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Frkovic M, Turcic A, Gagro A, Srsen S, Frkovic SH, Rogic D, Jelusic M. Erythrocyte Glutathione S-Transferase Activity as a Sensitive Marker of Kidney Function Impairment in Children with IgA Vasculitis. Int J Mol Sci 2024; 25:3795. [PMID: 38612603 PMCID: PMC11011981 DOI: 10.3390/ijms25073795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
IgA vasculitis (IgAV) is the most common childhood vasculitis. The main cause of morbidity and mortality in children with IgAV is nephritis (IgAVN), but the risk of its development, severity, and chronicity remain unclear. Erythrocyte glutathione S-transferase (e-GST) activity has been previously detected as a sensitive marker of kidney function impairment in several diseases. We spectrophotometrically assessed and correlated e-GST activity between 55 IgAV patients without nephritis (IgAVwN), 42 IgAVN patients, and 52 healthy controls. At disease onset, e-GST activity was significantly higher in IgAVN patients (median (interquartile range)) (5.7 U/gHb (4.4-7.5)) than in IgAVwN patients (3.1 U/gHb (2.2-4.2); p < 0.001), and controls (3.1 U/gHb (1.9-4.2); p < 0.001). Therewithal, there were no differences between the IgAVwN patients and controls (p = 0.837). e-GST activity was also significantly higher in the IgAVN patients than in the IgAVwN patients after 3 months (5.0 U/gHb (4.2-6.2) vs. 3.3 U/gHb (2.3-4.1); p < 0.001) and 6 months (4.2 U/gHb (3.2-5.8) vs. 3.3 U/gHb (2.1-4.1); p < 0.001) since the disease onset. Consistent correlations between e-GST activity and serum creatinine, estimated glomerular filtration rate (eGFR), and proteinuria levels were not detected. In conclusion, increased e-GST activity can serve as a subtle indicator of kidney function impairment in children with IgAV.
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Affiliation(s)
- Marijan Frkovic
- Department of Pediatrics, University Hospital Centre Zagreb, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
| | - Ana Turcic
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, University of Zagreb Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Alenka Gagro
- Children’s Hospital Zagreb, Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, 10000 Zagreb, Croatia
| | - Sasa Srsen
- Department of Pediatrics, University Hospital Centre Split, School of Medicine, University of Split, 21000 Split, Croatia
| | - Sanda Huljev Frkovic
- Department of Pediatrics, University Hospital Centre Zagreb, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
| | - Dunja Rogic
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, University of Zagreb Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Marija Jelusic
- Department of Pediatrics, University Hospital Centre Zagreb, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
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Stone HK, Mitsnefes M, Dickinson K, Burrows EK, Razzaghi H, Luna IY, Gluck CA, Dixon BP, Dharnidharka VR, Smoyer WE, Somers MJ, Flynn JT, Furth SL, Bailey C, Forrest CB, Denburg M, Nehus E. Clinical course and management of children with IgA vasculitis with nephritis. Pediatr Nephrol 2023; 38:3721-3733. [PMID: 37316676 PMCID: PMC10514113 DOI: 10.1007/s00467-023-06023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND IgA vasculitis is the most common vasculitis in children and is often complicated by acute nephritis (IgAVN). Risk of chronic kidney disease (CKD) among children with IgAVN remains unknown. This study aimed to describe the clinical management and kidney outcomes in a large cohort of children with IgAVN. METHODS This observational cohort study used the PEDSnet database to identify children diagnosed with IgAV between January 1, 2009, and February 29, 2020. Demographic and clinical characteristics were compared among children with and without kidney involvement. For children followed by nephrology, clinical course, and management patterns were described. Patients were divided into four categories based on treatment: observation, renin-angiotensin-aldosterone system (RAAS) blockade, corticosteroids, and other immunosuppression, and outcomes were compared among these groups. RESULTS A total of 6802 children had a diagnosis of IgAV, of whom 1139 (16.7%) were followed by nephrology for at least 2 visits over a median follow-up period of 1.7 years [0.4,4.2]. Conservative management was the most predominant practice pattern, consisting of observation in 57% and RAAS blockade in 6%. Steroid monotherapy was used in 29% and other immunosuppression regimens in 8%. Children receiving immunosuppression had higher rates of proteinuria and hypertension compared to those managed with observation (p < 0.001). At the end of follow-up, 2.6 and 0.5% developed CKD and kidney failure, respectively. CONCLUSIONS Kidney outcomes over a limited follow-up period were favorable in a large cohort of children with IgAV. Immunosuppressive medications were used in those with more severe presentations and may have contributed to improved outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Hillarey K Stone
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kimberley Dickinson
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Evanette K Burrows
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ingrid Y Luna
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Caroline A Gluck
- Division of Pediatric Nephrology, Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Vikas R Dharnidharka
- Division of Pediatric Nephrology, Washington University School of Medicine, Saint Louis, MO, USA
| | - William E Smoyer
- Center for Clinical and Translational Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Michael J Somers
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph T Flynn
- Division of Nephrology, Department of Pediatrics, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Susan L Furth
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Charles Bailey
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Denburg
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward Nehus
- Department of Pediatrics, West Virginia University Charleston Campus, Charleston, WV, USA
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Wright RD, Marro J, Northey SJ, Corkhill R, Beresford MW, Oni L. Urinary complement proteins are increased in children with IgA vasculitis (Henoch-Schönlein purpura) nephritis. Pediatr Nephrol 2023; 38:1491-1498. [PMID: 36227437 PMCID: PMC10060309 DOI: 10.1007/s00467-022-05747-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/08/2022] [Accepted: 09/08/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Children with immunoglobulin A vasculitis (IgAV Henoch-Schönlein purpura) frequently encounter nephritis (IgAV-N) with 1-2% risk of kidney failure. The pathophysiology of IgAV-N is not fully understood with speculation that complement may contribute. The aim of this study was to identify whether urinary complement proteins are increased in children with IgAV-N. METHODS A cross-sectional prospective cohort of children with IgAV were recruited together with controls including healthy children and children with systemic lupus erythematosus (SLE). Patients were subdivided according to the presence of nephritis. Urinary C3, C4, C5, and C5a were measured by enzyme-linked immunosorbent assay (ELISA) and corrected for urinary creatinine. RESULTS The study included 103 children; 47 with IgAV (37 IgAV without nephritis, IgAVwoN; 10 IgAV-N), 30 SLE and 26 healthy children. Urinary complement C3, C4, and C5 were all statistically significantly increased in all children with IgAV compared to SLE patients (all p < 0.05). In patients with IgAV-N, urinary complement C3, C4, C5, C5a were all statistically significantly increased compared to IgAVwoN (C3 14.65 μg/mmol [2.26-20.21] vs. 2.26 μg/mmol [0.15-3.14], p = 0.007; C4 6.52 μg/mmol [1.30-9.72] vs. 1.37 μg/mmol [0.38-2.43], p = 0.04; C5 1.36 μg/mmol [0.65-2.85] vs. 0.38 μg/mmol [0.03-0.72], p = 0.005; C5a 101.9 ng/mmol [15.36-230.0] vs. 18.33 ng/mmol [4.27-33.30], p = 0.01). Using logistic regression, the urinary complement components produced an outstanding ability to discriminate between patients with and without nephritis in IgAV (AUC 0.92, p < 0.001). CONCLUSIONS Children with IgAV-N have evidence of increased complement proteins present in their urine that may indicate a pathological role and may allow treatment stratification. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Rachael D Wright
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Member of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP, UK
| | - Julien Marro
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Member of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP, UK
| | - Sarah J Northey
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Member of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP, UK
| | - Rachel Corkhill
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Member of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP, UK
| | - Michael W Beresford
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Member of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Member of Liverpool Health Partners, Liverpool, UK
| | - Louise Oni
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Member of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP, UK.
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Member of Liverpool Health Partners, Eaton Road, Liverpool, L12 2AP, UK.
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ASLAN C, GOKNAR N, KELESOGLU E, UCKARDES D, CANDAN C. Long-term Results in Children with Henoch-Schönlein Nephritis. Medeni Med J 2022; 37:159-164. [PMID: 35735000 PMCID: PMC9234360 DOI: 10.4274/mmj.galenos.2022.92331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Zhou F, Shao Q, Jia L, Cai C. Gut Microbiota Variations between Henoch-Schonlein Purpura and Henoch-Schonlein Purpura Nephritis. Gastroenterol Res Pract 2022; 2022:4003491. [PMID: 35462986 PMCID: PMC9023217 DOI: 10.1155/2022/4003491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background In China, little is known regarding the differences between children with Henoch-Schonlein purpura (HSP) and Henoch-Schonlein purpura nephritis (HSPN) concerning their gut microbiota. Methods We recruited 25 children with HSP, 25 children with HSPN, and 25 healthy children to investigate the differences. Fecal samples were collected and analyzed by sequencing the V3-V4 region of the 16S rRNA gene. The diversity of the fecal gut microbiota was compared between the patient groups. Results Rarefaction curves showed that the gut microbial diversity between the three groups differed significantly (P = 0.0224). The top five most abundant gut microbial genera were Bacteroides, Faecalibacterium, Prevotella, Ruminococcaceae, and Megamonas in children with HSP; Bacteroides, Faecalibacterium, Prevotella, Bifidobacterium, and Ruminococcaceae in children with HSPN; and Bacteroides, Prevotella, Faecalibacterium, Ruminococcaceae, and Bifidobacterium in healthy children. Children with HSP had the lowest Bifidobacterium abundance among the three groups (P < 0.05). Children with HSPN had a lower abundance of Akkermansia than children with HSP (P < 0.05), whereas children with HSPN had a higher Alistipes abundance than children with HSP (P < 0.05). Fecal microbial community composition did not differ significantly between groups (ANOSIM, R = -0.002, P = 0.46). Despite the small sample size, our results indicate that children with HSP or HSPN displayed dysbiosis of the gut microbiota. Conclusion This study provides valuable insights that will benefit the development of future microbe-based therapies to improve clinical outcomes or prevent the incidence of HSP or HSPN in children.
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Affiliation(s)
- Fang Zhou
- Department of Rheumatoid Immune Nephrology, Hangzhou Children's Hospital, Hangzhou, 310014 Zhejiang, China
| | - Qimin Shao
- Department of Rheumatoid Immune Nephrology, Hangzhou Children's Hospital, Hangzhou, 310014 Zhejiang, China
| | - Lihong Jia
- Department of Rheumatoid Immune Nephrology, Hangzhou Children's Hospital, Hangzhou, 310014 Zhejiang, China
| | - Chunyan Cai
- Department of Rheumatoid Immune Nephrology, Hangzhou Children's Hospital, Hangzhou, 310014 Zhejiang, China
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Hastings MC, Rizk DV, Kiryluk K, Nelson R, Zahr RS, Novak J, Wyatt RJ. IgA vasculitis with nephritis: update of pathogenesis with clinical implications. Pediatr Nephrol 2022; 37:719-733. [PMID: 33818625 PMCID: PMC8490493 DOI: 10.1007/s00467-021-04950-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/17/2020] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
IgA vasculitis with nephritis (IgAVN) shares many pathogenetic features with IgA nephropathy (IgAN). The purpose of this review is to describe our current understanding of the pathogenesis of pediatric IgAVN, particularly as it relates to the four-hit hypothesis for IgAN. These individual steps, i.e., hits, in the pathogenesis of IgAN are (1) elevated production of IgA1 glycoforms with some O-glycans deficient in galactose (galactose-deficient IgA1; Gd-IgA1), (2) generation of circulating IgG autoantibodies specific for Gd-IgA1, (3) formation of pathogenic circulating Gd-IgA1-containing immune complexes, and (4) kidney deposition of the Gd-IgA1-IgG immune complexes from the circulation and induction of glomerular injury. Evidence supporting the four-hit hypothesis in the pathogenesis of pediatric IgAVN is detailed. The genetics, pediatric outcomes, and kidney histopathologic features and the impact of these findings on future treatment and potential biomarkers are discussed. In summary, the evidence points to the critical roles of Gd-IgA1-IgG immune complexes and complement activation in the pathogenesis of IgAVN. Future studies are needed to characterize the features of the immune and autoimmune responses that enable progression of IgA vasculitis to IgAVN.
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Affiliation(s)
- M Colleen Hastings
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Children's Foundation Research Institute at the Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Dana V Rizk
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Raoul Nelson
- Division of Pediatric Nephrology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rima S Zahr
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
- Children's Foundation Research Institute at the Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Jan Novak
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J Wyatt
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.
- Children's Foundation Research Institute at the Le Bonheur Children's Hospital, Memphis, TN, USA.
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Bose S, Madke B. A comprehensive review of immunosuppressive drugs in pediatric dermatoses: Part I - Corticosteroids, azathioprine, and cyclosporine-A. INDIAN JOURNAL OF PAEDIATRIC DERMATOLOGY 2022. [DOI: 10.4103/ijpd.ijpd_83_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Comparison of clinical, pathological and long-term renal outcomes of children with Henoch-Schonlein purpura nephritis and IgA nephropathy. Int Urol Nephrol 2021; 54:1925-1932. [PMID: 34846620 DOI: 10.1007/s11255-021-03063-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 11/11/2021] [Indexed: 02/05/2023]
Abstract
PURPOSE To compare clinical, pathological, and long-term renal outcomes of children with Henoch-Schonlein purpura nephritis (HSPN) and IgA nephropathy (IgAN). METHODS The medical records of patients diagnosed as HSPN and IgAN during childhood were evaluated retrospectively. HSPN and IgAN groups were compared in terms of gender, age, upper respiratory infection history, blood pressure; presence of nephrotic and/or nephritic syndrome; hemoglobin level, leukocyte count, C-reactive protein (CRP), serum albumin (sAlb), creatinine, complement 3 (sC3), complement 4 (sC4) and immunoglobulin A (sIgA) levels; estimated glomerular filtration rate (eGFR) and proteinuria levels; and renal pathology findings at the onset of disease; total follow-up time; and blood pressure, eGFR and proteinuria levels at the last visit. RESULTS Fifty-four patients were enrolled in the study [38 (70%) HSPN and 16 (30%) IgAN]. The median follow-up time was 60.5 and 72.0 months in HSPN and IgAN groups, respectively (p > 0.05). The HSPN and IgAN groups were also not different in terms of gender, age at the onset; leukocyte count, eGFR, sC3-sC4-sIgA levels; and the presence of endocapillary, extracapillary and mesangial proliferation, tubular atrophy, interstitial fibrosis and IgA, IgM, C3 accumulation in renal tissue. Upper respiratory tract infection history was more common in children with IgAN (8/16 vs 8/38, p = 0.045). sAlb (3.96 ± 0.58 vs 4.40 ± 0.46 g/dL, p = 0.005), hemoglobin (12.1 ± 1.3 vs 13.3 ± 1.2 g/dL, p = 0.004,) and the incidence of mesangial IgG deposition (15/38 vs 11/16, p = 0.049) were lower, while CRP (16.3 ± 7.2 vs 7.8 ± 4.4 mg/L, p = 0.002) and proteinuria (72.1 ± 92.4 vs 34.2 ± 37.9 mg/m2/24 h, p = 0.041) was higher in HSPN group at the onset of disease. Proteinuria and eGFR were similar between the two groups at last visit. CONCLUSION Children with HSPN and IgAN have little clinical and histological differences in our population. The most prominent difference at presentation with nephritis was higher proteinuria in HSPN probably associated with inflammation due to systemic vasculitis. Long-term renal outcome was good in both HSPN and IgAN.
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The Efficacy of Tripterygium Glycosides Combined with LMWH in Treatment of HSPN in Children. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:7223613. [PMID: 34721642 PMCID: PMC8553442 DOI: 10.1155/2021/7223613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022]
Abstract
Objective This study aimed to explore the clinical efficacy and relevant mechanism of Tripterygium glycosides combined with low molecular weight heparin calcium (LMWH) in the treatment of Henoch–Schönlein purpura nephritis (HSPN) in children. Methods 64 cases of children patients with HSPN treated at Qilu Hospital (Qingdao) from January 2015 to May 2020 were selected and randomly divided into the control group and the observation group and 32 cases in each group. Conventional medical treatment was applied in the two groups, besides which the control group was given LMWH while the observation group was given Tripterygium glycosides based on the control group. The clinical efficacy and the indexes of clinical symptoms of the two groups were compared. Immune globulin level, fibrinogen content (FIB), prothrombin time (PT), platelet level (PLT), and activated partial thromboplastin time (APTT) level of the two groups were compared before and after the treatment. Results The total effective rate in the observation group was significantly higher than that of the control group, and the recurrence rate in the observation group was lower than that in the control group. After treatment, urine red blood cell count and 24 h urine protein were obviously better than those of the control group. There was no statistically significant difference in PT between the two groups of children before and after treatment. The levels of PLT and FIB in the two groups of patients after treatment were significantly lower than before treatment, and the PLT levels in the observation group were lower than those in the control group. Conclusion The combination of Tripterygium glycosides and LMWH had good clinical effects in the treatment of children with HSPN, and it could improve the clinical symptoms, the mechanism of which might be related to the increase of PT, a decrease of PLT, and the improvement of coagulation function.
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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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Peruzzi L, Coppo R. IgA vasculitis nephritis in children and adults: one or different entities? Pediatr Nephrol 2021; 36:2615-2625. [PMID: 33219450 DOI: 10.1007/s00467-020-04818-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/15/2020] [Accepted: 10/07/2020] [Indexed: 12/12/2022]
Abstract
The clinical features of the kidney involvement in immunoglobulin A (IgA) vasculitis (IgAVN) differ in children and adults for both clinical presentation and progression. IgAVN in children has mostly a self-limiting course and favorable resolution, while in adults the kidney involvement is frequently severe with unfavorable outcome. However, a subset of children is at risk of progression within the pediatric age or decades later in adulthood, particularly when the diagnosis and a prompt intervention are delayed. Factors predicting progression and outcome in the whole spectrum of age have been investigated in recent research, as well as the relationship between IgAVN and primary IgAN, which share the same pathology features, in the light of peculiar clinical differences and progression tendencies, and hence need for selective treatments. The search for a personalized treatment in children with IgAV and in different ages of life should rely on the identification of different risks for progression. This review will focus on recent studies which contribute to improve our knowledge in this still largely unclear area.
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Affiliation(s)
- Licia Peruzzi
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy.,Pediatric Nephrology Unit, Regina Margherita Department, City of Health and Science University Hospital, Turin, Italy
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy.
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Abstract
Immunoglobulin A (IgA) vasculitis (IgAV), previously called Henoch-Schönlein purpura, is characterized by IgA-dominant immune deposits affecting small vessels and often involves the skin, gastrointestinal tract, joints, and kidneys. IgAV is the most common cause of systemic vasculitis in children. The long-term prognosis is dependent on renal involvement: IgAV with nephritis (IgAVN) can progress to renal failure. IgAVN is an inflammatory disease, providing a rationale for the use of corticosteroids. However, data supporting the use of corticosteroids in patients with established IgAVN of any severity remain limited, although most clinicians use them. Even in patients with severe forms of IgAVN, methylprednisolone pulses added to oral corticosteroids appears to improve renal outcomes. Considering the multihit hypothesis for the pathogenesis of IgAVN, involving many other immune agents, there is a strong rationale for the use of other immunosuppressive drugs in patients with IgAVN, including mycophenolic acid, cyclophosphamide, rituximab, calcineurin inhibitors, and complement inhibitors. Thus, these immunosuppressive treatments have also been evaluated in IgAVN, usually in corticosteroid-dependent or corticosteroid-resistant forms and in small retrospective studies. However, their efficacy has not been proven. Thus, the risk of progression to renal failure and the ongoing debate about the best management of IgAVN justifies the interest in investigating and identifying treatments that can potentially preserve renal function in patients with IgAVN. This review reports on the efficacy of the different drugs currently used for the treatment of IgAVN in adults and children.
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[Efficacy and safety of mycophenolate mofetil versus cyclophosphamide in the treatment of Henoch-Schönlein purpura nephritis with nephrotic-range proteinuria in children: a prospective randomized controlled trial]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2021; 23. [PMID: 33840404 PMCID: PMC8050539 DOI: 10.7499/j.issn.1008-8830.2012145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To study the efficacy and safety of mycophenolate mofetil (MMF) versus cyclophosphamide (CTX) in the treatment of children with Henoch-Schönlein purpura nephritis (HSPN) and nephrotic-range proteinuria. METHODS A prospective clinical trial was conducted in 68 pediatric patients who were admitted to the Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics and who were diagnosed with HSPN and nephrotic-range proteinuria from August 2016 to November 2019. The patients were randomly divided into two groups:MMF treatment (n=33) and CTX treatment (n=35). The two groups were compared in terms of complete remission rate, response rate (complete remission + partial remission), urinary protein clearance time, and adverse events. RESULTS At months 3, 6, and 12 of treatment, there was no significant difference in the complete remission rate and the response rate between the MMF treament and CTX treatment groups (P > 0.05). There was also no significant difference between the two groups in the urinary protein clearance time and the incidence rate of adverse events (P > 0.05). CONCLUSIONS MMF and CTX have similar efficacy and safety in the treatment of HSPN children with nephrotic-range proteinuria.
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Characteristics of immune function in the acute phase of Henoch-Schönlein purpura. Clin Rheumatol 2021; 40:3711-3716. [PMID: 33782751 DOI: 10.1007/s10067-021-05707-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) is still diagnosed using symptoms and signs together with some histopathological findings. The purpose of this study was to summarize the characteristics and roles of cellular and humoral immunity in children with Henoch-Schönlein purpura (HSP). METHODS A total of 502 cases of patients with acute HSP were diagnosed and observed. The levels of T lymphocyte subsets, natural killer cells (NK cells), and B cells were analyzed by flow cytometry. The serum immunoglobulin G (IgG), immunoglobulin M (IgM), immunoglobulin A (IgA), and complement C3 (C3) and complement C4 (C4) levels were detected by velocity scatter turbidimetry. RESULTS Compared with the healthy groups, the levels of cluster of differentiation 3 (CD3), cluster of differentiation 4 (CD4), B cells, and NK cells and ratio of CD4/CD8 in patients with HSP were decreased (P < 0.05). The levels of IgG, IgA, IgM, and C3 were increased (P < 0.05). Compared with the Kawasaki disease (KD) group, the levels of CD3, CD4, CD8, B cells, NK cells, and IgA in patients with HSP were increased (P < 0.05), and the ratio of CD4/CD8 and levels of IgM, C3, and C4 was decreased (P < 0.05). Compared with the pneumonia group, the levels of CD3, CD4, B cells, and IgA in patients with HSP were increased (P < 0.05), and the ratio of CD4/CD8 and levels of IgM and C4 was decreased (P < 0.05). CONCLUSIONS Cellular immunity and humoral immunity were all involved in the pathogenesis of HSP. The decline of NK cells, B lymphocyte cells, CD3, CD4 the increased secretion of immunoglobulin, and the abnormal appearance of IgA and C3 may exist during the progression. It may indicate a worse prognosis and increasing the risk of dedifferentiation. Cellular immunity was lower, which lead to increased production of inflammatory mediators and increased secretion of immunoglobulin, which then mediated systemic small-vessel vasculitis. Key Points • The pathogenesis of Henoch-Schönlein purpura (HSP) was not completely illuminated. • There was a lack of disease-specific laboratory abnormalities that can be used in the clinical diagnosis of HSP. • We compared the laboratory abnormalities in the immune system of HSP with KD and pneumonia. • Cellular immunity and humoral immunity were all involved in the pathogenesis of HSP. Cellular immunity was lower, which lead to the following pathological changes.
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Chen L, Wang X, Yin L, Ma K, Liu X. Effects of dexamethasone and gamma globulin combined with prednisone on the therapeutic effect and immune function of Henoch-Schonlein purpura nephritis in children. J Clin Lab Anal 2020; 35:e23580. [PMID: 33174652 PMCID: PMC7843260 DOI: 10.1002/jcla.23580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/22/2020] [Accepted: 06/01/2020] [Indexed: 12/21/2022] Open
Abstract
Background Henoch‐Schonlein purpura nephritis (HSPN) is a serious complication of Henoch‐Schonlein purpura (HSP), which is usually treated with immunosuppressant and glucocorticoid. This study was designed to explore the effect of dexamethasone and gamma globulin combined with prednisone in the treatment of pediatric HSPN. Methods According to the treatment plan, 60 children treated with dexamethasone and gamma globulin were included in the control group, and the rest 55 children treated with dexamethasone and gamma globulin combined with prednisone were selected as the research group. The clinical manifestations, therapeutic effect, immune function, serum inflammatory factors, blood coagulation function, urine routine, renal function, and adverse reactions were compared between the two groups. Results The clinical manifestations of children in the research group were significantly better than those in the control group after treatment (P < .05). The total effective rate in the research group (94.55%) was markedly higher than that in the control group (76.67%) (P < .05). CD3+, CD4+, CD8+, IL‐10, PT, and APTT increased while CD4+/CD8+, IgA, IL‐8, TNF‐α, FIB, urine protein, urine red blood cell, Scr, and BUN decreased in both groups after treatment, and the changes of all the above indexes in the research group were significant than those in the control group (P < .05). The incidence of adverse reactions in the research group was remarkably superior to that in the control group (P < .05). Conclusion Dexamethasone and gamma globulin combined with prednisone can improve the immune function of children with HSPN and promote the recovery of renal function.
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Affiliation(s)
- Lei Chen
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Xinning Wang
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Liang Yin
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Kun Ma
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
| | - Xiangyang Liu
- Department of Pediatric Surgery, Cangzhou Central Hospital, Cangzhou, China
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Li L, Huang L, Zhang N, Guo CM, Hu YQ. Influence of transitional nursing on the compliance behavior and disease knowledge of children with purpura nephritis. World J Clin Cases 2020; 8:5213-5220. [PMID: 33269257 PMCID: PMC7674753 DOI: 10.12998/wjcc.v8.i21.5213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/27/2020] [Accepted: 09/22/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Purpura nephritis, also called Henoch-Schönlein purpura nephritis, is a systemic disease with small dead vasculitis as the main pathological change.
AIM To observe the influence of transitional nursing activities on the compliance behaviors and disease knowledge of children with purpura nephritis.
METHODS A total of 82 children with purpura nephritis were included and divided into a general nursing group (41 children) and transitional nursing group (41 children) using the envelope method. The general nursing group received routine nursing care, while the transitional nursing group received transitional nursing care. The behaviors, knowledge of the disease, and self-management ability of the two groups were evaluated after nursing care was provided.
RESULTS The scores of four items (self-care ability, self-responsibility, health knowledge level, and self-concept) in the transitional nursing group were significantly higher than those in the general nursing group.
CONCLUSION Transitional nursing can directly improve the disease knowledge level and self-management ability of children with purpura nephritis and effectively reduce complications.
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Affiliation(s)
- Li Li
- Department of Pediatrics, Hainan Provincial People's Hospital, Haikou 570000, Hainan Province, China
| | - Li Huang
- Department of Internal Medicine-neurology, Hainan Provincial People's Hospital, Haikou 570000, Hainan Province, China
| | - Ning Zhang
- Department of Pediatrics, Hainan Provincial People's Hospital, Haikou 570000, Hainan Province, China
| | - Chun-Mei Guo
- Department of Pediatrics, Hainan Provincial People's Hospital, Haikou 570000, Hainan Province, China
| | - Yan-Qun Hu
- Department of Healthcare Center, Hainan Provincial People's Hospital, Haikou 570000, Hainan Province, China
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Song YR, Guo WL, Sheng M, Lin Q, Zhu XM, Li XZ. Risk factors associated with renal crescentic formation in pediatric Henoch-Schönlein purpura nephritis: a retrospective cohort study. BMC Pediatr 2020; 20:501. [PMID: 33131493 PMCID: PMC7604931 DOI: 10.1186/s12887-020-02404-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 10/26/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The long-term prognosis of Henoch-Schönlein purpura (HSP) depends on the severity of renal involvement, and crescent formation is considered an important risk factor for poor prognosis of Henoch-Schönlein purpura nephritis (HSPN). The objective of this study was to evaluate factors affecting crescent formation in children with HSPN. METHODS Demographic factors, clinical characteristics, and laboratory data of children with HSPN with or without crescents were retrospectively analyzed. Univariate and multivariate logistic regression analyses were used to determine the risk factors of crescent formation in HSPN. RESULTS A total of 191 children with HSPN were enrolled in the study. There were 107 (56%) males and 84 (44%) females, with a median age of 7 years (range: 2 years-15 years). International Study of Kidney Disease in Children (ISKDC) grading was used to divide subjects into two groups: those without glomerular crescent formation (ISKDC grades I-II, n = 146 cases) and those with glomerular crescent formation (ISKDC grades III-V, n = 45 cases). Logistic regression analysis showed that higher urinary white blood cell (WBC) count (OR = 3.300; 95% CI, 1.119-9.739; P = 0.0306) and higher urinary microalbumin/creatinine ratio (ACR) (OR = 25.053; 95% CI, 1.354-463.708; P = 0.0305) were independent risk factors for the formation of crescents in HSPN. The area under the receiver operating characteristic curve of urinary WBC and ACR were 0.753 and 0.698 respectively, with the Hosmer and Lemeshow goodness-of-fit test (P = 0.0669, P > 0.05). CONCLUSION These results suggest that higher urinary WBC count and ACR should be strictly monitored for children with HSPN. Adequate clinical intervention for these risk factors may limit or prevent renal crescent formation.
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Affiliation(s)
- Yong-Rui Song
- Department of Radiology, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, 215025, Jiangsu, China
| | - Wan-Liang Guo
- Department of Radiology, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, 215025, Jiangsu, China
| | - Mao Sheng
- Department of Radiology, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, 215025, Jiangsu, China
| | - Qiang Lin
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215003, Jiangsu, China
| | - Xue-Ming Zhu
- Department of Pathology, Children's Hospital of Soochow University, 92 Zhongnan Street, Suzhou, 215025, Jiangsu, China
| | - Xiao-Zhong Li
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, 303 Jingde Road, Suzhou, 215003, Jiangsu, China.
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Yel S, Dursun I, Pinarbaşi AS, Günay N, Özdemir S, Şahin N, Akgün H, Ipekten F, Poyrazoğlu H, Düşünsel R. Patient Outcomes of Henoch-Schönlein Purpura Nephritis According to the New Semiquantitative Classification. Fetal Pediatr Pathol 2020; 39:381-389. [PMID: 31490094 DOI: 10.1080/15513815.2019.1658245] [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] [Indexed: 10/26/2022]
Abstract
Background: A new semiquantitative classification (SQC) for pediatric Henoch-Schönlein nephritis (HSN) was defined recently. The outcomes of pediatric HSN patients are reevaluated according to the new classification. Methods: Primary kidney biopsies from 80 HSN patients were scored using the new SQC. The International Study of Kidney Disease in Children (ISKDC) and SQC classifications were compared in terms of the patient outcomes. Outcomes were defined as: Outcome A (n = 44) patients with no sign of renal disease, Outcome B (n = 32) patients with minor urinary abnormalities, and Outcome C (n = 4) patients with active renal disease. Results: The patients with outcome C had significantly higher biopsy scores and chronicity indices than patients in group A. There was no significant difference in areas under the curve between total biopsy SQC scores and ISKDC findings. Conclusions: Our results suggest that the modified SQC is not more sensitive than ISKDC classification for predicting the outcome in HSN cases.
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Affiliation(s)
- Sibel Yel
- Department of Pediatric Nephrology and Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ismail Dursun
- Department of Pediatric Nephrology and Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ayşe Seda Pinarbaşi
- Department of Pediatric Nephrology and Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Neslihan Günay
- Department of Pediatric Nephrology and Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Sümeyra Özdemir
- Department of Pediatric Nephrology and Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Nihal Şahin
- Department of Pediatric Nephrology and Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Hülya Akgün
- Department of Pathology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Funda Ipekten
- Department of Biostatistics, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Hakan Poyrazoğlu
- Department of Pediatric Nephrology and Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ruhan Düşünsel
- Department of Pediatric Nephrology and Rheumatology, Erciyes University Faculty of Medicine, Kayseri, Turkey
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Delbet JD, Geslain G, Auger M, Hogan J, Salomon R, Peuchmaur M, Deschênes G, Buob D, Parmentier C, Ulinski T. Histological prognostic factors in children with Henoch-Schönlein purpura nephritis. Pediatr Nephrol 2020; 35:313-320. [PMID: 31696358 DOI: 10.1007/s00467-019-04363-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 07/29/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The management of IgA vasculitis with nephritis (IgAVN) remains controversial because of the difficulty to identify prognostic factors. This study reports the prognosis of children with IgAVN in relation to histological parameters. METHODS All children with IgAVN diagnosed between 2000 and 2015 in three pediatric nephrology centers were included. The following histological parameters were analyzed: mesangial proliferation (MP), endocapillary proliferation (EP), crescents, active, or chronic tubular and interstitial lesions (TIa lesions/TIc lesions), and segmental glomerulosclerosis (GS). Clinical and biological data were collected at the time of renal biopsy. The primary endpoint was IgAVN remission defined as a proteinuria < 200 mg/l without renal failure. RESULTS One hundred fifty-nine children were included with a median age of 7.6 years. Acute glomerular or TI lesions including MP, EP, crescents, and TIa lesions were observed, respectively, in 81%, 86%, 49%, and 21% of patients. Chronic glomerular lesions including GS and TIc lesions were observed in 6 and 7% of patients. Median initial proteinuria was 330 mg/mmol, albuminemia 32 g/l, and eGFR 110 ml/min/1.73 m2. One hundred twelve (70%) patients were in remission at the end of a median follow-up of 37.4 months. Chronic lesions were significantly associated with the absence of remission in multivariate analysis, whereas EP, crescents and TIa were not associated with a poor prognosis. CONCLUSIONS Of children with IgAVN, 30% present a persistent renal disease at the end of a 3-year follow-up. Chronic histological lesions, but not EP or crescents, are associated with a bad prognosis and must be evaluated in IgAVN histological classification.
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Affiliation(s)
- Jean-Daniel Delbet
- Pediatric Nephrology unit, Trousseau Hospital, APHP.6, DMU Origyne, 26 Avenue du Docteur Arnold Netter, 75012, Paris, France. .,Sorbonne Université, Paris 6, Paris, France.
| | - Guillaume Geslain
- Pediatric Nephrology unit, Trousseau Hospital, APHP.6, DMU Origyne, 26 Avenue du Docteur Arnold Netter, 75012, Paris, France
| | - Martin Auger
- Pediatric Nephrology unit, Trousseau Hospital, APHP.6, DMU Origyne, 26 Avenue du Docteur Arnold Netter, 75012, Paris, France
| | - Julien Hogan
- Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France.,University Paris Diderot, Paris 7, Paris, France
| | - Rémi Salomon
- Pediatric Nephrology, Necker Enfants Malades, APHP, Paris, France
| | - Michel Peuchmaur
- Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France
| | - Georges Deschênes
- Pediatric Nephrology, Robert Debré Hospital, APHP, Paris, France.,University Paris Diderot, Paris 7, Paris, France
| | - David Buob
- Pathology Department, Tenon Hospital, APHP, Paris, France
| | - Cyrielle Parmentier
- Pediatric Nephrology unit, Trousseau Hospital, APHP.6, DMU Origyne, 26 Avenue du Docteur Arnold Netter, 75012, Paris, France
| | - Tim Ulinski
- Pediatric Nephrology unit, Trousseau Hospital, APHP.6, DMU Origyne, 26 Avenue du Docteur Arnold Netter, 75012, Paris, France.,Sorbonne Université, Paris 6, Paris, France
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Yu Y, Chen J, Yin H, Deng Z, Xie Y, Yuan Q, Xu H, Liu S, Tao L, Peng Z. Efficacy of steroid and immunosuppressant combined therapy in Chinese patients with Henoch-Schönlein purpura nephritis: A retrospective study. Int Immunopharmacol 2020; 81:106229. [PMID: 32014710 DOI: 10.1016/j.intimp.2020.106229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 01/15/2023]
Abstract
/y) and proteinuria were measured. The primary outcome progression was analyzed using Kaplan-Meier survival curves. The effect of the combined therapy on renal outcome was analyzed by multivariable Cox regression. Propensity score matching and sensitivity analysis were used to explore whether pathological features impacted prognosis. Patients who received combined steroid and immunosuppressant therapy were more likely to recover from HSPN and had proteinuria <3 g/24 h (P = 0.02) or 1 g/24 h (P = 0.03). Multiple Cox regression analysis confirmed that this decrease was independent of renin-angiotensin system blockers. Further sensitivity analysis showed that combined therapy was effective in patients with crescents (P = 0.02). However, combined steroid and immunosuppressant therapy was not more effective in patients with endocapillary hypercellularity (E), tubular atrophy/interstitial fibrosis (T), or segmental sclerosis (S). Combined steroid and immunosuppressant therapy was significantly associated with HSPN remission, and more effectively decreased proteinuria during the initial disease phase.
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Affiliation(s)
- Yue Yu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Jingjing Chen
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Hongling Yin
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Zhenghao Deng
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Yanyun Xie
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Qiongjing Yuan
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Hui Xu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Shao Liu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Lijian Tao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Zhangzhe Peng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
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Jimenez A, Chen A, Lin JJ, South AM. Does MEST-C score predict outcomes in pediatric Henoch-Schönlein purpura nephritis? Pediatr Nephrol 2019; 34:2583-2589. [PMID: 31402405 PMCID: PMC8107696 DOI: 10.1007/s00467-019-04327-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 07/27/2019] [Accepted: 07/31/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Children with Henoch-Schönlein purpura nephritis (HSPN) have an increased risk of chronic kidney disease (CKD). Renal biopsy diagnostic of HSPN is graded using the International Study of Kidney Disease in Children criteria, which do not predict outcomes. The 2016 Oxford Classification's MEST-C scoring system predicts outcomes in adults with histologically identical IgA nephropathy, but evidence of its utility in pediatric HSPN is lacking. Our hypothesis was that MEST-C scores predict outcomes in children with HSPN. METHODS A retrospective cohort analysis of data from 32 children with HSPN who underwent renal biopsy was performed. We used logistic regression and receiver operator characteristic curves to analyze the ability of MEST-C to predict the composite outcome of hypertension (blood pressure ≥ 95% for age/sex/height), CKD (estimated glomerular filtration rate < 90 mL/min/1.73 m2), or proteinuria (urine protein-to-creatinine ratio > 0.2 mg/mg). RESULTS The median age at diagnosis was 7.9 years (IQR 5.8, 11.7); 56% were male, 19% were Hispanic, and 9% were Black. After a median follow-up of 2.7 years, 38% of patients (n = 12) reached the outcome. S1 score was significantly associated with the outcome (OR 7.9, 95% CI 1.5-42.6). S1 accurately predicted the outcome (area under the curve 0.72, 95% CI 0.55-0.88) with 58.3% sensitivity and 85.0% specificity, indicating a positive predictive value of 70.0% and a negative predictive value of 77.3%. CONCLUSIONS S1 accurately predicted our composite outcome of hypertension, CKD, and proteinuria in a diverse cohort of U.S. children with HSPN. Further investigation is warranted to validate these findings.
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Affiliation(s)
- Adam Jimenez
- Wake Forest School of Medicine, Winston-Salem, NC, 27157, USA.
| | - Ashton Chen
- Section of Nephrology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jen-Jar Lin
- Section of Nephrology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Andrew M. South
- Section of Nephrology, Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA,Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA,Cardiovascular Sciences Center, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Risk factors associated with IgA vasculitis with nephritis (Henoch-Schönlein purpura nephritis) progressing to unfavorable outcomes: A meta-analysis. PLoS One 2019; 14:e0223218. [PMID: 31574112 PMCID: PMC6772070 DOI: 10.1371/journal.pone.0223218] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 09/15/2019] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To identify risk factors associated with unfavorable outcomes in children with IgA vasculitis with nephritis (Henoch-Schőnlein purpura nephritis)(IgA-VN). METHODS PubMed, Embase, and Web of Science databases were searched for studies, published in English through February 2019. The data were extracted to perform pooled analysis, heterogeneity testing, subgroup analysis, sensitivity analysis, and publication bias analysis. RESULTS This meta-analysis showed that, older age at onset (WMD 1.77, 95% CI 0.35-3.18, p = 0.014), lower glomerular filtration rate (GFR; WMD -23.93, 95% CI -33.78- -14.09, p<0.0001), initial renal manifestations with nephrotic syndrome (OR 1.74, 95% CI 1.12-2.70, p = 0.013), with nephritic-nephrotic syndrome (OR 4.55, 95% CI 2.89-7.15, p<0.0001) and renal biopsy with crescentic nephritis (International Study of Kidney Disease in Children [ISKDC] grades III-V) (OR 3.85, 95% CI 2.37-6.28, p<0.0001) were significant risk factors associated with poor outcomes in IgA-VN, whereas initial clinical features with hematuria (OR 0.33, 95% CI 0.16-0.69, p = 0.003) and mild proteinuria±hematuria (OR 0.46, 95% CI 0.28-0.75, p<0.0001) were associated with progression to good outcomes. By contrast, gender, hypertension and initial renal manifestations of acute nephritic syndrome were not significantly associated with poor outcomes in IgA-VN. CONCLUSION This meta-analysis showed that older age at onset, lower GFR, initial renal features of nephrotic syndrome and nephritic-nephrotic syndrome and renal biopsy with crescentic nephritis (ISKDC grades III-V) were predictive of poor prognosis in children with IgA-VN.
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Ding Y, Zhang X, Ren X, Zhai W, He L, Liu J, Yao C, Han S, Wang L. Traditional Chinese medicine versus regular therapy in Henoch-Schönlein purpura nephritis in children: study protocol for a randomized controlled trial. Trials 2019; 20:538. [PMID: 31464626 PMCID: PMC6716925 DOI: 10.1186/s13063-019-3484-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Henoch-Schönlein purpura nephritis (HSPN) is the most common secondary glomerular disease in children. Currently, the treatment for HSPN is always selected based on the Kidney Disease Improving Global Outcomes guidelines; however, this approach may lead to undertreatment, especially in patients with persistent proteinuria that does not reach nephrotic levels and/or hematuria and those with a pathological classification between grades 1 and 3 according to the International Study of Kidney Disease in Children. This study was performed to evaluate the curative effect and safety of a traditional Chinese medicine (TCM) integrated treatment program in this type of HSPN. METHODS This multicenter, open-label, large-sample, randomized controlled trial was performed in China and included 500 children with HSPN exhibiting mild pathological patterns. The treatment group to control group ratio was 2:1, and each group was further stratified into two types, light and heavy, according to urinary protein quantification and pathological type. The treatment group received tripterygium glycosides (TGs), tanshinone IIa sodium sulfonate injection, and Chinese herbs selected based on syndrome differentiation in TCM. The heavy and light subgroups received treatment courses and dosages of TG. In the control groups, the light group received benazepril hydrochloride tablets, low molecular weight heparin calcium injection, dipyridamole tablets, and a Chinese medicine placebo, while the heavy group received the same treatment plus prednisone. All groups were treated for 3 months and then followed up for 9 months. The efficacy and safety of the treatments were then evaluated among the groups. DISCUSSION Currently, few treatments are available for HSPN patients with mild pathological patterns indicating light to moderate proteinuria and/or hematuresis. In this large-sample study, we provide a new approach for HSPN that includes an integrated treatment program that incorporates TCM. TRIAL REGISTRATION Clinical Trials.gov, NCT03591471 . Re-registered on 19 July 2018.
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Affiliation(s)
- Ying Ding
- Pediatric Kidney Disease Center, the First Affiliated Hospital of Henan University of TCM, Zhengzhou, China
| | - Xia Zhang
- Pediatric Kidney Disease Center, the First Affiliated Hospital of Henan University of TCM, Zhengzhou, China
| | - Xianqing Ren
- Pediatric Kidney Disease Center, the First Affiliated Hospital of Henan University of TCM, Zhengzhou, China
| | - Wensheng Zhai
- Pediatric Kidney Disease Center, the First Affiliated Hospital of Henan University of TCM, Zhengzhou, China
| | - Liyun He
- Clinical Evaluation Department, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jianping Liu
- Evidence-Based Medicine Center, Beijing University of TCM, Beijing, China
| | - Chen Yao
- Medical Statistics Department, Peking University First Hospital, Beijing, China
| | - Shanshan Han
- Pediatric Kidney Disease Center, the First Affiliated Hospital of Henan University of TCM, Zhengzhou, China
| | - Long Wang
- Pediatric Kidney Disease Center, the First Affiliated Hospital of Henan University of TCM, Zhengzhou, China
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Crescent lesions are not a predictive factor in adult-onset Henoch-Schönlein purpura nephritis. Clin Exp Med 2019; 19:449-456. [PMID: 31292781 DOI: 10.1007/s10238-019-00567-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
Abstract
Henoch-Schönlein purpura nephritis (HSPN) is a common secondary glomerulonephritis, and its prognosis mainly depends on the severity of renal impairment. To date, the significance of crescent lesions in adult-onset HSPN is still unclear. Therefore, the purpose of this research was to assess whether crescents could predict the renal outcomes in adult HSPN patients. A total of 188 adult patients with HSPN proven by renal biopsy were enrolled in this prospective study. Patients were divided into three groups based on the proportion of crescents: non-crescent group (C0, n = 110), crescent ≤ 25% group (C1, n = 50) and crescent > 25% group (C2, n = 28). The composited endpoint was defined as eGFR decreased > 50% of baseline level, reached end-stage renal disease and/or death. Among three groups, clinical pathological features, treatment regimens and renal outcomes were compared. During a mean follow-up of 26 months, 78 (42.5%) patients had crescent lesions. A total of ten (9.1%) patients in C0 group and five (17.9%) patients in C2 group reached the combined endpoint, but no patients in C1 group reached endpoint. Renal survival analysis indicated patients in C1 group tended to have the best renal outcome, while patients in C2 group had the poorest renal survival. Moreover, Cox regression analysis revealed crescents were not a predictor of poor developing to renal outcome after adjusting potential confounders [hazard ratio (HR) = 0.28, 95% confidence interval (CI) 0.07-1.18, P = 0.083]. Crescent formation is not necessarily a predictive factor of poor renal survival in adult HSPN patients who had small proportions of crescents (crescent ≤ 25%).
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Ferrara G, Petrillo MG, Giani T, Marrani E, Filippeschi C, Oranges T, Simonini G, Cimaz R. Clinical Use and Molecular Action of Corticosteroids in the Pediatric Age. Int J Mol Sci 2019; 20:ijms20020444. [PMID: 30669566 PMCID: PMC6359239 DOI: 10.3390/ijms20020444] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 01/14/2019] [Accepted: 01/15/2019] [Indexed: 12/19/2022] Open
Abstract
Corticosteroids are the mainstay of therapy for many pediatric disorders and sometimes are life-saving. Both endogenous and synthetic derivatives diffuse across the cell membrane and, by binding to their cognate glucocorticoid receptor, modulate a variety of physiological functions, such as glucose metabolism, immune homeostasis, organ development, and the endocrine system. However, despite their proved and known efficacy, corticosteroids show a lot of side effects, among which growth retardation is of particular concern and specific for pediatric age. The aim of this review is to discuss the mechanism of action of corticosteroids, and how their genomic effects have both beneficial and adverse consequences. We will focus on the use of corticosteroids in different pediatric subspecialties and most common diseases, analyzing the most recent evidence.
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Affiliation(s)
| | - Maria Grazia Petrillo
- Signal Transduction laboratory, NIEHS, NIH, Department of Health and Human Services, Research Triangle Park, Durham, NC 27709, USA.
| | - Teresa Giani
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
- Department of Medical Biotechnology, University of Siena, 53100 Siena, Italy.
| | | | - Cesare Filippeschi
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Teresa Oranges
- Department of Dermatology, Anna Meyer Children's University Hospital, 50139 Florence, Italy.
| | - Gabriele Simonini
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
| | - Rolando Cimaz
- Pediatric Rheumatology, Anna Meyer Children University Hospital, 50139 Florence, Italy.
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Abstract
PURPOSE OF REVIEW The review aims to summarize the recent findings in vasculitis that may have an impact in our understanding or management of these diseases. RECENT FINDINGS We are learning more about monogenic diseases that closely mimic the pediatric vasculitides. Deficiency of adenosine deaminase 2 can present with a polyarteritis nodosa (PAN)-like picture and should be included in the differential of all pediatric cases of PAN with a family history or in cases with early stroke, or in cases resistant to conventional therapy. Mutations in tumor necrosis factor α-induced protein 3 results in a disease that can present as Behçet disease called haploinsufficiency of A20. In fact, these patients would also fulfill the existing criteria for PAN and Behçet disease, respectively. Additional advances in Behçet disease pathogenesis come from a large genetic study of Turkish Behçet disease using data obtained from genotyping using the Immunochip. This confirmed the HLA-B-51 locus as the most significant association and identified new risk loci. Large Iranian and Japanese cohorts were used as replication cohorts. Best treatment of pediatric vasculitis remains a challenge as we continue to lack controlled studies. There are new reports in treatment on Henoch-Schönlein purpura/Immunoglobulin A vasculitis which is one of our most frequent childhood vasculitides. Small series of new treatments for central nervous system vasculitis and Takayasu disease will also be summarized. Diagnostic criteria have been reassessed in pediatric Behçet disease as well as adult and childhood forms of antineutrophil cytoplasmic antibodies-positive vasculitis. SUMMARY The new pathways defined in monogenic diseases may help us better understand the pathogenesis and may help us design more targeted therapy. Although pediatric cases are being increasingly recognized, the relative rarity of the diseases presents an obstacle for studies. Thus, we can reach conclusive results for their management through multicenter studies only.
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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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Buscatti I, Casella B, Aikawa N, Watanabe A, Fahrat S, Campos L, Silva C. NEFRITE NA PÚRPURA HENOCH SCHONLEIN: FATORES DE RISCO INICIAIS E EVOLUÇÃO. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2017.07.581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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