1
|
杜 培, 文 煜, 陈 朝, 涂 娟, 李 华. [Therapeutic effect of mycophenolate mofetil or cyclophosphamide in children with Henoch-Schönlein purpura nephritis of different age groups]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:1113-1117. [PMID: 37990454 PMCID: PMC10672954 DOI: 10.7499/j.issn.1008-8830.2306085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/04/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVES To investigate the difference in the therapeutic effect of mycophenolate mofetil (MMF) or cyclophosphamide (CTX) in children with Henoch-Schönlein purpura nephritis (HSPN) of different age groups. METHODS A retrospective analysis was conducted on the clinical data of 135 children with HSPN who were treated with MMF or CTX in the Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics, from October 2018 to October 2020. According to the immunosuppressant used, they were divided into two groups: MMF group and CTX group, and according to the age, each group was further divided into two subgroups: ≤12 years and >12 years, producing four groups, i.e, the ≤12 years MMF subgroup (n=30), the >12 years MMF subgroup (n=15), the ≤12 years CTX subgroup (n=71), and the >12 years CTX subgroup (n=19). All children were followed up for at least 12 months, and the above groups were compared in terms of clinical outcomes and the incidence rate of adverse reactions. RESULTS There was no significant difference in the complete response rate between the MMF group and the CTX group after 3, 6, and 12 months of treatment (P>0.05). There were no significant difference in the complete response rate and the incidence rate of adverse reactions between the >12 years MMF subgroup and the ≤12 years MMF subgroup at 3, 6, and 12 months of treatment (P>0.05). The >12 years CTX subgroup had a significantly lower complete response rate than the ≤12 years CTX subgroup at 6 and 12 months of treatment (P<0.05). The >12 years CTX subgroup had a significantly higher incidence rate of adverse reactions than the >12 years MMF subgroup (P<0.05). CONCLUSIONS The efficacy and adverse reactions of MMF are not associated with age, but the efficacy of CTX is affected by age, with a higher incidence rate of adverse reactions. CTX should be selected with caution for children with HSPN aged >12 years.
Collapse
|
2
|
Mukanhaire L, Ren X, Liu G, Wang T, Kasumba YY, Zhou X, Peng H. Recurrence of Henoch Schoenlein Purpura Nephritis in Children: A Retrospective Study. Heliyon 2023; 9:e22501. [PMID: 38034624 PMCID: PMC10687055 DOI: 10.1016/j.heliyon.2023.e22501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023] Open
Abstract
The aim of the study was to identify predictive patient characteristics for Henoch Schoenlein Purpura (HSPN) relapse in childhood HSPN. One hundred and thirty-five Chinese children with HSPN were enrolled in this study, mean age 10.25 ± 3.39 years. The pathology of HSPN was according to the International Study of Kidney Disease in Children criteria.(ISKDC); ISKDC II(mesangial proliferation (MP)) AND ISKDC III (MP with <50 % crescents).Recurrence of HSPN was observed in 66.3 % patients; male to female ratio (2:1)Statistically significant correlation existed between biopsy grade(p < 0.001), gender(p < 0.001),age ranges(p = 0.002) and treatment regimen (p < 0.001)in the frequency of recurrent HSPN episodes. We identified some significant predictors for HSPN relapse such as the severity of HSPN, adjunctive therapies administered to these patients,and close attention should be paid in patients between the ages 7 and 12 years old. In addition, the use of mycophenolate mofetil as an adjunctive therapy in the treatment of HSPN may reduce the frequency of HSPN relapse episodes in children.
Collapse
Affiliation(s)
- Lydia Mukanhaire
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
- Department of Pediatrics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 211166, China
- Department of Pediatrics, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, 210008, China
| | - Xianguo Ren
- Department of Pediatrics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 211166, China
| | - Guangling Liu
- Department of Pediatrics, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, 210008, China
| | - Ting Wang
- Department of Pediatrics, Sir Run Run Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, 211166, China
| | - Yeukai Y. Kasumba
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Xiaohui Zhou
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, Jiangsu, 211198, China
| | - Hongjun Peng
- Department of Pediatrics, Nanjing Drum Tower Hospital, Nanjing, Jiangsu Province, 210008, China
| |
Collapse
|
3
|
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
|
4
|
Samsonov D, Zolotnitskaya A, Matloff R, Pereira T, Solomon S. Mycophenolate Mofetil for Severe IgA Vasculitis Nephropathy in Children: An Observational Study. Kidney Med 2022; 4:100534. [PMID: 36159165 PMCID: PMC9490199 DOI: 10.1016/j.xkme.2022.100534] [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] [Indexed: 11/19/2022] Open
Abstract
Rationale & Objective Individuals with IgA vasculitis nephritis (IGAVN) may develop rapidly progressive glomerulonephritis and/or nephrotic-range proteinuria, which are associated with worse prognosis. We report our experience of treatment of children with IGAVN with nephrotic-range proteinuria. Study Design Case series. Setting & Participants We retrospectively analyzed all children who presented with IGAVN, cutaneous purpura, and nephrotic-range proteinuria from January 1, 2000 until December 31, 2018. Outcome We evaluated time required to achieve remission of proteinuria, resolution of hematuria, and glomerular filtration rate (GFR) at 12 months and last follow-up. Results Twelve patients, 8 boys and 4 girls, mean age 7.5 years (range 4-15) were included in the study. Mean urinary protein to creatinine ratio (UPC) was 12.5 ± 8.7 mg/mg and GFR 90.7 ± 19.1 mL/min/1.73 m2 before initiation of immunosuppression. All patients were treated with steroids and mycophenolate mofetil. Mean UPC declined progressively from 12.5 mg/mg to 4.6, 2.7, 0.3, and 0.2 mg/mg after 1, 3, 6, and 12 months, respectively. All patients achieved remission of proteinuria (UPC <0.3 mg/mg) and normalization of kidney function (GFR 102.2 ± 8.0 mL/min/1.73 m2) at 12 months. Immunosuppression was successfully withdrawn in all patients, and at last follow-up (mean 33.5 months), all patients except one remained in remission. All patients except one that relapsed maintained normal GFR at the last follow-up. Limitations Retrospective study, single-center experience, no standard immunosuppressive protocol, lack of control group. Conclusions Remission can be achieved in patients with IGAVN and nephrotic-range proteinuria using mycophenolate mofetil-based immunosuppression. Magnitude of proteinuria is a key laboratory finding that correlates with time to achieve remission. Prolonged follow-up of patients with severe IGAVN is warranted.
Collapse
|
5
|
Wu D, Ma R, Wang X, Yang Y. Efficacy and Safety of Tacrolimus in the Treatment of Pediatric Henoch-Schönlein Purpura Nephritis. Paediatr Drugs 2022; 24:389-401. [PMID: 35508891 DOI: 10.1007/s40272-022-00506-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with severe Henoch-Schönlein purpura nephritis (HSPN) may progress to end-stage renal disease without appropriate treatment. OBJECTIVE This study aimed to investigate the efficacy and safety of tacrolimus combined with glucocorticoids in the treatment of pediatric HSPN. METHODS A total of 87 HSPN patients with urinary protein ≥ 0.75 g/24 h received standard of care, including angiotensin II receptor blockers/angiotensin-converting enzyme inhibitors and glucocorticoids. Patients were divided into three groups and additionally received tacrolimus (n = 30), cyclophosphamide (n = 31), or mycophenolate mofetil (MMF) (n = 26). We monitored outcome measures, including proteinuria, hematuria, and renal function and analyzed the efficacy and side effects in each group. RESULTS At 2-month follow-up, the overall efficacy was 93.3%, 83.9%, and 61.5% for tacrolimus, cyclophosphamide, and MMF, respectively (P < 0.05). Urinary protein significantly decreased for all groups. Urinary red blood cell counts significantly decreased for patients treated with tacrolimus (P < 0.001) and cyclophosphamide (P < 0.05), whereas no significant decrease was seen for those receiving MMF (P = 0.09). Although urine β2-microglobulin significantly decreased following 2 months of treatment with all medications, efficacy was greater with tacrolimus than with cyclophosphamide and MMF (P < 0.001). Major adverse events were respiratory and urinary infections, with MMF having the highest infection rate. The cyclophosphamide group also experienced additional adverse events, including arrhythmia, hemorrhagic cystitis, leukocytosis, thrombocytopenia, and hyperglycemia. CONCLUSIONS These results indicate that tacrolimus is more effective at reducing proteinuria and hematuria and improving renal function, with relatively milder side effects, in the treatment of pediatric HSPN. CLINICAL TRIAL REGISTRATION NUMBER ChiCTR2200055323, retrospectively registered on January 7, 2022.
Collapse
Affiliation(s)
- Dengyan Wu
- Department of Pediatric Nephrology, Lanzhou University Second Hospital, Lanzhou, Gansu, 730030, China
| | - Rui Ma
- Department of Pediatric Nephrology, Lanzhou University Second Hospital, Lanzhou, Gansu, 730030, China
| | - Xingmin Wang
- Nantong Institute of Genetics and Reproductive Medicine, Affiliated Maternity and Child Healthcare Hospital of Nantong University, Nantong, Jiangsu, 226018, China
| | - Yonghong Yang
- Department of Pediatric Nephrology, Lanzhou University Second Hospital, Lanzhou, Gansu, 730030, China. .,Department of Pediatrics, Affiliated Maternity and Child Healthcare Hospital of Nantong University, Nantong, Jiangsu, 226018, China. .,Department of Nephrology, Rheumatology, and Immunology, Nantong Children's Hospital, 399 Century Ave., Nantong, Jiangsu, 226018, China.
| |
Collapse
|
6
|
Carmona-Cruz SA, Durán-McKinster LC, García-Romero MT. Atypical purpura and other features associated with unfavorable outcomes of IgA vasculitis (Henoch-Schönlein purpura) in children: A retrospective study. Pediatr Dermatol 2022; 39:369-371. [PMID: 35178758 DOI: 10.1111/pde.14927] [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: 08/24/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
Abstract
The prognosis of IgA vasculitis (also known as Henoch-Schönlein purpura) is determined by renal or other organ involvement. We conducted a retrospective study to identify the initial features of 106 children with IgA vasculitis and their association with unfavorable outcomes. Location of purpura above the waist and an altered urinalysis at diagnosis predicted a more aggressive course of disease.
Collapse
|
7
|
Abstract
PURPOSE OF REVIEW The purpose of this update is to summarize current knowledge on the pathophysiology of immunglobulin A (IgA) vasculitis nephritis (IgAVN) as well as to critically review evidence for established therapeutic regimes and available biomarkers. An additional purpose is to raise the discussion what could be done to further improve our understanding of IgAVN, identify patients at risk for adverse outcome and increase the evidence for therapy recommendations. RECENT FINDINGS Clinical and experimental studies have established the concept of a multilevel pathogenesis. Toll-like-receptor activation, B cell proliferation, micro-RNAs and complement activation have been identified or confirmed as potential therapeutic targets which can modify the course of the disease. Currently, kidney injury molecule-1, monocyte chemotactic protein-1, N-acetyl-β-glucosaminidase, and angiotensinogen are the most promising urinary biomarkers for early diagnosis of renal involvement in IgA vasculitis. SUMMARY Close surveillance of all IgAV patients for renal involvement is recommended. Given the multilevel pathogenesis, early treatment of even mild cases should be initiated. Further therapeutic options should be considered in case first-line therapy (mostly corticosteroids) has no effect. The evidence supporting current therapeutic regimes is predominantly based on expert opinion. Prospective studies are needed and should involve substances inhibiting B cell proliferation and complement activation.
Collapse
Affiliation(s)
- Eva Nüsken
- Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Faculty of Medicine, University of Cologne, Köln, Germany
| | | |
Collapse
|
8
|
Abu-Zaid MH, Salah S, Lotfy HM, El Gaafary M, Abdulhady H, Tabra SAA, Salah H, Farag Y, Eissa M, Maher SE, Radwan A, El-Shanawany AT, Medhat BM, El Mikkawy D, Mosad Mosa D, El Deriny G, Mortada M, Osman NS, Fouad NA, Elkaraly NE, Mohamed SS, Hassan WA, Amer YA, Nasef SI, El Miedany Y. Consensus evidence-based recommendations for treat-to-target management of immunoglobulin A vasculitis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211059610. [PMID: 34917176 PMCID: PMC8669874 DOI: 10.1177/1759720x211059610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 12/20/2022] Open
Abstract
IgA vasculitis (IgAV), formerly known as Henoch-Schönlein purpura, is the most common cause of systemic vasculitis in childhood. Given its potential life-threatening systemic complications, early and accurate diagnosis as well as management of IgAV represent a major challenge for health care professionals. This study was carried out to attain an evidence-based expert consensus on a treat-to-target management approach for IgAV using Delphi technique. The preliminary scientific committee identified a total of 16 key clinical questions according to the patient, intervention, comparison, and outcomes (PICO) approach. An evidence-based, systematic, literature review was conducted to compile evidence for the IgAV management. The core leadership team identified researchers and clinicians with expertise in IgAV management in Egypt upon which experts were gathered from different governorates and health centers across Egypt. Delphi process was implemented (two rounds) to reach a consensus. An online questionnaire was sent to expert panel (n = 26) who participated in the two rounds. After completing round 2, a total of 20 recommendation items, categorized into two sections were obtained. Agreement with the recommendations (rank 7-9) ranged from 91.7-100%. Consensus was reached (i.e. ⩾75% of respondents strongly agreed or agreed) on the wording of all the 20 clinical standards identified by the scientific committee. Algorithms for the diagnosis and management have been suggested. This was an expert, consensus recommendations for the diagnosis and treatment of IgAV and IgA vasculitic nephritis, based on best available evidence and expert opinion. The guideline presented a strategy of care with a pathway to achieve a state of remission as early as possible. Plain Language Summary Given its potential life-threatening systemic complications, early and accurate diagnosis of immunoglobulin A vasculitis represents a major challenge for health care professionals. This work provided cornerstone principles for the management of the condition. Adopting PICO approach and implementing Delphi process a consensus was reached on evidence-based treat-to-target treatment recommendations. This will endorse enhancement and consistency of care of this cohort of patients in standard practice.
Collapse
Affiliation(s)
| | - Samia Salah
- Pediatric Rheumatology, Cairo University, Cairo, Egypt
| | - Hala M Lotfy
- Pediatric Rheumatology, Cairo University, Cairo, Egypt
| | - Maha El Gaafary
- Community Medicine and Public Health, Ain Shams University, Cairo, Egypt
| | - Hala Abdulhady
- Rheumatology and Rehabilitation, Ain Shams University, Cairo, Egypt
| | | | - Hala Salah
- Pediatric Rheumatology, Cairo University, Cairo, Egypt
| | - Yomna Farag
- Pediatric Rheumatology, Cairo University, Cairo, Egypt
| | | | | | - Ahmed Radwan
- Rheumatology and Rehabilitation, Sohag University, Sohag, Egypt
| | | | - Basma M Medhat
- Rheumatology and Rehabilitation, Cairo University, Cairo, Egypt
| | - Dalia El Mikkawy
- Rheumatology and Rehabilitation, Ain Shams University, Cairo, Egypt
| | | | | | - Mohamed Mortada
- Rheumatology and Rehabilitation, Zagazig University, Zagazig, Egypt
| | | | | | | | - Sally S Mohamed
- Rheumatology and Rehabilitation, Cairo University, Cairo, Egypt
| | - Waleed A Hassan
- Rheumatology and Rehabilitation, Benha University, Benha, Egypt
| | - Youmna A Amer
- Rheumatology and Rehabilitation, Zagazig University, Zagazig, Egypt
| | | | | |
Collapse
|
9
|
Resztak M, Sobiak J, Czyrski A. Recent Advances in Therapeutic Drug Monitoring of Voriconazole, Mycophenolic Acid, and Vancomycin: A Literature Review of Pediatric Studies. Pharmaceutics 2021; 13:1991. [PMID: 34959272 PMCID: PMC8707246 DOI: 10.3390/pharmaceutics13121991] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 01/05/2023] Open
Abstract
The review includes studies dated 2011-2021 presenting the newest information on voriconazole (VCZ), mycophenolic acid (MPA), and vancomycin (VAN) therapeutic drug monitoring (TDM) in children. The need of TDM in pediatric patients has been emphasized by providing the information on the differences in the drugs pharmacokinetics. TDM of VCZ should be mandatory for all pediatric patients with invasive fungal infections (IFIs). Wide inter- and intrapatient variability in VCZ pharmacokinetics cause achieving and maintaining therapeutic concentration during therapy challenging in this population. Demonstrated studies showed, in most cases, VCZ plasma concentrations to be subtherapeutic, despite the updated dosages recommendations. Only repeated TDM can predict drug exposure and individualizing dosing in antifungal therapy in children. In children treated with mycophenolate mofetil (MMF), similarly as in adult patients, the role of TDM for MMF active form, MPA, has not been well established and is undergoing continued debate. Studies on the MPA TDM have been carried out in children after renal transplantation, other organ transplantation such as heart, liver, or intestine, in children after hematopoietic stem cell transplantation or cord blood transplantation, and in children with lupus, nephrotic syndrome, Henoch-Schönlein purpura, and other autoimmune diseases. MPA TDM is based on the area under the concentration-time curve; however, the proposed values differ according to the treatment indication, and other approaches such as pharmacodynamic and pharmacogenetic biomarkers have been proposed. VAN is a bactericidal agent that requires TDM to prevent an acute kidney disease. The particular group of patients is the pediatric one. For this group, the general recommendations of the dosing may not be valid due to the change of the elimination rate and volume of distribution between the subjects. The other factor is the variability among patients that concerns the free fraction of the drug. It may be caused by both the patients' population and sample preconditioning. Although VCZ, MMF, and VAN have been applied in pediatric patients for many years, there are still few issues to be solve regarding TDM of these drugs to ensure safe and effective treatment. Except for pharmacokinetic approach, pharmacodynamics and pharmacogenetics have been more often proposed for TDM.
Collapse
Affiliation(s)
- Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland; (J.S.); (A.C.)
| | | | | |
Collapse
|
10
|
IgA Vasculitis: a Review and Update on the Management of Renal and Extrarenal Disease, Highlighting What’s New for Biomarkers and Treatment. CURRENT PEDIATRICS REPORTS 2021. [DOI: 10.1007/s40124-021-00247-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
11
|
[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.
Collapse
|
12
|
Mycophenolic acid area under the concentration-time curve is associated with therapeutic response in childhood-onset lupus nephritis. Pediatr Nephrol 2021; 36:341-347. [PMID: 32856157 DOI: 10.1007/s00467-020-04733-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/15/2020] [Accepted: 07/28/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Mycophenolic acid (MPA), the active compound of mycophenolate mofetil (MMF), is widely used in lupus nephritis treatment. Therapeutic drug monitoring of adults suggests that area under the concentration-time curve (AUC) of MPA (MPA-AUC) is associated with clinical outcomes, but childhood data are scarce. METHODS Retrospective study of 27 children with biopsy-proven lupus nephritis treated with MMF between 2008 and 2016. In 25 children, MPA-AUC was performed within 6 months after kidney biopsy and MMF initiation. Treatment response at 6 months was defined as normal or improved GFR by 25% compared with baseline, 50% reduction of proteinuria to < 0.5 g/day or 50 mg/mmol, and no hematuria. RESULTS A total of 62 MPA-AUC were analyzed in 27 patients. Overall median was 44 mg h/L (interquartile range [IQR] 33-54). Individual dose adaptation was required in 32 cases (52%) to achieve target AUC of 30-60 mg h/L. At 6 months, 14/25 patients were defined as responders (56%, median MPA-AUC 49 mg h/L (40-59)) and 11/25 as non-responders (44%, 29 mg h/L (24-38)). Patients with MPA-AUC levels > 45, 30-45, and < 30 mg h/L had 6-month response rates of 89% (8/9), 60% (6/10), and 0% (0/6), respectively. In a logistic regression model adjusted for age, sex, lupus nephritis classification, and time since MMF initiation, an MPA-AUC > 45 mg h/L was significantly associated with therapeutic response (OR 3.6, 95% CI 2.4-9.5, p = 0.03). CONCLUSIONS Therapeutic drug monitoring leading to individualized dosing may improve efficacy of MMF. MPA-AUC > 45 mg h/L is associated with better response rate and may be considered as a target value in pediatric lupus nephritis.
Collapse
|
13
|
Gicchino MF, Iafusco D, Marrapodi MM, Melone R, Cuomo G, Zanfardino A, del Giudice EM, Olivieri AN. Gastrointestinal Henoch-Schönlein purpura successfully treated with Mycophenolate Mofetil: Description of 2 case reports. Medicine (Baltimore) 2021; 100:e24093. [PMID: 33429774 PMCID: PMC7793365 DOI: 10.1097/md.0000000000024093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 12/08/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Henoch-Schönlein Purpura (HSP) is an acute small vessel vasculitis. It is the most common vasculitis in children. In majority of the cases, the disease is self-limited. Relapses can occur, in particular during the first year of the disease. There is no consensus on a specific treatment. The efficacy and safety of steroidal treatment in treating HSP is still controversial. Immunosuppressive treatment of HSP nephritis is used in patients with severe renal involvement (nephrotic range proteinuria and/or progressive renal impairment). The literature on immunosuppressive treatment of severe HSP without kidney involvement is scanty. PATIENTS CONCERNS We report 2 case reports of 2 adolescents affected from Henoch-Schönlein Purpura and severe gastrointestinal involvement. Both patients presented a poor response to steroids treatment. DIAGNOSES The diagnosis of HSP was made according to the diagnostic criteria published by European League against Rheumatism and Pediatric Rheumatology European Society in 2006. INTERVENTIONS In consideration of the recurrence of the Henoch Schönlein Purpura and the gastrointestinal involvement, we decided to start Mycophenolate Mofetil treatment. OUTCOMES In both patients all clinical manifestations resolved in few days. LESSONS In our cases of HSP with gastrointestinal involvement Mycophenolate Mofetil treatment has been very effective. This experience teaches us that immunosuppressive agents may be very useful to induce and maintain remission not only in renal involvement, but in all cases of persistent, recurrent, or complicated Henoch Schönlein Purpura in children.
Collapse
Affiliation(s)
| | - Dario Iafusco
- Department of Woman, Child and General and Specialized Surgery
| | | | - Rosa Melone
- Department of Woman, Child and General and Specialized Surgery
| | - Giovanna Cuomo
- Department of Precision Medicine, University of the Study of Campania “Luigi Vanvitelli,” Naples, Italy
| | | | | | | |
Collapse
|
14
|
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
|
15
|
Zhang Q, Yan L, Chen M, Gui M, Lu L, Deng F, Ren Z. IgA1 isolated from Henoch-Schönlein purpura children promotes proliferation of human mesangial cells in vitro. Cell Biol Int 2019; 43:760-769. [PMID: 30958627 DOI: 10.1002/cbin.11142] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/23/2019] [Indexed: 01/31/2023]
Abstract
Previous studies show that the proliferation of human mesangial cells (HMCs) played a significant part in the pathogenesis of Henoch-Schönlein purpura nephritis (HSPN). The aim of this study was to explore the proliferation of HMCs induced by IgA1 isolated from the sera of HSP patients. HMCs were cultured in three different types of media, including IgA1 from patients with HSP (HSP IgA1 group), healthy children (healthy IgA1 group) and medium (control group). The proliferation of HMCs incubated with IgA1 was determined by cell counting kit-8 assay and bromodeoxyuridine incorporation. The expression of ERK1/2 and phosphatidylinositol 3 kinase/protein kinase B/mammalian targets of the rapamycin (PI3K/AKt/mTOR) signals and transferrin receptor (TfR/CD71) was detected with the methods of immunoblotting. The results indicated that the proliferation of HMCs significantly increased in the HSP IgA1 group compared with that in the control group or the healthy IgA1 group (P < 0.001). Moreover, we found that IgA1 isolated from HSP patients activated ERK and PI3K/AKt/mTOR signals, and markedly increased TfR/CD71 expression in HMCs. These effects induced by IgA1 isolated from patients with HSP were inhibited by human TfR polyclonal antibody (hTfR pAb) and soluble human transferrin receptor (sTfR), indicating that IgA1-induced HMC proliferation and ERK1/2 and PI3K/AKt/mTOR activation were dependent on TfR/CD71 engagement. Altogether, these data suggested that TfR/CD71 overexpression and ERK1/2 and PI3K/AKt/mTOR activation were engaged in HMC proliferation induced by IgA1 from HSP patients, which might be related to the mesangial injury of HSPN.
Collapse
Affiliation(s)
- Qin Zhang
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Heifei, Anhui, China
| | - Lili Yan
- Department of Anatomy, Anhui Medical University, Hefei, Anhui, China
| | - Mingyu Chen
- Department of Anatomy, Anhui Medical University, Hefei, Anhui, China
| | - Ming Gui
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Heifei, Anhui, China
| | - Ling Lu
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Heifei, Anhui, China
| | - Fang Deng
- Department of Pediatrics, First Affiliated Hospital of Anhui Medical University, Heifei, Anhui, China
| | - Zhenhua Ren
- Department of Anatomy, Anhui Medical University, Hefei, Anhui, China
| |
Collapse
|
16
|
Ozen S, Marks SD, Brogan P, Groot N, de Graeff N, Avcin T, Bader-Meunier B, Dolezalova P, Feldman BM, Kone-Paut I, Lahdenne P, McCann L, Pilkington C, Ravelli A, van Royen A, Uziel Y, Vastert B, Wulffraat N, Kamphuis S, Beresford MW. European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis—the SHARE initiative. Rheumatology (Oxford) 2019; 58:1607-1616. [DOI: 10.1093/rheumatology/kez041] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/09/2019] [Indexed: 01/25/2023] Open
Abstract
Abstract
Objectives
IgA vasculitis (IgAV, formerly known as Henoch–Schönlein purpura) is the most common cause of systemic vasculitis in childhood. To date, there are no internationally agreed, evidence-based guidelines concerning the appropriate diagnosis and treatment of IgAV in children. Accordingly, treatment regimens differ widely. The European initiative SHARE (Single Hub and Access point for paediatric Rheumatology in Europe) aims to optimize care for children with rheumatic diseases. The aim therefore was to provide internationally agreed consensus recommendations for diagnosis and treatment for children with IgAV.
Methods
Recommendations were developed by a consensus process in accordance with the EULAR standard operating procedures. An extensive systematic literature review was performed, and evidence-based recommendations were extrapolated from the included papers. These were evaluated by a panel of 16 international experts via online surveys and subsequent consensus meeting, using nominal group technique. Recommendations were accepted when ⩾80% of experts agreed.
Results
In total, 7 recommendations for diagnosis and 19 for treatment of paediatric IgAV were accepted. Diagnostic recommendations included: appropriate use of skin and renal biopsy, renal work-up and imaging. Treatment recommendations included: the importance of appropriate analgesia and angiotensin-converting enzyme inhibitor use and non-renal indications for CS use, as well as a structured approach to treating IgAV nephritis, including appropriate use of CS and second-line agents in mild, moderate and severe disease along with use of angiotensin-converting enzyme inhibitors and maintenance therapy.
Conclusion
The SHARE initiative provides international, evidence-based recommendations for the diagnosis and treatment of IgAV that will facilitate improvement and uniformity of care.
Collapse
Affiliation(s)
- Seza Ozen
- Department of Paediatrics, Hacettepe University, Ankara, Turkey
| | - Stephen D. Marks
- Great Ormond Street Hospital for Children NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Paul Brogan
- Great Ormond Street Hospital for Children NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Noortje Groot
- Wilhelmina Children’s Hospital, University Medical Center, Utrecht
- Sophia Children’s Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Nienke de Graeff
- Wilhelmina Children’s Hospital, University Medical Center, Utrecht
| | - Tadej Avcin
- Department of Paediatric Rheumatology, University Children’s Hospital Ljubljana, Ljubljana, Slovenia
| | | | - Pavla Dolezalova
- General University Hospital and 1 Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Brian M. Feldman
- The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Isabelle Kone-Paut
- Department of Paediatric Rheumatology, Bicêtre University Hospital, Paris, France
| | - Pekka Lahdenne
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Liza McCann
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Clarissa Pilkington
- Great Ormond Street Hospital for Children NHS Foundation Trust, University College London Great Ormond Street Institute of Child Health, London, UK
| | | | - Annet van Royen
- Wilhelmina Children’s Hospital, University Medical Center, Utrecht
| | - Yosef Uziel
- Meir Medical Centre, Tel Aviv University, Tel Aviv, Israel
| | - Bas Vastert
- Wilhelmina Children’s Hospital, University Medical Center, Utrecht
| | - Nico Wulffraat
- Wilhelmina Children’s Hospital, University Medical Center, Utrecht
| | - Sylvia Kamphuis
- Sophia Children’s Hospital, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Michael W. Beresford
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
- Institute of Translational Medicine, University of Liverpool and Alder Hey children's NHS Foundation Trust, Members of Liverpool Health Partners, Liverpool, UK
| |
Collapse
|
17
|
González-Gay MA, López-Mejías R, Pina T, Blanco R, Castañeda S. IgA Vasculitis: Genetics and Clinical and Therapeutic Management. Curr Rheumatol Rep 2018; 20:24. [PMID: 29611051 DOI: 10.1007/s11926-018-0735-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
PURPOSE OF REVIEW The purpose of the study is to perform an update on the current knowledge on genetics, clinical manifestations, and therapy in immunoglobulin A vasculitis (IgAV) (Henoch-Schönlein purpura). RECENT FINDINGS A strong genetic predisposition in individuals with IgAV was confirmed. It was due to the association with the HLA class II region that in people of European background is mainly related to HLA-DRB1*01 allele. Recent reports support the claim that kidney disease is more common in adults than in children with IgAV. The clinical spectrum and outcome of adults with IgAV depends on the age of onset. Relapses are not uncommon in IgAV. The presence of renal impairment or proteinuria excretion exceeding 1 g/24 h at the time of disease diagnosis and the degree of renal damage on the kidney biopsy are the best predictors of end-stage renal failure in adults with IgAV. The levels of urinary IgA at the onset of the disease may predict a poor renal outcome. The use of prednisone does not seem to prevent persistent kidney disease in children with IgAV. No additional benefit of adding cyclophosphamide to glucocorticoids in adults with IgAV was found. Rituximab seems to be a promising therapy in the management of adults with IgAV. In this overview, we focus on the genetics, clinical manifestations, and therapy of IgA vasculitis, emphasizing the main differences in the clinical expression of the disease between children and adults.
Collapse
Affiliation(s)
- Miguel A González-Gay
- University of Cantabria, Santander, Spain.
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Rheumatology Division, IDIVAL, Hospital Universitario Marqués de Valdecilla, Avenida de Valdecilla, s/n, 39008, Santander, Spain.
- Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Raquel López-Mejías
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Rheumatology Division, IDIVAL, Hospital Universitario Marqués de Valdecilla, Avenida de Valdecilla, s/n, 39008, Santander, Spain
| | - Trinitario Pina
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Rheumatology Division, IDIVAL, Hospital Universitario Marqués de Valdecilla, Avenida de Valdecilla, s/n, 39008, Santander, Spain
| | - Ricardo Blanco
- Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Rheumatology Division, IDIVAL, Hospital Universitario Marqués de Valdecilla, Avenida de Valdecilla, s/n, 39008, Santander, Spain
| | - Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, IIS-Princesa, Universidad Autónoma de Madrid (UAM), Madrid, Spain
| |
Collapse
|