1
|
De Mutiis C, Wenderfer SE, Basu B, Bagga A, Orjuela A, Sar T, Aggarwal A, Jain A, Boyer O, Yap HK, Ito S, Ohnishi A, Iwata N, Kasapcopur O, Laurent A, Chan EYH, Mastrangelo A, Ogura M, Shima Y, Rianthavorn P, Silva CA, Trindade V, Tullus K. Development of clinical and laboratory biomarkers in an international cohort of 428 children with lupus nephritis. Pediatr Nephrol 2024; 39:2959-2968. [PMID: 38802607 DOI: 10.1007/s00467-024-06405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Lupus nephritis (LN) is a very severe manifestation of lupus. There is no consensus on which treatment goals should be achieved to protect kidney function in children with LN. METHODS We retrospectively analyzed trends of commonly used laboratory biomarkers of 428 patients (≤ 18 years old) with biopsy-proven LN class ≥ III. We compared data of patients who developed stable kidney remission from 6 to 24 months with those who did not. RESULTS Twenty-five percent of patients maintained kidney stable remission while 75% did not. More patients with stable kidney remission showed normal hemoglobin and erythrocyte sedimentation rate from 6 to 24 months compared to the group without stable kidney remission. eGFR ≥ 90 ml/min/1.73m2 at onset predicted the development of stable kidney remission (93.8%) compared to 64.7% in those without stable remission (P < 0.00001). At diagnosis, 5.9% and 20.2% of the patients showed no proteinuria in the group with and without stable kidney remission, respectively (P = 0.0001). dsDNA antibodies decreased from onset of treatment mainly during the first 3 months in all groups, but more than 50% of all patients in both groups never normalized after 6 months. Complement C3 and C4 increased mainly in the first 3 months in all patients without any significant difference. CONCLUSIONS Normal eGFR and the absence of proteinuria at onset were predictors of stable kidney remission. Significantly more children showed normal levels of Hb and erythrocyte sedimentation rate (ESR) from 6 to 24 months in the group with stable kidney remission.
Collapse
Affiliation(s)
- Chiara De Mutiis
- Paediatric Unit, Maggiore Hospital, Azienda USL, Bologna, Italy.
| | - Scott E Wenderfer
- Pediatric Nephrology, The University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Alvaro Orjuela
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - 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 Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
- Department of Clinical Immunology and Rheumatology, Sawai Mansingh Medical College, Jaipur, India
| | - Olivia Boyer
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, Paris, France
- Néphrologie Pédiatrique, Hôpital Necker, Paris, France
| | - 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
| | - Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 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
| | - Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Wenderfer SE, Cooper JC. Do we really need cyclophosphamide for lupus nephritis? Pediatr Nephrol 2024:10.1007/s00467-024-06367-9. [PMID: 38607424 DOI: 10.1007/s00467-024-06367-9] [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: 12/06/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
A 14-year-old patient presents with hematuria and proteinuria. Clinical evaluation reveals a positive anti-nuclear antibody titer, positive anti-double stranded DNA antibody and hypocomplementemia. Systemic lupus erythematosus (SLE) is diagnosed based on the 2019 EULAR/ACR (European League Against Rheumatism/American College of Rheumatology) classification criteria (Aringer et al. Arthritis Rheumatol 71:1400-1412, 2019). A kidney biopsy is performed that confirms the presence of immune complex glomerulonephritis, ISN-RPS (International Society of Nephrology/Renal Pathology Society) class IV (Bajema et al. Kidney Int 93:789-796, 2018). According to the latest clinical practice guidelines (Rovin et al. Kidney Int 100:753-779, 2021; Fanouriakis et al. Ann Rheum Dis 83:15-29, 2023), there are alternatives to treating this patient with cyclophosphamide. But what if this patient also presented with oliguria and volume overload requiring intensive care and dialysis? What if this patient also presented with altered mental status and seizures, and was diagnosed with neuropsychiatric lupus? What if this patient was also diagnosed with a pulmonary hemorrhage and respiratory failure? The clinical practice guidelines do not address these scenarios that are not uncommon in patients with SLE. Moreover, in some countries worldwide, patients do not have the privilege of access to biologics or more expensive alternatives. The purpose of this review is to evaluate the contemporary options for initial treatment of nephritis in patients with SLE.
Collapse
Affiliation(s)
- Scott E Wenderfer
- Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada.
- Pediatric Nephrology, BC Children's Hospital, Vancouver, BC, Canada.
| | - Jennifer C Cooper
- Department of Pediatrics, University of Colorado, Denver, CO, USA
- Pediatric Rheumatology, Children's Hospital Colorado, Aurora, CO, USA
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Tullus K, De Mutiis C. Outcome of lupus nephritis in children. Rheumatology (Oxford) 2024; 63:906-907. [PMID: 37847665 DOI: 10.1093/rheumatology/kead554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/19/2023] Open
Affiliation(s)
- Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | | |
Collapse
|
6
|
De Mutiis C, Wenderfer SE, Basu B, Bagga A, Orjuela A, Sar T, Aggarwal A, Jain A, Yap HK, Teo S, Ito S, Ohnishi A, Iwata N, Kasapcopur O, Yildiz M, Laurent A, Mastrangelo A, Ogura M, Shima Y, Rianthavorn P, Silva CA, Trindade V, Gianviti A, Akinori M, Hamada R, Fujimura J, Minamikawa S, Kamiyoshi N, Kaito H, Ishimori S, Iannuzzella F, Tullus K. International cohort of 382 children with lupus nephritis - presentation, treatment and outcome at 24 months. Pediatr Nephrol 2023; 38:3699-3709. [PMID: 37221349 DOI: 10.1007/s00467-023-06018-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Children with lupus have a higher chance of nephritis and worse kidney outcome than adult patients. METHODS We retrospectively analyzed clinical presentation, treatment and 24-month kidney outcome in a cohort of 382 patients (≤ 18 years old) with lupus nephritis (LN) class ≥ III diagnosed and treated in the last 10 years in 23 international centers. RESULTS The mean age at onset was 11 years 9 months and 72.8% were females. Fifty-seven percent and 34% achieved complete and partial remission at 24-month follow-up, respectively. Patients with LN class III achieved complete remission more often than those with classes IV or V (mixed and pure). Only 89 of 351 patients maintained stable complete kidney remission from the 6th to 24th months of follow-up. eGFR ≥ 90 ml/min/1.73 m2 at diagnosis and biopsy class III were predictive of stable kidney remission. The youngest and the oldest age quartiles (2y-9y, 5m) (14y, 2m-18y,2m) showed lower rates of stable remission (17% and 20.7%, respectively) compared to the two other age groups (29.9% and 33.7%), while there was no difference in gender. No difference in achieving stable remission was found between children who received mycophenolate or cyclophosphamide as induction treatment. CONCLUSION Our data show that the rate of complete remission in patients with LN is still not high enough. Severe kidney involvement at diagnosis was the most important risk factor for not achieving stable remission while different induction treatments did not impact outcome. Randomized treatment trials involving children and adolescents with LN are needed to improve outcome for these children. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Chiara De Mutiis
- Paediatric Unit, Maggiore Hospital, Azienda USL, Bologna, Italy.
| | - Scott E Wenderfer
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Alvaro Orjuela
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - 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 Clinical Immunology and Rheumatology, Sawai Mansingh Medical College, Jaipur, India
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Sharon Teo
- Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, 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
| | - Mehmet Yildiz
- 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, Ospedale Maggiore Policlinico, 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
| | - Alessandra Gianviti
- Division of Nephrology and Dialysis, Children's Hospital Bambino Gesù, IRCCS, Rome, Italy
| | - Miyazono Akinori
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shogo Minamikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroshi Kaito
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Aijinkai Takatsuki General Hospital, Osaka, Japan
| | | | - Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| |
Collapse
|
7
|
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.
Collapse
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.
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Chan EYH, Yap DYH, Wong WT, Wong WHS, Wong SW, Lin KYK, Hui FYW, Yee-ming J, Lam SSY, Wong JKY, Lai FFY, Ho TW, Tong PC, Lai WM, Chan TM, Ma ALT. Long-Term Outcomes of Children and Adolescents With Biopsy-Proven Childhood-Onset Lupus Nephritis. Kidney Int Rep 2022; 8:141-150. [PMID: 36644360 PMCID: PMC9831948 DOI: 10.1016/j.ekir.2022.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Long-term data pertaining to childhood-onset lupus nephritis (cLN) remain extremely scarce. Methods We conducted a retrospective cohort study of biopsy-proven cLN with onset age <18 years diagnosed from 2001 to 2020 to ascertain the long-term patient and kidney survival rates, and the incidence of advanced chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] <60 ml/min per 1.73 m2). Results A total of 92 subjects (78 female; age 13.7 ± 3.3 years; all Chinese) were included, with follow-up duration of 10.3 years (interquartile range, 5.8-15.9). Of these, 83 children (90%) had proliferative lupus nephritis (LN) (Class III/IV ± V). Mycophenolate was used for induction in 36%, whereas 34% received cyclophosphamide (CYC); 55% received mycophenolate as maintenance immunosuppression. The rates of complete remission (CR) and partial remission (PR) at 6 months and 12 months, respectively, were 65% and 20% and 78% and 8%. Two patients died (mortality rate 2.1/1000 patient-years), with a standardized mortality ratio of 22.3. Three patients (3.2%) developed end-stage kidney disease (ESKD), and advanced CKD occurred in 5 patients (5.4%). Survival rates without advanced CKD, ESKD, or death were 96.7%, 94.2%, 92.7%, 83.2% and 83.2% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively. Multivariate analysis revealed that severe kidney failure necessitating dialysis at presentation (adjusted hazard ratio 37.7, 95% confidence interval [CI] 4.0-355.6, P = 0.002), nonresponse (NR) after 12 months of treatment (adjusted hazard ratio 11.2, 95% CI 2.3-54.9, P = 0.003), and multiple nephritis flares (adjusted hazard ratio 2.6, 95% CI 1.1-6.2, P = 0.03) were predictive of advanced CKD, ESKD, or death. Other adverse outcomes included infections (2.9 episodes/100 patient-years), osteopenia (32%), hypertension (17%), short stature (14%), and avascular necrosis (7%). Conclusion The long-term outcomes of cLN appeared to have improved in the present era with effective immunosuppression, cautious drug tapering, and assurance of medication adherence. There is still an unacceptably high prevalence of adverse outcomes.
Collapse
Affiliation(s)
- Eugene Yu-hin Chan
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Desmond Yat-hin Yap
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wing-tung Wong
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Wilfred Hing-sang Wong
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Sze-wa Wong
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Kyle Ying-kit Lin
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Felix Yan-wai Hui
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Jennifer Yee-ming
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | | | | | | | - Tsz-wai Ho
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Pak-chiu Tong
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Wai-ming Lai
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Tak Mao Chan
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong,Correspondence: Tak Mao Chan, Paediatric Nephrology Centre, Hong Kong Children's Hospital; Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
| | - Alison Lap-tak Ma
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong,Alison Lap-tak Ma, Pediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong.
| |
Collapse
|