Obesity is associated with Henoch-Schönlein Purpura Nephritis and development of end-stage renal disease in children

Clinical characteristics and risk factors for kidney involvement in children with immunoglobulin A vasculitis

BACKGROUND

Immumoglobulin A (IgA) vasculitis (IgAV), formerly known as Henoch-Schönlein purpura (HSP), is a self-limiting systemic vasculitis in children. Kidney involvement is associated with a long-term unfavorable outcome and can lead to significant morbidity. This study was conducted to describe the clinical and laboratory characteristics of childhood IgAV with kidney involvement and to identify risk factors associated with IgAV nephritis (IgAVN).

METHODS

This was an ambidirectional descriptive study of 77 children with IgAV. All demographic data, clinical features, and laboratory tests were collected from electronic medical records from January 2010 to December 2022. Risk factors for kidney involvement in IgAV were assessed using multivariate logistic regression. Kaplan-Meier survival analysis was used to calculate the time to commencement of kidney involvement.

RESULTS

Twenty-five children (32.4% of the IgAV patients) developed IgAVN. The common findings in IgAV with kidney involvement were microscopic hematuria (100%), nephrotic range proteinuria (44%), and non-nephrotic range proteinuria (40%). Multivariate logistic regression showed that age greater than 10 years (adjusted hazard ratio, AHR 4.66; 95% confidence interval, CI, 1.91-11.41; p = 0.001), obesity (body mass index, BMI, z-score ≥ +2 standard deviations, SDs) (AHR 3.59; 95% CI 1.41-9.17; p = 0.007), and hypertension at onset (AHR 4.78; 95% CI 1.76-12.95; p = 0.002) were associated significantly with kidney involvement. During follow up, most IgAV patients developed nephritis within the first 9 months.

CONCLUSION

Age greater than 10 years, obesity, and hypertension at presentation were predictive factors for IgAVN. Our study emphasized that IgAV patients with risk factors should be closely monitored for at least 1 year after the onset of the disease.

Causal relationships between circulating inflammatory factors and IgA vasculitis: a bidirectional Mendelian randomization study

Background

IgA vasculitis (IgAV) is an immune-associated vasculitis, yet its exact etiology remains unclear. Here, we explore the interaction between IgAV and inflammatory factors using bidirectional Mendelian randomization (MR).

Methods

We conducted a bidirectional summary-level MR analysis to delineate the causality of C-reactive protein (CRP), procalcitonin (PCT), and 41 circulating inflammatory regulators with IgAV. Data on genetic variants related to inflammation were obtained from three genome-wide association studies (GWASs) on CRP, PCT, and human cytokines, whereas data on IgAV was from large meta-analyses of GWAS among 216 569 FinnGen Biobank participants. The primary MR analysis was performed using the inverse-variance weighted (IVW) approach, and the sensitivity analyses were carried out using MR-Egger, weighted median, weighted mode, and MR-pleiotropy residual sum and outlier.

Results

This study revealed the association of CRP higher levels with increased risk of IgAV through IVW method (Estimate odds ratio [OR] = 1.41, 95% confidence interval [CI]: 1.01-1.98, P = 0.04), MR-Egger (OR = 1.87, CI: 1.15-3.02, P = 0.01), weighted median (OR = 2.00, CI: 1.21-3.30, P = 0.01) and weighted mode (OR = 1.74, CI: 1.13-2.68, P = 0.02). Furthermore, elevated IL-8 was strongly implicated with a higher risk of IgAV (IVW OR = 1.42, CI: 1.05-1.92; P = 0.02). Conversely, genetically predicted IgAV was associated with decreased levels of TNF-β (IVW estimate β = -0.093, CI: -0.178 - -0.007; P = 0.033). Additionally, no such significant statistical differences for other inflammatory factors were found.

Conclusion

Our current study using bidirectional MR analysis provides compelling evidence for a causal effect of CRP, PCT, and circulating inflammatory regulators on IgAV. These findings contribute to a better understanding of the pathogenesis of IgAV and emphasize the potential of targeting inflammatory factors for therapeutic interventions.

Association of Pediatric Vasculitis Activity Score with immunoglobulin A vasculitis with nephritis

BACKGROUND

Immunoglobulin A vasculitis with nephritis (IgAVN) is the most serious complication affecting long-term prognosis. Understanding the risk factors and markers for the development of IgAVN is essential. The aim of this study is to identify IgAVN-associated factors and to evaluate the usability of Pediatric Vasculitis Activity Score (PVAS) at diagnosis as an early marker for the development of IgAVN.

METHODS

We conducted a retrospective case-control study of 314 patients divided into two groups: those with nephritis (IgAVN) and without nephritis (non-IgAVN). The groups were compared in terms of clinical symptoms, laboratory values, and PVAS values.

RESULTS

In total, 18.5% of the patients had IgAVN; they were older than the non-IgAVN patients (median age was 8.8, p < 0.05). Arthritis/arthralgia, abdominal pain, and intestinal bleeding were more common, systolic and diastolic BP were higher in IgAVN (p < 0.05). CRP, serum creatinine, and urine protein/Cr, PVAS were higher, while serum albumin was lower in IgAVN (p < 0.05). The receiver operator characteristic curve (ROC) analysis showed that IgAV patients with a determined cut-off PVAS value greater than 3 had 70.7% sensitivity in predicting whether or not they would develop IgAVN. Logistic regression analysis found that PVAS > 3 and low serum albumin at the time of diagnosis were independent risk factors for IgAVN.

CONCLUSION

Our study revealed that PVAS > 3 at diagnosis is an independent predictor of IgAVN. Patients with PVAS > 3 should be followed more closely to ensure early diagnosis and management of IgAVN. A higher resolution version of the Graphical abstract is available as Supplementary information.

Obesity as a comorbidity in children and adolescents with autoimmune rheumatic diseases

Childhood obesity is the public health issue with alarming rates recorded throughout developed world and an important modifiable health risk for developing various chronic diseases, with childhood-onset autoimmune rheumatic diseases among them also. The aim of this article was to summarize epidemiological, pathophysiological and clinical implication of obesity on juvenile idiopathic arthritis (JIA), childhood-onset systemic lupus erythematosus (cSLE), juvenile dermatomyositis (JDM), IgA vasculitis (IgAV) and Kawasaki disease (KD). We reviewed PubMed database and selected 74 relevant articles. Epidemiological data of obesity among children with autoimmune rheumatic diseases indicate an increased prevalence of it. Pathophysiological link between obesity, humoral adipokines and cytokines released from fat tissue and childhood-onset autoimmune rheumatic diseases is complex and still not entirely clear. From the clinical point of view, obesity was not associated with disease activity in JIA and cSLE, but proved to contribute on functional impairment in both diseases and affect poor treatment response in JIA patients. Early atherosclerosis and cardiovascular disease (CVD) development in obese children and adolescents with JIA, cSLE and JDM are certainly important obesity-related complications. Understanding how obesity affects children and adolescents with autoimmune rheumatic diseases may encourage clinicians to consider taking better preventive strategies in this population to improve their long-term outcome.

Time of Onset and Risk Factors of Renal Involvement in Children with Henoch-Schönlein Purpura: Retrospective Study

Background: Henoch-Schönlein purpura (HSP) is a common systemic vasculitis in children, involving the skin, musculoskeletal system, gastrointestinal tract and kidneys. Some studies in children have shown possible risk factors linked with the development and severity of HSP Nephritis (HSPN). The aim of this study was to research predicting factors for the development of HSPN. Methods: We retrospectively evaluated 132 pediatric patients with HSP, according to EULAR/PRINTO/PRESS criteria. All patients were screened for HSPN by urinalysis. Finally, we compared demographic, clinical and laboratory data in HSP patients with and without nephritis. Results: The median age at HSP diagnosis [6.2 (2.6–17.5) vs. 5.5 (0.8–15.4) years, p = 0.03] and the incidence of abdominal pain (48 vs. 27%, p = 0.01) were significantly higher in HSPN patients. No differences were evidenced regarding gender, allergic diseases, skin recurrences, gastrointestinal involvement, musculoskeletal involvement, scrotal involvement, and laboratory data (white blood cell count, neutrophil count, lymphocyte count, platelet count, C-reactive protein, erythrocyte sedimentation rate, and blood concentration of IgA). Conclusions: The age at diagnosis and abdominal pain were independent risk factors for renal involvement in HSP patients. However, due to the retrospective nature of this study, further long-term and prospective studies will be necessary.

Clinical predictive model for the 1-year remission probability of IgA vasculitis nephritis

PURPOSE

Early remission of Immunoglobulin A vasculitis nephritis (IgAVN) substantially affects its prognosis. In this work, a multivariate model to predict the 1-year remission probability of patients with IgAVN was developed on the basis of clinical laboratory data.

METHODS

Data of 187 patients with IgAVN confirmed by renal biopsy were retrospectively assessed. Least absolute shrinkage and selection operator regression analysis were conducted to establish a multivariate logistic regression model. A nomogram based on the multivariate logistic regression model was constructed for easy application in clinical practice. Concordance index, receiver operating characteristic (ROC) curves, decision curve analysis (DCA), and clinical impact curves (CIC) were used to evaluate the predictive accuracy and clinical value of this nomogram.

RESULTS

The predictive factors contained in the multivariate model included duration, gender, respiratory infection, arthritis, edema, estimated glomerular filtration rate, 24 h urine protein, uric acid, and renal ultrasound intensity. The area under the curves (AUC) of the nomogram in the training set and testing set were 0.814 and 0.822, respectively, indicating its good predictive ability. Moreover, the DCA curve and CIC revealed its clinical utility.

CONCLUSION

The developed multivariate predictive model combines the clinical and laboratory factors of patients with IgAVN and is useful in the individualized prediction of the 1-year remission probability aid for clinical decision-making during treatment and management of IgAVN.

Predicting Severe Renal and Gastrointestinal Involvement in Childhood Immunoglobulin A Vasculitis with Routine Laboratory Parameters

BACKGROUND

Immunoglobulin A vasculitis (IgAV) is the most common vasculitis in children. Although childhood IgAV is generally considered as a self-limited disease, progressive course and poor prognosis could occur in some cases which mostly result from severe renal involvement and gastrointestinal (GI) involvement.

METHODS

We performed a retrospective study of pediatric patients diagnosed as IgAV in our institution from 2016 to 2019. Patients were divided into groups based on the occurrence and severity of GI and renal involvement. Analysis of variance (ANOVA) and Kruskal-Wallis test were used to compare results of laboratory parameters among groups and prediction models were built by using logistic regression analysis.

RESULTS

A total of 286 patients were enrolled. GI involvement occurred in 148 (51.7%) patients, 30 (20.3%) of which were severe cases. Renal involvement developed in 120 (42.0%) patients, 22 (18.3%) of which were severe cases. Compared with patients with only cutaneous manifestations, white blood cell (WBC) count, neutrophil-to-lymphocyte ratio (NLR), and D-dimer levels were higher in those with GI involvement, and D-dimer level was found to be positively associated with severity. Increased NLR and lower complement 3 (C3) were found in patients with renal involvement, but only C3 was relevant in distinguishing moderate and severe cases. The prediction model for severe renal involvement was: Logit (P) = 6.820 + 0.270 (age) + 0.508 (NLR) - 16.130 (C3), with an AUC of 0.914. The prediction model for severe GI involvement was: Logit (P) = -5.459 + 0.005 (WBC) + 1.355 (D-dimer) - 0.020 (NLR), with an AUC of 0.849.

CONCLUSION

Our data suggest C3 to be an exclusive predictor for severe renal involvement and D-dimer level to be positively associated with the severity of GI involvement. Prediction models consisting of the above parameters were built for obtaining prognostic information in the early phase of IgAV.

Clinical effect of combined western medicine and traditional Chinese medicine on children with Henoch-Schönlein purpura nephritis

OBJECTIVE

To investigate the efficacy of combined Chinese and western medicine in the treatment of children with Henoch-Schönlein purpura nephritis (HSPN) and its effects on immune function, interleukin (IL)-16, and IL-18 expressione.

METHODS

The clinical data of 91 children with HSPN were retrospectively collected and divided into two groups according to the treatment regimen. Group A (n=45) was treated only with western medicine, while group B (n=46) was treated with combined Chinese and western medicine. The clinical efficacy, traditional Chinese medicine (TCM) syndrome points before and after treatment, immune function indices, urinary indices, levels of IL-16 and IL-18, and the recurrence rate were compared between the two groups.

RESULTS

The total effective rate was 95.65% in group B, higher than 75.56% in group A (P<0.05). The TCM scores after treatment in group B was lower than that in group A (P<0.05). The levels of immunoglobulin IgA and IgM after treatment were lower while IgG levels were higher in group B than those in group A (P<0.05); Urinary microalbumin, urinary beta₂ microglobulin, 24 h urine protein elimination, and red blood cells (RBC) in the urine were lower in group B after treatment than in group A (P<0.05). The serum levels of IL-16 and IL-18 in group B were lower than those in group A after treatment (P<0.05). The recurrence rate was 4.35% in group B, lower than 26.67% in group A (P<0.05).

CONCLUSION

Combined regimen of western and Chinese medicine in children showed significant efficacy on improving immune function and reducing recurrence rate and IL-16 and IL-18 levels in patients with HSPN.

Influence of transitional nursing on the compliance behavior and disease knowledge of children with purpura nephritis

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.