Renal manifestations in Henoch-Schönlein purpura: a 10-year clinical study

Immunoglobulin A vasculitis: The clinical features and pathophysiology

Palpable purpura, gastrointestinal symptoms, joint involvement, and renal disease characterize immunoglobulin A vasculitis (IgAV). Renal involvement ranging from mild proteinuria to severe nephritic or nephrotic syndrome highlights the importance of monitoring kidney function in patients with IgAV. Recognizing these key features is crucial for early diagnosis and appropriate management to prevent long-term complications related to kidney disease. However, the pathogenesis of IgAV remains unclear. Disease mechanisms involve various factors, including the interplay of aberrantly glycosylated IgA, anti-endothelial cell antibodies, and neutrophils following infection triggers, which are the main pathogenic mechanisms of IgAV. Insights from cases of IgAV related to Coronavirus disease 2019 have offered additional understanding of the connection between infection and IgAV pathogenesis. This review provides a valuable resource for healthcare professionals and rheumatology researchers seeking a better understanding of the clinical features and pathophysiology of IgAV.

Overview of childhood vasculitis

Pediatric vasculitis and adult vasculitis differ in several aspects. While both involve inflammation of blood vessels, pediatric vasculitis tends to present with distinct clinical features and may involve different types of blood vessels compared to adult vasculitis. Despite its relatively rare occurrence compared to adult vasculitis, pediatric vasculitis warrants careful attention due to its potential for profound and diverse clinical manifestations, ranging from mild cutaneous symptoms to life-threatening systemic complications. Childhood vasculitis should be suspected in children who present symptoms attributable to systemic inflammation and complications arising from multi-organ dysfunction. However, achieving a diagnosis necessitates thorough exclusion of alternative conditions manifesting similar symptoms and findings. Hence, children suspected of vasculitis should undergo meticulous history-taking, comprehensive physical examination, and requisite laboratory investigations, imaging studies, and sometimes tissue biopsies to elucidate the diagnosis. Early detection and treatment of childhood vasculitis are crucial, as the condition can affect various organs and potentially lead to life-threatening complications or long-term sequelae in adulthood if left untreated. This review aimed to provide an exhaustive overview of childhood vasculitis, outlining its epidemiology, classification, clinical presentation, diagnostic modalities, therapeutic strategies and outcome.

Vasculitis and Kidney Disease

Pediatric vasculitis is a complex group of disorders that commonly presents with multisystem involvement. Renal vasculitis can be isolated to the kidneys or can occur as part of a broader multiorgan vasculitis. Depending on severity, renal vasculitis may present as acute glomerulonephritis (AGN) often associated with hypertension and sometimes with a rapidly deteriorating clinical course. Prompt diagnosis and initiation of therapy are key to preserving kidney function and preventing long-term morbidity and mortality. This review focuses on the clinical presentation, diagnosis, and treatment objectives for common forms of renal vasculitis seen in pediatric patients.

Bibliometric analysis of IgA vasculitis nephritis in children from 2000 to 2022

Background

IgA vasculitis Nephritis (IgAVN) is a kidney-damaging disease that occurs during the course of IgA vasculitis (IgAV) and is the most serious complication of IgAV. However, there is a lack of reports of bibliometric analysis of IgAVN in children. The purpose of this study is to conduct a bibliometric analysis of IgAVN in children from 2000 to 2022, to explore the current status and cutting-edge trends in the field of IgAVN in children, and to establish new directions for subsequent research.

Methods

Screening the literature in the field of IgAVN in children in the Web of Science Core Collection (WoSCC) from 2000 to 2022. Visual analysis of their annual publications, countries, institutions, authors, journals, keywords, and references were using CiteSpace5.8.R3 and VOSviewer1.6.18.

Results

A total of 623 publications were included in the study, since the beginning of 2014, there has been an overall increasing trend in the number of articles issued. The most prolific country and institution were China and Zhejiang University. The most frequently cited author was Coppo R, with 331 citations, who has made great contributions to IgAVN. Mao Jianhua, Lee JS and Wyatt Robert J were the most prolific authors, all with 9 articles. Pediatric Nephrology was the most published and cited journal. The highest burst strength keyword is IgA vasculitis, and the highest burst strength reference is Davin JC, 2014.

Conclusion

The research hotspots and trends predicted by the analysis of this study provide a reference for in-depth research in this field with a view to promoting the development of IgAVN research in children.

Comparison of clinical, pathological and long-term renal outcomes of children with Henoch-Schonlein purpura nephritis and IgA nephropathy

PURPOSE

To compare clinical, pathological, and long-term renal outcomes of children with Henoch-Schonlein purpura nephritis (HSPN) and IgA nephropathy (IgAN).

METHODS

The medical records of patients diagnosed as HSPN and IgAN during childhood were evaluated retrospectively. HSPN and IgAN groups were compared in terms of gender, age, upper respiratory infection history, blood pressure; presence of nephrotic and/or nephritic syndrome; hemoglobin level, leukocyte count, C-reactive protein (CRP), serum albumin (sAlb), creatinine, complement 3 (sC3), complement 4 (sC4) and immunoglobulin A (sIgA) levels; estimated glomerular filtration rate (eGFR) and proteinuria levels; and renal pathology findings at the onset of disease; total follow-up time; and blood pressure, eGFR and proteinuria levels at the last visit.

RESULTS

Fifty-four patients were enrolled in the study [38 (70%) HSPN and 16 (30%) IgAN]. The median follow-up time was 60.5 and 72.0 months in HSPN and IgAN groups, respectively (p > 0.05). The HSPN and IgAN groups were also not different in terms of gender, age at the onset; leukocyte count, eGFR, sC3-sC4-sIgA levels; and the presence of endocapillary, extracapillary and mesangial proliferation, tubular atrophy, interstitial fibrosis and IgA, IgM, C3 accumulation in renal tissue. Upper respiratory tract infection history was more common in children with IgAN (8/16 vs 8/38, p = 0.045). sAlb (3.96 ± 0.58 vs 4.40 ± 0.46 g/dL, p = 0.005), hemoglobin (12.1 ± 1.3 vs 13.3 ± 1.2 g/dL, p = 0.004,) and the incidence of mesangial IgG deposition (15/38 vs 11/16, p = 0.049) were lower, while CRP (16.3 ± 7.2 vs 7.8 ± 4.4 mg/L, p = 0.002) and proteinuria (72.1 ± 92.4 vs 34.2 ± 37.9 mg/m²/24 h, p = 0.041) was higher in HSPN group at the onset of disease. Proteinuria and eGFR were similar between the two groups at last visit.

CONCLUSION

Children with HSPN and IgAN have little clinical and histological differences in our population. The most prominent difference at presentation with nephritis was higher proteinuria in HSPN probably associated with inflammation due to systemic vasculitis. Long-term renal outcome was good in both HSPN and IgAN.

IgA Vasculitis in Patients with Inflammatory Bowel Disease: new insights into the role of TNF-α blockers

OBJECTIVE

Association of IgA vasculitis (IgAV) and inflammatory bowel diseases (IBD) is rarely described, mainly during anti-TNF-α therapy. We aimed to describe the association of IgAV and IBD.

METHODS

We retrospectively analyzed the association of IgAV and IBD through the implication of the GETAID and FVSG networks. Characteristics of IBD and IgAV were collected using a standardized case report form.

RESULTS

Forty-three cases were included. IBD (mainly Crohn's disease (CD) in 58%) preceded IgAV in 38 (88%), with median interval of 9.2 (IQR 5.4-15.4) years. In these 38 patients, at IgAV diagnosis, 5 (13%) had active IBD and 28 (74%) were treated with anti-TNF-α for a median duration of 31.5 (IQR 19-56) months. Main IgAV manifestations were purpura all patients (100%), joints in 20/35 (57%), renal in 15/35 (43%) and gastrointestinal in 11/35 (31%) involvement. IgAV was treated with glucocorticoids in 25 (66%), colchicine in 6 (16%), cyclophosphamide in 6 (16%), and anti-TNF-α were discontinued in 15/28 (54%). No IgAV relapse occurred when TNF-α blockers were stopped, vs 23% in patients pursuing it. Conversely, 5 (33%) had IBD flare or complication after anti-TNF-α cessation vs 1 (8%) in those continuing biologics. Anti-TNF-α were resumed in 6 (40%), with subsequent IgAV relapse in 4 (67%).

CONCLUSIONS

This large cohort suggests that TNF-α blockers may promote the onset of IgAV in IBD. Discontinuation of anti-TNF-α was associated with vasculitis remission but increased risk of IBD relapses, whereas continuation of anti-TNF-α was associated with IBD remission but vasculitis relapse.

A case of IgA vasculitis with necrotizing arteritis in a 13-year-old girl

IgA vasculitis (IgAV) is the most frequent form of vasculitis in childhood which classically presents with purpura of the lower extremities, joint pain or swelling and abdominal pain. Though it is a self-limiting disease, and its prognosis is generally good, glomerulonephritis is one of the most important complications. IgAV is classified as a small vessel vasculitis, and though glomerulonephritis develops in IgAV, necrotizing arteritis is rarely seen. Here, we present a case of a 13-year-old girl with IgAV, glomerulonephritis, and necrotizing arteritis in the small renal arteries. There have been only a few reports of adult cases of IgAV with necrotizing arteritis in the kidneys, but there have been no pediatric cases. Some previous reports showed a high mortality rate and implied the possibility of overlap with other vasculitides. In the current report, a rare case of IgAV is described which exhibited necrotizing arteritis rather than overlap with another vasculitis, with a relatively typical clinical course for IgAV and laboratory tests.

Streptococcal infection in childhood Henoch-Schönlein purpura: a 5-year retrospective study from a single tertiary medical center in China, 2015-2019

BACKGROUND

The present study focuses on the associations of streptococcal infection with the clinical phenotypes, relapse/recurrence and renal involvement in Henoch-Schönlein purpura (HSP) children.

METHODS

Two thousand seventy-four Chinese children with HSP were recruited from January 2015 to December 2019. Patients' histories associated with HSP onset were obtained by interviews and questionnaires. Laboratory data of urine tests, blood sample and infectious agents were collected. Renal biopsy was performed by the percutaneous technique.

RESULTS

(1) Streptococcal infection was identified in 393 (18.9%) HSP patients, and served as the most frequent infectious trigger. (2) Among the 393 cases with streptococcal infection, 43.0% of them had arthritis/arthralgia, 32.1% had abdominal pain and 29.3% had renal involvement. (3) 26.1% of HSP patients relapsed or recurred more than 1 time within a 5-year observational period, and the relapse/recurrence rate in streptococcal infectious group was subjected to a 0.4-fold decrease as compared with the non-infectious group. (4) No significant differences in renal pathological damage were identified among the streptococcal infectious group, the other infectious group and the non-infectious group.

CONCLUSIONS

Streptococcal infection is the most frequent trigger for childhood HSP and does not aggravate renal pathological damage; the possible elimination of streptococcal infection helps relieve the relapse/recurrence of HSP.

Drug-induced IgA vasculitis in children and adults: Revisiting drug causality using a dual pharmacovigilance-based approach

OBJECTIVES

IgA vasculitis (IgAV) is an immune complex small-vessel vasculitis. Drug-induced IgAV cases were rarely reported in the literature. Drug causality assessment is challenging as many other etiological factors can be involved. We performed a pharmacovigilance study to identify the main drugs reported to induce IgAV.

METHODS

We used the French pharmacovigilance database (FPVD) and the WHO global individual case safety reports database (VigiBase) to retrieve IgAV cases. Cases from the FPVD were reviewed by two investigators using predefined criteria. Disproportionality analyses (case - non-case approach) were conducted in VigiBase to identify drugs significantly associated with IgAV reporting.

RESULTS

Of the 467 IgAV cases retrieved from the FPVD, 115 (47 children and 68 adults) have been assessed as definite or probable, reported with 178 suspected drugs. Overall IgAV cases were mainly male (58%), with a median age of 33.5 (8.0-63.3) years. No death was reported. Besides, we identified 1558 possible IgAV cases in VigiBase. Among them, 40 were associated with a disproportionality in IgAV reporting. Drugs were mainly vaccines, antibiotics and TNF-α blockers, these finding being consistent in both databases. IgAV reporting with TNF-α blockers was significantly associated with their use in inflammatory bowel diseases, psoriasis or ankylosing spondylitis compared to other indications.

CONCLUSIONS

Our systematic study enables the identification of culprit drugs in drug-induced IgAV. These results strengthen the immune pathophysiology of IgAV and the role of underlying disease. The list of suspected drugs may be useful for physicians to manage patients with IgAV and consider appropriate drug discontinuation.

KEY MESSAGES

What is already known about this subject? IgA vasculitis has multifactorial etiology. To date, possible culprit drugs have been reported only in case reports. What does this study add? Using a dual pharmacovigilance-based approach, we identified drugs associated with the occurrence of IgA vasculitis, such as all types of vaccines, major antibiotics and immunomodulatory agents, mainly TNF-α blockers. How might this impact on clinical practice or future developments? Physicians should be aware of drug-induced IgA vasculitis and we provide evidence on the most frequent implicated drugs.

Changes of inflammatory mediators and oxidative stress indicators in children with Henoch-Schönlein purpura and clinical effects of hemoperfusion in the treatment of severe Henoch-Schönlein purpura with gastrointestinal involvement in children

BACKGROUND

To explore the changes of inflammatory and oxidative stress responses in Henoch-Schönlein purpura (HSP) children, and further analyzed the therapeutic effects and mechanisms of hemoperfusion (HP) on HSP with severe gastrointestinal (GI) involvement.

METHODS

There were 200 children with HSP were divided into three groups according to their clinical manifestations: 60 in HSP without GI and renal involvement group, 60 in HSP with GI involvement group, and 80 in HSPN group. The HSP with GI involvement group was subdivided into conventional treatment (n = 30) and HP (n = 30) groups. Thirty children who visited the department of children healthcare for healthy physical examinations from January to December 2017 were set as healthy control group. The IL-6 and TNF-α levels were detected by chemoluminescence method. The MDA, SOD and T-AOC levels were determined by thiobarbituric acid colorimetric method, hydroxylamine method and chemical colorimetry.

RESULTS

Compared with healthy group, IL-6, TNF-α and MDA levels in HSP were increased in each group, while SOD and T-AOC were decreased (P = 0.000). IL-6, TNF-α and MDA levels in the HSPN group were the highest, SOD and T-AOC levels were the lowest (P = 0.000). Compared with those before treatment, IL-6, TNF-α and MDA levels in the conventional and HP groups were decreased and SOD and T-AOC levels were increased (P = 0.000). The changes in HP group were more significant than those in conventional group (P < 0.047). Compared with conventional group, glucocorticoid dosage and the occurrence rate of hematuria and/or proteinuria within 3 months were lower in HP group. (P = 0.000, 0.004).

CONCLUSIONS

Inflammatory and oxidative stress may be involved in the acute phase of HSP children. The intensity of inflammatory and oxidative stress responses were related to the degree of renal involvement. HP can reduce glucocorticoid dosage and the rate of renal involvement in children with severe HSP with GI involvement. The mechanism may be related to the fact that HP can effectively remove IL-6, TNF-α, MDA in HSP children.

Clinical Characteristics of Biopsy-Proven IgA Vasculitis in Children and Adults: A Retrospective Cohort Study

OBJECTIVE

To describe the differences in clinical characteristics and outcome between adult- and childhood-onset biopsy-proven IgA vasculitis (IgAV) in North America.

PATIENTS AND METHODS

Patients with IgAV diagnosed from January 1, 1997, through December 31, 2016, were retrospectively identified. Data were abstracted from direct medical record review. Kaplan-Meier methods were used to estimate survival rates.

RESULTS

A total of 243 patients with IgAV were included (227 [93.4%] white, 141 [58.0%] male); 174 patients were adults (≥21 years), and 69 were younger than 21 years. Compared with patients younger than 21 years, adults at baseline more frequently had ulcerative skin lesions (19 [10.9%] vs 1 [1.4%]; P=.02) and nephrotic-range proteinuria (21 of 96 [21.9%] vs 1 of 38 [2.6%]; P=.007) but less commonly had abdominal pain (59 [33.9%] vs 42 [60.9%]; P<.001), ischemic gastrointestinal tract involvement (18 [10.3%] vs 14 [20.3%]; P=.04), and arthralgias (66 [37.9%] vs 42 [60.8%]; P<.001). During 389 person-years of follow-up, 29 deaths were observed. Five-year survival rates for patients aged younger than 21, 21 to 50, and 51 years or older were 100%, 94%, and 40%, respectively. In comparison to data from the United States life tables for whites, patients 51 years or older at diagnosis had a greater than 7-fold increased risk of mortality (standardized mortality, 7.60 [95% CI, 5.01-11.06]; P<.001).

CONCLUSION

IgA vasculitis in adults is associated with more severe skin/kidney involvement and poorer renal outcome. Among adults with IgAV, patients aged 51 years or older at diagnosis have significantly higher mortality (P<.001).

The clinical spectrum of Henoch-Schönlein purpura in children: a single-center study

OBJECTIVES

Henoch-Schönlein purpura (HSP) is the most common vasculitis of children. The aim of this study is to evaluate the demographic and clinic findings of patients with HSP and also to determine predictive factors for assessing the development of gastrointestinal system (GIS) and renal involvement.

METHODS

This study was performed prospectively among children with HSP who are under 18 years of age and being followed-up in the Pediatric Rheumatology Unit of Health Sciences University Kanuni Sultan Süleyman Training and Research Hospital between January 2016 and January 2018.

RESULTS

A total of 265 patients, 137 boys (51.7%) and 128 girls (48.3%), were involved to the study. The mean ± standard deviation of age at the diagnosis was 7.5 ± 3.2. The most common disease onset season was spring (31.7%). The rate of arthritis, GIS involvement, and renal involvement were 54%, 51.3%, and 29.1%, respectively. GIS bleeding was more frequent in males than females (p = 0.007). Boys over 7 years of age had significantly more common GIS bleeding (p = 0.04). Intussusception, relapse, and serious GIS involvement requiring hospitalization and steroid treatment were highly associated with severe renal involvement.

CONCLUSIONS

We demonstrated that patients suffering intussusception, relapse, and serious GIS involvement or requiring hospitalization and steroid treatment had tendency to present with severe renal involvement. Therefore, these patients should be followed up carefully for not overlooking renal involvement of HSP.

Approach to the Child with Hematuria

The causes of macroscopic and microscopic hematuria overlap; both are often caused by urinary tract infections or urethral/bladder irritation. Coexistent hypertension and proteinuria should prompt investigation for glomerular disease. The most common glomerulonephritis in children is postinfectious glomerulonephritis. In most patients, and especially with isolated microscopic hematuria, the diagnostic workup reveals no clear underlying cause. In those cases whereby a diagnosis is made, the most common causes of persistent microscopic hematuria are thin basement membrane nephropathy, immunoglobulin A nephropathy, or idiopathic hypercalciuria. Treatment and long-term prognosis varies with the underlying disease.

Vasculitis: Kids are not just little people

Cutaneous vasculitis, inflammatory destruction of blood vessels, can present with a wide range of clinical and pathologic findings across a number of heterogeneous conditions. Although some vasculitides are present in both children and adults, some important differences exist in clinical presentation, etiology, management, and prognosis in childhood vasculitis versus adult vasculitis. Cutaneous vasculitis is rare in children, and most childhood vasculitides, of which Henoch-Schönlein purpura is the most common, histologically are small vessel leukocytoclastic vasculitis. In children, infectious etiologies are more common than in adults. Childhood cutaneous vasculitis is most often self-limited with a good prognosis, and treatment is mainly supportive. © 2017 Elsevier Inc. All rights reserved.

"Joining the Spots in Adults and Young Tots": A Clinicopathological Study of Henoch-Schönlein Purpura (IgA Vasculitis)

INTRODUCTION

Henoch-Schönlein Purpura (HSP; IgA vasculitis), the most common vasculitis of childhood, has a wide spectrum of clinical manifestations ranging from palpable purpura with abdominal pain and arthritis to the more morbid renal involvement.

AIMS AND OBJECTIVES

To study and correlate the clinical presentation, laboratory values, skin and renal histopathology and immunofluoroscence findings in HSP.

MATERIAL AND METHODS

A total of 44 cases of HSP from March 2011 to February 2014 were studied for the above features along with their clinical outcomes.

RESULTS

The mean age of the patients at presentation was 28.4 years (range 4.5-69 years) with 26.2% being children younger than 15 years. Purpura at presentation was seen in all with 77.1% cases exhibiting extracutaneous involvement. Skin biopsy revealed leukocytoclastic vasculitis in all cases, dominant IgA deposition in the papillary dermal vessels in 43 cases (97.7%), associated C3 in 10 cases (23.3%), and full-house positivity in 1 case. One case without skin immunofluorescence had renal mesangial IgA deposits. Nine cases (20.9%) with an average age of 39 years had renal symptoms and displayed varied histology from focal mesangioproliferative glomerulonephritis to crescentic. All of them had dominant mesangial IgA deposits, majority falling into International Study of Kidney Disease in Children (ISKDC) class IIIb. Peritubular capillaritis was noted in 3 cases. Two patients (4.5%) progressed to end stage renal disease, one of whom had cellular crescents at presentation.

CONCLUSIONS

HSP was seen both in children and adults. Renal involvement was seen in 20.9% cases, all older than 14 years, and 66.7% with extracutaneous manifestations. The outcome in this series was favorable in 96% cases.

[Skin diseases due to systemic vasculitides and vasculopathies]

Vasculitis and vasculopathy are two distinct disease entities. Each entity comprises a large number of heterogeneous diseases, which can occur alone or associated with autoimmune, infectious or neoplastic diseases. The terms vasculitis and vasculopathy are often falsely used synonymously. A vasculitis initially causes inflammation of the vessel walls that may result in a secondary occlusion. In contrast, a vasculopathy is a primary occlusion of the vascular lumen, which is followed by inflammation after ischemia and ulceration. In most patients the distinction can be made based on the clinical presentation. A clear clinical diagnosis is then followed by targeted serological, histological and imaging procedures to confirm the clinical diagnosis. On this basis a well-founded treatment can be initiated. In the presence of vasculitis an anti-inflammatory therapy is indicated, whereas in the case of vasculopathy, removal of the vascular occlusion is the main focus. This article provides an overview of the various diseases and addresses the pathogenetic and clinical characteristics used to differentiate the individual disease entities. It also provides an insight into the therapy options and prophylaxis.

A Case of Henoch-Schonlein Purpura Associated with Rotavirus Infection in an Elderly Asian Male and Review of the Literature

Patient: Male, 73

Final Diagnosis: Henoch-Schönlein purpura (HSP)

Symptoms: Abdominal pain • bloating • blood in stool • nausea • vomiting

Medication: —

Clinical Procedure: EGD • colonoscopy • kidney biopsy • skin biopsy • arthrocentesis

Specialty: Rheumatology

Long-term outcomes of end-stage kidney disease for patients with IgA nephropathy: A multi-centre registry study

BACKGROUND

Clinical outcomes of patients with end-stage kidney disease (ESKD) receiving renal replacement therapy (RRT) secondary to IgA nephropathy (IgAN) have not been well described.

AIM

To investigate the characteristics, treatments and outcomes of ESKD because of kidney-limited IgAN and Henoch-Schönlein purpura nephritis (HSPN) in the Australian and New Zealand RRT populations.

METHODS

All ESKD patients who commenced RRT in Australia and New Zealand between 1971 and 2012 were included. Dialysis and transplant outcomes were evaluated in both a contemporary cohort (1998-2012) and the entire cohort (1971-2012).

RESULTS

Of 63 297 ESKD patients, 3721 had kidney-limited IgAN, and 131 had HSPN. For the contemporary cohort of IgAN patients on dialysis (n = 2194), 10-year patient survival was 65%. Of 1368 contemporary IgAN patients who received their first renal allograft, 10-year patient, overall renal allograft and death-censored renal allograft survival were 93%, 82% and 88%, respectively. Using multivariable Cox regression analysis, patients with IgAN had favourable dialysis patient survival (adjusted hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.57-0.69), overall renal allograft survival (HR 0.67, 95% CI 0.57-0.79) and renal transplant patient survival (HR 0.58, 95% CI 0.45-0.74) compared with ESKD controls. Similar results were found in the entire cohort and when using competing-risks models. Compared with kidney-limited IgAN patients, those with HSPN had worse dialysis patient survival (HR 1.94, 95% CI 1.02-3.69), overall renal allograft survival (HR 3.40, 95% CI 1.00-11.55) and renal transplant patient survival (HR 3.50, 95% CI 1.03-11.92).

CONCLUSION

IgAN ESKD was associated with better dialysis and renal transplant outcomes compared with other forms of ESKD. The survival outcomes of ESKD patients with HSPN were worse than kidney-limited IgAN.

Association between allergic diseases and risks of HSP and HSP nephritis: a population-based study

BACKGROUND

Some allergic inflammation-associated mediators have been reported in acute stage of Henoch-Schönlein purpura (HSP). However, the association of children with allergic diseases and their subsequent risks of HSP and HSP nephritis remain unknown.

METHODS

In this study, we included 2,240 children with HSP diagnosed between 2000 and 2008 as well as 8,960 non-HSP controls matched for age, sex, and level of urbanization. The odds ratios (ORs) of HSP were calculated with respect to associations with pre-existing allergic diseases.

RESULTS

Children with allergic diseases had an increased subsequent risk of HSP; the lowest adjusted OR (aOR) was 1.33 for allergic conjunctivitis (95% confidence interval (CI): 1.17-1.52) and the highest was 1.68 for asthma (95% CI: 1.48-1.91). The aOR increased to 2.03 (95% CI: 1.80-2.31) in children with at least two allergic diseases. Children who visited medical institutes more often per year for associated allergic diseases had an increased risk of HSP. Of the 2,240 children with HSP, 249 (11%) had HSP nephritis and 45.8% of those with nephritis had history of any allergic disease.

CONCLUSION

Atopic children had an increased subsequent risk of HSP but not an increased risk of HSP nephritis.

Atopic Dermatitis and Association of Risk for Henoch-Schönlein Purpura (IgA Vasculitis) and Renal Involvement Among Children: Results From a Population-Based Cohort Study in Taiwan

Elevation of Th2 cytokine-driven inflammatory mediators has been reported in acute stage of Henoch-Schönlein purpura (HSP). However, the temporal interaction between Th2-mediated allergic diseases and HSP with renal involvement remains unknown. Herein, we conducted a population-based cohort analysis to investigate the risk of HSP and renal involvement in children with atopic dermatitis (AD) as 1 of the first steps in the atopic march.From 2000 to 2007, 95,208 children with newly diagnosed AD and 190,416 randomly selected non-AD controls were included in the study. By the end of 2008, incidences of HSP in both cohorts and the AD cohort to non-AD cohort hazard ratios (HRs) and confidence intervals (CIs) were measured. Comparison of renal involvement in HSP between children with and without AD was analyzed.The incidence of HSP during the study period was 1.75-fold greater (95% CI: 1.27-2.42) in the AD cohort than in the non-AD cohort (14.2 vs 8.11 per 100,000 person-years). The AD to non-AD HR of HSP was greater for girls (1.92, 95% CI: 1.18-3.13), children older than 6 years (2.54, 95% CI: 1.15-5.59), and those living in less urbanized area (2.74, 95% CI: 1.10-6.82). Concurrent allergic rhinitis or asthma did not increase the HR of HSP further. The HR for HSP in AD children increased from 0.67 (95% CI: 0.41-1.11) for those with ≤2 AD-related visits to 9.77 (95% CI: 6.44-14.8) for those with >4 visits (P < 0.0001, by the trend test). The risk of developing HSP in the AD cohort was highest within first year after AD diagnosis (HR: 3.99; 95% CI: 1.61-9.89). AD cohort with HSP had higher occurrence rate of renal involvement, particular hematuria, than non-AD cohort with HSP.AD children had a greater risk of developing HSP and HSP with renal involvement. Further research is needed to clarify the role of allergy in the pathogenesis of HSP and renal involvement.

Obesity increases the risk of renal involvement in children with Henoch-Schönlein purpura

The main aim of this study was to evaluate the relationship between obesity and renal involvement in children with Henoch-Schönlein purpura (HSP). A retrospective study of 141 pediatric patients with HSP was conducted in our hospital. The clinical data of all patients were collected from the electronic medical record management system from January 2010 to June 2014. The possible risk factors of renal involvement, especially obesity, were analyzed using univariate and multivariate analyses. Renal involvement occurred in 45/141 of the patients. A univariate analysis showed that an age more than 7 years at onset, persistent purpura, obesity, time from symptoms onset to diagnosis more than 14 days, and decreased C3 all increased the risk of renal involvement in HSP. The forward stepwise logistic regression analysis indicated obesity (odds ratio (OR) 4.43, 95 % confidence interval (CI) 1.896 to 10.358), age more than 7 years at onset (OR 2.81, 95 % CI 1.142 to 6.907), and persistent purpura (OR 2.57, 95 % CI 1.119 to 5.909) were independent risk factors for renal involvement.

CONCLUSIONS

Our results show that obesity can increase the hazard of renal involvement in children with HSP and reconfirm that older age at onset and persistent purpura are the independent risk factors for renal involvement.

WHAT IS KNOWN

• There have been some reports that obesity was associated with the development of renal injury. • It is not clear whether obesity can increase the risk of renal involvement in children with HSP. What is New: • The main finding of this study is that obesity can increase the hazard of renal involvement in children with HSP.

Stenosing ureteritis in Henoch-Schönlein purpura: report of two cases

Stenosing ureteritis (SU), a rare complication of Henoch-Schönlein purpura (HSP), typically presents with severe symptoms. We report the cases of two HSP patients presenting with gross hematuria, blood clotting, and colicky flank pain, followed by purpura on the lower extremities. Early-stage ultrasonography indicated hydronephrosis, thickened renal pelvic mucous membrane, and ureteral dilatation (UD), suggesting HSP complicated with SU. After early SU treatment with prednisolone, kidney function, thickened renal pelvic mucous membrane, and UD progressively normalized and the pain gradually disappeared. Regular ultrasonography of HSP patients from the onset of gross hematuria can be useful to detect early SU and facilitate conservative therapy with prednisolone. Diagnosis of SU can be easily missed by assuming HSP nephritis, particularly owing to the non-specific symptoms. Common characteristics as well as treatment methods and prognosis of SU are given in the literature review.

Platelet Counts in Children With Henoch-Schonlein Purpura--Relationship to Renal Involvement

BACKGROUND

The aim of this study is to identify the clinical and laboratory risk factors for renal involvement and to determine the relationship between platelet counts and renal involvement in (Henoch-Schönlein purpura) HSP patients.

METHODS

We reviewed the medical records of 107 children with HSP according to Eular/Press diagnostic criteria. Clinical and laboratory parameters for renal involvement were evaluated and compared to no renal involvement.

RESULTS

A retrospective study consisted of 107 children, 61 boys (57%), and 46 girls (43%). Twenty-eight of the 107 patients (26.1%) had renal involvement. The mean platelet count was significantly higher in patients with renal involvement when compared to patients without renal involvement (P = 0.001). The multivariate logistic regression analysis identified that age (P = 0.022), sex (P = 0.037), gastrointestinal involvement (P = 0.019), and platelet count (P = 0.019) were significantly associated with the renal involvement of HSP. The platelet count was predictive of renal involvement, which had odds ratio of 1.0, and achieved area under the curve of 0.66 for predicting the renal involvement within the acute stage of HSP (P = 0.009).

CONCLUSION

Our study indicated that age, sex, gastrointestinal involvement, and platelet count were significant risk factors of renal involvement of HSP.

Adjuvant treatments for Henoch-Schönlein purpura nephritis in children: A systematic review

BACKGROUND

The management of Henoch-Schönlein purpura nephritis (HSPN) in childhood is controversial. Adjuvant therapies such as immunoglobulin, anticoagulants, and vitamins have been used with conventional treatments despite a lack of evidence of their efficacy.

OBJECTIVE

The aim of this study was to review the scientific literature regarding adjuvant treatments administered with conventional drugs in the treatment of childhood HSPN.

METHODS

Published articles were identified from the MEDLINE and EMBASE databases (1988-December 2008; key words: Henoch-Schönlein nephritis and Henoch-Schönlein purpura). The search was limited to published English-language studies on therapeutic options for HSPN in children.

RESULTS

A total of 12 studies were identified and included in this review; most (n = 8) were case series or retrospective studies. Studies of conventional therapy combined with adjuvant treatment should be interpreted with caution. In particular, factor XIII administration was reported to improve kidney symptoms in 1 study. Based on the results from 9 studies, no convincing evidence on intravenous immunoglobu-lin, urokinase, or anticoagulants was identified. No substantial information was available on the benefit of antiplatelet agents or heparin in treating HSPN. Integrating treatment with vitamin E was not recommended based on the results from 1 randomized controlled trial. Fish oil was reported to be effective in 1 case series.

CONCLUSIONS

Studies concerning the treatment of HSPN in children with adjuvant therapies were retrospective and recommendations were drawn from level IV evidence. One randomized controlled trial on the use of tocopherol as adjuvant treatment was identified; however, no clinical utility was reported. At present, there is no strong evidence supporting benefits with the use of adjuvant treatments.

Rheumatological diseases and kidneys: a nephrologist's perspective

Renal involvement is a common occurrence in subjects with rheumatological diseases and can develop either due to the disease itself or secondary to drugs used in the treatment. The prevalence of renal involvement and its severity depends on the underlying disease as well as aggressiveness of the therapy. For most rheumatological diseases, renal involvement heralds a poor prognosis and warrants aggressive immunosuppressive treatment. Thus, it is important to diagnose and manage them at an early stage. On the other hand, patients with primary kidney disease can also develop rheumatological manifestations which need to be differentiated from the former. This article provides the nephrologist's perspective upon various rheumatological disorders and associated renal involvement with the aim of sensitizing the rheumatological community about them, resulting in better management of these subjects.

Henoch-Schönlein purpura in 535 Chinese children: clinical features and risk factors for renal involvement

OBJECTIVES

To analyse the clinical features of Henoch-Schönlein purpura (HSP) with or without nephritis in Chinese children and to determine the risk factors for renal involvement.

METHODS

Patient characteristics, clinical parameters and laboratory data were retrospectively analysed in patients with HSP with or without nephritis. Logistic regression analysis was used to identify the risk factors for renal involvement.

RESULTS

A total of 535 patients with HSP were included in the study. HSP nephritis occurred in 267 patients (49.9%), ranging from isolated haematuria in 5.2%, mild proteinuria in 77.5%, moderate proteinuria in 6.4% and severe proteinuria in 10.9% of cases. In 90% of the cases, nephritis developed within 1 week of HSP onset; 98.5% of the cases with nephritis developed the condition within 1 month. Risk factors for the development of nephritis were age ≥6 years, purpura on sites other than the lower limbs and the presence of occult blood in the stool.

CONCLUSION

These results suggest that patients aged ≥6 years, or who have purpura on the upper limbs or face, or who have occult blood in the stool should be particularly monitored for signs of nephritis.

Diagnosis and management of cutaneous vasculitis in children

Cutaneous vasculitis in children is rare. Causes of cutaneous vasculitis are varied and are typically differentiated by the affected vessel size. A skin biopsy remains the gold standard for diagnosis but other causes for vasculitis, including systemic conditions, should be considered. This article discusses the childhood conditions commonly presenting with cutaneous vasculitis (leukocytoclastic vasculitis, cutaneous polyarteritis nodosa), biopsy recommendations and findings, and management and potential differential diagnoses, and includes a brief summary of other diseases that may include cutaneous symptoms as a constellation of other systemic findings.

Validation of the absolute renal risk of dialysis/death in adults with IgA nephropathy secondary to Henoch-Schönlein purpura: a monocentric cohort study

Background

We established earlier the absolute renal risk (ARR) of dialysis/death (D/D) in primary IgA nephropathy (IgAN) which permitted accurate prospective prediction of final prognosis. This ARR was based on the potential presence at initial diagnosis of three major, independent, and equipotent risk factors such as hypertension, quantitative proteinuria ≥ 1 g per day, and severe pathological lesions appreciated by our local classification scoring ≥ 8 (range 0–20). We studied the validity of this ARR concept in secondary IgAN to predict future outcome and focused on Henoch-Schönlein purpura (HSP) nephritis.

Methods

Our cohort of adults IgAN concerned 1064 patients with 101 secondary IgAN and was focused on 74 HSP (59 men) with a mean age of 38.6 at initial diagnosis and a mean follow-up of 11.8 years. Three major risk factors: hypertension, proteinuria ≥1 g/d, and severe pathological lesions appreciated by our global optical score ≥8 (GOS integrated all elementary histological lesions), were studied at biopsy-proven diagnosis and their presence defined the ARR scoring: 0 for none present, 3 for all present, 1 or 2 for the presence of any 1 or 2 risk factors. The primary end-point was composite with occurrence of dialysis or death before (D/D). We used classical statistics and both time-dependent Cox regression and Kaplan-Meier survival curve methods.

Results

The cumulative rate of D/D at 10 and 20 years post-onset was respectively 0 and 14% for ARR = 0 (23 patients); 10 and 23% for ARR = 1 (N = 19); 27 and 33% for ARR = 2 (N = 24); and 81 and 100% (before 20 y) in the 8 patients with ARR = 3 (P = 0.0007). Prediction at time of diagnosis (time zero) of 10y cumulative rate of D/D event was 0% for ARR = 0, 10% for ARR = 1, 33% for ARR = 2, and 100% by 8.5y for ARR = 3 (P = 0.0003) in this adequately treated cohort.

Conclusion

This study clearly validates the Absolute Renal Risk of Dialysis/Death concept in a new cohort of HSP-IgAN with utility to individual management and in future clinical trials.

Renal manifestations of rheumatic diseases. A review

BACKGROUND

Renal manifestations of rheumatic diaseases are sometimes very discrete and mild. At others, they can present the leading symptomatology of a given disease. Systemic lupus erythematosus, systemic scleroderma, renal vasculitis, rheumatoid arthritis, mixed connective tissue disease, Sjögren's syndrome and gout can all manifest in or be accompanied by renal impairment.

METHODS AND RESULTS

The authors reviewed the literature on renal manifestation of rheumatic diseases using the key words, lupus erythematosus, systemic autoimmune diseases, rheumatoid arthritis, vasculitis and gout. The review below is accompanied by their own histological findings.

CONCLUSION

Diagnosis requires proper interpretation of the clinical situation, laboratory results and image analysis methods plus close interdisciplinary collaboration between nephrologist and clinical pathologist/nephropathologist.

Kawasaki disease and Henoch-Schönlein purpura - 10 years' experience of childhood vasculitis at a university hospital in Taiwan

BACKGROUND/PURPOSE

To investigate the clinical manifestations, disease activity and prognosis in different types of vasculitis.

METHODS

The charts of pediatric patients with vasculitis diagnosed from December 1997 to December 2007 were retrospectively reviewed. The first clinical manifestations and laboratory results were recorded at the time of diagnosis, and outcome evaluations with history of flare-ups were analyzed.

RESULTS

A total of 508 vasculitis patients were included in this study, of whom 124 had Henoch-Schönlein purpura (HSP), and 351 had Kawasaki disease (KD). Hematuria was observed in 79% of recurrent HSP patients at the time of diagnosis, and was associated with an increased risk of relapse (p = 0.000). In Kawasaki disease, the clinical symptoms with erythematous changes in Bacille Calmette-Guérin scars and coronary artery dilatation were more prominent in patients younger than 1 year old, and lymphadenopathy was more common in patients older than 1 year old (p = 0.001). The risk of coronary dilatation was significant in the patients with an initial presentation of thrombocytosis, and greater in patients younger than 1 year old (p = 0.027). Thrombocytopenia was more prominent in vasculitis-associated autoimmune diseases. Marked lymphocytosis with increased C-reactive protein levels was significantly noted in urticarial vasculitis patients compared with HSP patients in multivariate logistic regression analysis.

CONCLUSION

Vasculitis disease activity and prognosis were associated with initial laboratory results and clinical manifestations. Further large-scale clinical trials are warranted to validate these findings.

Henoch-Schönlein purpura outcome in children: a ten-year clinical study

INTRODUCTION

Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. It is characterized by symptoms including nonthrombocytopenic purpura, abdominal pain, haematuria/proteinuria, and arthralgia/arthritis. The pleiomorphism of clinical signs in HSP could be confused with other conditions or other vasculitis forms.

OBJECTIVE

Evaluation of HSP clinical presentation, the onset and severity of renal manifestation in affected children and their outcome.

METHODS

A retrospective study of 49 patients diagnosed with HSP was conducted from September 1999 to September 2009. Children with severe renal manifestations (nephrotic range proteinuria, with or without nephrotic or nephritic syndrome) have undergone kidney biopsy.

RESULTS

Twenty-five patients developed renal manifestations after onset of the disease. In our study child's older age was a risk factor for association with HSP nephritis. Six of the patients required kidney biopsy. They were successfully treated with various immunosuppressive protocols, as well as three of nine patients with nephrotic range proteinuria. Two patients developed most severe form of HSP nephritis, nephrotic-nephritic syndrome with histology grade IIIb/IVb. During the study period (average followup 6 years), all patients had a normal global renal function with mild proteinuria in only two cases. The prognosis of renal involvement was better than reports from other patient series.

CONCLUSION

Long-term morbidity of HSP is predominantly attributed to renal involvement. During the study period, no patient had renal insufficiency or end stage renal disease after various combinations of immunosuppressive treatment. It is recommended that patients with HSP nephritis are followed for longer periods of time with a regular measurement of renal function and proteinuria.

Stenosing ureteritis in a 7-year-old boy with Henoch-Schönlein purpura nephritis: A case report and review of the literature

INTRODUCTION

Urinary tract obstruction resulting from Henoch-Schönlein purpura (HSP) is an extremely rare urologic entity. If the genitourinary system is involved, it is primarily in the form of a focal proliferative glomerulonephritis. Stenosing disease has received little attention in the literature and treatment options are limited. Despite early intervention renal loss may be inevitable.

CASE REPORT

A 7-year-old African American male presented with renal failure secondary to bilateral sclerosing ureteritis 1 month after initial presentation with HSP. There was significant disease progression and he required multiple procedures, ultimately bilateral ureterocalycostomies and a left nephrectomy.

DISCUSSION

HSP is an immune-mediated necrotizing vasculitis. It can affect any organ system; however, in the genitourinary system, focal proliferative glomerulonephritis is a common manifestation, occurring in 20-90% of cases [8]. Extrarenal manifestations are rare.

CONCLUSION

Ureteritis and obstruction may be late occurrences, but should be considered in all patients presenting with a history of HSP and new-onset flank pain, acute renal failure, or anuria. Families and patients should be counseled that renal impairment may be a consequence of stenosing ureteritis. Management of these patients can be complicated but surgical correction must be considered in the treatment algorithm once the disease has stabilized.

Clinical practice: Diagnosis and management of Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. In this review, the main clinical features and complications are described. Although most features are self-limiting, renal disease is the most likely to result in long-term morbidity. Treatment of HSP nephritis is controversial, and the evidence for both prevention and treatment of established disease is reviewed. Follow-up for children presenting with HSP should be for at least 6 months and should include regular urine testing for proteinuria and haematuria and a blood pressure measurement. Women with a history of HSP during childhood are at increased risk of complications (such as proteinuria and hypertension) during pregnancy and should be monitored closely. This paper describes current practice with regard to investigation and management and proposes a practical care pathway of the management of a child with HSP.

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

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

Vasculitis in children

Primary systemic vasculitides of the young are relatively rare diseases, but can have a significant morbidity and mortality. The purpose of this review is to provide an overview of the paediatric vasculitides. Vasculitides that predominantly affect children will be considered in more detail than vasculitic diseases that although are seen in children affect adults more commonly, such as the ANCA associated vasculitides. New classification criteria for childhood vasculitis have recently been proposed and are currently undergoing validation. Epidemiological clues continue to implicate infectious triggers in Kawasaki Disease and Henoch Schönlein purpura. Several genetic polymorphisms have now been described in the vasculitides that may be relevant in terms of disease predisposition or development of disease complications. Treatment regimens continue to improve, with the use of different immunosuppressive medications and newer therapeutic approaches such as biologic agents. However new challenges are looming in regards to the role of inflammation in endothelial health and the long term cardiovascular morbidity for children with primary systemic vasculitis. International multicenter collaboration is of utmost importance in order for us to further advance our understanding and improve the treatment and outcome of systemic vasculitis in the young.

Successful treatment of Henoch-Schonlein purpura nephritis with plasma exchange in an adult male

Henoch-Schonlein purpura (HSP) frequently occurs in children under 15 years of age but is quite rare in adults. Most children who develop HSP nephritis completely recover from the illness, whereas up to 40% of adults have persistent hematuria and 10% develop chronic renal failure. Plasma exchange alone has been shown to be beneficial in children who have HSP nephritis. Adults have been treated using immunosuppressive drugs such as cyclophosphamide but effects are not certain. Here, we present a case of a 59-year-old white male who developed HSP nephritis while undergoing treatment with steroids. The patient developed acute renal failure with proteinuria and hematuria ∼2 weeks after being initially diagnosed with HSP by skin biopsy. Renal biopsy showed proliferative, exudative glomerulonephritis involving all 20 glomeruli; some with early crescent formation. Immunofluorescence staining showed 3+ IgA deposits in mesangium suggesting HSP-induced GN. The patient's serum creatinine rose to 2.5 mg/dl with ∼5 g of proteinuria by dipstick. Steroids were continued and the patient received plasma exchange treatments. Due to a very low leukocyte count, immunosuppressive agents were not given. Subsequently, renal function improved and the creatinine level came down to 1.3 mg/dl and proteinuria to <1 g/24 h. Since then, 1 year after this event, his serum creatinine has continued to stay at 1.2 mg/dl and he has trace proteinuria while taking a low-dose ACE inhibitor. This case illustrates the usefulness of plasma exchange in adult onset HSP nephritis, even without concomitant use of cytotoxic agents.

IgA nephropathy and Henoch-Schönlein purpura nephritis

PURPOSE OF REVIEW

IgA nephropathy and Henoch-Schönlein purpura nephritis are common glomerular disorders in pediatrics that can potentially progress to end-stage renal disease in some patients. This review summarizes our current understanding of the pathogenesis of these closely related conditions and discusses the rationale for development of diagnostic tests and prognostic markers. The review also presents the best data for long-term outcome, clinical markers of prognosis, and the results of randomized controlled trials.

RECENT FINDINGS

Our understanding of the defective galactosylation of O-linked glycans in the hinge region of human IgA1 and its role in the pathogenesis of IgA nephropathy and Henoch-Schönlein purpura nephritis has evolved over the past decade. This review discusses studies that suggest that demonstration of galactose-deficient IgA1 in the serum may become an important diagnostic tool for these conditions. Proteomic techniques for development of biomarkers for diagnosis and prognosis show promise. Although data from randomized controlled trials have failed to support the use of immunosuppressive agents in pediatric IgA nephropathy and Henoch-Schönlein purpura nephritis, recent data indicate that angiotensin converting enzyme inhibitor therapy is indicated for reduction of proteinuria.

SUMMARY

Childhood IgA nephropathy and Henoch-Schönlein purpura nephritis have the potential for serious morbidity, either during childhood or later in adulthood. In the future clinical tests will be used for noninvasive diagnosis and as markers for judging response to treatment, particularly in those individuals at highest risk for eventual progression to end-stage renal disease.

Renal involvement in childhood vasculitis

BACKGROUND/AIMS

Renal involvement comprises one of the major organ involvements in childhood vasculitis and has also an important role in the long term prognosis. The aim of this retrospective study was to analyze the demographic, clinical, laboratory features, and the treatment modalities of patients with vasculitis who had renal involvement.

METHODS

Patients with the diagnosis of vasculitis who had been followed in two pediatric nephrology centers between 1990 and 2005 were analyzed retrospectively. Patients with renal involvement were selected and further evaluated.

RESULTS

The study population consisted of 152 of 816 patients with vasculitis. Renal involvement was seen in 134 patients (17%) with Henoch-Schonlein purpura(HSP), 14 patients (45%) with polyarteritis nodosa(PAN), 3 patients with Takayasu arteritis (TA) (50%) and in 1 Wegener granulomatosis (WG) patient. The mean age of patients with renal involvement was 9.2 +/- 0.91 years in the HSP group. Hematuria with proteinuria was the most common renal finding and joint manifestations were seen less in this group. During the follow-up, only 1 patient developed chronic renal failure. Proteinuria, hematuria and aneurysms were seen in 26, 35 and 57% respectively in the PAN group. Only 1 patient (3.2%) had developed chronic renal failure. All 3 patients with TA had bilateral renal arterial involvement.

CONCLUSION

Renal involvement constitutes an important part of childhood vasculitides. With the institution of early and aggressive immunosuppressive treatment significant improvement in the long-term survival of these patients can be achieved.

[Nephropathy in Schönlein-Henoch purpura: a retrospective study of the last 25 years]

Schönlein-Henoch purpura is a systemic vasculitis due to IgA-mediated hypersensitivity, almost exclusively affecting the pediatric age group. Long-term prognosis is mainly conditioned by renal involvement, which can appear at onset or during the course of the disease. To evaluate renal involvement, 764 patients with Schönlein-Henoch purpura were retrospectively reviewed. Of these, 153 (20 %) had renal involvement, the most frequent form of presentation being non-nephrotic hematuria/proteinuria (67 patients) followed by isolated hematuria (41 patients). Renal biopsy was performed in 39 patients, and the most frequent pathological findings were diffuse mesangial proliferation with IgA deposits and less than 50 % of crescentic glomeruli. Treatment was not curative. Three patients (2 %) progressed to end-stage renal failure and required renal transplantation. One patient died. Notably, two of the patients who underwent renal transplantation had disease recurrence. We stress that nephropathy is usually benign and that it requires long-term follow-up.

Henoch-Schonlein purpura: polymorphisms in thrombophilia genes

Henoch-Schonlein purpura (HSP) is a small-sized vasculitis affecting mainly children. Based on the hypothesis that an inherited predilection to hypercoagulability may predispose to HSP or may mark those who develop acute clinical manifestations, we evaluated the possible roles of methylenetetrahydrofolate reductase (MTHFR) gene C677T, factor V (FV) gene G1691A (Leiden), and prothrombin gene G20210A polymorphisms in patients with HSP. Fifty-two HSP patients (32 boys and 20 girls) from different ethnic groups (22 Jews and 30 Arabs) and 104 ethnically matched controls were studied for these three polymorphisms. The frequencies of these mutations for each group, separately and in combinations, are described. The mutation frequencies in the MTHFR, prothrombin and FV genes in HSP patients did not differ from those in controls. In a small number of individuals (n=5) homozygosity for the 677T thermolabile variant of MTHFR was associated with hematuria. To summarise, hypercoagulability does not seem to play a role in HSP. Studies in larger cohorts and possibly inclusion of additional factors may be needed to ascertain whether homozygoty for MTHFR 677T polymorphism can influence disease severity.

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

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

Update on pediatric vasculitis

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the recent research and progress made in the field of pediatric vasculitis.

RECENT FINDINGS

Over the past year, researchers have described several polymorphisms in Henoch-Schonlein purpura and Kawasaki Disease as well as the association between various vasculitides and infections. International and multidisciplinary efforts in Kawasaki Disease have resulted in recommendations for its diagnosis, treatment, and long-term management to improve patient care and further increase global collaboration. Researchers are investigating the role of inflammation and its role in endothelial health and atherosclerosis. Treatment regimens continue to improve, with the use of different immunosuppressive medications; however, we continue to have incomplete treatment successes.

SUMMARY

Vasculitides are rare conditions with significant morbidity and mortality whose prognosis has improved with newer diagnostic modalities and treatments; however, we continue to have insufficient knowledge of vasculitides and lack unambiguous diagnostic criteria. As technology continues to progress it is clear that a single cause of these diseases may be an oversimplification: the genetic makeup of individuals, as well as various environmental exposures, are of vital importance in the pathophysiology and evolution of disease processes, as well as response to therapy. Efforts should continue to improve international multicenter collaboration and interdisciplinary efforts to help solve this ever-growing puzzle.