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Bloom JL, Wu EY. Update on antineutrophil cytoplasmic autoantibody vasculitis in children. Curr Opin Rheumatol 2024:00002281-990000000-00124. [PMID: 38990100 DOI: 10.1097/bor.0000000000001033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
PURPOSE OF REVIEW Antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) is often organ- or life-threatening in children and impacts them during important periods of psychosocial and physical development. This review covers recent advances in the pathophysiology, diagnosis, management, and outcomes of AAV in children and highlights the ongoing need for funding and increased research collaboration. RECENT FINDINGS Recent work has improved our understanding of AAV disease pathogenesis, potentially identifying new biomarkers and therapeutic targets. Collaborative clinical studies have also highlighted the variable manifestations in children and identified potential factors associated with poorer outcomes. Consensus-based treatment guidelines are also appearing, but clinical trials are still essential to better understanding treatment efficacy and safety in children affected by AAV. New, validated outcome measures, including those that are patient-reported, will facilitate these much-needed clinical trials in pediatric AAV. SUMMARY There is a continued need for more rigorous study in pediatric AAV, however, there is certainly excitement with the increase in recent research relevant to the pediatric population.
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Affiliation(s)
- Jessica L Bloom
- University of Colorado, Department of Pediatrics, Division of Rheumatology, Denver, Colorado
| | - Eveline Y Wu
- University of North Carolina at Chapel Hill, Department of Pediatrics, Division of Rheumatology
- University of North Carolina at Chapel Hill, Department of Pediatrics, Division of Allergy/Immunology, Chapel Hill, North Carolina, USA
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Cody E, Brunner HI. Renal disease in pediatric rheumatology. Curr Opin Rheumatol 2024:00002281-990000000-00121. [PMID: 38752864 DOI: 10.1097/bor.0000000000001027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
PURPOSE OF REVIEW This review will provide updates in the outcomes in the common rheumatologic diseases with kidney involvement. Covered are also advances in therapeutics for the use of pediatric rheumatologic diseases with kidney involvement, as well as the potential kidney complications from other rheumatologic diseases and their medications. RECENT FINDINGS Two of the more common rheumatologic diseases with kidney involvement, lupus and vasculitis, continue to show inadequate response to initial therapy of renal disease and practice continues to be driven by results of adult studies. SUMMARY There is a continued need for pediatric specific studies in rheumatologic diseases with kidney involvement as outcomes continue to be inadequate. Despite recently approved treatments for adults with rheumatic diseases and kidney involvement, therapeutic options in pediatrics remain limited, contributing to the overall morbidity and mortality.
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Affiliation(s)
- Ellen Cody
- Medical College of Wisconsin, Department of Pediatrics, Division of Nephrology, Milwaukee, Wisconsin
| | - Hermine I Brunner
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Department of Pediatrics, Division of Rheumatology, Ohio, USA
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Chan EYH, Yap DYH, Wong WHS, Wong SW, Lin KYK, Hui FYW, Li JYM, Lam SSY, Wong JKY, Lai FFY, Ho TW, Tong PC, Lai WM, Chan TM, Ma ALT. Renal relapse in children and adolescents with childhood-onset lupus nephritis: a 20-year study. Rheumatology (Oxford) 2024; 63:953-961. [PMID: 37632777 DOI: 10.1093/rheumatology/kead447] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/13/2023] [Accepted: 08/01/2023] [Indexed: 08/28/2023] Open
Abstract
OBJECTIVES There is little data on renal relapse in childhood-onset LN (cLN). We investigate the incidence, predictive factors and outcomes related to renal relapse. METHODS We conducted a retrospective cohort study of all cLN diagnosed at ≤18 years between 2001-2021 to investigate the incidence and outcomes related to renal relapse. RESULTS Ninety-five Chinese cLN patients (91% proliferative LN) were included. Induction immunosuppression was prednisolone and CYC [n = 36 (38%)] or MMF [n = 33 (35%)]. Maintenance immunosuppression was prednisolone and MMF [n = 53 (54%)] or AZA [n = 29 (31%)]. The rates of complete remission/partial remission (CR/PR) at 12 months were 78.9%/7.4%. Seventy renal relapses occurred in 39 patients over a follow-up of 10.2 years (s.d. 5.9) (0.07 episode/patient-year). Relapse-free survival was 94.7, 86.0, 80.1, 71.2, 68.3, 50.3 and 44.5% at 1, 2, 3, 4, 5, 10 and 20 years, respectively. Multivariate analysis showed that LN diagnosis <13.1 years [adjusted hazard ratio (HRadj) 2.59 995% CI 1.27, 5.29), P = 0.01], AZA maintenance [HRadj 2.20 (95% CI 1.01, 4.79), P = 0.05], PR [HRadj 3.9 (95% CI 1.03, 9.19), P = 0.01] and non-remission [HRadj 3.08 (95% CI 1.35, 11.3), P = 0.04] at 12 months were predictive of renal relapse. Renal relapse was significantly associated with advanced chronic kidney disease (stages 3-5) and end-stage kidney disease (17.9% vs 1.8%, P < 0.01). Furthermore, patients with renal relapse showed an increased incidence of infections (30.8% vs 10.7%, P = 0.02), osteopenia (38.5% vs 17.9%, P = 0.04) and hypertension (30.8% vs 7.1%, P < 0.01). CONCLUSION Renal relapse is common among cLN, especially among young patients, and is associated with an increased incidence of morbidity and mortality. Attaining CR and the use of MMF appear to decrease the incidence of renal relapse.
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Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong
| | - Desmond Yat-Hin Yap
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, University of Hong Kong School of Clinical Medicine, Hong Kong
| | | | - Sze-Wa Wong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
| | - Kyle Ying-Kit Lin
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
| | - Felix Yan-Wai Hui
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
| | | | | | | | | | - Tsz-Wai Ho
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
| | - Pak-Chiu Tong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
| | - Wai-Ming Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
| | - Tak Mao Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, University of Hong Kong School of Clinical Medicine, Hong Kong
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong
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Chan EYH, Lai FFY, Ma ALT, Chan TM. Managing Lupus Nephritis in Children and Adolescents. Paediatr Drugs 2024; 26:145-161. [PMID: 38117412 DOI: 10.1007/s40272-023-00609-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/21/2023]
Abstract
Lupus nephritis is an important manifestation of systemic lupus erythematosus, which leads to chronic kidney disease, kidney failure, and can result in mortality. About 35%-60% of children with systemic lupus erythematosus develop kidney involvement. Over the past few decades, the outcome of patients with lupus nephritis has improved significantly with advances in immunosuppressive therapies and clinical management. Nonetheless, there is a paucity of high-level evidence to guide the management of childhood-onset lupus nephritis, because of the relatively small number of patients at each centre and also because children and adolescents are often excluded from clinical trials. Children and adults differ in more ways than just size, and there are remarkable differences between childhood- and adult-onset lupus nephritis in terms of disease severity, treatment efficacy, tolerance to medications and most importantly, psychosocial perspective. In this article, we review the 'art and science' of managing childhood-onset lupus nephritis, which has evolved in recent years, and highlight special considerations in this specific patient population.
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Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong.
| | - Fiona Fung-Yee Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tak Mao Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, School of Clinical Medicine, Pok Fu Lam, Hong Kong.
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Lai FFY, Chan EYH, Tullus K, Ma ALT. Therapeutic drug monitoring in childhood idiopathic nephrotic syndrome: a state of the art review. Pediatr Nephrol 2024; 39:85-103. [PMID: 37147510 DOI: 10.1007/s00467-023-05974-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/30/2023] [Accepted: 03/30/2023] [Indexed: 05/07/2023]
Abstract
Immunosuppressants are commonly used as steroid-sparing agents in childhood idiopathic nephrotic syndrome (NS) to induce and sustain remissions. These drugs have narrow therapeutic indices with high inter- and intra-patient variability. Therapeutic drug monitoring (TDM) would therefore be essential to guide the prescription. Multiple factors in NS contribute to additional variability in drug concentrations, especially during relapses. In this article, we review the currently available evidence of TDM in NS and suggest a practical approach for clinicians' reference.
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Affiliation(s)
- Fiona Fung-Yee Lai
- Department of Pharmacy, Hong Kong Children's Hospital, Kowloon City, Hong Kong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong
| | - Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong.
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon City, Hong Kong
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Chan EYH, Wong SW, Lai FFY, Ho TW, Tong PC, Lai WM, Ma ALT, Yap DYH. Long-term outcomes with rituximab as add-on therapy in severe childhood-onset lupus nephritis. Pediatr Nephrol 2023; 38:4001-4011. [PMID: 37358717 DOI: 10.1007/s00467-023-06025-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/14/2023] [Accepted: 05/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Long-term data pertaining to rituximab as add-on therapy in childhood-onset lupus nephritis (cLN) is scarce. METHODS A retrospective cohort study was conducted on all patients with proliferative cLN, diagnosed ≤ 18 years and between 2005 and 2021, who received rituximab for LN episodes that were life/organ threatening and/or treatment resistant to standard immunosuppression. RESULTS Fourteen patients with cLN (female, n = 10) were included, with median follow-up period of 6.9 years. LN episodes (class III, n = 1; class IV, n = 11; class IV + V, n = 2) requiring rituximab occurred at 15.6 years (IQR 12.8-17.3), urine protein:creatinine ratio was 8.2 mg/mg (IQR 3.4-10.1) and eGFR was 28 mL/min/1.73 m2 (IQR 24-69) prior to rituximab treatment. Ten and four patients received rituximab at 1500 mg/m2 and 750 mg/m2, which were given at 46.5 days (IQR 19-69) after commencement of standard therapies. Treatment with rituximab resulted in improvements in proteinuria (ps < 0.001), eGFR (ps < 0.01) and serological parameters, including haemoglobin levels, complement 3 levels and anti-dsDNA antibodies, compared with baseline. Rates of complete/partial remission at 6-, 12- and 24-month post-rituximab were 28.6/42.8%, 64.2/21.4% and 69.2/15.3%. All three patients who required acute kidney replacement therapy became dialysis-free after rituximab. Relapse rate following rituximab was 0.11 episodes/patient-year. There was no lethal complication or severe infusion reaction. Hypogammaglobulinaemia was the most frequent complication (45%) but was mostly asymptomatic. Neutropenia and infections were observed in 20% and 25% of treatments. Upon last follow-up, three (21%) and two (14%) patients developed chronic kidney disease (stage 2, n = 2; stage 4; n = 1) and kidney failure, respectively. CONCLUSION Add-on rituximab is an effective and safe rescue therapy for cLN patients with life-/organ-threatening manifestations or treatment-resistance. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR.
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR.
| | - Sze-Wa Wong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Fiona Fung-Yee Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Tsz-Wai Ho
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Pak-Chiu Tong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Wai-Ming Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR.
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR.
| | - Desmond Yat-Hin Yap
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR.
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong School of Clinical Medicine, Pokfulam, Hong Kong SAR.
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Chan EYH, Yap DYH, Wong WT, Wong WHS, Wong SW, Lin KYK, Hui FYW, Yee-ming J, Lam SSY, Wong JKY, Lai FFY, Ho TW, Tong PC, Lai WM, Chan TM, Ma ALT. Long-Term Outcomes of Children and Adolescents With Biopsy-Proven Childhood-Onset Lupus Nephritis. Kidney Int Rep 2022; 8:141-150. [PMID: 36644360 PMCID: PMC9831948 DOI: 10.1016/j.ekir.2022.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Long-term data pertaining to childhood-onset lupus nephritis (cLN) remain extremely scarce. Methods We conducted a retrospective cohort study of biopsy-proven cLN with onset age <18 years diagnosed from 2001 to 2020 to ascertain the long-term patient and kidney survival rates, and the incidence of advanced chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] <60 ml/min per 1.73 m2). Results A total of 92 subjects (78 female; age 13.7 ± 3.3 years; all Chinese) were included, with follow-up duration of 10.3 years (interquartile range, 5.8-15.9). Of these, 83 children (90%) had proliferative lupus nephritis (LN) (Class III/IV ± V). Mycophenolate was used for induction in 36%, whereas 34% received cyclophosphamide (CYC); 55% received mycophenolate as maintenance immunosuppression. The rates of complete remission (CR) and partial remission (PR) at 6 months and 12 months, respectively, were 65% and 20% and 78% and 8%. Two patients died (mortality rate 2.1/1000 patient-years), with a standardized mortality ratio of 22.3. Three patients (3.2%) developed end-stage kidney disease (ESKD), and advanced CKD occurred in 5 patients (5.4%). Survival rates without advanced CKD, ESKD, or death were 96.7%, 94.2%, 92.7%, 83.2% and 83.2% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively. Multivariate analysis revealed that severe kidney failure necessitating dialysis at presentation (adjusted hazard ratio 37.7, 95% confidence interval [CI] 4.0-355.6, P = 0.002), nonresponse (NR) after 12 months of treatment (adjusted hazard ratio 11.2, 95% CI 2.3-54.9, P = 0.003), and multiple nephritis flares (adjusted hazard ratio 2.6, 95% CI 1.1-6.2, P = 0.03) were predictive of advanced CKD, ESKD, or death. Other adverse outcomes included infections (2.9 episodes/100 patient-years), osteopenia (32%), hypertension (17%), short stature (14%), and avascular necrosis (7%). Conclusion The long-term outcomes of cLN appeared to have improved in the present era with effective immunosuppression, cautious drug tapering, and assurance of medication adherence. There is still an unacceptably high prevalence of adverse outcomes.
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Affiliation(s)
- Eugene Yu-hin Chan
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Desmond Yat-hin Yap
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wing-tung Wong
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Wilfred Hing-sang Wong
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Sze-wa Wong
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Kyle Ying-kit Lin
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Felix Yan-wai Hui
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Jennifer Yee-ming
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | | | | | | | - Tsz-wai Ho
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Pak-chiu Tong
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Wai-ming Lai
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Tak Mao Chan
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong,Correspondence: Tak Mao Chan, Paediatric Nephrology Centre, Hong Kong Children's Hospital; Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
| | - Alison Lap-tak Ma
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong,Alison Lap-tak Ma, Pediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong.
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