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Bigatti C, Chiarenza DS, Angeletti A. To biopsy or not to biopsy a teenager with idiopathic nephrotic syndrome? Biopsy first. Pediatr Nephrol 2024:10.1007/s00467-024-06510-6. [PMID: 39251432 DOI: 10.1007/s00467-024-06510-6] [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: 04/23/2024] [Revised: 08/15/2024] [Accepted: 08/16/2024] [Indexed: 09/11/2024]
Abstract
Kidney biopsy plays a crucial role in the diagnosis and management of several glomerular diseases. While it is generally considered a routine and safe procedure in children, it should be conducted with the primary objective of addressing the following question: do the prognosis and treatments vary based on the findings of kidney biopsy? In children presenting with idiopathic nephrotic syndrome (INS), guidelines suggest to consider kidney biopsy for individuals older than 12 years, primarily due to the possible increased incidence of different glomerulonephritis compared to younger patients, who predominantly manifest with minimal change disease. However, these guidelines also advocate for uniform therapeutic strategies, typically steroids, irrespective of the age or histological findings. Whether the age of more than 12 years may be a recommendation for performing kidney biopsy at presentation of INS is debatable. Instead, kidney biopsy could be reserved for steroid-resistant cases. On the other hand, when kidney biopsy is performed in INS, particularly in focal segmental glomerulosclerosis, histology may reveal additional lesions, that are strongly associated with a poorer response to treatment and worse clinical outcomes. Therefore, current guidelines on treatments of nephrotic syndrome may appear overly restrictive, despite the relevant findings provided by kidney biopsy. Therefore, in the present manuscript, which is part of a pro-con debate on the management of nephrotic syndrome in adolescents, we emphasize the potential role of performing a kidney biopsy before initiating corticosteroid treatment.
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Affiliation(s)
- Carolina Bigatti
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Via Gaslini 5, 16147, Genoa, GE, Italy
| | - Decimo S Chiarenza
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Via Gaslini 5, 16147, Genoa, GE, Italy
| | - Andrea Angeletti
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Via Gaslini 5, 16147, Genoa, GE, Italy.
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2
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Dimelow R, Liefaard L, Green Y, Tomlinson R. Extrapolation of the Efficacy and Pharmacokinetics of Belimumab to Support its Use in Children with Lupus Nephritis. Clin Pharmacokinet 2024; 63:1313-1326. [PMID: 39320441 PMCID: PMC11450137 DOI: 10.1007/s40262-024-01422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND AND OBJECTIVE Lupus nephritis (LN), a severe manifestation of systemic lupus erythematosus, has greater severity in children versus adults. Belimumab is approved for systemic lupus erythematosus treatment in patients aged ≥ 5 years, and for active LN in adults in the European Union, China, Japan and Latin America, and patients aged ≥ 5 years in the USA. Low prevalence of paediatric active LN makes conducting a clinical study within a reasonable period unfeasible. We describe a model-based extrapolation of belimumab efficacy and pharmacokinetics from adults to children with LN to support US Food and Drug Administration approval of intravenous belimumab 10 mg/kg (administered every 4 weeks after the loading dose) in children (aged 5-17 years) with active LN. METHODS This concept assumed that disease progression, response to belimumab, exposure-response, and the target belimumab exposure for efficacy are similar across adult and paediatric systemic lupus erythematosus and LN, evaluated against the published literature for paediatric LN and belimumab systemic lupus erythematosus and LN clinical trial data in adults and children. A two-compartmental population pharmacokinetic model, previously developed for adults with LN, was used to extrapolate belimumab pharmacokinetics to children with LN. RESULTS The model captured the dependence of time-varying proteinuria on belimumab clearance, and therefore exposure. Sufficient target exposures for efficacy were achieved in children with active LN. A small proportion of children aged 5-11 years are predicted to have exposures below adult levels but no impact to efficacy is expected. CONCLUSIONS Our model demonstrated that intravenous belimumab 10 mg/kg every 4 weeks is appropriate for children aged 5-17 years with active LN.
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Affiliation(s)
- Richard Dimelow
- GSK, Clinical Pharmacology Modelling and Simulation, Gunnels Wood Rd, Stevenage , Hertfordshire, SG1 2NY, UK.
| | - Lia Liefaard
- GSK, Clinical Pharmacology Modelling and Simulation, Gunnels Wood Rd, Stevenage , Hertfordshire, SG1 2NY, UK
| | - Yulia Green
- GSK, Clinical Development, Brentford, Middlesex, UK
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Peyronel F, Rossi GM, Palazzini G, Odone L, Errichiello C, Emmi G, Vaglio A. Early-onset lupus nephritis. Clin Kidney J 2024; 17:sfae212. [PMID: 39135943 PMCID: PMC11318049 DOI: 10.1093/ckj/sfae212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Indexed: 08/15/2024] Open
Abstract
Early-onset systemic lupus erythematous (SLE) is a distinct clinical entity characterized by the onset of disease manifestations during childhood. Despite some similarities to patients who are diagnosed during adulthood, early-onset SLE typically displays a greater disease severity, with aggressive multiorgan involvement, lower responsiveness to classical therapies, and more frequent flares. Lupus nephritis is one of the most severe complications of SLE and represents a major risk factor for long-term morbidity and mortality, especially in children. This review focuses on the clinical and histological aspects of early-onset lupus nephritis, aiming at highlighting relevant differences with adult patients, emphasizing long-term outcomes and discussing the management of long-term complications. We also discuss monogenic lupus, a spectrum of conditions caused by single gene variants affecting the complement cascade, extracellular and intracellular nucleic acid sensing and processing, and occasionally other metabolic pathways. These monogenic forms typically develop early in life and often have clinical manifestations that resemble sporadic SLE, whereas their response to standard treatments is poor.
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Affiliation(s)
- Francesco Peyronel
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giovanni M Rossi
- Nephrology Unit, Parma University Hospital, Parma, Italy
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Laboratorio di Immunopatologia Renale “Luigi Migone”, University of Parma, Parma, Italy
| | - Giulia Palazzini
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
| | - Ludovica Odone
- Nephrology and Dialysis Unit, Azienda Socio-Sanitaria Territoriale (ASST) Papa Giovanni XXIII, Bergamo, Italy
| | - Carmela Errichiello
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Giacomo Emmi
- Department of Medical, Surgery and Health Sciences, University of Trieste, Italy
- Clinical Medicine and Rheumatology Unit, Cattinara University Hospital, Trieste, Italy
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Melbourne, Australia
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
- Department of Biomedical Experimental and Clinical Sciences “Mario Serio”, University of Florence, Florence, Italy
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4
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Uzzo M, Kronbichler A, Alberici F, Bajema I. Nonlupus Full House Nephropathy: A Systematic Review. Clin J Am Soc Nephrol 2024; 19:743-754. [PMID: 38527995 PMCID: PMC11168831 DOI: 10.2215/cjn.0000000000000438] [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: 10/19/2023] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
Key Points Nonlupus full house nephropathy is a rare, complex entity: confusion arises by the low-quality evidence and the lack of consensus on nomenclature. This systematic review supports that systemic lupus erythematosus and nonlupus full house nephropathy are distinct clinical entities, with comparable outcomes. The identification of three pathogenetic categories provides further clues for a shared clinical and diagnostic approach to the disease. Background The presence of a full house pattern at immunofluorescence on kidney biopsy in a patient without clinical and laboratory features of systemic lupus erythematosus (SLE) has led to the descriptive term nonlupus full house nephropathy. This systematic review and meta-analysis focus on nonlupus full house nephropathy nomenclature, clinical findings, and outcomes. Methods In a reiterative process, all identified terms for nonlupus full house nephropathy and other medical subject headings terms were searched in PubMed. Out of 344 results, 57 records published between 1982 and 2022 were included in the analysis. Clinical data of single patients from different reports were collected. Patients were classified into three pathogenetic categories, which were compared according to baseline characteristics, treatments, and outcomes. Results Out of the 57 records, 61% were case reports. Nonlupus full house nephropathy was addressed with 17 different names. We identified 148 patients: 75 (51%) were men; median age 35 (23–58) years. Serum creatinine and proteinuria at onset were 1.4 (0.8–2.5) mg/dl and 5.7 (2.7–8.8) g/d. About half of patients achieved complete response. A causative agent was identified in 51 patients (44%), mainly infectious (41%). Secondary nonlupus full house nephropathy was mostly nonrelapsing with worse kidney function at onset compared with idiopathic disease (P = 0.001). Among the 57 patients (50%) with idiopathic nonlupus full house nephropathy, complete response was comparable between patients treated with immunosuppression and supportive therapy; however, proteinuria and creatinine at onset were higher in patients treated with immunosuppression (P = 0.09 and P = 0.07). The remaining 7 patients (6%) developed SLE after a median follow-up of 5.0 (1.9–9.0) years. Conclusions Our data support that SLE and nonlupus full house nephropathy are distinct clinical entities, with comparable outcomes. A small subset of patients develops SLE during follow-up. Nonlupus full house nephropathy is addressed by many different names in the literature. The identification of three pathogenetic categories provides further clues for the management of the disease.
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Affiliation(s)
- Martina Uzzo
- Department of Medicine and Surgery, University of Milano-Bicocca and ASST Monza, Monza, Italy
- Department of Pathology and Medical Biology, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Ingeborg Bajema
- Department of Pathology and Medical Biology, University Medical Center, University of Groningen, Groningen, The Netherlands
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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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Biswas D, Dasgupta D, Pal P, Sinha R. Presentation and outcome of pediatric lupus nephritis from a large single centre contemporary cohort in Eastern India. Lupus 2023; 32:1440-1446. [PMID: 37707867 DOI: 10.1177/09612033231202843] [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] [Indexed: 09/15/2023]
Abstract
BACKGROUND We present clinical, biochemical, and histopathological characteristics and treatment outcomes of biopsy proven childhood lupus nephritis (LN) from a low/middle income setting treated in the current era of increased use of Mycophenolate Mofetil (MMF) and biologics. METHODS Retrospective observational study of children (1-18 years) with biopsy proven LN treated from 01.01.2010 to 31.01.2020. RESULTS 60 children met our inclusion criteria (80%, n = 48 were females). The median age at diagnosis was 11 (IQR: 9-12) years. The most common extra-renal manifestation was mucocutaneous (n = 54, 90%) and the most common kidney manifestation was edema (n = 50, 83.3%). The median 24-h urinary protein excretion was 1117.8 (IQR: 795.4-1941.7) mg/m2/day with 67% (n = 40) having nephrotic range proteinuria (>1000 mg/m2/day). 75% (n = 45) children had eGFR <90 mL/min/1.73 m2 (median eGFR = 71; IQR: 56-90 mL/min/1.73 m2). Anti-Nuclear Antibody was positive in all, both complement three and four were low in 82% (n = 49) and anti-double stranded DNA antibodies were positive in 63% (n = 38). 85% (n = 51) had proliferative LN with majority being class IV (57%, n = 34). All children received steroids for induction therapy. MMF was given as the sole induction agent in 48% (n = 29) and cyclophosphamide in 27% (n = 16). Rituximab was added in 17% (n = 10) as a rescue agent. Median follow up duration was 50 (IQR: 28-82) months. Six children (10%) died as a result of serious infections and none of them had shown complete response (CR). Out of the 52 children who had a follow up duration of at least 2 years, CR was achieved in 46 children (88%) and partial response (PR) or no response (NR) in three children (6%) each. Although children who were in CR/PR at last follow up had lower proteinuria, higher eGFR, and lower histopathology activity index at onset; low numbers in the NR group precluded us from subjecting them to any statistical correlation tests. 36% (n = 22) of children developed 36 episodes of renal flares with overall incidence of 0.14/person-year. CONCLUSION Our study on a contemporary cohort of childhood LN highlights the importance of achieving CR and its feasibility.
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Affiliation(s)
- Debopoma Biswas
- Pediatric Rheumatology, Institute of Child Health, Kolkata, India
| | | | - Priyankar Pal
- Pediatric Rheumatology, Institute of Child Health, Kolkata, India
| | - Rajiv Sinha
- Pediatric Nephrology, Institute of Child Health, Kolkata, India
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Das J, Kalita P, Dey B, Raphael V, Mishra J, Khonglah Y, Marbaniang E, Handique G, Saurabh A. Clinicopathological, Immunological, and Laboratory Parameters of Childhood Lupus Nephritis: A Study from Northeast India. J Lab Physicians 2023; 15:361-364. [PMID: 37564220 PMCID: PMC10411078 DOI: 10.1055/s-0043-1768168] [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] [Indexed: 08/12/2023] Open
Abstract
Background Lupus nephrtis in children is associated with high morbidity and mortality. The incidence of childhood systemic lupus erythematosus (SLE) ranges from 3.3 to 8.8/100000 children with a higher Asian preponderance. The predominance of SLE in female pediatric patients increases gradually with age to the values observed in adults. Objectives To assess the clinical, immunological, and histopathological spectrum of childhood lupus nephritis in northeast India and explore the relationship between clinical, biochemical, serological, and histopathological findings. Materials and Methods A retrospective descriptive study was performed over 8 years. Histopathology slides were reviewed by two pathologists, whereas other details were collected from patients' records. Statistical Analysis Statistical analysis was based on the chi-square test and a p -value < 0.05 was considered statistically significant. Results Fifty-three cases of lupus nephritis were included in the study. The patients' age ranged from 5 to 18 years with a mean age of 14.5 years and a female: male ratio of 6.5:1. Edema and hypertension were the commonest clinical presentations, whereas proteinuria was the commonest presenting laboratory parameter. Amongst all the immunological markers, dsDNA was the commonest. Histopathologically, predominantly study population belonged to class IV lupus nephritis. The patients with class IV showed a statistically significant correlation with proteinuria and hematuria at the time of diagnosis. Immunological markers, namely, ANA and anti-ds-DNA positivity were significantly associated with advanced renal histopathology. Conclusion cSLE in northeast India presents mostly as Class IV LN presenting mostly with deranged laboratory parameters and preponderance of various immunological markers and clinical presentations.
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Affiliation(s)
- Jonali Das
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Pranjal Kalita
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Biswajit Dey
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Vandana Raphael
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Jaya Mishra
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Yookarin Khonglah
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Evarisalin Marbaniang
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Gauranga Handique
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Animesh Saurabh
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
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Khandelwal P, Govindarajan S, Bagga A. Management and outcomes in children with lupus nephritis in the developing countries. Pediatr Nephrol 2023; 38:987-1000. [PMID: 36255555 DOI: 10.1007/s00467-022-05769-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/14/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lupus nephritis (LN) has variable prevalence, severity, and outcomes across the world. OBJECTIVES This review compares the outcomes of childhood LN in low- and middle-income countries (LMICs) and high-income countries (HICs) and aims to summarize long-term outcomes of pediatric LN from LMICs. DATA SOURCES A systematic literature search, conducted in PubMed, EMBASE, and Cochrane database in the last 30-years from January 1992, published in the English language, identified 113 studies including 52 from lower (n = 1336) and upper MICs (n = 3014). STUDY ELIGIBILITY CRITERIA Cohort studies or randomized controlled trials, of patients ≤ 18 years of age (or where such data can be separately extracted), with > 10 patients with clinically or histologically diagnosed LN and outcomes reported beyond 12 months were included. PARTICIPANTS AND INTERVENTIONS Patients ≤ 18 years of age with clinically or histologically diagnosed LN; effect of an intervention was not measured. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently extracted data. We separately analyzed studies from developed countries (high income countries; HIC) and developing countries (LMICs). Middle-income countries were further classified as lower and upper MICs. Meta-analyses of data were performed by calculating a pooled estimate utilizing the random-effects model. Test for heterogeneity was applied using I2 statistics. Publication bias was assessed using funnel plots. RESULTS Kidney remission was similar across MICs and HICs with 1-year pooled complete remission rates of 59% (95% CI 51-67%); one third of patients had kidney flares. The pooled 5-year survival free of stage 5 chronic kidney disease (CKD5) was lower in MICs, especially in lower MICs compared to HICs (83% vs. 93%; P = 0.002). The pooled 5-year patient survival was significantly lower in MICs than HICs (85% vs. 94%; P < 0.001). In patients with class IV LN, the 5-and 10-year respective risk of CKD5 was 14% and 30% in MICs; corresponding risks in HICs were 8% and 17%. Long-term data from developing countries was limited. Sepsis (48.8%), kidney failure (14%), lupus activity (18.1%), and intracranial hemorrhage/infarct (5.4%) were chief causes of death; mortality due to complications of kidney failure was more common in lower MICs (25.6%) than HICs (6.4%). LIMITATIONS The review is limited by heterogenous approach to diagnosis and management that has changed over the period spanning the review. World Bank classification based on income might not correlate with the standards of medical care. The overall quality of evidence is low since included studies were chiefly retrospective and single center. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Challenges in LMICs include limited access to pediatric nephrology care, dialysis, increased risk of infection-induced mortality, lack of frequent monitoring, and non-compliance due to cost of therapy. Attention to these issues might update the existing data and improve patient follow-up and outcomes. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO 2022 number: CRD42022359002, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022359002.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Srinivasavaradan Govindarajan
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
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Kisaoglu H, Baba O, Kalyoncu M. Lupus low disease activity state as a treatment target for pediatric patients with lupus nephritis. Pediatr Nephrol 2023; 38:1167-1175. [PMID: 36156735 DOI: 10.1007/s00467-022-05742-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lupus low disease activity state (LLDAS) is a treatment target for patients with SLE and is associated with decreased risk for severe flare and new damage. We investigated the utility of the achievement of LLDAS in children with lupus nephritis and whether attainment of LLDAS is associated with more favorable outcomes. METHODS Data of children, diagnosed with biopsy-proven lupus nephritis between January 2012 and December 2020, were retrospectively analyzed. RESULTS For patients who did not achieve LLDAS after initial treatment (first 6 months), presence of autoimmune hemolytic anemia (62% vs. 18%, p = 0.047), anti-Sm (85% vs. 18%, p = 0.003) and anti-dsDNA (77% vs. 27%, p = 0.038) antibodies, proliferative lupus nephritis (77% vs. 27%, p = 0.038), and hypertension (69% vs. 9%, p = 0.005) at onset were more frequently encountered. Also, a lower rate of complete kidney response (43% vs. 100%, p = 0.005) and a higher rate of hypertension (86% vs. 13%, p = 0.002) were observed in patients who did not achieve LLDAS-50, defined as being in LLDAS at least 50% of the observation time. Attainment of both LLDAS after initial treatment and LLDAS-50 were associated with lower rates of kidney flare (p = 0.001 and p = 0.002, respectively) and damage accrual (p = 0.007 and p = 0.02, respectively) through the observation period. CONCLUSIONS LLDAS is an attainable treatment target for children with lupus nephritis and associated with lower rates of kidney flare and damage. Presence of hematologic involvement, hypertension, and proliferative lupus nephritis at onset adversely influenced the early achievement of LLDAS. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Hakan Kisaoglu
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey.
| | - Ozge Baba
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Mukaddes Kalyoncu
- Division of Pediatric Rheumatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey.,Division of Pediatric Nephrology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
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Hydroxychloroquine in children with proliferative lupus nephritis: a randomized clinical trial. Eur J Pediatr 2023; 182:1685-1695. [PMID: 36752895 PMCID: PMC10167107 DOI: 10.1007/s00431-023-04837-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/14/2023] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
UNLABELLED Hydroxychloroquine (HCQ) is an antimalarial agent used to treat mucocutaneous, musculoskeletal, constitutional manifestations of systemic lupus erythematosus (SLE). This study assessed the efficacy and side effects of HCQ in children with proliferative lupus nephritis (LN). This double-blind, randomized, placebo-controlled trial study was conducted on 60 children with proliferative LN classes III and IV treated with steroids and a mycophenolate (MMF) regimen. Patients were categorized into two groups, the HCQ group (n = 30) and the placebo group (n = 30). They were evaluated initially at 6- and a 12-month follow-up by mucocutaneous, ophthalmological examination, and investigations (BUN, creatinine, 24 h proteinuria, triglycerides (TG), cholesterol, Antids-DNA, C3, C4). Disease activity was assessed using the SLE disease activity index (SLEDAI-2 k). After 12 months, TG, cholesterol, 24 h proteinuria, Antids-DNA, and SLEDAI score were significantly decreased in the HCQ group (P: 0.002, 0.012, 0.031, 0.001, respectively). After 12 months, the cumulative probabilities of developing primary end-points (LN partial and complete remission) were 40% and 60% in the HCQ group versus 53.3% and 36.7% in the placebo group (P: 0.002). After 12 months, the HCQ group experienced mucocutaneous alopecia (3.3%), hyperpigmentation (10%), and ophthalmological mild retinal changes (6.7%), but they did not differ significantly from the placebo group. Cunclusion: HCQ improved the disease and LN activity in children with proliferative LN, with documented skin hyperpigmentation and mild retinal changes following HCQ use in a few cases. This study was registered on http://www. CLINICALTRIALS gov/ with trial registration number (TRN): NCT03687905, September 2018 "retrospectively registered." WHAT IS KNOWN • Hydroxychloroquine (HCQ) is documented as an adjunctive treatment in children with systemic lupus erythematosus (c-SLE) LN with efficacy in improving lupus musculoskeletal and mucocutaneous manifestations. • Due to the paucity of studies, its effects and side effects in children with LN remain unclear. WHAT IS NEW • This pilot randomized clinical trial assessed the efficacy and adverse effects of HCQ in children with proliferative LN. • HCQ had numerous advantages for LN, including rapid and sustained remission, antilipidemic effect, and rapid improvement of kidney functions.
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12
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Wenderfer SE, Orjuela A, Bekheirnia MR, Pereira M, Muscal E, Braun MC, De Guzman M. Lupus Nephritis, Autoantibody Production and Kidney Outcomes in Males with Childhood-Onset Systemic Lupus Erythematosus. Pediatr Rep 2022; 14:220-232. [PMID: 35645367 PMCID: PMC9149811 DOI: 10.3390/pediatric14020030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 02/04/2023] Open
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) only represents 20% of all SLE patients, and males with SLE only represent 10%. To study this rare SLE subset, males diagnosed with cSLE over a 30-year period were identified. Organ involvement, autoantibody production, hypocomplementemia, and kidney biopsy findings were compared to cSLE females. Outcomes were assessed using SLE Disease Activity Index scores, Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, and Childhood Arthritis and Rheumatology Research Alliance definitions for nephritis responsiveness. Of 95 males and 545 females with cSLE, 62% and 57% developed nephritis, respectively. Median age of cSLE onset was 14 years in both genders. Among males, 80% of non-Hispanic whites, 64% of blacks, 59% of Hispanics, and 50% of Asians developed nephritis. The prevalence of pure and mixed class V membranous nephritis was 33%. Median follow-up was 3.2 years (range 0.1-18). Complete kidney responses were seen in 70% after a median 24 months; however, relapse rates were 46%. Kidney disease flares were 56% nephritic and 44% proteinuric. Males and females with cSLE present with comparable rates and nephritis class. While overall and kidney response rates are favorable, kidney disease relapses are common among males.
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Affiliation(s)
- Scott E. Wenderfer
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- British Columbia Children’s Hospital, Vancouver, BC V6H 3V4, Canada
| | - Alvaro Orjuela
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Mir Reza Bekheirnia
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Maria Pereira
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Eyal Muscal
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Michael C. Braun
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Marietta De Guzman
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
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13
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Boussetta A, Louati D, Jellouli M, Gaied H, Mabrouk S, Maalej B, Zouaghi K, Goucha R, Gargah T. Lupus Nephritis in Tunisian Children: Predictive Factors of Poor Outcomes. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:440-448. [PMID: 37843146 DOI: 10.4103/1319-2442.385968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder of unknown etiology. Lupus nephritis (LN) is one of the most severe clinical manifestations observed in patients with SLE; it is more frequent and more severe in children than in adults. The aim of our study was to assess the predictive factors of poor outcomes in Tunisian children with LN. This was a multicenter retrospective observational study on 40 pediatric patients with biopsy-proven LN from five nephrology departments in Tunisia. The patients were 12.33 ± 3.3 years of age at the time of their kidney biopsy. Eleven patients developed end-stage renal disease (ESRD) (27.5%), and seven patients died. Overall, 18 (45%) patients reached our composite endpoint (ESRD or death). An age at diagnosis of more than 14 years, elevated serum creatinine at the time of the kidney biopsy, the existence of wire loops, thromboembolic complications as well as infectious complications are the most important clinical features associated with an increased risk of ESRD. Predictive factors of death were a baseline creatinine level of more than 2.26 mg/dL, a high proteinuria at baseline, fibrous crescents determined by renal biopsy, thromboembolic complications, infectious compli-cations, and ESRD. In summary, our results suggest that early and appropriate management is the best guarantee of a good renal outcome in children with LN.
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Affiliation(s)
- Abir Boussetta
- Department of Pediatric Nephrology, Charles Nicolle Hospital; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Dalia Louati
- Department of Pediatrics Hedi Chaker Hospital, Sfax, Tunisia
| | - Manel Jellouli
- Department of Pediatric Nephrology, Charles Nicolle Hospital; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Hanen Gaied
- Faculty of Medicine of Tunis, University of Tunis El Manar; Department of Nephrology, Mongi Slim Hospital, Tunis, Tunisia
| | - Sameh Mabrouk
- Department of Pediatrics, Sahloul Hospital, Sousse, Tunisia
| | - Bayen Maalej
- Department of Pediatrics Hedi Chaker Hospital, Sfax, Tunisia
| | - Karim Zouaghi
- Faculty of Medicine of Tunis, University of Tunis El Manar; Department of Nephrology, Rabta Hospital, Tunis, Tunisia
| | - Rym Goucha
- Faculty of Medicine of Tunis, University of Tunis El Manar; Department of Nephrology, Mongi Slim Hospital, Tunis, Tunisia
| | - Tahar Gargah
- Department of Pediatric Nephrology, Charles Nicolle Hospital; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
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14
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De Mutiis C, Wenderfer SE, Orjuela A, Bagga A, Basu B, Sar T, Aggarwal A, Jain A, Yap HK, Ito S, Ohnishi A, Iwata N, Kasapcopur O, Laurent A, Mastrangelo A, Ogura M, Shima Y, Rianthavorn P, Silva CA, Trindade V, Dormi A, Tullus K. Defining renal remission in an international cohort of 248 children and adolescents with lupus nephritis. Rheumatology (Oxford) 2021; 61:2563-2571. [PMID: 34626102 DOI: 10.1093/rheumatology/keab746] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 09/20/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE We studied the rate of remission of lupus nephritis (LN) in an international cohort of 248 children and adolescents with biopsy proven LN. Five different definitions from scientific studies and the definitions recommended by the American College of Rheumatology and Kidney Disease Improving Global Outcomes (KDIGO) were used. METHODS Anonymized clinical data in patients with biopsy proven LN class ≥ III (International Society of nephrology/Royal Pathology Society-ISN/RPS) diagnosed and treated in the last 10 years in 23 international centers from 10 countries were collected. We compared the rate of patients in complete and partial remission applying the different definitions. RESULTS The mean age at diagnosis was 11 years and 4 month and 177 were females.The number of patients in complete and partial remission varied a lot between the different definitions. At 24 months, between 50% and 78.8% of the patients were in full remission as defined by the different criteria. The number of patients in partial remission was low, between 2.3% and 25%. No difference in achieved remission was found between boys and girls or between children and adolescents (P > 0.05). Patients with East Asian ethnicity reached remission more often than other ethnicities (P = 0.03-0.0008). Patients treated in high income countries showed a higher percentage of complete remission at 12 and 24 months (P = 0.002-0.000001). CONCLUSION The rate of children and adolescents with LN achieving remission varied hugely with the definition used. Our results give important information for long awaited treatment studies in children and young people.
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Affiliation(s)
| | - Scott E Wenderfer
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Alvaro Orjuela
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Tanmoy Sar
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Avinash Jain
- Department of Medicine, Sawai Man Singh Medical College, Jaipur, India
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Ai Ohnishi
- Department of Pediatrics, Yokohama City University, Fukuura, Kanazawa-ku, Yokohama, Kanagawa, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Audrey Laurent
- Department of Pediatric Nephrology, Rheumatology and Dermatology, Hospices Civils de Lyon, Lyon, France
| | - Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Maggiore Policlinico Hospital, Milan, Italy
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Pornpimol Rianthavorn
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Vitor Trindade
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ada Dormi
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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15
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IgM on the surface of T cells: a novel biomarker of pediatric-onset systemic lupus erythematosus. Pediatr Nephrol 2021; 36:909-916. [PMID: 33025206 DOI: 10.1007/s00467-020-04761-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/07/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Children with systemic lupus erythematosus (SLE) frequently have kidney involvement. Lupus nephritis sometimes presents alone, without systemic SLE features, representing the so-called full-house nephropathy (FHN). Distinguishing patients with SLE or FHN has therapeutic and prognostic implications. METHODS In this retrospective observational study, we determined the presence of IgM on the surface of T cells (T cell IgM) by flow cytometry and characterized its ability in distinguishing SLE and FHN patients in a large pediatric cohort (n = 84). Fifty-seven patients with SLE (≥ 4 SLICC criteria at disease onset or during the follow-up) and 27 patients with FHN (3 or less SLICC criteria) were enrolled. RESULTS Elevated T cell IgM levels were found in 24/25 SLE patients in active phase of disease and in 29/45 SLE patients in remission. In contrast, among FHN patients, only 1/9 presented this characteristic in active phase of disease and 0/20 in remission. Compared with standardized SLICC laboratory parameters, i.e., autoantibody titers and hypocomplementemia, T cell IgM positivity showed an extremely high sensitivity and specificity for the diagnosis of SLE, with the highest area under the curve (0.97, p < 0.001) by receiver operating characteristic analysis, similar to ANA (0.96, p < 0.001) and anti-dsDNA (0.90, p < 0.001) autoantibodies. CONCLUSIONS Altogether, our data indicate that T cell IgM intensity may be a useful tool to correctly classify patients with lupus nephritis as SLE or FHN since disease onset.
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16
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Abdulrahman MA, Sallam DE. Treatment response and progression to end stage renal disease in adolescents and young adults with lupus nephritis: A follow up study in an Egyptian cohort. THE EGYPTIAN RHEUMATOLOGIST 2020. [DOI: 10.1016/j.ejr.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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17
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Suhlrie A, Hennies I, Gellermann J, Büscher A, Hoyer P, Waldegger S, Wygoda S, Beetz R, Lange-Sperandio B, Klaus G, Konrad M, Holder M, Staude H, Rascher W, Oh J, Pape L, Tönshoff B, Haffner D. Twelve-month outcome in juvenile proliferative lupus nephritis: results of the German registry study. Pediatr Nephrol 2020; 35:1235-1246. [PMID: 32193650 DOI: 10.1007/s00467-020-04501-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/27/2020] [Accepted: 02/06/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Children presenting with proliferative lupus nephritis (LN) are treated with intensified immunosuppressive protocols. Data on renal outcome and treatment toxicity is scare. METHODS Twelve-month renal outcome and comorbidity were assessed in 79 predominantly Caucasian children with proliferative LN reported to the Lupus Nephritis Registry of the German Society of Paediatric Nephrology diagnosed between 1997 and 2015. RESULTS At the time of diagnosis, median age was 13.7 (interquartile range 11.8-15.8) years; 86% showed WHO histology class IV, nephrotic range proteinuria was noted in 55%, and median estimated glomerular filtration rate amounted to 75 ml/min/1.73 m2. At 12 months, the percentage of patients with complete and partial remission was 38% and 41%, respectively. Six percent of patients were non-responders and 15% presented with renal flare. Nephrotic range proteinuria at the time of diagnosis was associated with inferior renal outcome (odds ratio 5.34, 95% confidence interval 1.26-22.62, p = 0.02), whereas all other variables including mode of immune-suppressive treatment (e.g., induction treatment with cyclophosphamide (IVCYC) versus mycophenolate mofetil (MMF)) were not significant correlates. Complications were reported in 80% of patients including glucocorticoid toxicity in 42% (Cushingoid appearance, striae distensae, cataract, or osteonecrosis), leukopenia in 37%, infection in 23%, and menstrual disorder in 20%. Growth impairment, more pronounced in boys than girls, was noted in 78% of patients. CONCLUSIONS In this cohort of juvenile proliferative LN, renal outcome at 12 months was good irrespectively if patients received induction treatment with MMF or IVCYC, but glucocorticoid toxicity was very high underscoring the need for corticoid sparing protocols. Graphical abstract.
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Affiliation(s)
- Adriana Suhlrie
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Center for Rare Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Imke Hennies
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Center for Rare Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Jutta Gellermann
- Department of Paediatrics, University Children's Hospital Berlin, University Hospital, Berlin Charité, Berlin, Germany
| | - Anja Büscher
- Department of Paediatrics II, University Hospital Essen, Essen, Germany
| | - Peter Hoyer
- Department of Paediatrics II, University Hospital Essen, Essen, Germany
| | - Siegfried Waldegger
- Department of Peadiatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Rolf Beetz
- University Children's Hospital Mainz, Mainz, Germany
| | - Bärbel Lange-Sperandio
- Dr. v. Hauner Children's Hospital, Division of Paediatric Nephrology, Ludwig-Maximilians, University of Munich, Munich, Germany
| | - Günter Klaus
- University Children's Hospital Marburg, Marburg, Germany
| | - Martin Konrad
- Department of General Paediatrics, University Children's Hospital, Münster, Germany
| | - Martin Holder
- Department of Pediatrics, Klinikum Stuttgart, Olgahospital, Stuttgart, Germany
| | - Hagen Staude
- University Children's Hospital Rostock, Rostock, Germany
| | - Wolfgang Rascher
- Department of Paediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Jun Oh
- Department of Paediatrics, University Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Lars Pape
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.,Center for Rare Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Burkhard Tönshoff
- Department of Paediatrics I, University Children's Hospital Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School Children's Hospital, Carl-Neuberg-Str. 1, 30625, Hannover, Germany. .,Center for Rare Diseases, Hannover Medical School Children's Hospital, Hannover, Germany.
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Non-lupus full house nephropathy in pediatrics: Case reports. ACTA ACUST UNITED AC 2020; 40:220-227. [PMID: 32673451 PMCID: PMC7505501 DOI: 10.7705/biomedica.4863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Indexed: 11/21/2022]
Abstract
Full house nephropathy is defined as the simultaneous detection of IgA, IgG, IgM, C3, and C1q deposits by immunofluorescence, usually indicating lupus nephritis. There are patients with this immunofluorescence pattern, but with negative autoantibody serology, which means they cannot be diagnosed with systemic lupus erythematosus. Patients presenting with full house nephropathy but no other criteria for lupus are diagnosed as having nonlupus full house nephropathy.
Here, we describe two cases: A male patient who debuted with rapidly progressive glomerulonephritis and a female patient with nephrotic syndrome. Both had negative autoantibody serology, findings in the renal biopsy of class IV lupus nephritis and afull house immunofluorescence pattern. Histological findings in non-lupus full house nephropathy are similar to those in lupus nephritis and, probably, similar physiopathological bases. However, prospective studies are needed to determine risk factors and the renal prognosis and to make suggestions for specific treatments.
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Santos SS, Ramos CM, Monteiro MLGDR, Machado JR, Reis MAD, Corrêa RRM, Rocha LP. Mast cells in the kidney biopsies of pediatric patients with lupus nephritis. ACTA ACUST UNITED AC 2020; 42:59-66. [PMID: 32023339 PMCID: PMC7213939 DOI: 10.1590/2175-8239-jbn-2018-0222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 10/15/2019] [Indexed: 11/24/2022]
Abstract
Introduction: Mast cells may be involved in inflammation and contribute to the onset of
fibrosis in lupus nephritis (LN). Objective: This study aimed to correlate the presence of mast cells in kidney biopsy
specimens of pediatric patients with LN with activity (AI) and chronicity
(CI) indices and assess how effectively mast cells may be used as a
prognostic factor. Method: The study included 40 patients aged 6-18 years diagnosed with LN at the
Renal Disease Service of the Federal University of Triângulo Mineiro between
1996 and 2015. Workup and epidemiological data were evaluated vis-à-vis AI,
CI, and mast cell counts (MCC). Results: Significant positive correlations were found between mast cell counts (MCC)
and AI (p = 0.003; r: 0.66) and MCC and CI
(p = 0.048; r: 0.48). The ROC curve showed that mast
cells were highly sensitive and specific in the differentiation of patients
with an AI > 12 from individuals with an AI ≤ 12. Serum creatinine levels
were higher in individuals with class IV LN than in patients with class V
disease [1.50 (0.40-20.90) vs. 0.70 (0.62-0.90), p = 0.04].
Blood urea nitrogen had a positive significant correlation with MCC
(p = 0.002; r: 0.75). A trend toward a negative
correlation was observed between MCC and serum albumin (p =
0.06; r: -0.5459). Kidney biopsies of patients with nephrotic syndrome had
higher MCC [2.12 (0.41-5.140) vs. 0.53 (0.0-3.94), p =
0.07]. Conclusion: Inflammatory cell infiltration and morphological differences between cell
types in the inflammatory infiltrate are relevant factors in the assessment
of the LN. Mast cell analysis and AI/CI assessment may be relevant
prognostic indicators for pediatric patients with LN.
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Affiliation(s)
- Stéfany Silva Santos
- Departamento de Patologia Genética e Evolução, Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brasil
| | - Carolina Marques Ramos
- Departamento de Patologia Genética e Evolução, Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brasil
| | | | - Juliana Reis Machado
- Departamento de Patologia Genética e Evolução, Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brasil
| | - Marlene Antônia Dos Reis
- Departamento de Patologia Genética e Evolução, Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brasil
| | - Rosana Rosa Miranda Corrêa
- Departamento de Patologia Genética e Evolução, Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brasil
| | - Laura Penna Rocha
- Departamento de Patologia Genética e Evolução, Instituto de Ciências Biológicas e Naturais, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brasil
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Zhang CX, Cai L, Zhou ZY, Mao YY, Huang H, Yin L, Chen TX, Zhou W. Clinical manifestations, immunological features and prognosis of Chinese pediatric systemic lupus erythematosus: A single-center study. Int J Rheum Dis 2019; 22:1070-1076. [PMID: 30957986 DOI: 10.1111/1756-185x.13547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 02/15/2019] [Accepted: 02/17/2019] [Indexed: 11/30/2022]
Abstract
AIM Since there are only a few reports on pediatric systemic lupus erythematosus (pSLE) in Chinese populations, therefore we retrospectively report the clinical and immunological features as well as renal outcome in Chinese pSLE. METHODS Patients diagnosed with pSLE at Shanghai Children's Medical Center between 2001 and 2016 were evaluated and clinical data were retrospectively collected. RESULTS A total of 102 pSLE patients were analyzed. Renal disorder including proteinuria (81.37%) and hematuria (65.69%) were most commonly identified. Class IV was the most common finding on renal biopsy. In lupus nephritis (LN), 67.21%, 78.0%, 86.0% and 94.55% achieved complete remission within 6, 12, 18 and 24 months, respectively. Furthermore, 16.67% of LN patients suffered at least one renal flare. Antinuclear antibodies were detected in nearly all patients (97.62%), followed by anti-double-stranded DNA (anti-dsDNA) antibodies (70.0%) and anti-Sjögren's syndrome A (anti-SSA) antibodies (60.64%). Oral corticosteroid (93.14%) and mycophenolate mofetil (64.71%) was used in the majority of patients. Infection (32.35%) was the main side effect caused by the medications. CONCLUSIONS Our population-based pSLE cohort indicated that compared to other international cohorts, there was a higher prevalence of LN in Chinese pSLE. Proteinuria was the most frequent manifestation both at disease onset and during the entire clinical course. Class IV LN was the dominant renal pathological type. Nevertheless, there was a favorable renal remission rate and relatively low incidence of renal flare in our cohort. Apart from antinuclear antibodies and anti-dsDNA antibodies, anti-SSA antibodies were most frequently detected. Infection was the leading complication caused by the medications.
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Affiliation(s)
- Chen-Xing Zhang
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Division of Immunology, Institute of Pediatric Translational Medicine, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li Cai
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Division of Immunology, Institute of Pediatric Translational Medicine, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zheng-Yu Zhou
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - You-Ying Mao
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hua Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Yin
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tong-Xin Chen
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Division of Immunology, Institute of Pediatric Translational Medicine, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Department of Allergy and Immunology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Zhou
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
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21
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Emma F, Montini G, Gargiulo A. Equations to estimate prednisone dose using body weight. Pediatr Nephrol 2019; 34:685-688. [PMID: 30368613 DOI: 10.1007/s00467-018-4127-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/14/2018] [Accepted: 10/19/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND In the clinical practice, prednisone (PDN) dose in children is often prescribed using the patient weight, despite dose calculation using body surface area (BSA) is assumed to be preferable, because it parallels better with PDN metabolism in human subjects. METHODS Calculations based on body weight (W) carry the risk of underdosing, particularly in young children. Conversely, BSA estimation requires knowing the patient height, which is not always available, and more complex calculations. RESULTS To overcome these limitations, we have developed linear equations allowing approximating the BSA-based dose using only the patient weight in kilogram. To this end, we have used anthropomorphic data from 754 pediatric patients and have validated the proposed equations with a prospective cohort of 77 children with steroid sensitive nephrotic syndrome. The equation estimating a dose of 60 mg/m2 was [2 × W + 8] and the equation estimating a dose of 40 mg/m2 was [W + 11]. CONCLUSIONS Both equations performed very well and predicted reliably the BSA-based dose with an average error of 3.4% and 2.2%, respectively.
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Affiliation(s)
- Francesco Emma
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Giovanni Montini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca'Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Gargiulo
- Department of Pediatric Subspecialties, Division of Nephrology, Bambino Gesù Children's Hospital - IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
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22
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Aljaberi N, Bennett M, Brunner HI, Devarajan P. Proteomic profiling of urine: implications for lupus nephritis. Expert Rev Proteomics 2019; 16:303-313. [PMID: 30855196 DOI: 10.1080/14789450.2019.1592681] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Lupus nephritis (LN) is a common and significant manifestation, affecting 60% of adults and 80% of children with systemic lupus erythematosus, with up to 30% of patients progressing to end stage renal disease. There remains an unmet need for non-invasive markers of disease activity, damage, and response to therapy. In addition, non-invasive biomarkers that predict therapeutic efficacy are needed to enable cost-effective clinical trials of novel agents. Areas covered: This review examines the methodological aspects of urinary proteomics, the role of proteome profiling in identifying promising urinary biomarkers in LN, and the translation of research findings into clinically useful tools in the management of LN. Expert opinion: Targeted and unbiased proteomics have identified several promising urinary biomarkers that predict LN activity, damage (chronicity), and response to therapy. In particular, a combination of biologically plausible urinary biomarkers termed as RAIL (Renal Activity Index for Lupus) has emerged as an excellent predictor of LN activity as well as response to therapy, being able to predict efficacy within 3 months of therapy. If validated in additional large prospective studies, the RAIL biomarkers will transform the care of patients with LN, allowing for a personalized and predictive approach and improved outcomes.
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Affiliation(s)
- Najla Aljaberi
- a Divisions of Rheumatology, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Michael Bennett
- b Division of Nephrology & Hypertension, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Hermine I Brunner
- a Divisions of Rheumatology, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Prasad Devarajan
- b Division of Nephrology & Hypertension, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
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Rahbar MH, Rahbar MR, Mardanpour N, Mardanpour S. The potential diagnostic utility of coexpression of Ki-67 and P53 in the renal biopsy in pediatric lupus nephritis. Int J Nephrol Renovasc Dis 2018; 11:343-350. [PMID: 30588061 PMCID: PMC6296180 DOI: 10.2147/ijnrd.s175481] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background The proliferative activity as well as apoptosis has been suggested to play a role in the pathogenesis of lupus nephritis (LN). The aim of the study was to investigate the coexpression of Ki-67-triggered marked proliferation and P53-induced apoptosis in renal biopsy of childhood lupus nephritis (cLN) and to compare the coexpression of proliferative and apoptotic indices between different subgroups and clinicopathologic patterns of renal disease. Methods Renal biopsy specimens of 33 children with lupus nephritis (LN) and 10 healthy subjects were retrospectively evaluated. The type of LN and activity and chronicity indices were determined. Ki-67 and P53 immunostaining were performed. The coexpression of Ki-67 and P53 was compared among different subgroups of LN and correlated with disease activity index, serum creatinine, proteinuria, anticardiolipin antibodies, and complement levels. Histopathological examination of LN was classified based on the International Society of Nephrology/Renal Pathology. Histological LN activity was measured by the National Institutes of Health activity index (NIH-AI). Results In comparison with the healthy control group, the coexpression of Ki-67and P53 was greater in cLN (particularly in classes II, III, and IV) than in normal renal tissue. The coexpression of Ki-67and P53 shows a positive correlation with subclasses II, III, and IV of LN (P<0.02) and LN activity index (P<0.03). Moreover, the positive correlation was found between the coexpression of Ki-67 and P53 with erythrocyte sedimentation rate (P<0.02), D-dimer (P<0.03), serum creatinine (P<0.03), proteinuria (P<0.04), and anticardiolipin antibodies (P<0.05) significantly. Unexpectedly, adverse correlation between the coexpression of Ki-67 and P53 with serum C3 (P<0.02) and C4 complement (P<0.03) was significant. Conclusion Our data showed that the coexpression of Ki-67-induced marked proliferation and P53-induced apoptosis in proliferative and active phases of cLN could reflect a valuable marker for treatment and remission in cLN patients before reaching the end stage of renal disease.
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Affiliation(s)
- Mahtab H Rahbar
- Pathology Department, Iran University of Medical Sciences, Tehran, Iran,
| | - Maryam R Rahbar
- Nephrology department, Tehran University of Medical Sciences, Tehran, Iran
| | - Nyousha Mardanpour
- Pathology Department, Iran University of Medical Sciences, Tehran, Iran,
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24
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Ruggiero B, Vivarelli M, Gianviti A, Pecoraro C, Peruzzi L, Benetti E, Ventura G, Pennesi M, Murer L, Coppo R, Emma F. Outcome of childhood-onset full-house nephropathy. Nephrol Dial Transplant 2018; 32:1194-1204. [PMID: 27270291 DOI: 10.1093/ndt/gfw230] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 04/27/2016] [Indexed: 11/14/2022] Open
Abstract
Background Patients with full-house nephropathy (FHN) present renal lesions that are indistinguishable from those of lupus nephritis (LN) but lack the systemic features necessary to meet diagnostic criteria for systemic lupus erithematosus (SLE). Some have been reported to develop a delayed SLE with time. The clinical outcome of children having FHN without SLE has never been reported. Methods Children with biopsy-proven FHN were selected after excluding SLE cases by the absence of America College of Rheumatology criteria. The proportion of patients with complete (proteinuria <0.5 g/day) or partial remission (proteinuria ≤50% from baseline), relapse (estimated glomerular filtration rate <25% and/or proteinuria ≥50% from baseline) and progression to Stage III chronic kidney disease (CKD) was described according to age and gender groups with the Kaplan-Meier curve and compared with the Log-rank test. Entity of treatment was summarized by a score at induction (0-6 months) and maintenance (6-18 months). Cox-regression model was performed to test predictors of remission, relapse and progression to CKD. Results Among 42 patients (28 pre-pubertal) who met the inclusion criteria, 39 (92.9%) achieved partial and 32 (76.2%) complete remission of nephropathy over 2.78 and 7.51 months of follow-up. At 10 years, the probability of progressing to CKD was 4.8%. Of those achieving remission, 18% had a renal flare mainly within 4 years after remission. Pre-pubertal males achieved complete remission more frequently than other patients but often relapsed; pre-pubertal females were treated more aggressively. Cox-regression analysis did not find independent predictors of remission or relapse. Conclusions The outcome of the patients with FHN we investigated was encouraging. Recurrences are limited to the first 4 years following diagnosis, allowing progressive withdrawal of immunosuppression in patients achieving remission. Evaluation of risk factors for adverse outcome is necessary especially in pre-pubertal children.
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Affiliation(s)
- Barbara Ruggiero
- IRCCS - Istituto di Ricerche Farmacologiche Mario Negri, Clinical Reasearch Center for Rare Diseases 'Aldo e Cele Daccò', Bergamo, Italy
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Alessandra Gianviti
- Division of Nephrology and Dialysis, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Carmine Pecoraro
- Unit of Nephrology and Dialysis, Santobono Hospital, Naples, Italy
| | - Licia Peruzzi
- Division of Nephrology, Regina Margherita Children's Hospital, Turin, Italy
| | - Elisa Benetti
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman and Child Health, Azienda Ospedaliera-University of Padova, Padua, Italy
| | - Giovanna Ventura
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Marco Pennesi
- Department of Pediatrics, Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Luisa Murer
- Pediatric Nephrology, Dialysis and Transplant Unit, Department of Woman and Child Health, Azienda Ospedaliera-University of Padova, Padua, Italy
| | - Rosanna Coppo
- Division of Nephrology, Regina Margherita Children's Hospital, Turin, Italy
| | - Francesco Emma
- Division of Nephrology and Dialysis, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
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25
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Hogan J, Godron A, Baudouin V, Kwon T, Harambat J, Deschênes G, Niel O. Combination therapy of rituximab and mycophenolate mofetil in childhood lupus nephritis. Pediatr Nephrol 2018; 33:111-116. [PMID: 28780657 DOI: 10.1007/s00467-017-3767-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/08/2017] [Accepted: 07/10/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND In clinical trials, the addition of rituximab (RTX) to the combination therapeutic regimen of mycophenolate mofetil (MMF) and corticosteroids failed to improve outcome in lupus nephritis (LN). However, recent data suggest that RTX may have steroid-sparing beneficial effects with an efficacy similar to that of conventional regimens. We report our experience with RTX in the treatment of children with LN. METHODS Patients treated with RTX for first occurrence of LN class III to V were enrolled in the study. Treatment consisted of methylprednisolone pulse (500 mg/m2) followed by RTX (1000 mg/1.73 m2) at days 1 and 15, and MMF (1200 mg/m2/day). Prednisolone tapering and withdrawal was left to the physician's discretion. Complete remission (CR) was defined as a urine protein-to-creatinine ratio (U Pr/Cr) of <5 mg/mg and normal serum creatinine, and partial remission (PR) as a U Pr/Cr of <30 mg/mg and a <15% rise in serum creatinine over baseline. RESULTS Twelve patients were included in the study, with median follow-up of 23.7 [interquartile range (IQR) 12.8-33.5] months. Median age of the patients was 13.6 [12.3-15.1] years, median proteinuria was 32 [19-67] mg/mg and median estimated glomerular filtration rate was 76.1 [59.3-97.7] mL/min/1.73 m2. Median CD20 depletion duration was 10 [6.8-11.0] months. Prednisolone was rapidly tapered, with median dose of 0.3 [0.15-0.41], 0.10 [0.09-0.16] and 0.0 [0.0-0.04] mg/kg/day at 3, 6 and 12 months respectively. At 3 months, three and seven patients achieved CR and PR, respectively; at 6 and 12 months all patients achieved remission (9 CR, 3 PR) and none relapsed during follow-up. Five infectious complications were observed, including three varicella-zoster virus (VZV) infections. CONCLUSIONS In our pediatric patients with LN, therapy with RTX + MMF combined with a rapid decrease in steroid appears to have been an efficacious treatment for severe LN but was associated with high rate of VZV infection. The potential of RTX to allow complete steroid avoidance warrants further investigation in children.
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Affiliation(s)
- Julien Hogan
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France.
| | - Astrid Godron
- Pediatric Nephrology Unit, Pellegrin-Enfants Hospital-Bordeaux University, Bordeaux, France
| | - Véronique Baudouin
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France
| | - Theresa Kwon
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Pellegrin-Enfants Hospital-Bordeaux University, Bordeaux, France
| | - Georges Deschênes
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France
| | - Olivier Niel
- Pediatric Nephrology Department, Robert Debré Hospital, Assistance publique-Hôpitaux de Paris (APHP), Paris, France
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Touzot M, Terrier CSP, Faguer S, Masson I, François H, Couzi L, Hummel A, Quellard N, Touchard G, Jourde-Chiche N, Goujon JM, Daugas E. Proliferative lupus nephritis in the absence of overt systemic lupus erythematosus: A historical study of 12 adult patients. Medicine (Baltimore) 2017; 96:e9017. [PMID: 29310419 PMCID: PMC5728820 DOI: 10.1097/md.0000000000009017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Severe lupus nephritis in the absence of systemic lupus erythematosus (SLE) is a rare condition with an unclear clinical presentation and outcome.We conducted a historical observational study of 12 adult (age >18 years) patients with biopsy-proven severe lupus nephritis or lupus-like nephritis without SLE immunological markers at diagnosis or during follow-up. Excluded were patients with chronic infections with HIV or hepatitis B or C; patients with a bacterial infectious disease; and patients with pure membranous nephropathy. Electron microscopy was retrospectively performed when the material was available. End points were the proportion of patients with a complete response (urine protein to creatinine ratio <0.5 g/day and a normal or near-normal eGFR), partial response (≥50% reduction in proteinuria to subnephrotic levels and a normal or near-normal eGFR), or nonresponse at 12 months or later after the initiation of the treatment.The study included 12 patients (66% female) with a median age of 36.5 years. At diagnosis, median creatinine and proteinuria levels were 1.21 mg/dL (range 0.5-11.6) and 7.5 g/day (1.4-26.7), respectively. Six patients had nephrotic syndrome and acute kidney injury. Renal biopsy examinations revealed class III or class IV A/C lupus nephritis in all cases. Electron microscopy was performed on samples from 5 patients. The results showed mesangial and subendothelial dense deposits consistent with LN in 4 cases, and a retrospective diagnosis of pseudo-amyloid fibrillary glomerulonephritis was made in 1 patient.Patients received immunosuppressive therapy consisting of induction therapy followed by maintenance therapy, similar to treatment for severe lupus nephritis. Remission was recorded in 10 patients at 12 months after the initiation of treatment. One patient reached end-stage renal disease. After a median follow-up of 24 months, 2 patients relapsed.Lupus nephritis in the absence of overt SLE is a nosological entity requiring careful etiological investigation, including systematic electron microscopy examination of renal biopsies to rule out fibrillary glomerulonephritis. In this series, most patients presented with severe glomerulonephritis, which was highly similar to lupus nephritis at presentation and in terms of response to immunosuppressive therapy.
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Affiliation(s)
| | | | - Stanislas Faguer
- Département de Néphrologie et Transplantation d’organes, Hôpital Rangueil, CHU de Toulouse
| | - Ingrid Masson
- Service de néphrologie, Service de néphrologie, CHU Saint-Etienne
| | - Hélène François
- Service de Médecine interne et immunologie clinique, CHU Bicêtre, Kremlin-Bicêtre
| | - Lionel Couzi
- Service de néphrologie-transplantation, CHU de Bordeaux, FHU ACRONYM, CNRS-UMR 5164 Immuno Concept
| | | | | | | | | | | | - Eric Daugas
- Service de néphrologie, CHU Bichat, AP-HP, INSERM U1199, Paris Diderot University and DHU FIRE, Paris, France
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27
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Knight A, Kogon AJ, Matheson MB, Warady BA, Furth SL, Hooper SR. Cognitive Function in Children with Lupus Nephritis: A Cross-Sectional Comparison with Children with Other Glomerular Chronic Kidney Diseases. J Pediatr 2017; 189:181-188.e1. [PMID: 28734655 PMCID: PMC5614831 DOI: 10.1016/j.jpeds.2017.06.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 05/10/2017] [Accepted: 06/19/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To identify factors contributing to cognitive impairment in children with lupus nephritis. STUDY DESIGN A cross-sectional analysis of a large multicenter national cohort of children with chronic kidney disease (CKD) using standardized measures to determine baseline neuropsychiatric function and health-related quality of life (HRQoL) in children with lupus nephritis (n = 34), and to compare baseline function with that in children with other forms of glomerular CKD (gCKD; n = 171). We used inverse probability weighting via a logistic model for propensity score analysis to achieve balance between children with lupus nephritis and those with other glomerular causes of CKD, adjusting for known confounders. We used linear regression models to compare neurocognitive outcomes between exposure groups, adjusting for current prednisone use and testing for an interaction between current prednisone use and lupus nephritis, and to test for an association between cognitive function and HRQoL. RESULTS Current prednisone use was independently associated with worse attention (P < .01) and better adaptive skills (P = .04), and there was a significant interaction between current prednisone use and lupus nephritis for internalizing problems, with worse parent-reported internalizing problems in children with lupus nephritis on prednisone (P = .047). Better parent-reported HRQoL was associated with better visual memory (P = .01), and better child-reported HRQoL was associated with better attention (P < .01) and inhibitory control (P < .01). Both parent and child HRQoL were associated with better measures of executive function (P = .02 and < .001, respectively). CONCLUSION Children with lupus nephritis have comparable or better cognitive function than their peers with other gCKDs, which is reassuring given the multiorgan and lifelong complications associated with lupus.
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Affiliation(s)
- Andrea Knight
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Amy J. Kogon
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Matthew B. Matheson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Susan L. Furth
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA and
| | - Stephen R. Hooper
- Department of Allied Health Sciences, University of North Carolina School of Medicine, Chapel Hill, NC
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28
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Boneparth A, Radhakrishna SM, Greenbaum LA, Yen E, Okamura DM, Cooper JC, Mason S, Levy DM, Sule SD, Jensen PT, Yildirim-Toruner C, Ardoin SP, Wenderfer SE. Approach to Membranous Lupus Nephritis: A Survey of Pediatric Nephrologists and Pediatric Rheumatologists. J Rheumatol 2017; 44:1619-1623. [PMID: 28916546 DOI: 10.3899/jrheum.170502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To describe treatment practices for childhood pure membranous lupus nephritis (MLN). METHODS Survey study of Childhood Arthritis and Rheumatology Research Alliance and American Society of Pediatric Nephrology members. RESULTS There were 117 respondents who completed the survey (60 pediatric nephrologists, 57 pediatric rheumatologists). Steroids and nonsteroid immunosuppression (NSI) were routinely used by the majority for MLN. Mycophenolate mofetil was the favored initial NSI. Nephrologists used steroids (60% vs 93%) and NSI (53% vs 87%) less often than did rheumatologists for MLN without nephrotic syndrome (NS). CONCLUSION Pediatric rheumatologists and nephrologists both recommend steroids and NSI for children with MLN, with or without NS.
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Affiliation(s)
- Alexis Boneparth
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. .,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine.
| | - Suhas M Radhakrishna
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Larry A Greenbaum
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Eric Yen
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Daryl M Okamura
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Jennifer C Cooper
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Sherene Mason
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Deborah M Levy
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Sangeeta D Sule
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Paul T Jensen
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Cagri Yildirim-Toruner
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Stacy P Ardoin
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
| | - Scott E Wenderfer
- Columbia University Medical Center, New York, New York; Rady Children's Hospital, University of California San Diego, San Diego; University of California Los Angeles, Los Angeles; University of California San Francisco, San Francisco, California; Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia; Seattle Children's Hospital Research Institute, University of Washington, Seattle, Washington; Connecticut Children's Hospital, University of Connecticut, Hartford, Connecticut; Johns Hopkins University, Baltimore, Maryland; Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,A. Boneparth, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Columbia University Medical Center; S.M. Radhakrishna, MD, Assistant Clinical Professor of Pediatrics, Pediatric Rheumatologist, Rady Children's Hospital, University of California San Diego; L.A. Greenbaum, MD, PhD, Marcus Professor of Pediatrics, Pediatric Nephrologist, Children's Healthcare of Atlanta, Emory University; E. Yen, MD, Pediatric Rheumatology Fellow, University of California Los Angeles; D.M. Okamura, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Seattle Children's Hospital Research Institute, University of Washington; J.C. Cooper, MD, PharmD, Pediatric Rheumatology Fellow, University of California San Francisco; S. Mason, MD, MBA, Assistant Professor of Pediatrics, Pediatric Nephrologist, Connecticut Children's Hospital, University of Connecticut; D.M. Levy, MD, MS, FRCPC, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Hospital for Sick Children, University of Toronto; S.D. Sule, MD, Associate Professor of Pediatrics, Pediatric Nephrologist, Johns Hopkins University; P.T. Jensen, MD, Pediatric and Adult Rheumatology Fellow, Nationwide Children's Hospital, The Ohio State University; C. Yildirim-Toruner, MD, Assistant Professor of Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.P. Ardoin, MD, Associate Professor of Medicine and Pediatrics, Pediatric Rheumatologist, Nationwide Children's Hospital, The Ohio State University; S.E. Wenderfer, MD, PhD, Assistant Professor of Pediatrics, Pediatric Nephrologist, Texas Children's Hospital, Baylor College of Medicine
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Groot N, de Graeff N, Marks SD, Brogan P, Avcin T, Bader-Meunier B, Dolezalova P, Feldman BM, Kone-Paut I, Lahdenne P, McCann L, Özen S, Pilkington CA, Ravelli A, Royen-Kerkhof AV, Uziel Y, Vastert BJ, Wulffraat NM, Beresford MW, Kamphuis S. European evidence-based recommendations for the diagnosis and treatment of childhood-onset lupus nephritis: the SHARE initiative. Ann Rheum Dis 2017; 76:1965-1973. [PMID: 28877866 DOI: 10.1136/annrheumdis-2017-211898] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/18/2017] [Accepted: 08/13/2017] [Indexed: 12/13/2022]
Abstract
Lupus nephritis (LN) occurs in 50%-60% of patients with childhood-onset systemic lupus erythematosus (cSLE), leading to significant morbidity. Timely recognition of renal involvement and appropriate treatment are essential to prevent renal damage. The Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) initiative aimed to generate diagnostic and management regimens for children and adolescents with rheumatic diseases including cSLE. Here, we provide evidence-based recommendations for diagnosis and treatment of childhood LN. Recommendations were developed using the European League Against Rheumatism standard operating procedures. A European-wide expert committee including paediatric nephrology representation formulated recommendations using a nominal group technique. Six recommendations regarding diagnosis and 20 recommendations covering treatment choices and goals were accepted, including each class of LN, described in the International Society of Nephrology/Renal Pathology Society 2003 classification system. Treatment goal should be complete renal response. Treatment of class I LN should mainly be guided by other symptoms. Class II LN should be treated initially with low-dose prednisone, only adding a disease-modifying antirheumatic drug after 3 months of persistent proteinuria or prednisone dependency. Induction treatment of class III/IV LN should be mycophenolate mofetil (MMF) or intravenous cyclophosphamide combined with corticosteroids; maintenance treatment should be MMF or azathioprine for at least 3 years. In pure class V LN, MMF with low-dose prednisone can be used as induction and MMF as maintenance treatment. The SHARE recommendations for diagnosis and treatment of LN have been generated to support uniform and high-quality care for all children with SLE.
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Affiliation(s)
- Noortje Groot
- Wilhelmina Children's Hospital, Utrecht, The Netherlands.,Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Stephen D Marks
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Paul Brogan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tadej Avcin
- University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | | | - Pavla Dolezalova
- 1st Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Brian M Feldman
- Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - 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
| | - Seza Özen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | | | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | | | - Yosef Uziel
- Meir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Bas J Vastert
- Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | - Michael W Beresford
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Sylvia Kamphuis
- Sophia Children's Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
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Brunner HI, Bennett MR, Gulati G, Abulaban K, Klein-Gitelman MS, Ardoin SP, Tucker LB, Rouster-Stevens KA, Witte D, Ying J, Devarajan P. Urine Biomarkers to Predict Response to Lupus Nephritis Therapy in Children and Young Adults. J Rheumatol 2017; 44:1239-1248. [PMID: 28620062 PMCID: PMC6719540 DOI: 10.3899/jrheum.161128] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To delineate urine biomarkers that forecast response to therapy of lupus nephritis (LN). METHODS Starting from the time of kidney biopsy, patients with childhood-onset systemic lupus erythematosus who were diagnosed with LN were studied serially. Levels of 15 biomarkers were measured in random spot urine samples, including adiponectin, α-1-acid glycoprotein (AGP), ceruloplasmin, hemopexin, hepcidin, kidney injury molecule 1, monocyte chemotactic protein-1, lipocalin-like prostaglandin D synthase (LPGDS), transforming growth factor-β (TGF-β), transferrin, and vitamin D binding protein (VDBP). RESULTS Among 87 patients (mean age 15.6 yrs) with LN, there were 37 treatment responders and 50 nonresponders based on the American College of Rheumatology criteria. At the time of kidney biopsy, levels of TGF-β (p < 0.0001) and ceruloplasmin (p = 0.006) were significantly lower among responders than nonresponders; less pronounced differences were present for AGP, hepcidin, LPGDS, transferrin, and VDBP (all p < 0.05). By Month 3, responders experienced marked decreases of adiponectin, AGP, transferrin, and VDBP (all p < 0.01) and mean levels of these biomarkers were all outstanding (area under the receiver-operating characteristic curve ≥ 0.9) for discriminating responders from nonresponders. Patient demographics and extrarenal disease did not influence differences in biomarker levels between response groups. CONCLUSION Low urine levels of TGF-β and ceruloplasmin at baseline and marked reduction of AGP, LPGDS, transferrin, or VDBP and combinations of other select biomarkers by Month 3 are outstanding predictors for achieving remission of LN. If confirmed, these results can be used to help personalize LN therapy.
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Affiliation(s)
- Hermine I Brunner
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA.
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine.
| | - Michael R Bennett
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Gaurav Gulati
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Khalid Abulaban
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Marisa S Klein-Gitelman
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Stacy P Ardoin
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Lori B Tucker
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Kelly A Rouster-Stevens
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - David Witte
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Jun Ying
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Prasad Devarajan
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
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Jebali H, Hajji M, Rais L, Hamida FB, Beji S, Zouaghi MK. Clinicopathological findings and outcome of lupus nephritis in Tunisian children: a review of 43 patients. Pan Afr Med J 2017; 27:153. [PMID: 28904681 PMCID: PMC5567971 DOI: 10.11604/pamj.2017.27.153.10915] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 05/16/2017] [Indexed: 12/02/2022] Open
Abstract
We report clinical and renal histological data, treatment modalities and outcome of 43 Tunisian children with biopsy-proven lupus nephritis seen over a 23-year period. There were 39 girls and 4 boys with a mean age of 12.5 years at diagnosis of lupus nephritis and followed for a mean period of 77 months. Renal symptoms included urinary abnormalities in all patients, hypertension in 40% of cases, nephrotic syndrome in 60% of cases and renal failure in 25% of cases. Class IV and class III nephritis were observed in 48.8 % and 30.2 % respectively. Corticosteroids were used in all cases, associated to immunosuppressive therapy in 23%. Overall survival was 86% at 5 years and 74% at 10 and 15 years. Renal survival was 83% at 5 and 10 years and 63% at 15 years. Initial renal failure and tubulointerstitial fibrosis were significantly increased risk for the development of end-stage renal disease in our study group. Renal histological findings provide the basis for treatment recommendations. Timely performed renal biopsy is greatly needed to accurately determine the prognosis and to guide treatment in children lupus nephritis.
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Affiliation(s)
- Hela Jebali
- Nephrology Departement, La Rabta Hospital, Tunis, Tunisia
| | - Meriam Hajji
- Nephrology Departement, La Rabta Hospital, Tunis, Tunisia
| | - Lamia Rais
- Nephrology Departement, La Rabta Hospital, Tunis, Tunisia
| | - Fethi Ben Hamida
- Laboratory of Kidney pathology LR00SP01, Charles Nicolle Hospital, Tunis, Tunisia
| | - Soumaya Beji
- Nephrology Departement, La Rabta Hospital, Tunis, Tunisia
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Oni L, Beresford MW, Witte D, Chatzitolios A, Sebire N, Abulaban K, Shukla R, Ying J, Brunner HI. Inter-observer variability of the histological classification of lupus glomerulonephritis in children. Lupus 2017; 26:1205-1211. [PMID: 28478696 DOI: 10.1177/0961203317706558] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The gold standard for the classification of lupus nephritis is renal histology but reporting variation exists. The aim of this study was to assess the inter-observer variability of the 2003 International Society of Nephrology/Royal Pathology Society (ISN/RPS) lupus nephritis histological classification criteria in children. Histopathologists from a reference centre and three tertiary paediatric centres independently reviewed digitalized renal histology slides from 55 children with lupus nephritis. Histological ISN/RPS Class was assigned and features scored; lupus nephritis-activity [scored 0-24], lupus nephritis-chronicity [0-12] and tubulointerstitial activity [0-21]. In the cohort (73% females), the age at the time of biopsy was 15.5 ± 0.39 (mean ± standard error) years. Based on the reference centre, 42% (23/55) had ISN/RPS Class IV with lupus nephritis-activity score 4.23 ± 0.50, lupus nephritis-chronicity 1.81 ± 0.18 and tubulointerstitial activity 4.45 ± 0.35. There were 4-54 (mean 16.7) glomeruli per biopsy. Pathologists had fair agreement for ISN/RPS assignment (kappa; 0.26 ± 0.12), lupus nephritis-chronicity (intra-class correlation 0.36 ± 0.09) and tubulointerstitial activity (0.22 ± 0.09) scores. There was good agreement for lupus nephritis-activity scores (intra-class correlation 0.69 ± 0.06). When categorized into proliferative and non-proliferative disease, poor agreement among sites remained (kappa 0.24 ± 0.11). Despite unified criteria for the interpretation of histological features of lupus nephritis, marked reporting variation remains in clinical practice. As proliferative lupus nephritis is managed more intensively, this may influence renal outcomes.
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Affiliation(s)
- L Oni
- 1 Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.,2 Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M W Beresford
- 2 Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,3 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - D Witte
- 4 Department of Pediatric Histopathology, Cincinnati Children's Hospital Medical Centre, Cincinnati, USA
| | - A Chatzitolios
- 5 Department of Histopathology, Southmead Hospital, Bristol, UK
| | - N Sebire
- 6 Department of Paediatric Histopathology, Great Ormond Street Hospital, London, UK
| | - K Abulaban
- 7 Department of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Centre, Cincinnati, USA
| | - R Shukla
- 8 Department of Paediatric Histopathology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - J Ying
- 9 Centre for Biostatistical Services, University of Cincinnati College of Medicine, Cincinnati, USA
| | - H I Brunner
- 7 Department of Pediatric Rheumatology, Cincinnati Children's Hospital Medical Centre, Cincinnati, USA
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Rijnink EC, Teng YO, Kraaij T, Wolterbeek R, Bruijn JA, Bajema IM. Idiopathic non-lupus full-house nephropathy is associated with poor renal outcome. Nephrol Dial Transplant 2017; 32:654-662. [DOI: 10.1093/ndt/gfx020] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 01/24/2017] [Indexed: 02/04/2023] Open
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Advances in the care of children with lupus nephritis. Pediatr Res 2017; 81:406-414. [PMID: 27855151 DOI: 10.1038/pr.2016.247] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/07/2016] [Indexed: 12/27/2022]
Abstract
The care of children with lupus nephritis (LN) has changed dramatically over the past 50 y. The majority of patients with childhood-onset systemic lupus erythematosus (cSLE) develop LN. In the 1960's, prognosis in children was worse than in adults; therapies were limited and toxic. Nearly half of cases resulted in death within 2 y. Since this time, several diagnostic recommendations and disease-specific indices have been developed to assist physicians caring for patients with LN. Pediatric researchers are validating and adapting these indices and guidelines for the treatment of LN in cSLE. Classification systems, activity, and chronicity indices for kidney biopsy have been validated in pediatric cohorts in several countries. Implementation of contemporary immunosuppressive agents has reduced treatment toxicity and improved outcomes. Biomarkers sensitive to LN in children have been identified in the kidney, urine, and blood. Multi-institutional collaborative networks have formed to address the challenges of pediatric LN research. Considerable variation in evaluation and treatment has been addressed for proliferative forms of LN by development of consensus treatment practices. Patient survival at 5 y is now 95-97% and renal survival exceeds 90%. Moreover, international consensus exists for quality indicators for cSLE that consider the unique aspects of chronic disease in childhood.
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Wu CY, Yang HY, Yao TC, Liu SH, Huang JL. Serum IL-18 as biomarker in predicting long-term renal outcome among pediatric-onset systemic lupus erythematosus patients. Medicine (Baltimore) 2016; 95:e5037. [PMID: 27749566 PMCID: PMC5059068 DOI: 10.1097/md.0000000000005037] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
An urge of biomarker identification is needed to better monitor lupus nephritis (LN) disease activity, guide clinical treatment, and predict patient's long-term outcome. With the proinflammatory effect and its association with inflammasomes, the significance of interleukin-18 (IL-18) among pediatric-onset systemic lupus erythematous (pSLE) patient, especially, its importance in predicting long-term renal outcome was investigated.In a pSLE cohort of 96 patients with an average follow-up period of 10.39 ± 3.31 years, clinical data and laboratory workups including serum IL-18 were collected at time of disease onset and 6 months after treatment despite their initial renal status. Through Cox regression analysis, the parameters at baseline and at 6 months posttreatment were carefully analyzed.Average age of all cases was 12.74 ± 3.01 years old and 65 of them underwent renal biopsy at the time of diagnosis. Nine subjects (9.38%) progressed to end-stage renal disease (ESRD) and 2 cases (2.08%) died during follow-up. Through multivariate analysis, serum IL-18 level 6 months posttreatment was found to be the most unfavorable factor associating poor clinical outcome despite patient's initial renal status. In addition, the presentation of serum IL-18 in its correlation with SLE global disease activity as well as the presence and severity of LN were all significant (P < 0.001, P = 0.03, and P = 0.02, respectively). The histological classification of LN, however, was not associated with the level of IL-18 among the pSLE patients (P = 0.64).The role of serum IL-18 as biomarker representing global disease activity and status of renal flares among pSLE population was shown for the first time. Additionally, we have identified IL-18 at 6 months posttreatment a novel marker for long-term renal outcome prediction.
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Affiliation(s)
- Chao-Yi Wu
- Division of Allergy, Asthma, and Rheumatology, Chang Gung Children's Hospital
- Chang Gung University, College of Medicine
| | - Huang-Yu Yang
- Chang Gung University, College of Medicine
- Department of Nephrology
| | - Tsung-Chieh Yao
- Division of Allergy, Asthma, and Rheumatology, Chang Gung Children's Hospital
- Chang Gung University, College of Medicine
| | - Su-Hsun Liu
- Chang Gung University, College of Medicine
- Department of Family Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jing-Long Huang
- Division of Allergy, Asthma, and Rheumatology, Chang Gung Children's Hospital
- Chang Gung University, College of Medicine
- Correspondence: Jing-Long Huang, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (e-mail: )
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Boneparth A, Wenderfer SE, Moorthy LN, Radhakrishna SM, Sagcal-Gironella ACP, von Scheven E. Clinical characteristics of children with membranous lupus nephritis: the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry. Lupus 2016; 26:299-306. [PMID: 27510603 DOI: 10.1177/0961203316662720] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective The objective of this article is to describe and compare clinical features, treatment, and renal outcomes of children with membranous lupus nephritis (MLN), through analysis of a national multicenter registry. Methods Patients with pediatric systemic lupus erythematosus (SLE) and MLN from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry were included. Demographic, disease and medication-related data were collected between 2010 and 2014 from 59 CARRA Legacy Registry sites. Results A total of 132 individuals had MLN, either in isolation or in combination with proliferative LN. Seventy-four patients had pure MLN. The proportion of patients with daily corticosteroid treatment was similar among groups (96%, 91%, and 96%, for class III+V, IV+V, and V, respectively, p = 0.67). Proportion of individuals exposed to any disease-modifying antirheumatic drug (DMARD) or biologic was similar among the three groups (83%, 91%, 95% for class III+V, IV+V, and V, respectively, p = 0.189). Proportion of patients with decreased glomerular filtration rate (less than 90 ml/min/1.73 m2) was significantly different among groups (4%, 38%, and 4%, for class III+V, IV+V, and V, respectively, p < 0.0001). Conclusion This is the largest reported cohort of children with MLN. More research is needed to understand treatment practices for pediatric MLN, particularly decisions related to pharmacologic treatment of pure MLN. More work is also needed to identify prognostic factors and predictors of outcome for pediatric MLN. Future observational studies will be a first step toward understanding and formulating a standardized approach to treatment of pediatric membranous LN and allowing for the initiation of prospective comparative effectiveness studies and interventional trials.
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Affiliation(s)
- A Boneparth
- 1 Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - L Nandini Moorthy
- 1 Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | | | - E von Scheven
- 4 University of California at San Francisco, San Francisco, CA, USA
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Goilav B, Putterman C, Rubinstein TB. Biomarkers for kidney involvement in pediatric lupus. Biomark Med 2016; 9:529-43. [PMID: 26079958 DOI: 10.2217/bmm.15.25] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Lupus nephritis (LN), the renal involvement in systemic lupus erythematosus, is currently diagnosed by histopathology obtained by percutaneous renal biopsy and is associated with increased morbidity and mortality in both adults and children. LN is more prevalent and severe in children, requiring aggressive and prolonged immunosuppression. The consequences of the diagnosis and its treatment have devastating long-term effects on the growth, well-being and quality of life of affected children. The paucity of reliable clinical indicators of the presence and severity of renal involvement have contributed to a halt in the reduction of progression to end-stage renal disease in recent years. Here, we discuss the recent development of biomarkers in the management of LN and their role as therapeutic targets.
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Affiliation(s)
- Beatrice Goilav
- Children's Hospital at Montefiore, Department of Pediatrics, Division of Nephrology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York, NY 10461, USA
| | - Chaim Putterman
- Division of Rheumatology & Department of Microbiology & Immunology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York, NY 10461, USA
| | - Tamar B Rubinstein
- Children's Hospital at Montefiore, Department of Pediatrics, Division of Rheumatology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, New York, NY 10461, USA
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Campbell JF, Swartz SJ, Wenderfer SE. Nocturnal Hypertension and Attenuated Nocturnal Blood Pressure Dipping is Common in Pediatric Lupus. F1000Res 2015; 4:164. [PMID: 26664705 PMCID: PMC4654458 DOI: 10.12688/f1000research.6532.2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2015] [Indexed: 01/22/2023] Open
Abstract
Hypertension is an important manifestation of systemic lupus erythematosus (SLE) but reports of prevalence vary between 20-70% in published reports of adult and pediatric patients. For both children and adults with SLE, the clinical diagnosis and management of hypertension has traditionally been based on guidelines developed for the general population. In clinical trials, the criteria used for defining participants with hypertension are mostly undefined. As a first step towards formally assessing the blood pressure (BP) patterns of children diagnosed with SLE, 24-hr ambulatory BP monitoring data was analyzed on clinic patients who presented with prehypertension or stage I hypertension. In this pediatric SLE cohort (n=10), 20% met daytime criteria for a diagnosis of hypertension. Patterns of BP elevation varied widely with white coat, masked, isolated systolic, and diastolic nocturnal hypertension all identified. Nocturnal hypertension was detected in 60% and attenuated nocturnal BP dipping in 90% of both hypertensive and normotensive SLE patients. In SLE patients, the median nighttime systolic and diastolic loads were 25% and 15.5% compared with median daily loads of 12.5% and 11.5%. Daytime and nighttime systolic and diastolic BP load and nocturnal dipping was compared to a control population consisting of 85 non-SLE patients under 21 years old with prehypertension or stage 1 hypertension presenting to hypertension clinic. Median systolic BP dipped 5.3 mmHg in SLE patients compared to 11.9 mmHg in non-lupus ( p-value = 0.001). Median diastolic BP dipped 12.9 mmHg versus 18.5 mmHg in non-lupus ( p-value = 0.003). Patterns of BP dysregulation in pediatric SLE merit further exploration. Children with or without SLE displaying prehypertensive or stage 1 casual BP measurements had similar rates of hypertension by ambulatory BP monitoring. However, regardless of BP diagnosis, and independent of kidney involvement, there was an increased proportion with attenuated nocturnal dipping and nocturnal hypertension in SLE patients.
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Affiliation(s)
- J Fallon Campbell
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Sarah J Swartz
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Scott E Wenderfer
- Department of Pediatrics, Renal Section, Baylor College of Medicine, Houston, TX, 77030, USA
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Srivastava P, Abujam B, Misra R, Lawrence A, Agarwal V, Aggarwal A. Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years. Lupus 2015; 25:547-57. [PMID: 26637291 DOI: 10.1177/0961203315619031] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 11/02/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Childhood SLE (cSLE) has a higher prevalence of lupus nephritis (LN), and there are ethnic variations in response to treatment as well as outcome of LN. There are limited data on long-term outcome of LN in cSLE from the Indian subcontinent. METHODS Retrospective analysis of case records of patients with cSLE (satisfying revised American College of Rheumatology (ACR) 1997 criteria for diagnosis) and age of onset <18 years was conducted from 1989 to 2013. Data on clinical features, renal involvement and biopsy findings, treatment, renal outcome, damage accrual and mortality were collected. End-stage renal disease (ESRD) was defined as the need for renal replacement therapy. Actuarial ESRD-free survival was studied as the primary outcome measure using Kaplan-Meier analysis. RESULTS Among 205 children with cSLE, 134 (121 girls) had evidence of LN. The mean age at disease onset was 13.7 ± 3.5 years and the mean disease duration at presentation was 1.9 ± 2.5 years. Kidney biopsy was available for 92 patients, and histology included: 13 (14.2%) Class II, 24 (26%) Class III, 43 (46.7%) Class IV and 12 (13.1%) Class V LN. The mean follow-up period was 6.75 ± 5.7 years. At last visit, 81 (60.4%) children were in complete remission, 28 (20.9%) were in partial remission, 15 (11.2%) still had active nephritis and 10 (7.4%) had progressed to ESRD. Almost two-thirds (62.9%) of patients experienced lupus flares, and mean flare rate was 0.09 flares/patient follow-up year. Fifty-six (43.8%) children accrued damage and the mean Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage score was 0.79 ± 1.13. Actuarial ESRD-free survival at five, 10 and 15 years was 91.1%, 79% and 76.2%, and five-, 10- and 15-year renal survival was 93.8%, 87.1% and 84%, respectively. Although multiple factors individually predicted poor outcome (death/ESRD), only raised serum creatinine at onset (R square = 0.65, p ≤ 0.0001) and damage accrual (R square = 0.62, p ≤ 0.0001) remained significant on multivariate analysis. Eleven (8.2%) children died during the follow-up period, and infections were the leading cause of mortality. CONCLUSIONS Long-term outcome of LN in cSLE in our cohort was better than previous reports from India. However, a high rate of major infection still remains the leading cause of mortality.
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Affiliation(s)
- P Srivastava
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - B Abujam
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - R Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A Lawrence
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - V Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Rianthavorn P, Buddhasri A. Long-term renal outcomes of childhood-onset global and segmental diffuse proliferative lupus nephritis. Pediatr Nephrol 2015; 30:1969-76. [PMID: 26054714 DOI: 10.1007/s00467-015-3138-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 12/24/2022]
Abstract
BACKGROUND Data on global (IV-G) and segmental (IV-S) diffuse proliferative lupus nephritis (DPLN) in children are lacking. METHODS To determine the clinicopathology and prognosis of DPLN subclasses IV-G and IV-S, we analyzed the clinical, laboratory, and demographic data of 56 children aged <18 years diagnosed with DPLN [36 (64.3%) with IV-G; 20 (35.7%) with IV-S] between 2004 and 2013. Clinical endpoints were: (1) complete remission (CR), (2) chronic kidney disease [CKD; defined as estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m(2) or end-stage renal disease (ESRD)], and (3) death. RESULTS Proteinuria and the activity index were higher in patients with IV-G (p < 0.05). Global endocapillary proliferation and leukocyte exudation were predominant in IV-G patients, whereas segmental endocapillary proliferation was predominant in patients with IV-S (p < 0.005). CR rates in IV-G and IV-S patients were 50 and 60%, respectively (p = 0.47). Renal survival rates, defined as an eGFR of ≥60 mL/min/1.73 m(2), were 93, 78, and 64% at 1, 5, and 10 years, respectively. Patient survival rates at 1, 5, and 10 years were 98, 96, and 91%, respectively. Patient and renal survival rates were similar in both subclasses. CONCLUSIONS Although patients with IV-G and IV-S displayed some clinical and histopathological disparities, renal outcomes were similar. The majority of children with DPLN reached adulthood but accrued significant renal damage. Treatment regimens which can slow the progression of CKD are needed.
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Affiliation(s)
- Pornpimol Rianthavorn
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, 1873 King Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand.
| | - Athitaya Buddhasri
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, 1873 King Rama 4 Road, Pathumwan, Bangkok, 10330, Thailand
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Ntatsaki E, Isenberg D. Risk factors for renal disease in systemic lupus erythematosus and their clinical implications. Expert Rev Clin Immunol 2015; 11:837-48. [DOI: 10.1586/1744666x.2015.1045418] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Chen Y, Gao Q, Liu Y, Cao Y, Gao D, Liu J, Zhao J, Li Y, Liu W, Li W. Synthesis, crystal structures and luminescent properties of CdIIand ZnIIcomplexes assembled by 4-aminophenylhydroxamic acid. RSC Adv 2014. [DOI: 10.1039/c3ra44489a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
Lupus nephritis is a common complication of systemic lupus erythematosus in children and adolescents. This article reviews the clinical relevance of lupus nephritis and its current treatment. The reader is introduced to novel biomarkers that are expected to improve the management of lupus nephritis in the future, and support the testing of novel medication regimens.
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Affiliation(s)
- Michael Bennett
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, MC 7022, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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