1
|
Zhu Y, Dong Y, Li Y, Jin J, Ma Y. Adding Methylprednisolone and Cyclophosphamide Pulse Therapy Provides No Benefit in Pediatric IgAV Nephritis Grade III. Clin Pediatr (Phila) 2023; 62:615-621. [PMID: 36475327 DOI: 10.1177/00099228221142782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Although immunoglobulin (Ig) A vasculitis (IgAV) nephritis is a common form of secondary pediatric glomerulonephritis, there is no consensus on an appropriate therapeutic regimen for moderate-to-severe pediatric IgAV nephritis grade III or the effectiveness of aggressive immunosuppressive therapy. The objective is to evaluate the efficacy and renal outcomes of methylprednisolone pulse therapy with or without cyclophosphamide pulse therapy for grade III IgAV nephritis in children. This retrospective, single-center study included 115 children with IgAV nephritis grade III. The primary endpoint was proteinuria reduction from moderate or severe levels to a normal level. The secondary endpoint was stable renal function, that is, an increase of less than 25% from the baseline creatinine level over the 4-month follow-up period. Among 115 children with IgAV nephritis grade III, 59 received methylprednisolone and cyclophosphamide double-pulse treatment; methylprednisolone and cyclophosphamide double-pulses did not significantly improve proteinuria remission. Proteinuria improvement did not show any difference with or without cyclophosphamide treatment. Furthermore, methylprednisolone pulse therapy showed no benefit over steroid therapy alone. The demographic and baseline disease characteristics among the treatment groups were well-balanced. The rates of complete remission in 24-hour proteinuria excretion over the 4-month follow-up period in the methylprednisolone and cyclophosphamide double-pulse, methylprednisolone plus oral prednisolone, and oral prednisolone-only groups were 91.52%, 92.31%, and 100%, respectively. Renal function remained stable in all the patients. Most patients with IgAV nephritis grade III showed a good prognosis. However, the addition of methylprednisolone and/or cyclophosphamide pulses did not offer benefits over steroid-only therapy.
Collapse
Affiliation(s)
- Yaju Zhu
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Dong
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yufeng Li
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jing Jin
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yifei Ma
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
2
|
Kallash M, Vogt BA, Zeid A, Khin E, Najjar M, Aldughiem A, Benoit E, Stotter B, Rheault M, Warejko JK, Daga A. The scope of treatment of pediatric IgA vasculitis nephritis and its outcome: a Pediatric Nephrology Research Consortium study. Pediatr Nephrol 2022; 37:2687-2697. [PMID: 35233641 DOI: 10.1007/s00467-022-05496-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND IgA vasculitis (IgAV) is the most common type of vasculitis in children. There is a lack of consensus for management of significant IgAV nephritis (IgAVN). This study was designed to identify the most used treatment options and describe their efficacy. METHODS This is a multicenter retrospective study of children age 1-21 years with IgAVN who were managed for at least 6 months by a nephrologist. Subjects with at least microscopic hematuria and proteinuria and/or decreased kidney function were enrolled. Kidney outcome was assessed by eGFR and urine protein/creatinine (UPC) ratios at 2-4 weeks, 3, 6, and 12 months post-diagnosis. RESULTS A total of 128 subjects with median age of 7 years (range 2-18) were included. Of these, 69 subjects had kidney biopsy with crescents detected in 53%. AKI (P = 0.039), nephrosis (P = 0.038), and crescents on biopsy (P = 0.013) were more likely in older patients. Patients with UPC > 1 mg/mg were more likely to get a kidney biopsy (P < 0.001) and to be treated with steroids ± immunosuppressive (IS) agents (P = 0.001). Sixty-six percent of patients were treated with steroids and/or IS agents for variable durations. Anti-metabolite agents were the most common IS agents used with variability in dosing and duration. At 12 months, most subjects had a normal eGFR (79%) (median 123, range 68-207 mL/min/1.73 m2) and no proteinuria (median UPC 0.15, range 0.01-4.02 mg/mg). CONCLUSIONS IS agents are frequently used in managing IgAVN associated with heavy proteinuria, nephrosis, and/or AKI. Prospective studies are needed to determine indications and needed duration of IS therapy. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Mahmoud Kallash
- Section of Pediatric Nephrology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Beth A Vogt
- Section of Pediatric Nephrology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ahmed Zeid
- Section of Pediatric Nephrology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ei Khin
- Section of Pediatric Nephrology, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Mohammed Najjar
- Section of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ahmad Aldughiem
- Section of Pediatric Nephrology, Dayton Children's Hospital, Dayton, OH, USA
| | - Elizabeth Benoit
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Stotter
- Division of Nephrology, Hypertension, and Pheresis, Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO, USA
| | - Michelle Rheault
- Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Jillian K Warejko
- Section of Pediatric Nephrology, Yale University School of Medicine, New Haven, CT, USA
| | - Ankana Daga
- Pediatric Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
3
|
Butzer S, Hennies I, Gimpel C, Gellermann J, Schalk G, König S, Büscher AK, Lemke A, Pohl M. Early clinical course of biopsy-proven IgA vasculitis nephritis. BMC Pediatr 2022; 22:570. [PMID: 36195856 PMCID: PMC9531371 DOI: 10.1186/s12887-022-03611-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND IgA vasculitis (IgAV) is the most common form of systemic vasculitis in childhood and frequently involves the kidney. A minority of patients with IgA vasculitis nephritis (IgAVN), especially those presenting with heavy proteinuria and/or kidney failure at onset, are at risk of chronic end-stage kidney disease. For deciding upon treatment intensity, knowledge of the short-term clinical course of IgAVN is needed to improve treatment algorithms. METHODS For this retrospective multicenter study, the medical records of 66 children with biopsy-proven IgAVN were reviewed. Age, gender, medical history and therapeutic interventions were recorded. Laboratory data included serum creatinine, albumin, urinary protein excretion (UPE) and glomerular filtration rate (eGFR). Threshold values were determined for each parameter, full remission was defined as no proteinuria and eGFR > 90 ml/min/1.73m2. RESULTS Median age at onset of IgAVN was 8.9 years. 14.1% of the children presented with nephrotic syndrome, 50% had an eGFR below 90 ml/min/1.73 m2 and 51.5% showed cellular crescents in renal histology. The treatment regimens varied notably. Forty-four patients were treated with immunosuppression; 17 patients with crescents or nephrotic syndrome were treated with corticosteroid (CS) pulse therapy. After 6 months, UPE had decreased from 3.7 to 0.3 g/g creatinine and the proportion of patients with a decreased eGFR had fallen from 50.0% to 35.5%. Thirteen children (26.5%) achieved full remission within 6 months. CONCLUSIONS In most patients with IgAVN proteinuria decreases slowly and kidney function improves, but full remission is reached only in a minority after 6 months. Persistent heavy proteinuria in the first two months rarely developed into long-term proteinuria. Therefore, decisions for more intense treatment should take into account the course of UPE over time. For a comparison of treatment effects, patient numbers were too small. Prospective, randomized controlled trials are necessary to clarify risk factors and the effect of immunosuppressive therapies.
Collapse
Affiliation(s)
- Sarina Butzer
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany. .,University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany.
| | - 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, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jutta Gellermann
- Department of Pediatric Nephrology, Charité University Hospital, Berlin, Germany
| | - Gesa Schalk
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany
| | - Sabine König
- University Children's Hospital Münster, Münster, Germany
| | - Anja K Büscher
- Department of Pediatrics II, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Anja Lemke
- Department of Pediatrics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
4
|
Yang X, Li Q, He Y, Zhu Y, Yang R, Zhu X, Zheng X, Xiong W, Yang Y. Individualized medication based on pharmacogenomics and treatment progress in children with IgAV nephritis. Front Pharmacol 2022; 13:956397. [PMID: 35935867 PMCID: PMC9355498 DOI: 10.3389/fphar.2022.956397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Immunoglobulin A vasculitis (IgAV) nephritis, also known as Henoch-Schönlein purpura nephritis (HSPN), is a condition in which small blood vessel inflammation and perivascular IgA deposition in the kidney caused by neutrophil activation, which more often leads to chronic kidney disease and accounts for 1%–2% of children with end-stage renal disease (ESRD). The treatment principles recommended by the current management guidelines include general drug treatment, support measures and prevention of sequelae, among which the therapeutic drugs include corticosteroids, immunosuppressive agents and angiotensin system inhibitors. However, the concentration range of immunosuppressive therapy is narrow and the individualized difference is large, and the use of corticosteroids does not seem to improve the persistent nephropathy and prognosis of children with IgAV. Therefore, individualized maintenance treatment of the disease and stable renal prognosis are still difficult problems. Genetic information helps to predict drug response in advance. It has been proved that most gene polymorphisms of cytochrome oxidase P450 and drug transporter can affect drug efficacy and adverse reactions (ADR). Drug therapy based on genetics and pharmacogenomics is beneficial to providing safer and more effective treatment for children. Based on the pathogenesis of IgAV, this paper summarizes the current therapeutic drugs, explores potential therapeutic drugs, and focuses on the therapeutic significance of corticosteroids and immunosuppressants in children with IgAV nephritis at the level of pharmacogenomics. In addition, the individualized application of corticosteroids and immunosuppressants in children with different genotypes was analyzed, in order to provide a more comprehensive reference for the individualized treatment of IgAV nephritis in children.
Collapse
Affiliation(s)
- Xuerong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qi Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuanyuan He
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yulian Zhu
- Department of Pharmacy, Ziyang People’s Hospital, Ziyang, China
| | - Rou Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoshi Zhu
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
| | - Xi Zheng
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Xiong
- Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- *Correspondence: Wei Xiong, ; Yong Yang,
| | - Yong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- *Correspondence: Wei Xiong, ; Yong Yang,
| |
Collapse
|
5
|
Timely and individualized use of immunosuppression is associated with favourable outcomes in paediatric IgA vasculitis nephritis. Pediatr Nephrol 2022; 37:913-914. [PMID: 35006360 DOI: 10.1007/s00467-021-05405-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/09/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
|
6
|
Kang Z, Xun M, Li Z, Yang Z. Association of the clinicopathological characteristics and proteinuria remission of pediatric IgAV with nephrotic-range proteinuria: A retrospective cohort study. Front Pediatr 2022; 10:959212. [PMID: 36340706 PMCID: PMC9634576 DOI: 10.3389/fped.2022.959212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND IgA vasculitis (IgAV) combined with nephrotic-range proteinuria is uncommon, and nephrotic-range proteinuria is considered a risk factor for poor prognosis in children with IgAV. There are few clinical studies with large samples. METHODS Children with IgAV and nephrotic-range proteinuria who were hospitalized at the Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, from March 2008 to January 2020 were retrospectively studied; the patients were aged ≤18 years and were followed up for ≥12 months. We analyzed clinical characteristics, pathological changes, treatment responses, and their relationships in patients with IgAV combined with nephrotic-range proteinuria. RESULTS Two hundred seventy-seven children with an average age at onset of IgAV with nephritis (IgAVN) of 8.0 years (interquartile range (IQR), 6.0-10.0) were enrolled; 65.7% were aged 6-10 years. The male-to-female ratio was 1.35:1. All children had both nephrotic-range proteinuria and hematuria, 49 (17.7%) had hypoalbuminemia, and 9 (3.2%) had estimated glomerular filtration rate < 90 (mL/min/1.73 m2). All included children were followed up for at least 1 year. At 3, 6, and 12 months of follow-up, the remission rates of proteinuria in children with IgAV combined with nephrotic-range proteinuria were 27.8%, 62.1%, and 83.0%, respectively, and the remission rates of hematuria were 1.4%, 8.7%, and 35.7%, respectively. In addition, children with age at onset of IgAV with nephrotic-range proteinuria ≥10 years, who were female, who had proteinuria ≥100 mg/kg/24 h, and who had a pathological grade III or above had lower remission rates of hematuria and proteinuria (P < 0.05). Multivariate factor analysis was performed by logistic regression and showed age at onset of IgAVN ≥ 10 years and crescents to be risk factors for nonremission of proteinuria at 12 months of follow-up (P < 0.05). CONCLUSIONS Age at onset of IgAVN, sex, proteinuria level, pathological grade, and crescents significantly affect proteinuria remission in children with IgAV combined with nephrotic-range proteinuria.
Collapse
Affiliation(s)
- Zhijuan Kang
- Department of Pediatrics, Third Xiangya Hospital of Central South University, Changsha, China.,Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Mai Xun
- Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Zhihui Li
- Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Zuocheng Yang
- Department of Pediatrics, Third Xiangya Hospital of Central South University, Changsha, China
| |
Collapse
|
7
|
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP), also called IgA vasculitis, is a systemic vasculitis characterized by deposits of immunoglobulin A in blood vessels. Renal impairment of these patients is the main determinant of prognosis. The optimal treatment of HSP nephritis (HSPN) in children remains controversial, but many clinicians administer an immunosuppressive agent with a corticosteroid. A previous study reported that leflunomide (LEF) with a corticosteroid was effective for adult patients with HSPN and nephrotic proteinuria. However, data on this treatment in pediatric patients is limited. METHODS We described our experience at a single center on the use of LEF in 5 pediatric patients who had IgA vasculitis with proteinuria that was nearly 50 mg/kg (nephrotic range) and remained high despite administration of intravenous steroid, and biopsy-proven nephritis. All patients had class II to IIIb lesions based on the International Study of Kidney Disease in Children (ISKDC). RESULTS We successfully treated all 5 children who had IgA vasculitis with nephritis using LEF with a corticosteroid. Four patients achieved a complete remission of proteinuria, and 1 patient had significantly reduced proteinuria. The children received LEF for 6 months to 12 months, and none of them had severe adverse events. CONCLUSIONS To our knowledge, this is the first case series to report successful treatment of pediatric HSPN with LEF in combination with a corticosteroid.
Collapse
Affiliation(s)
- Ling Hou
- Department of Pediatrics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, 110004, Shenyang, China
| | - Zhou Zhang
- Department of Pediatrics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, 110004, Shenyang, China
| | - Yue Du
- Department of Pediatrics, Shengjing Hospital of China Medical University, No. 36 Sanhao Street Heping District, 110004, Shenyang, China.
| |
Collapse
|
8
|
Kara MA, Kiliç BD, Büyükçelik M, Balat A. Renal biopsy in children with IgA vasculitis. ACTA ACUST UNITED AC 2021; 44:48-57. [PMID: 34328167 PMCID: PMC8943869 DOI: 10.1590/2175-8239-jbn-2021-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/02/2021] [Indexed: 11/23/2022]
Abstract
Introduction Henoch-Schönlein purpura nephritis (HSN) is defined as Henoch-Schönlein purpura with kidney involvement, including hematuria and/or proteinuria. The aim of this study was to evaluate the data of HSN patients who underwent renal biopsy, and compare the main clinical and laboratory parameters that may affect renal biopsy findings, treatment protocols, and short- and long-term outcome of those patients. Methods Biopsies performed in 72 HSN patients between January 2007 to January 2017 were retrospectively evaluated. They were divided into two groups according to renal biopsy classification of the International Study of Kidney Disease in Children. Renal outcome, clinical and laboratory parameters, treatment protocols, and outcome were compared between groups. Short- and long-term follow-up of patients were evaluated. Results Of 72 patients, 47 were male (65.3%) and 44 (61.1%) were ≤10 years of age. Neutrophil-lymphocyte ratio was found higher in patients with scrotal involvement (p=0.042). Short-term unfavorable outcome was significantly higher in patients with scrotal involvement (p=0.038). Patients with hypertension and decreased creatinine clearance were found to have more unfavorable outcomes in long-term follow-up (p=0.029, p=0.040). Conclusion Cyclosporin-A and cyclophosphamide could be effective in steroid unresponsive HSN patients. Patients with scrotal involvement, decreased creatinine clearance, and hypertension should be closely monitored for sequelae of HSN.
Collapse
Affiliation(s)
- Mehtap Akbalik Kara
- Gaziantep University, Faculty of Medicine, Department of Pediatric Nephrology, Gaziantep, Şehitkamil, Turkey
| | - Beltinge Demircioğlu Kiliç
- Gaziantep University, Faculty of Medicine, Department of Pediatric Nephrology, Gaziantep, Şehitkamil, Turkey
| | - Mithat Büyükçelik
- Gaziantep University, Faculty of Medicine, Department of Pediatric Nephrology, Gaziantep, Şehitkamil, Turkey
| | - Ayşe Balat
- Gaziantep University, Faculty of Medicine, Department of Pediatric Nephrology and Rheumatology, Gaziantep, Şehitkamil, Turkey
| |
Collapse
|
9
|
Imai T, Nishiyama K, Ueki K, Tanaka T, Kaku Y, Hara T, Ohga S. Involvement of activated cytotoxic T lymphocytes and natural killer cells in Henoch-Schönlein purpura nephritis. Clin Transl Immunology 2020; 9:e1212. [PMID: 33282293 PMCID: PMC7684975 DOI: 10.1002/cti2.1212] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 11/07/2022] Open
Abstract
Objectives Immunoglobulin A vasculitis/Henoch–Schönlein purpura (IgAV/HSP) is a major cause of vasculitis in children. It is often accompanied by nephritis (HSPN) and could progress to chronic kidney disease. Galactose‐deficient IgA1 was recently reported to be involved in the pathogenesis of HSPN, for which immunosuppressive drugs are considered key treatment. However, the involvement of immune cells in the development of HSPN remains unclear. Methods We compared gene expressions of peripheral blood mononuclear cells (PBMCs) among healthy controls (n = 10), IgAV/HSP patients (n = 21) and HSPN patients (n = 8), which required nephritis development within 3 months of IgAV/HSP onset. Immunohistochemistry analysis and flow cytometry were performed to assess renal biopsy specimens and PBMCs, respectively. Serum CX3CL1 levels were measured by ELISA. Results GNLY and GZMB expressions increased in HSPN patients, consistent with increased number of glomerular granulysin‐ and/or granzyme B‐positive cells demonstrated by immunohistochemistry analysis. Additionally, circulating cytotoxic T lymphocytes (CTLs) and natural killer (NK) cells were activated with the up‐regulated surface expressions of human leucocyte antigen DR (HLA‐DR) and CX3CR1 in HSPN patients with severe proteinuria. Renal biopsies demonstrated increased number of CD8+ cells and/or CD56+ cells and up‐regulated expression of glomerular CX3CL1, a specific ligand for CX3CR1, along with increased serum CX3CL1 level. Conclusion Activated CTLs and NK cells play roles in the development of nephritis in IgAV/HSP patients and can be used as novel biomarkers for HSPN.
Collapse
Affiliation(s)
- Takashi Imai
- Department of Pediatrics Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Kei Nishiyama
- Department of Pediatrics Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Tamami Tanaka
- Department of Pediatrics Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Yoshitsugu Kaku
- Department of Pediatric Nephrology Fukuoka Children's Hospital Fukuoka Japan
| | - Toshiro Hara
- Kawasaki Disease Center Fukuoka Children's Hospital Fukuoka Japan
| | - Shouichi Ohga
- Department of Pediatrics Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| |
Collapse
|
10
|
Maritati F, Canzian A, Fenaroli P, Vaglio A. Adult-onset IgA vasculitis (Henoch-Schönlein): Update on therapy. Presse Med 2020; 49:104035. [PMID: 32645417 DOI: 10.1016/j.lpm.2020.104035] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 03/05/2019] [Indexed: 12/22/2022] Open
Abstract
Immunoglobulin A vasculitis (IgAV, formerly Henoch-Schönlein purpura) is a systemic inflammatory disease affecting small vessels. While it is common and usually benign in childhood, in adults it is rarer has a more severe course. Its main manifestations are cutaneous purpura, arthralgias or arthritis, acute enteritis and glomerulonephritis. Renal involvement is associated with a poor prognosis in adults. The treatment of adult-onset IgAV is still a matter of debate: although in patients with a non-severe phenotype remission can occur spontaneously, more severe cases may need immunosuppressive therapy. There are some areas of uncertainty with respect to the efficacy of immunosuppressive regimens: almost all data come from studies performed in children or from patients with IgA nephropathy and/or IgA-crescentic glomerulonephritis. The only randomised study performed in adults with IgAV and renal involvement showed that immunosuppressive therapy with cyclophosphamide did not improve renal outcome nor did it affect patient survival. The possible efficacy of other drugs is reported only in small case series. Recent evidences show that rituximab could be an effective therapeutic option for adult-onset IgAV, but this also needs to be confirmed in controlled trials. In this review, we focus on therapeutic options for adult-onset IgAV treatment, and discuss the main results of the studies performed so far.
Collapse
Affiliation(s)
| | - Alice Canzian
- Nephrology Unit, Parma University Hospital, Parma, Italy
| | | | - Augusto Vaglio
- Department of Biochemical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, and Meyer Children's Hospital, Firenze, Italy.
| |
Collapse
|
11
|
Isobe M, Amano K, Arimura Y, Ishizu A, Ito S, Kaname S, Kobayashi S, Komagata Y, Komuro I, Komori K, Takahashi K, Tanemoto K, Hasegawa H, Harigai M, Fujimoto S, Miyazaki T, Miyata T, Yamada H, Yoshida A, Wada T, Inoue Y, Uchida HA, Ota H, Okazaki T, Onimaru M, Kawakami T, Kinouchi R, Kurata A, Kosuge H, Sada KE, Shigematsu K, Suematsu E, Sueyoshi E, Sugihara T, Sugiyama H, Takeno M, Tamura N, Tsutsumino M, Dobashi H, Nakaoka Y, Nagasaka K, Maejima Y, Yoshifuji H, Watanabe Y, Ozaki S, Kimura T, Shigematsu H, Yamauchi-Takihara K, Murohara T, Momomura SI. JCS 2017 Guideline on Management of Vasculitis Syndrome - Digest Version. Circ J 2020; 84:299-359. [PMID: 31956163 DOI: 10.1253/circj.cj-19-0773] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Koichi Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical Center, Saitama Medical University
| | - Yoshihiro Arimura
- Department of Rheumatology and Nephrology, Kyorin University School of Medicine.,Internal Medicine, Kichijoji Asahi Hospital
| | - Akihiro Ishizu
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine
| | | | - Yoshinori Komagata
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Graduate School of Medicine
| | - Kimihiro Komori
- Division of Vascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Kei Takahashi
- Department of Pathology, Toho University Ohashi Medical Center
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
| | - Hitoshi Hasegawa
- Department of Hematology, Clinical Immunology, and Infectious Diseases, Ehime University Graduate School of Medicine
| | - Masayoshi Harigai
- Department of Rheumatology, School of Medicine, Tokyo Women's Medical University
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki
| | | | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center
| | - Hidehiro Yamada
- Medical Center for Rheumatic Diseases, Seirei Yokohama Hospital
| | | | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Graduate School of Medical Sciences, Kanazawa University
| | | | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Hideki Ota
- Department of Advanced MRI Collaboration Research, Tohoku University Graduate School of Medicine
| | - Takahiro Okazaki
- Vice-Director, Shizuoka Medical Center, National Hospital Organization
| | - Mitsuho Onimaru
- Division of Pathophysiological and Experimental Pathology, Department of Pathology, Graduate School of Medical Sciences, Kyushu University
| | - Tamihiro Kawakami
- Division of Dermatology, Tohoku Medical and Pharmaceutical University
| | - Reiko Kinouchi
- Medicine and Engineering Combined Research Institute, Asahikawa Medical University.,Department of Ophthalmology, Asahikawa Medical University
| | - Atsushi Kurata
- Department of Molecular Pathology, Tokyo Medical University
| | | | - Ken-Ei Sada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Eiichi Suematsu
- Division of Internal Medicine and Rheumatology, National Hospital Organization, Kyushu Medical Center
| | - Eijun Sueyoshi
- Department of Radiological Science, Nagasaki University Graduate School of Biomedical Sciences
| | - Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University Faculty of Medicine
| | | | - Hiroaki Dobashi
- Division of Hematology, Rheumatology and Respiratory Medicine Department of Internal Medicine, Faculty of Medicine, Kagawa University
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute
| | - Kenji Nagasaka
- Department of Rheumatology, Ome Municipal General Hospital
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University
| | | | - Shoichi Ozaki
- Division of Rheumatology and Allergology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | - Hiroshi Shigematsu
- Clinical Research Center for Medicine, International University of Health and Welfare
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | | |
Collapse
|
12
|
Hao GX, Song LL, Zhang DF, Su LQ, Jacqz-Aigrain E, Zhao W. Off-label use of tacrolimus in children with glomerular disease: Effectiveness, safety and pharmacokinetics. Br J Clin Pharmacol 2020; 86:274-284. [PMID: 31725919 DOI: 10.1111/bcp.14174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022] Open
Abstract
Glomerular diseases are leading causes of end-stage renal disease in children. Tacrolimus is frequently used off-label in the treatment of glomerular diseases. The effectiveness, safety and pharmacokinetic data of tacrolimus in the treatment of glomerular diseases in children are reviewed in this paper to provide evidence to support its rational use in clinical practice. The remission rates in previously published studies were different. In 19 clinical trials on children with nephrotic syndrome, the overall remission rate was 52.6-97.6%. In four clinical trials on children with lupus nephritis, the overall remission rate was 81.8-89.5%. In a pilot study with paediatric Henoch-Schönlein purpura nephritis patients, the overall remission rate was 100.0%. Infection, nephrotoxicity, gastrointestinal symptoms and hypertension are the most common adverse events. Body weight, age, CYP3A5 genotype, cystatin-C and daily dose of tacrolimus may have significant effects on the pharmacokinetics of tacrolimus in children with glomerular disease. More prospective controlled trials with long follow-up are needed to demonstrate definitely the effectiveness, safety and pharmacokinetics of tacrolimus in children with glomerular diseases.
Collapse
Affiliation(s)
- Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Lin-Lin Song
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Dong-Feng Zhang
- Department of Pediatric Nephrology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Le-Qun Su
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| |
Collapse
|
13
|
Nuutinen M. Comment on: European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis-the SHARE initiative. Rheumatology (Oxford) 2019; 58:1697. [PMID: 31243449 DOI: 10.1093/rheumatology/kez257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 05/24/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Matti Nuutinen
- Department of Children and Adolescents, Oulu University Hospital.,PEDEGO Research Unit, Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology, Medical Research Center Oulu, Oulu, Finland
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Koshiba K, Muraoka S, Nanki T, Komatsumoto S. Successful Treatment of IgA Vasculitis Complicated with Bowel Perforation and Crescentic Glomerulonephritis by Combination Therapy of Glucocorticoid, Cyclosporine and Factor XIII Replacement. Intern Med 2018; 57:3035-3040. [PMID: 29877285 PMCID: PMC6232042 DOI: 10.2169/internalmedicine.0931-18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
We report the findings of an 18-year-old boy with immunoglobulin A vasculitis (IgAV) complicated with bowel perforation and nephritis. He presented with abdominal pain, arthralgia and palpable purpura. Massive proteinuria developed during his clinical course. The patient was treated successfully using combination therapy of glucocorticoid (GC), cyclosporine (CYA) and factor XIII (F XIII) replacement. A standard treatment strategy for severe IgAV patients has not been established due to its rarity. Combination therapy using GC, CYA and F XIII replacement should be considered for severe IgAV patients.
Collapse
Affiliation(s)
- Keiko Koshiba
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Japan
| | - Sei Muraoka
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Japan
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, Japan
| | - Toshihiro Nanki
- Division of Rheumatology, Department of Internal Medicine, Toho University School of Medicine, Japan
| | - Satoru Komatsumoto
- Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Japan
| |
Collapse
|
16
|
Zhang DF, Hao GX, Li CZ, Yang YJ, Liu FJ, Liu L, Yuan XY, Li RH, Dong L, Dong Q, Jacqz-Aigrain E, Zhao W. Off-label use of tacrolimus in children with Henoch-Schönlein purpura nephritis: a pilot study. Arch Dis Child 2018. [PMID: 29535109 DOI: 10.1136/archdischild-2017-313788] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Tacrolimus is used off-label in the treatment of Henoch-Schönlein purpura nephritis (HSPN) in children, with limited evidence-based data. Based on clinical empirical experience and mechanism of action, tacrolimus might be promoted as treatment for childhood HSPN. The objectives of this pilot study were to assess its effectiveness and safety, and to explore the potential impact of CYP3A5 genotype. METHODS Children with HSPN receiving tacrolimus as empirical treatment were included in this prospective, observational study. Effectiveness was classified as complete remission, partial remission or non-response. General safety data analyses during and after study drug exposure included adverse events, reasons for discontinuation, deaths, laboratory data and vital signs. Trough concentration was determined using high-performance liquid chromatography with tandem mass spectrometry. Pharmacogenetic analysis was performed on the CYP3A5 gene. RESULTS A total of 20 patients with a mean age of 7.5 (SD 2.1) years participated in the whole process of the study. Twelve patients reached complete remission and eight patients reached partial remission at the end of 6-month treatment. No patients discontinued tacrolimus treatment due to adverse events, and no drug-related adverse events were shown to have a causal association with tacrolimus therapy. Dose-adjusted trough concentration was significantly higher in children with CYP3A5*1 allele as compared with patients with CYP3A5*3/*3 genotype (170.7±100.9 vs 79.8±47.4 (ng/mL)/(mg/kg)). CONCLUSION This pilot study showed that tacrolimus might be an effective and well-tolerated drug for the treatment of HSPN in children. CYP3A5 polymorphism had a significant impact on tacrolimus concentration.
Collapse
Affiliation(s)
- Dong-Feng Zhang
- Department of Nephrology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Chun-Zhen Li
- Department of Nephrology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Yan-Jun Yang
- Department of Nephrology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Fu-Juan Liu
- Department of Nephrology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Ling Liu
- Department of Nephrology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Xiao-Ying Yuan
- Department of Nephrology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Rui-Hong Li
- Department of Pharmacy, Children's Hospital of Hebei Province, Jinan, China.,Pediatric Pharmacology, Pediatric Research Institute, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Lei Dong
- Department of Pharmacy, Children's Hospital of Hebei Province, Jinan, China.,Pediatric Pharmacology, Pediatric Research Institute, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Qian Dong
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France.,Clinical Investigation Center CIC1426, INSERM, Paris, France
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan, China
| |
Collapse
|
17
|
Hackl A, Becker JU, Körner LM, Ehren R, Habbig S, Nüsken E, Nüsken KD, Ebner K, Liebau MC, Müller C, Pohl M, Weber LT. Mycophenolate mofetil following glucocorticoid treatment in Henoch-Schönlein purpura nephritis: the role of early initiation and therapeutic drug monitoring. Pediatr Nephrol 2018; 33:619-629. [PMID: 29177628 DOI: 10.1007/s00467-017-3846-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 11/02/2017] [Accepted: 11/03/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) is the most common vasculitis in childhood and traditionally considered as a self-limiting disease. However, renal involvement can unfavorably determine long-term prognosis. The reported regimens to treat HSP nephritis (HSPN) are diverse, indicating that the most effective treatment remains controversial. METHODS This retrospective, single-center study involved 18 patients presenting with HSPN and nephrotic-range proteinuria. We aimed to investigate the efficacy and safety of mycophenolate mofetil (MMF) and identify a cut-off level for estimated mycophenolic acid area under the curve (eMPA-AUC0-12h) values, which can predict complete remission with high sensitivity. RESULTS Despite prior insufficient therapeutic response to corticosteroids, 89% of patients showed a significant decrease in proteinuria after 1 month of MMF treatment. None of them relapsed during treatment; however, two children relapsed after discontinuation. Based on results of a receiver operating characteristic (ROC) analysis, an eMPA-AUC0-12h >56.4 mg*h/l was a predictor for complete remission within 3 months (80% sensitivity, 83.3% specificity, p = 0.035). During MMF administration, we encountered no adverse event requiring discontinuation of treatment. CONCLUSION Our study demonstrates that MMF is a safe and potentially effective secondary treatment option for children with HSPN to achieve and maintain long-term remission without serious side effects. To achieve complete remission within 3 months, resolve severe inflammatory glomerular lesions, and avoid progression to chronic kidney disease, we propose timely diagnosis and early initiation of MMF with an eMPA-AUC0-12h value of 56.4 mg*h/l.
Collapse
Affiliation(s)
- Agnes Hackl
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany.
| | - Jan U Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Lisa M Körner
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Rasmus Ehren
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Sandra Habbig
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Eva Nüsken
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Kai-Dietrich Nüsken
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Kathrin Ebner
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Max C Liebau
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany.,Nephrology Research Laboratory, Department II of Internal Medicine, University Hospital of Cologne, Cologne, Germany.,Center for Molecular Medicine, University Hospital of Cologne, Cologne, Germany
| | - Carsten Müller
- Department of Therapeutic Drug Monitoring, Centre of Pharmacology, University Hospital of Cologne, Cologne, Germany
| | - Martin Pohl
- Department of General Pediatrics, Adolescent Medicine and Neonatology, Medical Center - Faculty of Medicine, University of Freiburg Germany, Freiburg, Germany
| | - Lutz T Weber
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| |
Collapse
|
18
|
|
19
|
Lopalco G, Rigante D, Venerito V, Emmi G, Anelli MG, Lapadula G, Iannone F, Cantarini L. Management of Small Vessel Vasculitides. Curr Rheumatol Rep 2017; 18:36. [PMID: 27118389 DOI: 10.1007/s11926-016-0580-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Inflammation mediated by cells of the immune system and necrosis are the most striking features observed at the histologic level in patients with vasculitides, clinical entities classified according to pathologic findings involving different organs, to etiology, or to size of vessels involved. Small vessel vasculitides (SVV) are a peculiar group of systemic disorders electively involving small intraparenchymal arteries, arterioles, capillaries, or venules and leading to different levels of vascular obstruction, tissue ischemia and risk of infarction; they can be divided into anti-neutrophil cytoplasmic antibody-associated vasculitides and immune complex vasculitides. Despite the significant advances in understanding the whole disease process and pathophysiology of SVV, strong efforts are still needed to draft, share and spread guidelines in the therapeutic management of these protean disorders. After an accurate evaluation of different open or double-blind trials and cohort studies in this review, we analyze the actual medical tools suggested for treating granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis, Henoch-Schönlein purpura, cryoglobulinemic vasculitis, anti-glomerular basement membrane disease and hypocomplementemic urticarial vasculitis.
Collapse
Affiliation(s)
- Giuseppe Lopalco
- Interdisciplinary Department of Medicine, Rheumatology Unit, University of Bari, Bari, Italy
| | - Donato Rigante
- Institute of Pediatrics, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica Sacro Cuore, Rome, Italy
| | - Vincenzo Venerito
- Interdisciplinary Department of Medicine, Rheumatology Unit, University of Bari, Bari, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Grazia Anelli
- Interdisciplinary Department of Medicine, Rheumatology Unit, University of Bari, Bari, Italy
| | - Giovanni Lapadula
- Interdisciplinary Department of Medicine, Rheumatology Unit, University of Bari, Bari, Italy
| | - Florenzo Iannone
- Interdisciplinary Department of Medicine, Rheumatology Unit, University of Bari, Bari, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoinflammatory Diseases and Behçet's Disease Clinic, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy. .,Rheumatology Unit, Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, Viale Bracci 1, 53100, Siena, Italy.
| |
Collapse
|
20
|
Henoch Schonlein Purpura as a Cause of Renal Failure in an Adult. Case Rep Med 2016; 2016:7890379. [PMID: 27672395 PMCID: PMC5031831 DOI: 10.1155/2016/7890379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 08/23/2016] [Indexed: 11/17/2022] Open
Abstract
Henoch Schonlein purpura (HSP) is an immune mediated disease associated Immunoglobulin A (IgA) deposition within the affected organs. While the disease is commonly seen in the pediatric age group, it is rarely seen in adults. We report the case of a 93-year-old Caucasian lady who presented with nonthrombocytopenic purpuric rash and acute kidney injury after an episode of bronchitis. Rapid and progressive deterioration of renal function prompted a kidney biopsy, which showed findings consistent with IgA nephropathy confirming the diagnosis of HSP. The patient was treated with high dose intravenous methylprednisolone followed by oral prednisone; however, her kidney disease progressed to end stage renal disease requiring hemodialysis. HSP is usually a self-limiting disease in children. However, adults are at an increased risk of severe renal involvement including end stage renal disease. Purpuric skin rash with renal involvement should raise suspicion for HSP. This is the oldest known patient with HSP.
Collapse
|
21
|
Lee YH, Kim YB, Koo JW, Chung JY. Henoch-Schonlein Purpura in Children Hospitalized at a Tertiary Hospital during 2004-2015 in Korea: Epidemiology and Clinical Management. Pediatr Gastroenterol Hepatol Nutr 2016; 19:175-185. [PMID: 27738599 PMCID: PMC5061659 DOI: 10.5223/pghn.2016.19.3.175] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/07/2016] [Accepted: 07/12/2016] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To investigate the epidemiology, clinical manifestations, investigations and management, and prognosis of patients with Henoch-Schonlein purpura (HSP). METHODS We performed a retrospective review of 212 HSP patients under the age of 18 years who were admitted to Inje University Sanggye Paik Hospital between 2004 and 2015. RESULTS The mean age of the HSP patients was 6.93 years, and the ratio of boys to girls was 1.23:1. HSP occurred most frequently in the winter (33.0%) and least frequently in the summer (11.3%). Palpable purpura spots were found in 208 patients (98.1%), and gastrointestinal (GI) and joint symptoms were observed in 159 (75.0%) and 148 (69.8%) patients, respectively. There were 57 patients (26.9%) with renal involvement and 10 patients (4.7%) with nephrotic syndrome. The incidence of renal involvement and nephrotic syndrome was significantly higher in patients with severe GI symptoms and in those over 7 years old. The majority of patients (88.7%) were treated with steroids. There was no significant difference in the incidence of renal involvement or nephrotic syndrome among patients receiving different doses of steroids. CONCLUSION In this study, the epidemiologic features of HSP in children were similar to those described in previous studies, but GI and joint symptoms manifested more frequently. It is essential to carefully monitor renal involvement and progression to chronic renal disease in patients ≥7 years old and in patients affected by severe GI symptoms. It can be assumed that there is no direct association between early doses of steroids and prognosis.
Collapse
Affiliation(s)
- Yong Hee Lee
- Department of Pediatrics, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yu Bin Kim
- Department of Pediatrics, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Ja Wook Koo
- Department of Pediatrics, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Ju-Young Chung
- Department of Pediatrics, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| |
Collapse
|
22
|
Dalpiaz A, Schwamb R, Miao Y, Gonka J, Walzter W, Khan SA. Urological Manifestations of Henoch-Schonlein Purpura: A Review. Curr Urol 2015; 8:66-73. [PMID: 26889120 DOI: 10.1159/000365692] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 09/30/2014] [Indexed: 11/19/2022] Open
Abstract
Henoch-Schonlein purpura (HSP) is an immune-mediated systemic vasculitis generally found in children. The standard manifestations of HSP are palpable purpura, arthritis, abdominal pain, and renal complications. Although less common, there are significant urological manifestations associated with HSP. The primary objective of this review is to encourage better understanding and management of HSP by emphasizing the common and rare manifestations of HSP, how they are diagnosed, and the latest treatment options for mild to severe complications. Medline searches of HSP and its urological manifestations were conducted along with searches on current diagnostic and treatment methods. Urological manifestations of HSP involve the kidney, ureter, bladder, prostate, scrotum, testicle, and penis. Diagnosis and management of HSP are not always clear due to differential diagnosis and diversity of symptom presentation. Treatment for HSP is mainly supportive and includes use of nonsteroidal anti-inflammatory drugs for pain relief. In more severe cases, glucocorticoids, methylprednisolone, plasmapheresis, and peritoneal and hemodialysis are reported successful. It is important to note different symptoms of HSP in order to distinguish HSP from other diseases. Early diagnosis may prevent severe complications. Treatment options vary from conservative to invasive depending on the severity of the disease and time frame of diagnosis.
Collapse
Affiliation(s)
- Amanda Dalpiaz
- Department of Physiology and Biophysics, Stony Brook, N.Y., USA
| | - Richard Schwamb
- Department of Physiology and Biophysics, Stony Brook, N.Y., USA
| | - Yimei Miao
- Department of Urology, SUNY School of Medicine, Stony Brook University, Stony Brook, N.Y., USA
| | - Jacquelyn Gonka
- Department of Urology, SUNY School of Medicine, Stony Brook University, Stony Brook, N.Y., USA
| | - Wayne Walzter
- Department of Urology, SUNY School of Medicine, Stony Brook University, Stony Brook, N.Y., USA
| | - Sardar A Khan
- Department of Urology, SUNY School of Medicine, Stony Brook University, Stony Brook, N.Y., USA
| |
Collapse
|
23
|
Ohara S, Kawasaki Y, Miyazaki K, Ono A, Suzuki Y, Suyama K, Hosoya M. Efficacy of cyclosporine A for steroid-resistant severe Henoch-Schönlein purpura nephritis. Fukushima J Med Sci 2015; 59:102-7. [PMID: 24500387 DOI: 10.5387/fms.59.102] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aggressive treatment is necessary for continuous high-range proteinuria in cases of pediatric Henoch-Schönlein purpura nephritis (HSPN) as the long-term prognosis is sometimes poor. Cyclosporine (CyA) has immunosuppressive effects as well as a very selective inhibitory effect on T-helper cell function. Here we report two 7-year-old boys with steroid-resistant HSPN treated with CyA. After diagnosis of HSPN, we treated both patients with methylprednisolone and urokinase pulse therapy (MUT) combined with multiple drugs; however, high-range proteinuria persisted and CyA was added to the treatment regimen. The proteinuria subsequently decreased gradually and pathological findings at the second renal biopsy were improved. Furthermore, neither patient showed any adverse effects, such as hypertension, encephalopathy, or chronic nephrotoxicity, to the CyA treatment.In conclusion, these results suggest that CyA may be a safe and effective treatment for steroid-resistant severe HSPN.
Collapse
|
24
|
Chen JY, Mao JH. Henoch-Schönlein purpura nephritis in children: incidence, pathogenesis and management. World J Pediatr 2015; 11:29-34. [PMID: 25557596 DOI: 10.1007/s12519-014-0534-5] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 09/12/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) is one of the most common vasculitides in children. It is manifested by skin purpura, arthritis, abdominal pain, renal involvement, etc. Typically, HSP is considered to be self-limiting, although renal involvement (HSP purpura nephritis, HSPN) is the principal cause of morbidity from this disease. For this reason, it is important to clarify the mechanism of onset and clinical manifestations of HSPN and to ascertain the most appropriate treatment for HSPN. In this article, we review the updated pathophysiology and treatment strategies for HSPN. DATA SOURCES We searched databases including PubMed, Elsevier and Wanfang for the following key words: Henoch-Schönlein purpura, nephritis, mechanism and treatment, and we selected those publications written in English that we judged to be relevant to the topic of this review. RESULTS Based on the data present in the literature, we reviewed the following topics: 1) the possible pathogenesis of HSPN: several studies suggest that immunoglobulin A immune complexes deposit in the mesangium and induce renal injury; 2) multiple-drug treatment for HSPN: although there have been few evidence-based treatment strategies for HSPN, several studies have suggested that immunosuppressive drugs and multiple drug combination therapy were effective in ameliorating proteinuria and histological severity. CONCLUSIONS HSPN is a severe disease of childhood. To better understand this disease, detailed investigations into the pathogenesis of HSPN and prospective randomized controlled treatment studies on children with severe HSPN are needed.
Collapse
Affiliation(s)
- Jun-Yi Chen
- Department of Nephrology, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | | |
Collapse
|
25
|
Pillebout É, Verine J. Purpura rhumatoïde de l’adulte. Rev Med Interne 2014; 35:372-81. [DOI: 10.1016/j.revmed.2013.12.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 12/02/2013] [Indexed: 12/20/2022]
|
26
|
Efficacy of triptolide for children with moderately severe Henoch-Schönlein purpura nephritis presenting with nephrotic range proteinuria: a prospective and controlled study in China. BIOMED RESEARCH INTERNATIONAL 2013; 2013:292865. [PMID: 24455682 PMCID: PMC3878807 DOI: 10.1155/2013/292865] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 12/02/2013] [Indexed: 12/03/2022]
Abstract
Objective. To observe the clinical efficacy of the Chinese herb, Triptolide, in children with moderately severe Henoch-Schönlein purpura nephritis (HSPN). Methods. From January 2007 to December 2011, 56 HSPN children manifested by nephrotic range proteinuria with normal kidney function and <50% crescents or sclerosing lesions on biopsy were hospitalized in the Children's Hospital of Zhejiang University School of Medicine. They were divided into two groups: the treatment group (n = 42; Triptolide at a dosage of 1 mg/kg·d, combined with prednisone at a dosage of 2 mg/kg·d, within a course of medium-to-long-term therapy of 6 to 9 months) and the control group (n = 14; prednisone alone, with the same procedure). Results. Short-term remission was observed in 95% of patients from treatment group and in 72% of patients from control group, respectively. There was a significant difference between both groups (χ2 = 6.222, P = 0.029) for short-term effects. Meanwhile, no significant difference, as proteinuria, hematuria, hypertension, and decreased eGFR, was observed between the two groups in long-term followup (χ2 = 3.111, P = 0.097). The Kaplan-Meier plot analysis also revealed no significant difference (χ2 = 2.633, P = 0.105). Conclusion. Triptolide is effective in relieving short-term symptoms for moderately severe HSPN children, though its long-term effects need to be observed further.
Collapse
|
27
|
Abstract
Henoch-Schönlein purpura is the most common systemic vasculitis of childhood. In the majority of children, the outcome of Henoch-Schönlein purpura is excellent with spontaneous resolution of symptoms and signs. However, a small subset of patients will develop long-term sequelae in the form of chronic kidney disease. While the clinical presentation and diagnosis of Henoch-Schönlein purpura is straightforward, treatment of Henoch-Schönlein purpura nephritis and long-term renal outcomes of more severely affected children are less certain. This review article gives a general overview of Henoch-Schönlein purpura with emphasis on recently published information, including the new classification of childhood vasculitis, insights into pathogenesis of Henoch-Schönlein purpura and a summary of various treatments of established Henoch-Schönlein purpura nephritis.
Collapse
Affiliation(s)
- Peter Trnka
- Queensland Child and Adolescent Renal Service, Royal Children's Hospital, Herston, Queensland, Australia
| |
Collapse
|
28
|
Beck L, Bomback AS, Choi MJ, Holzman LB, Langford C, Mariani LH, Somers MJ, Trachtman H, Waldman M. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis. Am J Kidney Dis 2013; 62:403-41. [PMID: 23871408 DOI: 10.1053/j.ajkd.2013.06.002] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 06/04/2013] [Indexed: 01/28/2023]
Abstract
Glomerulonephritis (GN) is an important cause of morbidity and mortality in patients of all ages throughout the world. Because these disorders are relatively rare, it is difficult to perform randomized clinical trials to define optimal treatment for many of the specific glomerulopathies. In the absence of high-grade evidence to guide the care of glomerular diseases, in June 2012, KDIGO (Kidney Disease: Improving Global Outcomes) published an international clinical guideline for GN. The Work Group report represents an important review of the literature in this area and offers valid and useful guidelines for the most common situations that arise in the management of patients with glomerular disease. This commentary, developed by a panel of clinical experts convened by the National Kidney Foundation, attempts to put the GN guideline into the context of the US health care system. Overall, we support the vast majority of the recommendations and highlight select areas in which epidemiological factors and medical practice patterns in this country justify modifications and adjustments in order to achieve favorable outcomes. There remain large gaps in our knowledge of the best approaches to treat glomerular disease and we strongly endorse an expanded clinical research effort to improve the health and long-term outcomes of children and adults with GN.
Collapse
Affiliation(s)
- Laurence Beck
- Boston University School of Medicine, Boston, MA, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Kanai H, Kobayashi A, Matsushita K, Sawanobori E, Sugita K, Higashida K. Methylprednisolone pulse therapy and intravenous cyclophosphamide therapy combined with cocktail therapy in severe pediatric Henoch-Schönlein purpura nephritis patient. CEN Case Rep 2013; 2:117-122. [PMID: 28509230 PMCID: PMC5411523 DOI: 10.1007/s13730-012-0056-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 12/11/2012] [Indexed: 11/20/2022] Open
Abstract
Henoch-Schönlein purpura (HSP) is a common self-limited vasculitis in children. The long-term prognosis depends on renal involvement. In severe Henoch-Schönlein purpura nephritis (HSPN) patients, >50 % have crescent formation and nephrotic syndrome that are important predicted outcomes. Therefore, for such patients, an aggressive immunosuppressive therapy is needed to prevent the progression. However, there is no consensus for an appropriate therapeutic regimen for severe pediatric HSPN patients. In this paper, we have reported on a 6-year-old boy who presented with HSPN with nephrotic syndrome and severe histopathological abnormalities; he was diagnosed with International Study of Kidney Disease in Children (ISKDC) grade IVb. Despite treatment with methylprednisolone pulse therapy, followed by oral prednisolone and dipyridamole; the nephrotic syndrome persisted. Subsequently, intravenous cyclophosphamide therapy (IVCY) (500–1,000 mg m−2 once a month for 7 months; total 6,000 mg m−2) was administered, followed by azathioprine and enarapril. Within 7 months of disease onset, complete remission was achieved. After 22 months of the initial renal biopsy, the second biopsy was performed to confirm treatment efficacy. Histopathological findings improved, and ISKDC grade IIIa was diagnosed. Even after 5 years of HSPN onset, complete remission and normal renal function is maintained. Although our evidence is restricted to single patient, we have shown that MPT and IVCY combined with cocktail therapy may be an effective treatment for severe pediatric HSPN.
Collapse
Affiliation(s)
- Hiroaki Kanai
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Shimokato 1110, Chuo-city, Yamanashi, 409-3898, Japan.
| | - Anna Kobayashi
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Shimokato 1110, Chuo-city, Yamanashi, 409-3898, Japan
| | - Kyoko Matsushita
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Shimokato 1110, Chuo-city, Yamanashi, 409-3898, Japan
| | - Emi Sawanobori
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Shimokato 1110, Chuo-city, Yamanashi, 409-3898, Japan
| | - Kanji Sugita
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Shimokato 1110, Chuo-city, Yamanashi, 409-3898, Japan
| | - Kosuke Higashida
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Shimokato 1110, Chuo-city, Yamanashi, 409-3898, Japan
| |
Collapse
|
30
|
Affiliation(s)
- Megan A. Kinney
- Department of Dermatology; Wake Forest University School of Medicine; Winston-Salem; North Carolina; USA
| | | |
Collapse
|
31
|
Treatment of children with Henoch-Schönlein purpura nephritis with mycophenolate mofetil. Pediatr Nephrol 2012; 27:765-71. [PMID: 22081165 DOI: 10.1007/s00467-011-2057-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 10/20/2011] [Accepted: 10/21/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) can progress to Henoch-Schönlein purpura nephritis (HSPN), and the most effective management remains unclear. Our aim was to evaluate the efficacy of mycophenolate mofetil (MMF) for treating pediatric patients with HSPN and nephrotic-range proteinuria. METHODS Twelve children, seven boys and five girls, mean age 8.33 (range 6-12) years at the time of HSPN diagnosis with nephrotic-range proteinuria, were treated with MMF. All patients failed steroid treatment, and mean proteinuria at the time of MMF initiation was 5.6 g/d. MMF dosage ranged from 20 to 25 mg/kg per day. Patients also received an angiotensin-converting enzyme inhibitor (cliazapril) at MMF initiation. Mean follow-up was 3.9 (range 2.3-5.5) years. RESULTS All patients responded to MMF at a mean of 2.5 (range 1-4 months). Among the 12 patients, MMF was administered for 10 months in five, 12 months in six, and 15 months in one. At last follow-up, all patients had negative proteinuria and normal renal function, and no relapses were noted. No serious adverse effects of MMF were noted in any patient. CONCLUSION MMF is useful for treating pediatric patients with HSPN and nephrotic-range proteinuria.
Collapse
|
32
|
Jauhola O, Ronkainen J, Autio-Harmainen H, Koskimies O, Ala-Houhala M, Arikoski P, Hölttä T, Jahnukainen T, Rajantie J, Ormälä T, Nuutinen M. Cyclosporine A vs. methylprednisolone for Henoch-Schönlein nephritis: a randomized trial. Pediatr Nephrol 2011; 26:2159-66. [PMID: 21626222 DOI: 10.1007/s00467-011-1919-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Revised: 05/11/2011] [Accepted: 05/13/2011] [Indexed: 02/06/2023]
Abstract
Knowledge about how to treat severe Henoch-Schönlein nephritis (HSN) is scarce. The aim of our study is to compare cyclosporine A (CyA) and methylprednisolone pulses (MP) in the treatment of severe HSN. Out of 24 pediatric HSN patients with nephrotic-range proteinuria or crescentic HSN in kidney biopsy, seven were randomized to receive CyA for 12 months at an initial dose of 5 mg/kg and eight to receive 3 MP pulses of 30 mg/kg followed by prednisone for 4 months. The other nine patients received identical treatment without randomization. Kidney biopsies were performed at inclusion and after 2 years. The primary outcomes were the duration of proteinuria and hematuria, estimated glomerular filtration rate, and renal biopsy histology. All the 11 CyA-treated patients achieved resolution of nephrotic-range proteinuria within 3 months, while the MP-group response was slower, and in 6/13 was not achieved with the initial treatment. Additional immunosuppressive treatment was needed in none of the CyA-treated patients but in six patients treated with MP (difference in proportion 46%, p = 0.008). The 2-year control biopsies were similarly improved in both groups. After mean 6.1 years (2.2-10.4 years), 16 patients (eight CyA, eight MP) had no renal symptoms and six (three CyA, three MP) had persistent nephropathy but normal renal function. One MP-treated patient had reduced renal function and another had developed ESRD and received a renal transplant. CyA gave a 100% resolution of nephrotic-range proteinuria and a 100% renal survival rate without additional therapy after a mean follow-up of 6 years. Treatment of HSN with CyA is efficacious, safe and not inferior to MP.
Collapse
Affiliation(s)
- Outi Jauhola
- Department of Children and Adolescents, Oulu University Hospital, PO Box 23, 90029, Oulu, Finland.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Kwamura T, Ueda H. [II. Autoimmune disease: 6. Henoch-Schönlein purpura nephritis]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2011; 100:1269-1274. [PMID: 21702143 DOI: 10.2169/naika.100.1269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Tetsuya Kwamura
- Division of Kidney and Hypertension, Department of Medicine, The Jikei University School of Medicine, Japan
| | | |
Collapse
|