemic lupus erythematosus (JSLE) patients may develop lupus nephritis (LN) during their initial presentation, or later in their disease. This study aimed to assess whether clinical/demographic factors characterize patients with LN within the United Kingdom JSLE Cohort Study, and whether such factors predict subsequent LN development. Methods Univariate logistic regression modelling compared clinical/demographic factors in patients with and without LN at baseline. For those who subsequently developed LN, Cox proportional-hazard modelling was used to test the association between such factors and time to LN development. Covariates with p < 0.2 univariately were included within a multiple-regression model. Results A total of 121/331 (37%) patients presented with active LN at baseline, with first American College of Rheumatology (ACR) score ( p < 2.0 × 10–16), severe hypertension ( p = 0.0006), proteinuria ( p < 2.0 × 10–16), creatinine ( p = 1.0 × 10–16), erythrocyte sedimentation rate ( p = 1.0 × 10–16), neutrophils ( p < 2.0 × 10–16), complement 3 (C3) ( p = 4.0 × 10–16) and ethnicity ( p = 3.0 × 10–13) differing between those with and without LN. Of the 210 individuals without active LN at baseline, 13 patients had a single visit and were excluded from further analysis. Thirty-four of 197 (17%) developed LN after a median of 2.04 years (interquartile range, 0.8–3.7), with higher ACR scores ( p = 0.014 , hazard ratio (HR) = 1.45, 95% confidence interval (CI) = 1.08–1.95) and lower C3 levels ( p = 0.0082 , HR = 0.27, 95% CI = 0.10–0.68) demonstrated as predictors of subsequent LN. Conclusions Clinical and demographic factors can help to characterize patients at increased risk of LN.
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Affiliation(s)
- E M D Smith
- Department of Women’s & Children’s Health, University of Liverpool, UK Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, UK
| | - P Yin
- Research Center for Biomedical Information Technology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - A L Jorgensen
- Department of Biostatistics, University of Liverpool, UK
| | - M W Beresford
- Department of Women’s & Children’s Health, University of Liverpool, UK Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, UK
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Barnado A, Carroll RJ, Casey C, Wheless L, Denny JC, Crofford LJ. Phenome-wide association study identifies marked increased in burden of comorbidities in African Americans with systemic lupus erythematosus. Arthritis Res Ther 2018; 20:69. [PMID: 29636090 PMCID: PMC5894248 DOI: 10.1186/s13075-018-1561-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/06/2018] [Indexed: 01/08/2023] Open
Abstract
Background African Americans with systemic lupus erythematosus (SLE) have increased renal disease compared to Caucasians, but differences in other comorbidities have not been well-described. We used an electronic health record (EHR) technique to test for differences in comorbidities in African Americans compared to Caucasians with SLE. Methods We used a de-identified EHR with 2.8 million subjects to identify SLE cases using a validated algorithm. We performed phenome-wide association studies (PheWAS) comparing African American to Caucasian SLE cases and African American SLE cases to matched non-SLE controls. Controls were age, sex, and race matched to SLE cases. For multiple testing, a false discovery rate (FDR) p value of 0.05 was used. Results We identified 270 African Americans and 715 Caucasians with SLE and 1425 matched African American controls. Compared to Caucasians with SLE adjusting for age and sex, African Americans with SLE had more comorbidities in every organ system. The most striking included hypertension odds ratio (OR) = 4.25, FDR p = 5.49 × 10− 15; renal dialysis OR = 10.90, FDR p = 8.75 × 10− 14; and pneumonia OR = 3.57, FDR p = 2.32 × 10− 8. Compared to the African American matched controls without SLE, African Americans with SLE were more likely to have comorbidities in every organ system. The most significant codes were renal and cardiac, and included renal failure (OR = 9.55, FDR p = 2.26 × 10− 40) and hypertensive heart and renal disease (OR = 8.08, FDR p = 1.78 × 10− 22). Adjusting for race, age, and sex in a model including both African American and Caucasian SLE cases and controls, SLE was independently associated with renal, cardiovascular, and infectious diseases (all p < 0.01). Conclusions African Americans with SLE have an increased comorbidity burden compared to Caucasians with SLE and matched controls. This increase in comorbidities in African Americans with SLE highlights the need to monitor for cardiovascular and infectious complications. Electronic supplementary material The online version of this article (10.1186/s13075-018-1561-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- April Barnado
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T3113 MCN, Nashville, TN, 37232, USA.
| | - Robert J Carroll
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolyn Casey
- Department of Medicine, Lehigh Valley Health Network, Allentown, PA, USA
| | - Lee Wheless
- Department of Dermatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joshua C Denny
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T3113 MCN, Nashville, TN, 37232, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Leslie J Crofford
- Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, T3113 MCN, Nashville, TN, 37232, USA
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Hiraki LT, Feldman CH, Marty FM, Winkelmayer WC, Guan H, Costenbader KH. Serious Infection Rates Among Children With Systemic Lupus Erythematosus Enrolled in Medicaid. Arthritis Care Res (Hoboken) 2017; 69:1620-1626. [PMID: 28217919 DOI: 10.1002/acr.23219] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 02/14/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the nationwide prevalence and incidence of serious infections among children with systemic lupus erythematosus (SLE) enrolled in Medicaid, the US health insurance program for low-income patients. METHODS From Medicaid claims (2000-2006) we identified children ages 5 to <18 years with SLE (≥3 International Classification of Diseases, Ninth Revision [ICD-9] codes of 710.0, each >30 days apart) and lupus nephritis (LN; ≥2 ICD-9 codes for kidney disease on/after SLE codes). From hospital discharge diagnoses, we identified infection subtypes (bacterial, fungal, and viral). We calculated incidence rates (IRs) per 100 person-years, mortality rates, and hazard ratios adjusted for sociodemographic factors, medications, and preventive care. RESULTS Among 3,500 children with identified SLE, 1,053 serious infections occurred over 10,108 person-years; the IR was 10.42 per 100 person-years (95% confidence interval [95% CI] 9.80-11.07) among all those with SLE and 17.65 per 100 person-years (95% CI 16.29-19.09) among those with LN. Bacterial infections were most common (87%, of which 39% were bacterial pneumonias). In adjusted models, African Americans and American Indians had higher rates of infections compared with white children, and those with comorbidities or receiving corticosteroids had higher infection rates than those without. Males had lower rates of serious infections compared to females. The 30-day postdischarge mortality rate was 4.4%. CONCLUSION Overall, hospitalized infections were very common in children with SLE, with bacterial pneumonia being the most common infection. Highest infection risks were among African American and American Indian children, those with LN, comorbidities, and those taking corticosteroids.
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Affiliation(s)
- Linda T Hiraki
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | - Hongshu Guan
- Brigham and Women's Hospital, Boston, Massachusetts
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Brunner HI, Bennett MR, Gulati G, Abulaban K, Klein-Gitelman MS, Ardoin SP, Tucker LB, Rouster-Stevens KA, Witte D, Ying J, Devarajan P. Urine Biomarkers to Predict Response to Lupus Nephritis Therapy in Children and Young Adults. J Rheumatol 2017; 44:1239-1248. [PMID: 28620062 PMCID: PMC6719540 DOI: 10.3899/jrheum.161128] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To delineate urine biomarkers that forecast response to therapy of lupus nephritis (LN). METHODS Starting from the time of kidney biopsy, patients with childhood-onset systemic lupus erythematosus who were diagnosed with LN were studied serially. Levels of 15 biomarkers were measured in random spot urine samples, including adiponectin, α-1-acid glycoprotein (AGP), ceruloplasmin, hemopexin, hepcidin, kidney injury molecule 1, monocyte chemotactic protein-1, lipocalin-like prostaglandin D synthase (LPGDS), transforming growth factor-β (TGF-β), transferrin, and vitamin D binding protein (VDBP). RESULTS Among 87 patients (mean age 15.6 yrs) with LN, there were 37 treatment responders and 50 nonresponders based on the American College of Rheumatology criteria. At the time of kidney biopsy, levels of TGF-β (p < 0.0001) and ceruloplasmin (p = 0.006) were significantly lower among responders than nonresponders; less pronounced differences were present for AGP, hepcidin, LPGDS, transferrin, and VDBP (all p < 0.05). By Month 3, responders experienced marked decreases of adiponectin, AGP, transferrin, and VDBP (all p < 0.01) and mean levels of these biomarkers were all outstanding (area under the receiver-operating characteristic curve ≥ 0.9) for discriminating responders from nonresponders. Patient demographics and extrarenal disease did not influence differences in biomarker levels between response groups. CONCLUSION Low urine levels of TGF-β and ceruloplasmin at baseline and marked reduction of AGP, LPGDS, transferrin, or VDBP and combinations of other select biomarkers by Month 3 are outstanding predictors for achieving remission of LN. If confirmed, these results can be used to help personalize LN therapy.
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Affiliation(s)
- Hermine I Brunner
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA.
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine.
| | - Michael R Bennett
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Gaurav Gulati
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Khalid Abulaban
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Marisa S Klein-Gitelman
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Stacy P Ardoin
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Lori B Tucker
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Kelly A Rouster-Stevens
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - David Witte
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Jun Ying
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Prasad Devarajan
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
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Jebali H, Hajji M, Rais L, Hamida FB, Beji S, Zouaghi MK. Clinicopathological findings and outcome of lupus nephritis in Tunisian children: a review of 43 patients. Pan Afr Med J 2017; 27:153. [PMID: 28904681 PMCID: PMC5567971 DOI: 10.11604/pamj.2017.27.153.10915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 05/16/2017] [Indexed: 12/02/2022] Open
Abstract
We report clinical and renal histological data, treatment modalities and outcome of 43 Tunisian children with biopsy-proven lupus nephritis seen over a 23-year period. There were 39 girls and 4 boys with a mean age of 12.5 years at diagnosis of lupus nephritis and followed for a mean period of 77 months. Renal symptoms included urinary abnormalities in all patients, hypertension in 40% of cases, nephrotic syndrome in 60% of cases and renal failure in 25% of cases. Class IV and class III nephritis were observed in 48.8 % and 30.2 % respectively. Corticosteroids were used in all cases, associated to immunosuppressive therapy in 23%. Overall survival was 86% at 5 years and 74% at 10 and 15 years. Renal survival was 83% at 5 and 10 years and 63% at 15 years. Initial renal failure and tubulointerstitial fibrosis were significantly increased risk for the development of end-stage renal disease in our study group. Renal histological findings provide the basis for treatment recommendations. Timely performed renal biopsy is greatly needed to accurately determine the prognosis and to guide treatment in children lupus nephritis.
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Affiliation(s)
- Hela Jebali
- Nephrology Departement, La Rabta Hospital, Tunis, Tunisia
| | - Meriam Hajji
- Nephrology Departement, La Rabta Hospital, Tunis, Tunisia
| | - Lamia Rais
- Nephrology Departement, La Rabta Hospital, Tunis, Tunisia
| | - Fethi Ben Hamida
- Laboratory of Kidney pathology LR00SP01, Charles Nicolle Hospital, Tunis, Tunisia
| | - Soumaya Beji
- Nephrology Departement, La Rabta Hospital, Tunis, Tunisia
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Sanchez C, Rebolledo A, Gahona J, Rojas M, Jiménez R, Bojórquez A. Post-transplant immune complex nephritis in a patient with systemic lupus erythematosus associated with ANCA vasculitis. Pediatr Transplant 2017; 21. [PMID: 28133935 DOI: 10.1111/petr.12895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2017] [Indexed: 11/29/2022]
Abstract
Nearly 20% of SLE corresponds to the pediatric population, and 75% of them have kidney involvement representing an important etiology of chronic kidney disease. A correlation between SLE and ANCA-associated vasculitis has been identified as an overlapping syndrome. Kidney allograft recurrence is rare in SLE when disease control is achieved and with nowadays immunosuppression treatment. Histologic transformation is unusual, especially when there are negative serologic markers and no immune complex deposition reported in native kidneys. A 17-year-old female with crescentic glomerulonephritis, p-ANCA-positive antibodies with pauci-immune pattern in kidney biopsy develops end-stage renal disease requiring hemodialysis. Deceased donor kidney transplant was performed receiving triple immunosuppression thereafter. Thirteen months later serum creatinine rises without evidence of infection, urinary obstruction, or clinical and serologic disease relapse. Allograft biopsy reports mesangial proliferation and "full-house" immunofluorescence. The role of ANCA in SLE physiopathology is controversial, and its relation with lupus nephritis is also discordant. ANCA could represent an important factor in the heterogeneity of systemic lupus erythematosus and lupus nephritis.
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Affiliation(s)
- Carlos Sanchez
- Resident of Pediatric Nephrology, National Institute of Pediatrics, México City, Mexico
| | - Alejandra Rebolledo
- Resident of Pediatric Nephrology, National Institute of Pediatrics, México City, Mexico
| | - Junior Gahona
- Resident of Pediatric Nephrology, National Institute of Pediatrics, México City, Mexico
| | - Mauricio Rojas
- Anatomic-Pathology Department, National Institute of Pediatrics, México City, Mexico
| | - Raquel Jiménez
- Pediatric Nephrology Department, National Institute of Pediatrics, México City, Mexico
| | - Aurora Bojórquez
- Pediatric Nephrology Department, National Institute of Pediatrics, México City, Mexico
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Advances in the care of children with lupus nephritis. Pediatr Res 2017; 81:406-414. [PMID: 27855151 DOI: 10.1038/pr.2016.247] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/07/2016] [Indexed: 12/27/2022]
Abstract
The care of children with lupus nephritis (LN) has changed dramatically over the past 50 y. The majority of patients with childhood-onset systemic lupus erythematosus (cSLE) develop LN. In the 1960's, prognosis in children was worse than in adults; therapies were limited and toxic. Nearly half of cases resulted in death within 2 y. Since this time, several diagnostic recommendations and disease-specific indices have been developed to assist physicians caring for patients with LN. Pediatric researchers are validating and adapting these indices and guidelines for the treatment of LN in cSLE. Classification systems, activity, and chronicity indices for kidney biopsy have been validated in pediatric cohorts in several countries. Implementation of contemporary immunosuppressive agents has reduced treatment toxicity and improved outcomes. Biomarkers sensitive to LN in children have been identified in the kidney, urine, and blood. Multi-institutional collaborative networks have formed to address the challenges of pediatric LN research. Considerable variation in evaluation and treatment has been addressed for proliferative forms of LN by development of consensus treatment practices. Patient survival at 5 y is now 95-97% and renal survival exceeds 90%. Moreover, international consensus exists for quality indicators for cSLE that consider the unique aspects of chronic disease in childhood.
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Smith EMD, Jorgensen AL, Midgley A, Oni L, Goilav B, Putterman C, Wahezi D, Rubinstein T, Ekdawy D, Corkhill R, Jones CA, Marks SD, Newland P, Pilkington C, Tullus K, Beresford MW. International validation of a urinary biomarker panel for identification of active lupus nephritis in children. Pediatr Nephrol 2017; 32:283-295. [PMID: 27590021 PMCID: PMC5203828 DOI: 10.1007/s00467-016-3485-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/26/2016] [Accepted: 07/14/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Conventional markers of juvenile-onset systemic lupus erythematosus (JSLE) disease activity fail to adequately identify lupus nephritis (LN). While individual novel urine biomarkers are good at detecting LN flares, biomarker panels may improve diagnostic accuracy. The aim of this study was to assess the performance of a biomarker panel to identify active LN in two international JSLE cohorts. METHODS Novel urinary biomarkers, namely vascular cell adhesion molecule-1 (VCAM-1), monocyte chemoattractant protein 1 (MCP-1), lipocalin-like prostaglandin D synthase (LPGDS), transferrin (TF), ceruloplasmin, alpha-1-acid glycoprotein (AGP) and neutrophil gelatinase-associated lipocalin (NGAL), were quantified in a cross-sectional study that included participants of the UK JSLE Cohort Study (Cohort 1) and validated within the Einstein Lupus Cohort (Cohort 2). Binary logistic regression modelling and receiver operating characteristic curve analysis [area under the curve (AUC)] were used to identify and assess combinations of biomarkers for diagnostic accuracy. RESULTS A total of 91 JSLE patients were recruited across both cohorts, of whom 31 (34 %) had active LN and 60 (66 %) had no LN. Urinary AGP, ceruloplasmin, VCAM-1, MCP-1 and LPGDS levels were significantly higher in those patients with active LN than in non-LN patients [all corrected p values (p c) < 0.05] across both cohorts. Urinary TF also differed between patient groups in Cohort 2 (p c = 0.001). Within Cohort 1, the optimal biomarker panel included AGP, ceruloplasmin, LPGDS and TF (AUC 0.920 for active LN identification). These results were validated in Cohort 2, with the same markers resulting in the optimal urine biomarker panel (AUC 0.991). CONCLUSION In two international JSLE cohorts, urinary AGP, ceruloplasmin, LPGDS and TF demonstrate an 'excellent' ability for accurately identifying active LN in children.
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Affiliation(s)
- Eve Mary Dorothy Smith
- Department of Women's and Children's Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children's Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP, UK.
| | - Andrea Lyn Jorgensen
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Angela Midgley
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK
| | - Louise Oni
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK
| | - Beatrice Goilav
- Division of Nephrology, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY USA
| | - Chaim Putterman
- Division of Rheumatology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY USA
| | - Dawn Wahezi
- Division of Pediatric Rheumatology, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY USA
| | - Tamar Rubinstein
- Division of Pediatric Rheumatology, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY USA
| | - Diana Ekdawy
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK
| | - Rachel Corkhill
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK
| | - Caroline Ann Jones
- Department of Paediatric Nephrology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Stephen David Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital, London, UK
| | - Paul Newland
- Biochemistry Department, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital, London, UK
| | - Michael William Beresford
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK ,Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
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