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Association of kidney biopsy findings with short- and medium-term outcomes in children with moderate-to-severe IgA vasculitis nephritis. Eur J Pediatr 2021; 180:3209-3218. [PMID: 33934234 DOI: 10.1007/s00431-021-04065-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/31/2021] [Accepted: 04/04/2021] [Indexed: 10/21/2022]
Abstract
Assessing the initial severity of immunoglobulin A vasculitis nephritis (IgAV-N) is important due to its determining effect on kidney management and outcomes. This paper describes a multicentre paediatric cohort of IgAV-N patients and discusses relationships among clinical presentation, histological features, and kidney outcome. We retrospectively studied a cohort of 170 children with biopsy-proven IgAV-N, diagnosed between 2007 and 2017. One-quarter of the cohort (27%) presented with initial nephrotic syndrome (NS). Kidney biopsy revealed International Study of Kidney Disease (ISKDC) grade II or grade III in 83% of cases. Endocapillary proliferation was observed in 73% of patients, and chronic lesions were observed in 25%. Data analysis showed a significant association between NS at onset and endocapillary proliferation and cellular crescents. After a median follow-up of 21 months (IQR 12-39), 30% of patients had persistent proteinuria or decreased eGFR. At the end of follow-up, kidney impairment was more often observed in patients with NS at onset and those with cellular crescents and chronic lesions on initial kidney biopsy.Conclusion: This study highlights the relationship between the clinical and histological presentation of IgAV-N and the factors that affect kidney outcome. The ISKDC classification may be improved by including lesions that are more discriminating for disease severity and prognosis. What is Known: • Nephrotic syndrome (NS) or kidney failure at diagnosis and cellular crescents in more than 50% of the glomeruli are recognized as risk factors for poor kidney outcome in immunoglobulin A vasculitis nephritis (IgAV-N). • The reference histological classification of the International Study of Kidney Disease in Children (ISKDC) is primarily based on the presence and number of affected glomeruli (mesangial proliferation, cellular crescents). The updated Oxford classification, which emphasizes tubular atrophy and interstitial fibrosis, is also used to group pathological features of IgAV-N. Both classifications have limitations. What is New: • Medical treatment should not be postponed in patients with IgAV-N and NS until after biopsy, as NS at diagnosis is associated with initial histological severity and poorer kidney outcome. This proposal needs to be verified in further studies. • Endocapillary proliferation is associated with the initial severity of IgAV-N at diagnosis, while chronic glomerular changes and interstitial fibrosis are associated with poorer short- and medium-term kidney outcomes.
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Prediction of renal outcome in Henoch-Schönlein nephritis based on biopsy findings. Pediatr Nephrol 2020; 35:659-668. [PMID: 31797094 PMCID: PMC7056733 DOI: 10.1007/s00467-019-04415-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/05/2019] [Accepted: 11/01/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND In Henoch-Schönlein nephritis (HSN), a risk factor for unfavorable outcome is prolonged proteinuria, but the value of renal biopsies in prognosis assessment is debatable. METHODS We evaluated serial renal biopsies from 26 HSN patients. Follow-up biopsy occurred at median 2.1 years after diagnostic biopsy. Patients formed two groups at the follow-up biopsy: patients without proteinuria (group I; n = 11) and with proteinuria (group II; n = 15). Biopsies underwent evaluation according to three classifications: International Study of Kidney Disease in Children (ISKDC), Oxford (MEST-C), and semiquantitative classification (SQC) including an activity and chronicity score. Analysis also included expression of pro-fibrotic (alpha-smooth muscle actin and vimentin) and inflammatory (P-selectin glycoprotein ligand-1) molecules in the diagnostic biopsy specimens. Definition of unfavorable outcome was active renal disease or reduced renal function at last follow-up. RESULTS Between the biopsies, SQC chronicity score increased in 22 (85%) patients, whereas activity score and ISKDC grade decreased in 21 (81%) and 17 (65%), respectively. Of the MEST-C parameters, endocapillary proliferation (from 83 to 13%; p < 0.001) and crescents (from 63 to 25%; p = 0.022) showed significant reduction, and segmental glomerulosclerosis (from 38 to 79%; p = 0.006) significant increment. These changes occurred similarly in groups I and II. Expression of the pro-fibrotic and inflammatory molecules showed no clinically significant differences between groups I and II. None in group I and five (33%) patients in group II had unfavorable outcome (p = 0.053). CONCLUSIONS Our results suggest that follow-up biopsies provide limited additional information to clinical symptoms in HSN outcome prediction.
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Li X, Tang M, Yao X, Zhang N, Fan J, Zhou N, Sun Q, Chen Z, Meng Q, Lei L, Zhang H, Ling C, Hua L, Chen X, Liu X. A clinicopathological comparison between IgA nephropathy and Henoch–Schönlein purpura nephritis in children: use of the Oxford classification. Clin Exp Nephrol 2019; 23:1382-1390. [DOI: 10.1007/s10157-019-01777-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
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Koskela M, Jahnukainen T, Endén K, Arikoski P, Kataja J, Nuutinen M, Ylinen E. Methylprednisolone or cyclosporine a in the treatment of Henoch-Schönlein nephritis: a nationwide study. Pediatr Nephrol 2019; 34:1447-1456. [PMID: 30955086 DOI: 10.1007/s00467-019-04238-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/10/2019] [Accepted: 03/14/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Optimal treatment of Henoch-Schönlein purpura nephritis (HSN) remains unclear. We evaluated outcome of pediatric HSN patients treated initially with either methylprednisolone (MP) or cyclosporine A (CyA) in Finland between 1996 and 2011. METHODS Outcome of 62 HSN patients was evaluated by screening urine and blood samples (n = 51) or by collecting clinical parameters from medical charts until last follow-up visit (n = 11). Sixty (97%) patients had nephrotic-range proteinuria and/or ISKDC grade ≥ III before initial treatment. Patients were initially treated with either MP pulses (n = 42) followed by oral prednisone or with CyA (n = 20). Fifty-nine (95%) patients received angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers. RESULTS Mean follow-up time was 10.8 years (range 3.2-21.2 years). One patient developed end-stage renal disease and another had decreased renal function (eGFR < 60 mL/min/1.73m2), both initially treated with MP (3%). Six patients (5 MP, 1 CyA) had eGFR between 60 and 89 mL/min/1.73m2 (10%). Eighteen patients (13 MP, 5 CyA) had proteinuria and/or hematuria (29%) and four of them had proteinuria > 0.5 g/day at end of follow-up. Sixteen (38%) MP-treated and two (10%) CyA-treated patients needed additional immunosuppressive treatment (RR 3.81, 95% CI 1.16-14.3, p = 0.035). Late initiation of treatment was associated with an increased risk for persistent proteinuria. CONCLUSIONS Long-term outcome was relatively good in both treatment groups. However, since urinary abnormalities may persist or develop, long-term follow-up of HSN patients is mandatory. Early initiation of treatment had a favorable effect on proteinuria.
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Affiliation(s)
- Mikael Koskela
- Children's Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland. .,Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, 00290, Helsinki, Finland.
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, 00290, Helsinki, Finland
| | - Kira Endén
- Department of Pediatrics, Tampere University Hospital, Tampere, Finland
| | - Pekka Arikoski
- Department of Pediatrics, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Janne Kataja
- Pediatric and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Matti Nuutinen
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.,PEDEGO Research Unit, Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology, Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Stenbäckinkatu 9, 00290, Helsinki, Finland
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Wang F, Huang L, Tang H, Li X, Zhu X, Wang X. Significance of glomerular fibrinogen deposition in children with Henoch-Schönlein purpura nephritis. Ital J Pediatr 2018; 44:97. [PMID: 30115075 PMCID: PMC6097424 DOI: 10.1186/s13052-018-0538-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/09/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Henoch-Schönlein purpura nephritis (HSPN) is the most common pediatric secondary glomerular disease. This study aimed to investigate the significance of glomerular fibrinogen (Fib) deposition in children with HSPN. METHODS Eighty-two patients with HSPN were enrolled retrospectively at the Children's Hospital of Soochow University from January 2015 to March 2017. Patients were divided into groups according to the presence or absence and intensity of glomerular Fib deposits, and clinical and pathological features were compared among the groups. RESULTS Glomerular Fib deposition was observed in 64 children (78.05%), including 1 Fib± case (1.22%), 23 Fib+ cases (28.05%), 37 Fib++ cases (45.12%), and 3 Fib+++ cases (3.66%). Significantly different levels of high-sensitivity C-reactive protein (hs-CRP), D-dimer (DD), proportions of CD19 + CD23+ cells and urine microalbumin:creatinine ratios (UMA/Cr) were noted among the different Fib deposition groups (no, mild and severe). Pairwise comparison in multiple groups revealed significantly increased hs-CRP, proportion of CD19 + CD23+ cells and UMA/Cr in the severe deposition group compared with the mild and no deposition groups, and remarkably increased DD levels were noted in the severe and mild deposition groups compared with the no deposition group. The degree of glomerular Fib deposition was positively correlated with the degree of glomerular IgA deposition, and the incidence of glomerular IgG deposition in the severe deposition group was increased compared with the no deposition group. CONCLUSION HSPN children with glomerular Fib deposition, especially those with severe Fib deposition, exhibit more severely disordered immunologic function, inflammatory reactions and hypercoagulability; glomerular damage in these patients may also be more severe.
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Affiliation(s)
- Fengying Wang
- Department of Pediatrics, Taixing Hospital Affiliated to Yangzhou University, Taixing, Jiangsu, China.,Department of Nephrology and Immunology, Soochow University Affiliated Children's Hospital, Suzhou, Jiangsu, China
| | - Lusheng Huang
- Department of Pediatrics, Taixing Hospital Affiliated to Yangzhou University, Taixing, Jiangsu, China
| | - Hangyun Tang
- Department of Nephrology and Immunology, Soochow University Affiliated Children's Hospital, Suzhou, Jiangsu, China
| | - Xiaozhong Li
- Department of Nephrology and Immunology, Soochow University Affiliated Children's Hospital, Suzhou, Jiangsu, China.
| | - Xueming Zhu
- Department of Pathology, Soochow University Affiliated Children's Hospital, Suzhou, Jiangsu, China
| | - Xingdong Wang
- Department of Pathology, Soochow University Affiliated Children's Hospital, Suzhou, Jiangsu, China
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Hennies I, Gimpel C, Gellermann J, Möller K, Mayer B, Dittrich K, Büscher AK, Hansen M, Aulbert W, Wühl E, Nissel R, Schalk G, Weber LT, Pohl M, Wygoda S, Beetz R, Klaus G, Fehrenbach H, König S, Staude H, Beringer O, Bald M, Walden U, von Schnakenburg C, Bertram G, Wallot M, Häffner K, Wiech T, Hoyer PF, Pohl M. Presentation of pediatric Henoch-Schönlein purpura nephritis changes with age and renal histology depends on biopsy timing. Pediatr Nephrol 2018; 33:277-286. [PMID: 28983704 DOI: 10.1007/s00467-017-3794-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/02/2017] [Accepted: 08/20/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND This study correlates the clinical presentation of Henoch-Schönlein purpura nephritis (HSPN) with findings on initial renal biopsy. METHODS Data from 202 pediatric patients enrolled in the HSPN registry of the German Society of Pediatric Nephrology reported by 26 centers between 2008 and 2014 were analyzed. All biopsy reports were re-evaluated for the presence of cellular crescents or chronic pathological lesions (fibrous crescents, glomerular sclerosis, tubular atrophy >5%, and interstitial fibrosis >5%). RESULTS Patients with HSPN with cellular glomerular crescents were biopsied earlier after onset of nephritis (median 24 vs 36 days, p = 0.04) than those without, whereas patients with chronic lesions were biopsied later (57 vs 19 days, p < 0.001) and were older (10.3 vs 8.6 years, p = 0.01) than those without. Patients biopsied more than 30 days after the onset of HSPN had significantly more chronic lesions (52 vs 22%, p < 0.001), lower eGFR (88 vs 102 ml/min/1.73m2, p = 0.01), but lower proteinuria (2.3 vs 4.5 g/g, p < 0.0001) than patients biopsied earlier. Children above 10 years of age had lower proteinuria (1.98 vs 4.58 g/g, p < 0.001), lower eGFR (86 vs 101 ml/min/1.73m2, p = 0.002) and were biopsied significantly later after onset of nephritis (44 vs 22 days, p < 0.001) showing more chronic lesions (45 vs 30%, p = 0.03). Proteinuria and renal function at presentation decreased with age. CONCLUSIONS In summary, we find an age-dependent presentation of HSPN with a more insidious onset of non-nephrotic proteinuria, impaired renal function, longer delay to biopsy, and more chronic histopathological lesions in children above the age of 10 years. Thus, HSPN presents more like Immunoglobulin A (IgA) nephritis in older than in younger children.
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Affiliation(s)
- Imke Hennies
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Charlotte Gimpel
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Mathildenstrasse 1, 79106, Freiburg, Germany
| | - Jutta Gellermann
- Department of Pediatric Nephrology, Charité University Hospital, Berlin, Germany
| | - Kristina Möller
- Department of Pediatrics, Klinikum Links der Weser, Bremen, Germany
| | - Brigitte Mayer
- Children's Hospital Dresden, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Anja K Büscher
- Department of Pediatrics II, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Matthias Hansen
- KfH Center of Pediatric Nephrology, Clementine Children's Hospital, Frankfurt, Germany
| | - Wiebke Aulbert
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elke Wühl
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Richard Nissel
- Children's Hospital, Städtisches Klinikum, Karlsruhe, Germany
| | - Gessa Schalk
- Pediatric Nephrology Unit, University Children's Hospital, Zurich, Switzerland
| | - Lutz T Weber
- Department of Pediatrics, University Hospital of Cologne, Cologne, Germany
| | | | - Simone Wygoda
- KfH Center of Pediatric Nephrology, St Georg Hospital, Leipzig, Germany
| | - Rolf Beetz
- Department of Pediatrics, Division of Pediatric Nephrology, Mainz University Medical Center, Mainz, Germany
| | - Günter Klaus
- KfH Center of Pediatric Nephrology, University Hospital Marburg, Marburg, Germany
| | - Henry Fehrenbach
- KfH Center of Pediatric Nephrology, Children's Hospital Memmingen, Memmingen, Germany
| | - Sabine König
- University Children's Hospital Münster, Münster, Germany
| | - Hagen Staude
- University Children's Hospital, Rostock, Germany
| | | | - Martin Bald
- Children's Hospital, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Ulrike Walden
- Department of Pediatrics II, Children's Hospital Augsburg, Augsburg, Germany
| | | | - Gunhard Bertram
- Krankenhaus St Elisabeth und St Barbara, Klinik für Kinder- und Jugendmedizin, Halle (Saale), Germany
| | - Michael Wallot
- Department of Pediatrics, Bethanien Hospital, Moers, Germany
| | - Karsten Häffner
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Mathildenstrasse 1, 79106, Freiburg, Germany
| | - Thorsten Wiech
- Nephropathology Section, Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter F Hoyer
- Department of Pediatrics II, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, University of Freiburg Faculty of Medicine, University of Freiburg, Mathildenstrasse 1, 79106, Freiburg, Germany.
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St. John J, Vedak P, Garza-Mayers AC, Hoang MP, Nigwekar SU, Kroshinsky D. Location of skin lesions in Henoch-Schönlein purpura and its association with significant renal involvement. J Am Acad Dermatol 2018; 78:115-120. [DOI: 10.1016/j.jaad.2017.04.1122] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 04/19/2017] [Accepted: 04/23/2017] [Indexed: 11/26/2022]
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Lim BJ, Shin JI, Choi SE, Rhim H, Lee JS, Kim PK, Jeong HJ, Kim JH. The significance of tubulointerstitial lesions in childhood Henoch-Schönlein nephritis. Pediatr Nephrol 2016; 31:2087-93. [PMID: 27234910 DOI: 10.1007/s00467-016-3417-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/07/2016] [Accepted: 05/11/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little information is currently available on the development of tubulointerstitial lesions in children with Henoch-Schönlein nephritis (HSN). To identify the impact of the development of tubulointerstitial changes in HSN, we retrospectively analyzed renal biopsies obtained from children with HSN. METHODS Twenty-eight children with HSN from whom serial renal biopsies had been obtained before and after immunosuppressive therapy were enrolled in the study. The patients were divided into two groups according to the observed change in tubulointerstitial lesion development: group I (n = 15), with stable or improved tubulointerstitial lesions, and group II (n = 13), with worsened tubulointerstitial lesions. Group II patients had longer duration of proteinuria than group I patients (3.7 ± 3.7 years vs. 1.7 ± 1.7 years, p = 0.052). RESULTS The change in serum albumin level was negatively correlated with the change in tubulointerstitial scores before and after treatment (γ = -0.444, p = 0.018). Group II patients showed a significant decrease in immunoglobulin G (IgG) and IgA deposits after treatment (p = 0.039 and 0.003, respectively), while group II patients did not (p = 0.458 and 0.506, respectively). CONCLUSIONS Although the International Study of Kidney Disease in Children classification of HSN does not include tubulointerstitial lesions, they can progress during treatment and could have significant clinical implications in association with the duration of proteinuria.
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Affiliation(s)
- Beom Jin Lim
- Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea.,Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, C.P.O. Box 8044, 120-752, South Korea
| | - Sung-Eun Choi
- Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyechang Rhim
- Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Seung Lee
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, C.P.O. Box 8044, 120-752, South Korea
| | - Pyung Kil Kim
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, C.P.O. Box 8044, 120-752, South Korea
| | - Hyeon Joo Jeong
- Department of Pathology, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, C.P.O. Box 8044, 120-752, South Korea.
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Poterucha TJ, Wetter DA, Grande JP, Gibson LE, Camilleri MJ, Lohse CM. A retrospective comparison of skin and renal direct immunofluorescence findings in patients with glomerulonephritis in adult Henoch-Schönlein purpura. J Cutan Pathol 2015; 41:582-7. [PMID: 25097917 DOI: 10.1111/cup.12295] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Henoch-Sch¨onlein purpura (HSP) is a vasculitis tha tcan affect the skin and kidneys. It is characterized by immunoglobulin(Ig) A-predominant deposition in small blood vessels. To our knowledge, there has been no comparison of direct immunofluorescence (DIF) findings in skin and kidney biopsy specimens. METHODS We retrospectively studied 21 adults with HSP who had IgA deposition in the skin and kidneys. The skin and kidney DIF findings were compared and tested for an association with the progression of renal disease. RESULTS Mean age of the patients was 51.4 years. Follow-up data were available for 19 patients, of whom 5 had progression to chronic kidney disease or renal failure. Concordance between DIF findings onskin and renal biopsies was 100% for IgA, 80% for C3, 80% for IgG,71% for IgM and 53% for fibrinogen. A worse renal outcome was associated with renal IgG deposition (p=0.04). A trend for worse renal outcome was found with renal fibrinogen and skin IgM deposition(p=0.10 and 0.14, respectively). CONCLUSIONS In this retrospective study of adult HSP, theconcordance between DIF findings in skin and kidney specimens was low-moderate. Further study is required to elucidate the mechanisms responsible for these differences in Ig deposition.
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Zhang Y, Gao Y, Zhang Z, Liu G, He H, Liu L. Leflunomide in addition to steroids improves proteinuria and renal function in adult Henoch-Schoenlein nephritis with nephrotic proteinuria. Nephrology (Carlton) 2014; 19:94-100. [PMID: 24171710 DOI: 10.1111/nep.12175] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Yingjuan Zhang
- Department of Nephrology; Panzhihua Central Hospital; Panzhihua City China
| | - Yun Gao
- Department of Hematology and Oncology; Panzhihua Central Hospital; Panzhihua City China
| | - Zhengxiu Zhang
- Department of Nephrology; Panzhihua Central Hospital; Panzhihua City China
| | - Gaolun Liu
- Department of Nephrology; Panzhihua Central Hospital; Panzhihua City China
| | - Hongbing He
- Department of Nephrology; Panzhihua Central Hospital; Panzhihua City China
| | - Ling Liu
- Department of Nephrology; Panzhihua Central Hospital; Panzhihua City China
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Eliahou R, Sosna J, Bloom AI. Between a rock and a hard place: clinical and imaging features of vascular compression syndromes. Radiographics 2012; 32:E33-49. [PMID: 22236908 DOI: 10.1148/rg.321115011] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Vascular compression syndromes are caused by the entrapment of vessels between rigid or semirigid surfaces in a confined anatomic space. Chronic entrapment may lead to arterial ischemia and embolism, venous stasis and thrombosis, and hematuria. These syndromes are usually seen in otherwise healthy young patients, among whom underdiagnosis is common. Most occurrences of vascular compression are associated with an underlying anatomic abnormality. In a small percentage of cases, other contributing factors, including repetitive microtrauma, may cause pathologic changes leading to the onset of pain and other symptoms of vascular and neural compression. Hence, the diagnosis must be based on both clinical and radiologic findings. Because some cases of vascular entrapment become symptomatic only when specific physical maneuvers are performed, dynamic diagnostic imaging methods are especially useful. Digital subtraction angiography has been the mainstay of imaging-based diagnosis for most vascular compression syndromes, but other methods (eg, color Doppler ultrasonography, computed tomographic angiography, and magnetic resonance angiography) are used with increasing frequency for initial diagnostic evaluation. Because vascular compression syndromes are caused by the external compression of vessels, endoluminal treatment alone is rarely adequate and surgical decompression is likely to be required for optimal and durable clinical benefit. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg.321115011/-/DC1.
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Affiliation(s)
- Ruth Eliahou
- Department of Radiology, Hadassah-Hebrew University Medical Center, PO Box 12000, Jerusalem 91120, Israel
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Poterucha TJ, Wetter DA, Gibson LE, Camilleri MJ, Lohse CM. Correlates of systemic disease in adult Henoch-Schönlein purpura: a retrospective study of direct immunofluorescence and skin lesion distribution in 87 patients at Mayo Clinic. J Am Acad Dermatol 2012; 67:612-6. [PMID: 22243766 DOI: 10.1016/j.jaad.2011.11.946] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 11/14/2011] [Accepted: 11/19/2011] [Indexed: 12/01/2022]
Abstract
BACKGROUND Detection of IgM in lesional skin of adult patients with Henoch-Schönlein purpura via direct immunofluorescence (DIF) has been associated with the presence of renal disease. OBJECTIVE We sought to examine whether DIF findings of skin biopsy specimens and distribution of skin lesions were associated with the presence of systemic disease, including renal, gastrointestinal tract, and joint involvement. METHODS We performed a retrospective review of adult patients with Henoch-Schönlein purpura seen at Mayo Clinic between 1992 and 2011. RESULTS Of the 87 patients (mean age, 46.1 years), 51 (59%) were male. A total of 39 patients (45%) had renal disease; 32 (37%), gastrointestinal tract involvement; 39 (45%), joint involvement; and 65 (75%), some systemic involvement. In all, 61 patients (70%) had cutaneous lesions above the waist. The DIF findings showed the presence of IgA in all 87 patients (100%). In addition, findings were positive for IgM in 32 patients (37%); IgG in 3 patients (3%); C3 in 75 patients (87%); and fibrinogen in 78 patients (92%). IgM was not found to be significantly associated with renal disease (P = .10); however, absence of fibrinogen was correlated with presence of renal involvement (P = .04). No other correlations were detected between DIF findings and systemic disease. Lesions above the waist were not significantly associated with renal (P = .12) or any (P = .76) systemic involvement. LIMITATIONS This study is retrospective. CONCLUSIONS Neither IgM in lesional skin nor distribution of skin lesions above the waist was a reliable indicator of renal or systemic disease in adults with Henoch-Schönlein purpura.
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Affiliation(s)
- Timothy J Poterucha
- Mayo Medical School, College of Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Wakaki H, Ishikura K, Hataya H, Hamasaki Y, Sakai T, Yata N, Kaneko T, Honda M. Henoch-Schönlein purpura nephritis with nephrotic state in children: predictors of poor outcomes. Pediatr Nephrol 2011; 26:921-5. [PMID: 21373776 DOI: 10.1007/s00467-011-1827-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Revised: 02/07/2011] [Accepted: 02/11/2011] [Indexed: 01/25/2023]
Abstract
Nephritis develops in 18-81% of Henoch-Schönlein purpura patients, and the long-term outcomes of this nephritis show great variation. A nephrotic state at disease onset has been proposed as a predictor of poor renal outcomes. We studied 42 children with Henoch-Schönlein purpura nephritis (HSPN) who presented with a nephrotic state during the early phase of the disease. The median age of the patients at the time of diagnosis was 7.4 years. The median follow-up period was 6.2 years. Twenty-five children (60%) made a complete recovery; nine (21%) progressed to end-stage renal disease. Multivariate logistic regression analyses revealed that the nephrotic state lasting for more than 3 months had a significant effect on renal outcomes (odds ratio 11.6; 95% confidential interval, 1.16-348.4; p = 0.03), whereas initial renal insufficiency, renal pathological findings, age at onset, and types of treatment did not. These findings indicate that clinical presentation, particularly duration of the nephrotic state, is related to long-term outcomes in HSPN patients with nephrosis. Our results also indicate that the therapeutic options for HSPN patients with a nephrotic state should be based on the clinical presentation rather than on the initial pathological findings alone.
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Affiliation(s)
- Hitoshi Wakaki
- Department of Pediatrics, Yokohama Municipal Citizen's Hospital, 56 Okazawa-cho, Hodogaya-ku, Yokohama, 240-0062, Japan.
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Edström Halling S, Söderberg MP, Berg UB. Predictors of outcome in Henoch-Schönlein nephritis. Pediatr Nephrol 2010; 25:1101-8. [PMID: 20174831 DOI: 10.1007/s00467-010-1444-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 12/08/2009] [Accepted: 12/09/2009] [Indexed: 10/19/2022]
Abstract
Factors predictive of renal outcome were studied in 78 children with Henoch-Schönlein nephritis followed up for as long as 17 (mean 5.2) years. Patients with a good outcome (74%) were healthy or had microalbuminuria or mild proteinuria at the final follow-up (FU), and those with poor outcome (26%) had active renal disease or chronic kidney disease at stages IV-V. Patients with mild symptoms at onset (hematuria + or - mild proteinuria) had a poor outcome in 15% of cases versus 41% of those with severe symptoms (nephritic or nephrotic syndrome or nephritic-nephrotic picture) (p = 0.011). However, among patients with mild proteinuria at onset, 18% showed a poor prognosis; non-nephrotic proteinuria with a urine albumin/creatinine ratio at a cut-off value of >144 mg/mmol at the 1-year FU was predictive of a poor outcome. Among 59 biopsied patients, 37% of those with advanced histological findings [International Study of Kidney Disease in Children (ISKDC) stages III-V] had a poor outcome compared to none of those with mild findings (ISKDC stages I-II) (p = 0.0015). Patients with a poor outcome were older at onset, had more proteinuria, and lower glomerular filtration rate at the 1-year FU compared with patients with a good outcome. Multivariate analysis showed that proteinuria at the 1-year FU and the ISKDC grading score of the renal biopsy were the two most discriminant factors of a poor prognosis.
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Affiliation(s)
- Stella Edström Halling
- Department of Clinical Science, Intervention and Technology, Division of Pediatrics, Karolinska Institutet, Astrid Lindgren Children s Hospital, Karolinska University Hospital Huddinge, 141 86, Stockholm, Sweden.
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Andersen RF, Rubak S, Jespersen B, Rittig S. Early high-dose immunosuppression in Henoch-Schönlein nephrotic syndrome may improve outcome. ACTA ACUST UNITED AC 2010; 43:409-15. [PMID: 19921987 DOI: 10.3109/00365590903164480] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Renal involvement in Henoch-Schönlein purpura (HSP) constitutes a risk of end-stage renal disease (ESRD), especially in patients presenting with nephrotic syndrome. PATIENTS AND METHODS The clinical courses of six patients (mean age 13.2 years; four boys and two girls) admitted from 2000 to 2007 with HSP and nephrotic syndrome were reviewed. Average follow-up was 44 months (28-59). Treatment protocols included oral prednisolone and in non-responders cyclosporin A, cyclophosphamide, mycophenolate mofetil or tacrolimus. Five patients were treated immediately after presentation of nephrotic syndrome/nephrotic range proteinuria (median 277 mg/m(2)/h). The last patient was treated locally with low-dose prednisolone (0.2-0.9 mg/kg/day) and 3 months of low-dose cyclophosphamide (1 mg/kg/day). RESULTS All five patients treated promptly with high-dose immunosuppressant had normal estimated glomerular filtration rate (eGFR) (median 159 ml/min/1.73 m(2)) at follow-up. One obtained complete remission, two had positive dipstick proteinuria and two needed angiotensin-converting enzyme inhibitors to stay normotensive. The patient receiving low-dose immunosuppression at onset progressed to ESRD 44 months later. At initial presentation eGFR, blood pressure, renal biopsy grading, proteinuric range and plasma albumin were similar in all patients. CONCLUSION Follow-up data from the patients suggest that an early aggressive immunosuppressive approach improves long-term renal outcome in HSP patients with nephrotic syndrome.
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Affiliation(s)
- R F Andersen
- Department of Paediatrics, Aarhus University Hospital, Skejby, Aarhus, Denmark.
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Treatment-based literature of Henoch-Schönlein purpura nephritis in childhood. Pediatr Nephrol 2009; 24:1901-11. [PMID: 19066976 DOI: 10.1007/s00467-008-1066-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 11/05/2008] [Accepted: 11/10/2008] [Indexed: 10/21/2022]
Abstract
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.
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Shenoy M, Ognjanovic MV, Coulthard MG. Treating severe Henoch-Schönlein and IgA nephritis with plasmapheresis alone. Pediatr Nephrol 2007; 22:1167-71. [PMID: 17530298 DOI: 10.1007/s00467-007-0498-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2006] [Revised: 03/24/2007] [Accepted: 03/27/2007] [Indexed: 11/28/2022]
Abstract
The aim of our study was to determine the outcome of children with severe Henoch-Schönlein nephritis (HSN) and immunoglobulin A (IgA) nephritis (IgAN) treated with early plasmapheresis alone. Children with acute renal impairment, heavy proteinuria or both and histology greater than grade 3 were treated with early plasmapheresis alone. Glomerular filtration rate (GFR) estimated from plasma creatinine (eGFR), urine albumin:creatinine ratio (UA/UC) and blood pressure 2 weeks after treatment and were measured at the last follow-up. Sixteen children (14 HSN, 2 IgAN) had a mean eGFR of 56 (17-136) ml/min per 1.73 m2 and UA/UC of 590 (12-1,379) mg/mmol. Fifteen were referred at presentation and one after 2 months, and all commenced plasmapheresis within 6 (2-13) days. All had at least nine exchanges of 90 ml/kg over 2 weeks. At 2 weeks, the eGFR had increased by 51 (95% CI 34-68; P=0.002), and the UA/UC fell by 457 (95% CI 241-673; P=0.0001). At last review after 4 (1-7.5) years, the late-referred child had required a renal transplant but the other 15 had normal eGFRs (98-142), did not require hypotensive medication, and had normal or minimally elevated UA/UC (maximum 42). Children with severe HSN and IgAN recover well if treated with plasmapheresis alone without the need for immunosuppressive therapy. A randomised trial is needed.
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Affiliation(s)
- Mohan Shenoy
- Department of Paediatric Nephrology, Royal Victoria Infirmary, Newcastle, NE1 4LP, UK
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Dagan E, Brik R, Broza Y, Gershoni-Baruch R. Henoch-Schonlein purpura: polymorphisms in thrombophilia genes. Pediatr Nephrol 2006; 21:1117-21. [PMID: 16791607 DOI: 10.1007/s00467-006-0155-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 03/05/2006] [Accepted: 03/07/2006] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Efrat Dagan
- Department of Human Genetics, Rambam Medical Center and Department of Nursing, Faculty of Welfare and Social Studies, University of Haifa, Haifa, Israel
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