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Alladin A, Hahn D, Hodson EM, Ravani P, Pfister K, Quinn RR, Samuel SM. Immunosuppressive therapy for IgA nephropathy in children. Cochrane Database Syst Rev 2024; 6:CD015060. [PMID: 38864363 PMCID: PMC11167693 DOI: 10.1002/14651858.cd015060.pub2] [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] [Indexed: 06/13/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common cause of primary glomerulonephritis. It is a heterogeneous disease with different presentations and high morbidity. Thirty per cent of adults and 20% of children (followed into adulthood) will have a 50% decline in kidney function or develop kidney failure after 10 years. OBJECTIVES To determine the benefits and harms of immunosuppressive therapy for the treatment of IgAN in children. SEARCH METHODS We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 03 October 2023 using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs) investigating the treatment of IgAN in children with immunosuppressive therapies compared to placebo, no treatment, supportive care, standard therapy (Japanese protocol), other immunosuppressive therapies or non-immunosuppressive therapies. DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the risk of bias. Random effects meta-analyses were used to summarise estimates of treatment effects. Treatment effects were expressed as risk ratios (RR) and 95% confidence intervals (CI) for dichotomous outcomes, and the mean difference (MD) and 95% CI for continuous outcomes. The risk of bias was assessed using the Cochrane risk of bias tool for RCTs and the ROBIN-I tool for NRSIs. The certainty of the evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). MAIN RESULTS This review included 13 studies with 686 participants. Ten RCTs included 334 children and 191 adults, and three NRSIs included 151 participants, all children. Most participants had mild kidney disease. The risk of bias was unclear for most of the domains relating to allocation concealment, blinding of participants, personnel, and outcome assessment. In children with IgAN, it is uncertain if corticosteroid (steroid) therapy, compared to placebo reduces proteinuria (1 study, 64 children and young adults: RR 0.47, 95% CI 0.13 to 1.72; low certainty evidence) or the decline in estimated glomerular filtration rate (eGFR) (1 study, 64 children and young adults: RR 0.47, 95% CI 0.09 to 2.39; low certainty evidence). It is uncertain if steroids reduce proteinuria compared to supportive care (2 studies, 61 children: RR 0.04, 95% CI -0.83 to 0.72; low certainty evidence). Adverse events associated with steroid therapy were not assessed due to heterogeneity in steroid protocols, including dose and duration, and lack of systematic assessment for adverse events in the included studies. Azathioprine, mycophenolate mofetil, mizoribine, or cyclophosphamide alone or in combination with steroid therapy had uncertain effects on improving proteinuria or preventing eGFR decline in children with IgAN. Fish oil, vitamin E and tonsillectomy had uncertain effects on improving proteinuria or preventing eGFR decline. Effects of other immunosuppressive therapies, secondary outcomes and adverse events were not assessed due to insufficient data. AUTHORS' CONCLUSIONS There is a lack of high-quality evidence to guide the management of IgAN in children. There is no evidence to indicate that steroids, other immunosuppressive therapies, or tonsillectomy, when added to optimal supportive care, prevent a decline in eGFR or proteinuria in children with IgAN. Available studies were few, with small numbers, low-quality evidence, high or uncertain risk of bias, did not systematically assess harms associated with treatment, or report net benefits or harms. Severe cases and atypical presentations of IgAN were not included in the reviewed studies, and our findings cannot be generalised to these situations.
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Affiliation(s)
- Areefa Alladin
- Departments of Paediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
- School of Medicine, University of Guyana, Georgetown, Guyana
| | - Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Pietro Ravani
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Kenneth Pfister
- Department of Medicine, University of Calgary, Calgary, Canada
| | - Robert R Quinn
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Susan M Samuel
- Departments of Paediatrics and Community Health Sciences, University of Calgary, Calgary, Canada
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Hu YC, Yang YH, Chiang BL. Immunoglobulin A vasculitis: The clinical features and pathophysiology. Kaohsiung J Med Sci 2024. [PMID: 38828518 DOI: 10.1002/kjm2.12852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 06/05/2024] Open
Abstract
Palpable purpura, gastrointestinal symptoms, joint involvement, and renal disease characterize immunoglobulin A vasculitis (IgAV). Renal involvement ranging from mild proteinuria to severe nephritic or nephrotic syndrome highlights the importance of monitoring kidney function in patients with IgAV. Recognizing these key features is crucial for early diagnosis and appropriate management to prevent long-term complications related to kidney disease. However, the pathogenesis of IgAV remains unclear. Disease mechanisms involve various factors, including the interplay of aberrantly glycosylated IgA, anti-endothelial cell antibodies, and neutrophils following infection triggers, which are the main pathogenic mechanisms of IgAV. Insights from cases of IgAV related to Coronavirus disease 2019 have offered additional understanding of the connection between infection and IgAV pathogenesis. This review provides a valuable resource for healthcare professionals and rheumatology researchers seeking a better understanding of the clinical features and pathophysiology of IgAV.
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Affiliation(s)
- Ya-Chiao Hu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yao-Hsu Yang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Genome and Systems Biology Degree Program, College of Life Science, National Taiwan University, Taipei, Taiwan
- Medical Research, National Taiwan University Hospital, Taipei, Taiwan
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3
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Boissais A, Blasco H, Emond P, Lefèvre A, Bigot A, Ramdani Y, Maldent NF, Mulleman D, Pillebout E, Maillot F, Audemard-Verger A. A specific diagnostic metabolome signature in adult IgA vasculitis. Metabolomics 2024; 20:61. [PMID: 38787468 PMCID: PMC11126474 DOI: 10.1007/s11306-024-02107-0] [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: 04/30/2023] [Accepted: 02/28/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION IgA vasculitis diagnosis relies primarily on clinical features and is confirmed by pathological findings. To date, there is no reliable noninvasive diagnostic biomarker. OBJECTIVE We aimed to explore the baseline serum metabolome of adult patients with IgA vasculitis to identify potential diagnostic biomarkers. METHODS We performed a study comparing the serum metabolome of patients with IgA vasculitis to that of patients with inflammatory condition, namely spondyloarthritis. Serum analyses were performed by high-performance liquid chromatography-mass spectrometry. RESULTS Fifty-five patients with IgA vasculitis and 77 controls with spondyloarthritis (age- and sex-matched) were included in this study. The median age of IgA vasculitis patients was 53 years. Two-thirds of patients were female (n = 32). At the time of vasculitis diagnosis, 100% of patients had skin involvement and 69% presented with glomerulonephritis (n = 38). Joint and digestive involvement were observed in 56% (n = 31) and 42% (n = 23) of patients. Four discriminative metabolites between the two groups were identified: 1-methyladenosine, L-glutamic acid, serotonin, and thymidine. The multivariate model built from the serum metabolomes of patients with IgA vasculitis and spondyloarthritis revealed an accuracy > 90%. As this model was significant according to the permutation test (p < 0.01), independent validation showed an excellent predictive value of the test set: sensitivity 98%; specificity 98%, positive predictive value 97% and negative predictive value 98%. CONCLUSION To our knowledge, this study is the first to use the metabolomic approach for diagnostic purposes in adult IgA vasculitis, highlighting a specific diagnostic metabolome signature.
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Affiliation(s)
- Alexandre Boissais
- Department of Internal Medicine and Clinical Immunology, University Hospital Center of Tours, Tours, France.
| | - Hélène Blasco
- Biochemistry and Molecular Biology Department, University Hospital Center of Tours, Tours, France
- UMR 1253, iBrain, University of Tours, 37000, InsermTours, France
| | - Patrick Emond
- UMR 1253, iBrain, University of Tours, 37000, InsermTours, France
- In Vitro Nuclear Medicine Department, University Hospital Center of Tours, Tours, France
| | - Antoine Lefèvre
- UMR 1253, iBrain, University of Tours, 37000, InsermTours, France
| | - Adrien Bigot
- Department of Internal Medicine and Clinical Immunology, University Hospital Center of Tours, Tours, France
| | - Yanis Ramdani
- Department of Internal Medicine and Clinical Immunology, University Hospital Center of Tours, Tours, France
| | - Nicole Ferreira Maldent
- Department of Internal Medicine and Clinical Immunology, University Hospital Center of Tours, Tours, France
| | - Denis Mulleman
- Center for Molecular Biophysics, UPR CNRS 4301, Tours, France
- Department of Rheumatology, University Hospital Center of Tours, Tours, France
- Nanomedicines and Nanoprobes Department, University of Tours, Tours, France
| | | | - François Maillot
- Department of Internal Medicine and Clinical Immunology, University Hospital Center of Tours, Tours, France
- UMR 1253, iBrain, University of Tours, 37000, InsermTours, France
| | - Alexandra Audemard-Verger
- Department of Internal Medicine and Clinical Immunology, University Hospital Center of Tours, Tours, France
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Younger DS. Headaches and Vasculitis. Neurol Clin 2024; 42:389-432. [PMID: 38575258 DOI: 10.1016/j.ncl.2023.12.003] [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: 04/06/2024]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability making this a disorder of paramount importance to all clinicians. Headache may be an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. Primary neurologic vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY, USA; Department of Neurology, White Plains Hospital, White Plains, NY, USA.
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Gan Y, Chen J, Wang M, Li Q, Wang A, Yang H. The efficacy and safety of tacrolimus in treating refractory IgA vasculitis nephritis: a single-center retrospective study on 16 cases. Clin Kidney J 2024; 17:sfae115. [PMID: 38742208 PMCID: PMC11089412 DOI: 10.1093/ckj/sfae115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Indexed: 05/16/2024] Open
Abstract
Background This study aimed to observe the efficacy and safety of tacrolimus in the treatment of refractory immunoglobulin A vasculitis nephritis (IgAVN). Methods Sixteen patients with IgAVN who had been previously treated with cyclophosphamide shock therapy at least five times, some of whom had also received mycophenolate but still had persistent proteinuria, were enrolled. The clinical and pathological data were collected and analysed. Results The average (mean ± standard deviation) age at the initial assessment for the group of 16 patients was 10 ± 2.7 years. Finally, at the end of their respective follow-up time point, 6 of the 16 patients achieved complete remission (37.5%), 5 achieved partial remission (31.2%), and 5 had no remission (31.2%). A significant difference was found in the median proteinuria before and after a 6-month course of tacrolimus treatment [19.2 (11.2, 31.9) vs 7.8 (4.3, 13.9) mg/kg/day] (P < .05). During the first 6 months of tacrolimus treatment, all patients' estimated glomerular filtration rate levels remained normal. The mean tacrolimus blood concentration was 6.0 ± 2.6 ng/mL. The median prednisone dosage was decreased from 10 mg/day to 5 mg/day, and prednisone was eventually stopped in three individuals. No drug-related adverse effects were observed during treatment. Conclusions Tacrolimus has demonstrated efficacy in increasing remission rates, significantly lowering urinary protein levels, and reducing steroid use in children with refractory IgAVN. Further research is required to investigate its optimal blood concentrations, long-term effects and renoprotective properties.
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Affiliation(s)
- Yueheng Gan
- Department of Nephrology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China
| | - Jiahuan Chen
- Department of Nephrology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China
| | - Mo Wang
- Department of Nephrology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China
| | - Qiu Li
- Department of Nephrology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China
| | - Anshuo Wang
- Department of Nephrology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China
| | - Haiping Yang
- Department of Nephrology, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China
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Cao Y, Chen X, Peng Q, Huang TT, Fan XC. Clinical characteristics and risk factors of cardiac involvement in pediatric immunoglobulin A vasculitis: A 7-year retrospective study from a single tertiary medical center. Eur J Pediatr 2024; 183:1871-1880. [PMID: 38300364 DOI: 10.1007/s00431-024-05438-1] [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: 11/04/2023] [Revised: 12/30/2023] [Accepted: 01/14/2024] [Indexed: 02/02/2024]
Abstract
Immunoglobulin A vasculitis(IgAV) is the most common form of systemic vasculitis affecting children. To date, cardiac involvement in pediatric IgAV has not been fully investigated and its prevalence may be underestimated. This study aims to reveal the clinical and laboratory characteristics of cardiac involvement in pediatric IgAV and further determine its risk factors. A total of 1451 children with IgAV were recruited between January 2016 and December 2022. According to the severity of cardiac involvement, the patients were divided into the myocarditis/suspected myocarditis group, cardiac abnormalities group, and non-cardiac involvement group. Demographic, clinical, and laboratory characteristics were retrospectively extracted from the individual data collected in the medical records. Among the 1451 pediatric IgAV patients, 179 (12.3%) were identified with cardiac involvement, including 154 (10.6%) with cardiac abnormalities and 25 (1.7%) with myocarditis/suspected myocarditis. Cardiac involvement in pediatric IgAV mainly manifested as elevated cardiac biomarker levels (n = 162), electrocardiogram abnormalities (n = 46), and echocardiogram/chest X-ray abnormalities (n = 15); however, cardiac-related symptoms were only observed in 15.1% of patients with cardiac involvement. Multivariate analysis demonstrated that interval from disease onset to diagnosis > 7 days (OR, 2.157; 95% CI, 1.523-3.057; p < 0.001), IgAV with multi-organ involvement (OR, 1.806; 95% CI, 1.242-2.627; p = 0.002), and elevated D-dimer levels (OR, 1.939; 95% CI, 1.259-2.985; p < 0.001) were independent risk factors for cardiac involvement in pediatric IgAV. The length of hospital stay was significantly longer in the myocarditis/suspected myocarditis group compared with the other two groups (p < 0.05). Conclusion: This study suggests that cardiac involvements in pediatric IgAV is non-negligible, and cardiac involvement is associated with interval from disease onset to diagnosis > 7 days, IgAV with multi-organ involvement, and elevated D-dimer levels. Severe cardiac involvement may affect the prognosis of pediatric IgAV. What is Known: • Immunoglobulin A vasculitis (IgAV) is the most common form of systemic vasculitis affecting children and adolescents, which exhibits diverse clinical manifestations. Cases of severe IgAV complicated by cardiac involvement have been anecdotally reported. What is New: • The present study suggests that cardiac involvements in pediatric IgAV is non-negligible, and cardiac involvement is associated with interval from disease onset to diagnosis > 7 days, IgAV with multi-organ involvement, and elevated D-dimer levels. Severe cardiac involvement may affect the prognosis of pediatric IgAV.
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Affiliation(s)
- Yue Cao
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Xin Chen
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Qi Peng
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Tian Tuo Huang
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Xiao Chen Fan
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China.
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Frkovic M, Turcic A, Gagro A, Srsen S, Frkovic SH, Rogic D, Jelusic M. Erythrocyte Glutathione S-Transferase Activity as a Sensitive Marker of Kidney Function Impairment in Children with IgA Vasculitis. Int J Mol Sci 2024; 25:3795. [PMID: 38612603 PMCID: PMC11011981 DOI: 10.3390/ijms25073795] [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: 01/31/2024] [Revised: 03/24/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
IgA vasculitis (IgAV) is the most common childhood vasculitis. The main cause of morbidity and mortality in children with IgAV is nephritis (IgAVN), but the risk of its development, severity, and chronicity remain unclear. Erythrocyte glutathione S-transferase (e-GST) activity has been previously detected as a sensitive marker of kidney function impairment in several diseases. We spectrophotometrically assessed and correlated e-GST activity between 55 IgAV patients without nephritis (IgAVwN), 42 IgAVN patients, and 52 healthy controls. At disease onset, e-GST activity was significantly higher in IgAVN patients (median (interquartile range)) (5.7 U/gHb (4.4-7.5)) than in IgAVwN patients (3.1 U/gHb (2.2-4.2); p < 0.001), and controls (3.1 U/gHb (1.9-4.2); p < 0.001). Therewithal, there were no differences between the IgAVwN patients and controls (p = 0.837). e-GST activity was also significantly higher in the IgAVN patients than in the IgAVwN patients after 3 months (5.0 U/gHb (4.2-6.2) vs. 3.3 U/gHb (2.3-4.1); p < 0.001) and 6 months (4.2 U/gHb (3.2-5.8) vs. 3.3 U/gHb (2.1-4.1); p < 0.001) since the disease onset. Consistent correlations between e-GST activity and serum creatinine, estimated glomerular filtration rate (eGFR), and proteinuria levels were not detected. In conclusion, increased e-GST activity can serve as a subtle indicator of kidney function impairment in children with IgAV.
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Affiliation(s)
- Marijan Frkovic
- Department of Pediatrics, University Hospital Centre Zagreb, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
| | - Ana Turcic
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, University of Zagreb Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Alenka Gagro
- Children’s Hospital Zagreb, Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, 10000 Zagreb, Croatia
| | - Sasa Srsen
- Department of Pediatrics, University Hospital Centre Split, School of Medicine, University of Split, 21000 Split, Croatia
| | - Sanda Huljev Frkovic
- Department of Pediatrics, University Hospital Centre Zagreb, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
| | - Dunja Rogic
- Department of Laboratory Diagnostics, University Hospital Centre Zagreb, University of Zagreb Faculty of Pharmacy and Biochemistry, 10000 Zagreb, Croatia
| | - Marija Jelusic
- Department of Pediatrics, University Hospital Centre Zagreb, University of Zagreb School of Medicine, 10000 Zagreb, Croatia
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Sun Q, Bai J, Wang S, Fang H, Qiao J. JAK Inhibitors for Treating Steroid-Dependent IgA Vasculitis. Am J Ther 2024:00045391-990000000-00179. [PMID: 38525955 DOI: 10.1097/mjt.0000000000001683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
Affiliation(s)
- Qingmiao Sun
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Gusmão VCDL, Flausino TGDC, Couto DS, Abraão LM, Felix AMDS, Ciofi-Silva CL, Courtenay M, Ness V, Castro-Sanchez E, de Figueiredo RM, Padoveze MC. Adapting the Nominal Group Technique to a virtual version: an experience report. Rev Esc Enferm USP 2024; 58:e20230298. [PMID: 38488509 PMCID: PMC10950306 DOI: 10.1590/1980-220x-reeusp-2023-0298en] [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: 09/25/2023] [Accepted: 01/12/2024] [Indexed: 03/19/2024] Open
Abstract
OBJECTIVE To report on the adaptations made to the original Nominal Group Technique (NGT), allowing it to be applied to the virtual format, preserving all its key elements. METHOD An experience report on the adaptations and adjustments made to the original NGT to the virtual format using Information and Communication Technologies (ICT), using digital tools that are available free of charge or are low cost and easy to use. RESULTS The NGT was carried out entirely virtually and underwent adaptations in each of its four stages through the incorporation of specific digital resources. It was possible to present the most voted ideas and obtain final approval from the participants. The participants had no difficulty in using the virtual resources provided and, based on the reaction evaluation, they were satisfied with the tools provided. CONCLUSION The adapted NGT proved to be an effective method when used in a virtual setting, capable of producing a significant number of ideas and developing consensus. The adapted tool can be used by other researchers in countries with similar resources or dimensions to Brazil.
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Affiliation(s)
| | | | - Daniela Sanches Couto
- Universidade Federal de São Carlos, Departamento de Enfermagem, São
Carlos, SP, Brazil
| | - Ligia Maria Abraão
- Universidade de São Paulo, Escola de Enfermagem, Departamento de
Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil
| | - Adriana Maria da Silva Felix
- Universidade de São Paulo, Escola de Enfermagem, Departamento de
Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil
| | | | | | - Valerie Ness
- Glasgow Caledonian University, Glasgow, Scotland, UK
| | | | | | - Maria Clara Padoveze
- Universidade de São Paulo, Escola de Enfermagem, Departamento de
Enfermagem em Saúde Coletiva, São Paulo, SP, Brazil
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Ramegowda R, Singhal M, Gulati A, Samanta J, Singh H, Sharma V, Sharma A, Gupta P. Autoimmune disorders of the gastrointestinal tract: Review of radiological appearances. Curr Probl Diagn Radiol 2024; 53:259-270. [PMID: 37923635 DOI: 10.1067/j.cpradiol.2023.10.002] [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: 06/08/2023] [Revised: 09/26/2023] [Accepted: 10/18/2023] [Indexed: 11/07/2023]
Abstract
Autoimmune gastrointestinal (GI) disorders comprise a heterogeneous group of diseases with non-specific clinical manifestations. These are divided into primary and secondary. A high index of clinical suspicion complemented with endoscopic and radiological imaging may allow early diagnosis. Due to the relatively low incidence of autoimmune disorder, the imaging literature is sparse. In this review, we outline the pathogenesis, classification, and imaging appearances of autoimmune GI disorders.
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Affiliation(s)
- Rajath Ramegowda
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manphool Singhal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Gulati
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Park SH, Jo SM, Kim SW, Lee JM, Baek HS. An Investigation of the Relationship between Henoch-Schönlein Purpura and Viral Infection in Korea Using the Health Insurance Database. J Clin Med 2024; 13:1290. [PMID: 38592700 PMCID: PMC10931917 DOI: 10.3390/jcm13051290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/21/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: This study investigated the epidemiology and viral connections of Henoch-Schönlein purpura (HSP) using information from the Korea Disease Control and Prevention Agency and the Health Insurance Review and Assessment database. (2) Method: Between 2016 and 2019, a total of 25,443 patients with HSP were identified, with 51.3% of patients under the age of 20 years and the highest incidence in March. (3) Results: The autoregressive integrated moving average model and Granger causality test were used to analyze the association between the virus positivity detection rate and HSP incidence. (4) Conclusions: The incidence of HSP was associated with rotavirus, bocavirus, parainfluenza virus, and respiratory syncytial virus in individuals under 20 years of age, whereas adenovirus, respiratory syncytial virus, and norovirus were associated with individuals above that age.
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Affiliation(s)
- So Hyeon Park
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea; (S.H.P.); (S.M.J.)
| | - Su Min Jo
- Department of Medicine, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea; (S.H.P.); (S.M.J.)
| | - Sang Won Kim
- Medical Research Center, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea;
| | - Jae Min Lee
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
| | - Hee Sun Baek
- Department of Pediatrics, College of Medicine, Yeungnam University, Daegu 42415, Republic of Korea
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Day C, Shute R. UK Kidney Association guideline review: 'The initial management of IgA vasculitis (Henoch-Schönlein purpura) in children and young people' in conjunction with 'The management of complications-associated IgA vasculitis (Henoch-Schönlein purpura) in children and young people'. Arch Dis Child Educ Pract Ed 2024:edpract-2023-326239. [PMID: 38383140 DOI: 10.1136/archdischild-2023-326239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/05/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Charlotte Day
- West Suffolk Hospitals NHS Trust, Cambridgeshire, UK
| | - Rachel Shute
- Paediatrics, West Suffolk Hospitals NHS Trust, Cambridgeshire, UK
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13
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Laskarin G, Babarovic E, Kifer N, Bulimbasic S, Sestan M, Held M, Frkovic M, Gagro A, Coric M, Jelusic M. Involvement of M1-Activated Macrophages and Perforin/Granulysin Expressing Lymphocytes in IgA Vasculitis Nephritis. Int J Mol Sci 2024; 25:2253. [PMID: 38396930 PMCID: PMC10889255 DOI: 10.3390/ijms25042253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 02/02/2024] [Accepted: 02/10/2024] [Indexed: 02/25/2024] Open
Abstract
We investigated the polarisation of CD68+ macrophages and perforin and granulysin distributions in kidney lymphocyte subsets of children with IgA vasculitis nephritis (IgAVN). Pro-inflammatory macrophage (M)1 (CD68/iNOS) or regulatory M2 (CD68/arginase-1) polarisation; spatial arrangement of macrophages and lymphocytes; and perforin and granulysin distribution in CD3+ and CD56+ cells were visulaised using double-labelled immunofluorescence. In contrast to the tubules, iNOS+ cells were more abundant than the arginase-1+ cells in the glomeruli. CD68+ macrophage numbers fluctuated in the glomeruli and were mostly labelled with iNOS. CD68+/arginase-1+ cells are abundant in the tubules. CD56+ cells, enclosed by CD68+ cells, were more abundant in the glomeruli than in the tubuli, and co-expressed NKp44. The glomerular and interstitial/intratubular CD56+ cells express perforin and granulysin, respectively. The CD3+ cells did not express perforin, while a minority expressed granulysin. Innate immunity, represented by M1 macrophages and CD56+ cells rich in perforin and granulysin, plays a pivotal role in the acute phase of IgAVN.
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Affiliation(s)
- Gordana Laskarin
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism “Thalassotherapia-Opatija”, 51410 Opatija, Croatia
| | - Emina Babarovic
- Department of Pathology, Faculty of Medicine, University of Rijeka, 51000 Rijeka, Croatia;
| | - Nastasia Kifer
- Division of Rheumatology and Immunology, Department of Paediatrics, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, 10000 Zagreb, Croatia; (N.K.); (M.S.); (M.H.); (M.F.); (M.J.)
| | - Stela Bulimbasic
- Department of Pathology and Cytology, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, 10000 Zagreb, Croatia; (S.B.); (M.C.)
| | - Mario Sestan
- Division of Rheumatology and Immunology, Department of Paediatrics, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, 10000 Zagreb, Croatia; (N.K.); (M.S.); (M.H.); (M.F.); (M.J.)
| | - Martina Held
- Division of Rheumatology and Immunology, Department of Paediatrics, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, 10000 Zagreb, Croatia; (N.K.); (M.S.); (M.H.); (M.F.); (M.J.)
| | - Marijan Frkovic
- Division of Rheumatology and Immunology, Department of Paediatrics, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, 10000 Zagreb, Croatia; (N.K.); (M.S.); (M.H.); (M.F.); (M.J.)
| | - Alenka Gagro
- Children’s Hospital Zagreb, Faculty of Medicine, University of Osijek, 31000 Osijek, Croatia;
| | - Marijana Coric
- Department of Pathology and Cytology, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, 10000 Zagreb, Croatia; (S.B.); (M.C.)
| | - Marija Jelusic
- Division of Rheumatology and Immunology, Department of Paediatrics, School of Medicine, University Hospital Centre Zagreb, University of Zagreb, 10000 Zagreb, Croatia; (N.K.); (M.S.); (M.H.); (M.F.); (M.J.)
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14
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Jia L, Li X, Shen J, Teng Y, Zhang B, Zhang M, Gu Y, Xu H. Ang-1, Ang-2, and Tie2 are diagnostic biomarkers for Henoch-Schönlein purpura and pediatric-onset systemic lupus erythematous. Open Life Sci 2024; 19:20220812. [PMID: 38465338 PMCID: PMC10921503 DOI: 10.1515/biol-2022-0812] [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: 05/31/2023] [Revised: 11/16/2023] [Accepted: 11/16/2023] [Indexed: 03/12/2024] Open
Abstract
Henoch-Schönlein purpura (HSP) and pediatric-onset systemic lupus erythematosus (pSLE) are closely associated with vasculitis and vascular diseases. This study aimed to investigate the clinical diagnostic values of Ang-1, Ang-2, and Tie2 for HSP and pSLE. We surveyed 82 HSP patients, 34 pSLE patients, and 10 healthy children. The expression levels of Ang-1, Ang-2, and Tie2 in the serum and urine were assessed using enzyme-linked immunosorbent assay. The diagnostic values of Ang-1, Ang-2, and Tie2 for HSP and pSLE were evaluated using receiver operating characteristic curve analysis. The results revealed that the serum and urine expression levels of Ang-2 and Tie2 were significantly elevated in HSP and pSLE patients, whereas the Ang-1/Ang-2 values were reduced. Additionally, Ang-1 was highly expressed in the serum and urine of HSP patients and in the serum of pSLE patients. Ang-1, Ang-2, and Tie2 showed differential expression in various types of HSP and pSLE compared with their expression in healthy controls. In summary, Ang-1, Ang-2, and Tie2 can serve as biomarkers for HSP and pSLE. Moreover, Ang-1/Ang-2 values are reduced in HSP and pSLE patients. Ang-1, Ang-2, and Tie2 can be used as biomarkers for HSP and pSLE.
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Affiliation(s)
- Lishan Jia
- Department of Pediatrics, Taicang Affiliated Hospital of Soochow University, The First People’s Hospital of Taicang, No. 58 Changsheng South Road, Taicang City, Jiangsu Province, 215400, China
| | - Xiaozhong Li
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, No. 303 Jingde Road, Gusu District, Suzhou City, Jiangsu Province, 215003, China
| | - Jiayun Shen
- Department of Pediatrics, Taicang Affiliated Hospital of Soochow University, The First People’s Hospital of Taicang, No. 58 Changsheng South Road, Taicang City, Jiangsu Province, 215400, China
| | - Yan Teng
- Department of Pediatrics, Taicang Affiliated Hospital of Soochow University, The First People’s Hospital of Taicang, No. 58 Changsheng South Road, Taicang City, Jiangsu Province, 215400, China
| | - Baoqin Zhang
- Department of Pediatrics, Taicang Affiliated Hospital of Soochow University, The First People’s Hospital of Taicang, No. 58 Changsheng South Road, Taicang City, Jiangsu Province, 215400, China
| | - Min Zhang
- Department of Pediatrics, Taicang Affiliated Hospital of Soochow University, The First People’s Hospital of Taicang, No. 58 Changsheng South Road, Taicang City, Jiangsu Province, 215400, China
| | - Yueqin Gu
- Department of Pediatrics, Taicang Affiliated Hospital of Soochow University, The First People’s Hospital of Taicang, No. 58 Changsheng South Road, Taicang City, Jiangsu Province, 215400, China
| | - Hong Xu
- Department of Nephrology, Children’s Hospital of Fudan University, No. 399 Wanyuan Road, Minhang District, Shanghai City, 201102, China
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15
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Taşkın RB, Aydın İ, Aytaç G, Imamoglu S, Tunçay SC, Bulut İK, Karaca NE, Aksu G, Berdeli A, Kütükçüler N. Analysis of IL-1β, TGF-β, IL-5, ACE, PTPN22 gene polymorphisms, and gene expression levels in Turkish children with IgA vasculitis. Mol Biol Rep 2023; 51:15. [PMID: 38085361 DOI: 10.1007/s11033-023-08944-x] [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: 07/26/2023] [Accepted: 11/14/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Immunoglobulin-A vasculitis (IgAV) is an inflammatory disease that affects small blood vessels. This study was performed to identify an association between protein tyrosine phosphatase non-receptor type 22 (PTPN22) + 788G > A (rs33996649), transforming growth factor-beta (TGF-β) -509C > T (rs18004069), interleukin 1-beta (IL-1β) -511C > T (rs16944), interleukin 5 (IL-5) -746C/T (rs2069812), and angiotensin-converting enzyme (ACE) I/D (rs4646994) gene polymorphisms, susceptibility to IgAV, as well as the mRNA levels of IL-1β, IL-1β, and TGF-β. METHOD A total of 53 patients with IgAV and 50 healthy controls were enrolled. PTPN22, TGF-β, IL-1β, ACE gene polymorphisms, ACE gene I/D polymorphisms, and mRNA expression levels were analyzed using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method, allele-specific PCR, and real-time PCR with TaqMan kits, respectively. RESULTS PTPN22, TGF-β, IL-1β, IL-5, and ACE variants showed no genotype or allele differences between patients with IgAV and controls. Increased levels of IL-1β and TGF-β mRNA expressions were observed in patients with IgAV (p < 0.001). Patients with the IL-1β AG genotype showed significantly increased amounts of arthritis than patients with non-AG (p = 0.004). Age at disease onset was found to be significantly different in patients with IgAV according to the presence of TGF-β TT genotype (p = 0.047). CONCLUSION Polymorphisms in PTPN22, TGF-β, IL-5, IL-1β, and ACE genes are unlikely to confer susceptibility to IgAV. However, the presence of the AG genotype of IL-1β is associated with susceptibility to IgAV-related arthritis. This is the first study to report a significant increase in serum mRNA levels of IL-1β and TGF-β in IgAV patients, supporting a susceptibility to IgAV in childhood.
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Affiliation(s)
- Raziye Burcu Taşkın
- Faculty of Medicine, Department of Pediatric Rheumatology, Ege University, Izmir, Turkey.
| | - İlyas Aydın
- Faculty of Medicine, Department of Pediatric Rheumatology, Ege University, Izmir, Turkey
| | - Gülçin Aytaç
- Faculty of Medicine, Department of Pediatric Rheumatology, Ege University, Izmir, Turkey
| | - Süleyman Imamoglu
- Faculty of Medicine, Department of Pediatric Rheumatology, Ege University, Izmir, Turkey
| | - Secil Conkar Tunçay
- Faculty of Medicine, Department of Pediatric Nephrology, Ege University, Izmir, Turkey
| | - İpek Kaplan Bulut
- Faculty of Medicine, Department of Pediatric Nephrology, Ege University, Izmir, Turkey
| | - Neslihan Edeer Karaca
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ege University, Kazimdirik Neighborhood, University Street Number: 9, 35100, Bornova, Izmir, Turkey
| | - Güzide Aksu
- Faculty of Medicine, Department of Pediatric Rheumatology, Ege University, Izmir, Turkey
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ege University, Kazimdirik Neighborhood, University Street Number: 9, 35100, Bornova, Izmir, Turkey
| | - Afig Berdeli
- Faculty of Medicine, Department of Pediatric Rheumatology, Ege University, Izmir, Turkey
| | - Necil Kütükçüler
- Faculty of Medicine, Department of Pediatric Rheumatology, Ege University, Izmir, Turkey
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Immunology, Ege University, Kazimdirik Neighborhood, University Street Number: 9, 35100, Bornova, Izmir, Turkey
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16
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Younger DS. Systemic vasculitis and headache. Curr Opin Neurol 2023; 36:631-646. [PMID: 37865837 PMCID: PMC10624412 DOI: 10.1097/wco.0000000000001223] [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: 10/23/2023]
Abstract
PURPOSE OF REVIEW Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system or so called neurovasculitides, lead to pervasive injury and disability making these disorder of paramount importance to clinicians. RECENT FINDINGS Headache is an important clue to vasculitic involvement of central nervous system (CNS) vessels. CNS vasculitis may be primary, in which only intracranial vessels are involved in the inflammatory process, or secondary to another known disorder with overlapping systemic involvement. A suspicion of vasculitis based on the history, clinical examination, or laboratory studies warrants prompt evaluation and treatment to forestall progression and avert cerebral ischemia or infarction. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary adult and pediatric CNS vasculitides predicated on achievements in primary systemic forms. SUMMARY Vasculitis can be diagnosed with certainty after intensive evaluation that includes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, tempered by the recognition of anticipated medication side effects.
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Affiliation(s)
- David S Younger
- Department of Medicine, Section of Neuroscience, City University of New York School of Medicine, New York, NY; Department of Neurology, White Plains Hospital, White Plains, New York, USA
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17
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Williams CEC, Lamond M, Marro J, Chetwynd AJ, Oni L. A narrative review of potential drug treatments for nephritis in children with IgA vasculitis (HSP). Clin Rheumatol 2023; 42:3189-3200. [PMID: 37755547 PMCID: PMC10640478 DOI: 10.1007/s10067-023-06781-8] [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: 06/19/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
Immunoglobulin A (IgA) vasculitis (IgAV, also known as Henoch-Schoenlein purpura, HSP) is the most common vasculitis of childhood. It usually presents with a simple, self-limiting disease course; however, a small subset of patients may develop kidney involvement (IgAV-N) which occurs 4-12 weeks after disease onset and is the biggest contributor to long-term morbidity. Treatment currently targets patients with established kidney involvement; however; there is a desire to work towards early prevention of inflammation during the window of opportunity between disease presentation and onset of significant nephritis. There are no clinical trials evaluating drugs which may prevent or halt the progression of nephritis in children with IgAV apart from the early use of corticosteroids which have no benefit. This article summarises the latest scientific evidence and clinical trials that support potential therapeutic targets for IgAV-N that are currently being developed based on the evolving understanding of the pathophysiology of IgAV-N. These span the mucosal immunity, B-cell and T-cell modulation, RAAS inhibition, and regulation of complement pathways, amongst others. Novel drugs that may be considered for use in early nephritis include TRF-budesonide; B-cell inhibiting agents including belimumab, telitacicept, blisibimod, VIS649, and BION-1301; B-cell depleting agents such as rituximab, ofatumumab, and bortezomib; sparsentan; angiotensin converting enzyme inhibitors (ACE-Is); and complement pathway inhibitors including avacopan, iptacopan, and narsoplimab. Further clinical trials, as well as pre-clinical scientific studies, are needed to identify mechanistic pathways as there may be an opportunity to prevent nephritis in this condition. Key Points • Kidney involvement is the main cause of long-term morbidity and mortality in IgA vasculitis despite the current treatment recommendations. • The evolving understanding of the pathophysiology of IgA vasculitis is allowing exploration of novel treatment options which target underlying immune pathways. • Novel treatments currently being trialled in IgA nephropathy may have benefit in IgA vasculitis due to the similarities in the underlying pathophysiology, such as TRF-budesonide, B-cell modulators, and complement inhibitors. • Further studies, including clinical trials of novel drugs, are urgently needed to improve the long-term outcomes for children with IgA vasculitis nephritis.
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Affiliation(s)
- Chloe E C Williams
- Royal Liverpool and Broadgreen University Hospital Trusts, Liverpool, UK
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Megan Lamond
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julien Marro
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Andrew J Chetwynd
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Centre for Proteome Research, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Louise Oni
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Paediatric Nephrology, Institute in the Park Building, University of Liverpool, Alder Hey Children's NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP, UK.
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18
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Nagai S, Horinouchi T, Ninchoji T, Ichikawa Y, Tanaka Y, Kitakado H, Ueda C, Kondo A, Aoto Y, Sakakibara N, Kaito H, Tanaka R, Shima Y, Fujimura J, Kamiyoshi N, Ishimori S, Nakanishi K, Yoshikawa N, Iijima K, Nozu K. Long-term outcome of combination therapy with corticosteroids, mizoribine and RAS inhibitors as initial therapy for severe childhood IgA vasculitis with nephritis. Pediatr Nephrol 2023; 38:4023-4031. [PMID: 37380934 DOI: 10.1007/s00467-023-06052-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Patients with severe IgA vasculitis with nephritis (IgAVN) typically receive aggressive therapy as an initial approach. We have consistently performed combination therapy including corticosteroids and immunosuppressants as initial therapy for severe IgAVN over a 20-year-plus period, with only minor changes to the treatment protocol. This study seeks to reveal the efficacy of combination therapy for severe IgAVN. METHODS We retrospectively studied 50 Japanese children diagnosed between 1996 and 2019 with clinicopathologically severe IgAVN who were defined as ISKDC classification grade IIIb-V and/or serum albumin < 2.5 g/dL. RESULTS The median age at the onset of IgAVN was 8.0 years (IQR: 6.0-10.0). At biopsy, 44% of patients had nephrotic syndrome and 14% had kidney dysfunction. All patients were treated with combination therapy after biopsy. Abnormal proteinuria resolved after initial therapy in all 50 patients. However, eight patients (16%) had recurrence of proteinuria. Abnormal proteinuria was again resolved in three of these patients with additional treatment. At the last follow-up (median 59.5 months; IQR, 26.2-84.2), the median urine protein-to-creatine ratio was 0.08 g/gCr (IQR, 0.05-0.15), and only one patient had kidney dysfunction. CONCLUSIONS Combination therapy provided good kidney outcomes for Japanese children with severe IgAVN. Even including recurrent cases, the degree of proteinuria was slight, and kidney function was good at the last follow-up. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sadayuki Nagai
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan.
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
- Department of Pediatrics, Harima-Himeji General Medical Center, 3-264 Kamiyacho, Himeji, Hyogo, 6705860, Japan
| | - Yuta Ichikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Yu Tanaka
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Hideaki Kitakado
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Chika Ueda
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Atsushi Kondo
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Yuya Aoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
- Department of Pediatrics, Harima-Himeji General Medical Center, 3-264 Kamiyacho, Himeji, Hyogo, 6705860, Japan
| | - Nana Sakakibara
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kakogawa Central City Hospital, 439 Honmachi, Kakogawa-cho, 675-8611, Kakogawa, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Japanese Red Cross Society Himeji Hospital, 1-12-1 Shimoteno, Himeji, 670-8540, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-cho, 569-1192, Takatsuki, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Nakagami-gun, 903-0125, Okinawa, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, 1-3-13 Kosobe-cho, 569-1192, Takatsuki, Japan
| | - Kazumoto Iijima
- Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, 1-6-7 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
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19
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Stamellou E, Seikrit C, Tang SCW, Boor P, Tesař V, Floege J, Barratt J, Kramann R. IgA nephropathy. Nat Rev Dis Primers 2023; 9:67. [PMID: 38036542 DOI: 10.1038/s41572-023-00476-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/02/2023]
Abstract
IgA nephropathy (IgAN), the most prevalent primary glomerulonephritis worldwide, carries a considerable lifetime risk of kidney failure. Clinical manifestations of IgAN vary from asymptomatic with microscopic or intermittent macroscopic haematuria and stable kidney function to rapidly progressive glomerulonephritis. IgAN has been proposed to develop through a 'four-hit' process, commencing with overproduction and increased systemic presence of poorly O-glycosylated galactose-deficient IgA1 (Gd-IgA1), followed by recognition of Gd-IgA1 by antiglycan autoantibodies, aggregation of Gd-IgA1 and formation of polymeric IgA1 immune complexes and, lastly, deposition of these immune complexes in the glomerular mesangium, leading to kidney inflammation and scarring. IgAN can only be diagnosed by kidney biopsy. Extensive, optimized supportive care is the mainstay of therapy for patients with IgAN. For those at high risk of disease progression, the 2021 KDIGO Clinical Practice Guideline suggests considering a 6-month course of systemic corticosteroid therapy; however, the efficacy of systemic steroid treatment is under debate and serious adverse effects are common. Advances in understanding the pathophysiology of IgAN have led to clinical trials of novel targeted therapies with acceptable safety profiles, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, as well as blockade of complement components.
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Affiliation(s)
- Eleni Stamellou
- Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Claudia Seikrit
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Peter Boor
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
- Department of Pathology, RWTH Aachen University, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rafael Kramann
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany.
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands.
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20
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曹 峰, 徐 龙, 张 迎. [Association between vaccination and the risk of immunoglobulin A vasculitis in children]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:1137-1142. [PMID: 37990458 PMCID: PMC10672955 DOI: 10.7499/j.issn.1008-8830.2303129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 08/03/2023] [Indexed: 11/23/2023]
Abstract
OBJECTIVES To study the effect of vaccination on the short-term risk of immunoglobulin A vasculitis (IgAV) in children. METHODS A retrospective analysis was conducted on the general data and the vaccination history within one year prior to onset in children with IgAV hospitalized in the Children's Hospital Affiliated to Zhengzhou University from November 2021 to January 2023. Vaccine exposure rates in the risk period (3 months prior to IgAV onset) and the control period were compared by autocontrol-case crossover analysis, and the odds ratio and 95% confidence interval (95%CI) were calculated. A sensitivity analysis for the one-month and two-month risk periods was conducted. RESULTS A total of 193 children with IgAV were included, with a median age of 7.0 years. Among the 193 children, 36 (18.7%) received at least one dose of the vaccine within 1 year prior to IgAV onset, and 14 (7.3%) received at least one dose of the vaccine during the 3-month risk period. Compared to the unvaccinated IgAV group, the vaccinated IgAV group had a significantly younger age of onset (P<0.05). There were no significant differences in the proportions of children with gastrointestinal involvement, renal involvement, and joint involvement between the two groups (P>0.05). The odds ratio for developing IgAV after receiving any type of vaccine within 3 months prior to IgAV onset was 2.08 (95%CI: 0.82-5.27, P>0.05). Further sensitivity analysis for the 1-month and 2-month risk periods demonstrated that the odds ratios for developing IgAV after receiving any type of vaccine were 2.74 (95%CI: 0.72-10.48, P>0.05) and 2.72 (95%CI: 0.95-7.77, P>0.05), respectively. CONCLUSIONS Vaccination dose not increase the risk of IgAV, nor does it exacerbate clinical symptoms in children with IgAV.
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Rosenberg S, Sweetser P, Ismail L. Vomiting and Abdominal Pain in a 9-year-old Boy. Pediatr Rev 2023; 44:S103-S105. [PMID: 37777227 DOI: 10.1542/pir.2021-005385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Sedona Rosenberg
- University of Virginia School of Medicine, Department of Ophthalmology, Charlottesville, VA
| | - Peter Sweetser
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Lana Ismail
- Children's National Hospital, Division of Hospital Medicine, Washington, DC
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Held M, Sestan M, Kifer N, Jelusic M. Cerebrovascular involvement in systemic childhood vasculitides. Clin Rheumatol 2023; 42:2733-2746. [PMID: 36884156 DOI: 10.1007/s10067-023-06552-5] [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: 12/07/2022] [Revised: 02/02/2023] [Accepted: 02/15/2023] [Indexed: 03/09/2023]
Abstract
Pediatric vasculitides sometimes involve central nervous system (CNS). The manifestations are diverse, ranging from headache, seizures, vertigo, ataxia, behavioral changes, neuropsychiatric symptoms, consciousness disorders, and even cerebrovascular (CV) accidents that may lead to irreversible impairment and even death. Stroke, on the other hand despite the great progress in prevention and treatment, is still one of the leading causes of morbidity and mortality in the general population. The aim of this article was to summarize CNS manifestations and CV issues observed in primary pediatric vasculitides and the current knowledge of etiology and CV risk factors, preventive strategies, and therapeutic options in this target patient population. Pathophysiological links reveal similar immunological mechanisms involved in both pediatric vasculitides and CV events with endothelial injury and damage being the central point. From the clinical point of view, CV events in pediatric vasculitides were associated with increased morbidity and poor prognosis. If damage has already occurred, the therapeutic approach consists of good management of the vasculitis itself, antiplatelet and anticoagulation therapy, and early rehabilitation. Risk factors for acquiring cerebrovascular disease (CVD) and stroke, particularly hypertension and early atherosclerotic changes, already begin in childhood, with vessel wall inflammation contributing itself, once more emphasizing that appropriate preventive measures are certainly necessary in pediatric vasculitis population to improve their long-term outcome.
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Affiliation(s)
- Martina Held
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mario Sestan
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nastasia Kifer
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marija Jelusic
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
- Division of Clinical Immunology, Rheumatology and Allergology, Centre of Reference for Paediatric and Adolescent Rheumatology of Ministry of Health of the Republic Croatia, University Hospital Centre Zagreb, Kispaticeva 12, 10 000, Zagreb, Croatia.
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Amatruda M, Carucci NS, Chimenz R, Conti G. Immunoglobulin A vasculitis nephritis: Current understanding of pathogenesis and treatment. World J Nephrol 2023; 12:82-92. [PMID: 37766840 PMCID: PMC10520755 DOI: 10.5527/wjn.v12.i4.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/16/2023] [Accepted: 06/12/2023] [Indexed: 09/20/2023] Open
Abstract
The clinical spectrum of immunoglobulin A vasculitis nephritis (IgAVN) ranges from the relatively common transitory microscopic hematuria and/or low-grade proteinuria to nephritic or nephrotic syndrome, rapidly progressive glomerulonephritis, or even renal failure. Clinical and experimental studies have shown a multifactor pathogenesis: Infection triggers, impaired glycosylation of IgA1, complement activation, Toll-like-receptor activation and B cell proliferation. This knowledge can identify IgAVN patients at a greater risk for adverse outcome and increase the evidence for treatment recommendations.
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Affiliation(s)
- Michela Amatruda
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Nicolina Stefania Carucci
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Roberto Chimenz
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
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24
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Rose K, Turner JE, Iking-Konert C. [Immunoglobulin A vasculitis (IgAV)]. Z Rheumatol 2023; 82:587-598. [PMID: 37266676 PMCID: PMC10236391 DOI: 10.1007/s00393-023-01355-0] [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] [Accepted: 03/22/2023] [Indexed: 06/03/2023]
Abstract
IgA vasculitis (IgAV) is an immune complex-mediated vasculitis characterized by IgA1-dominant immune deposits in small vessels. It is the most common systemic vasculitis in childhood with a mostly uncomplicated and self-limiting course. Adults are less affected but the course is frequently more complicated and more frequently accompanied by renal involvement. IgAV characteristically manifests itself on the skin with palpable purpura and in joints, the kidneys and the gastrointestinal tract. In cases of incomplete or atypical symptoms a differential diagnostic work-up is required. A number of triggers have been suggested, especially infections and drugs. Disease management is tailored to organ manifestations and the severity of the symptoms. For children, optimized supportive care and targeted symptom relief are usually sufficient. Management of renal and gastrointestinal manifestations follows recommendations for ANCA-associated vasculitis and IgA nephropathy. Treatment options include glucocorticoids and immunosuppressive agents with varying and mostly insufficient evidence.
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Affiliation(s)
- Katharina Rose
- Abteilung für Rheumatologie, Stadtspital Zürich, Birmensdorferstr. 497, 8063, Zürich, Schweiz.
| | - Jan-Eric Turner
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Christof Iking-Konert
- Abteilung für Rheumatologie, Stadtspital Zürich, Birmensdorferstr. 497, 8063, Zürich, Schweiz
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25
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Keskinyan VS, Lattanza B, Reid-Adam J. Glomerulonephritis. Pediatr Rev 2023; 44:498-512. [PMID: 37653138 DOI: 10.1542/pir.2021-005259] [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] [Indexed: 09/02/2023]
Abstract
Glomerulonephritis (GN) encompasses several disorders that cause glomerular inflammation and injury through an interplay of immune-mediated mechanisms, host characteristics, and environmental triggers, such as infections. GN can manifest solely in the kidney or in the setting of a systemic illness, and presentation can range from chronic and relatively asymptomatic hematuria to fulminant renal failure. Classic acute GN is characterized by hematuria, edema, and hypertension, the latter 2 of which are the consequence of sodium and water retention in the setting of renal impairment. Although presenting signs and symptoms and a compatible clinical history can suggest GN, serologic and urinary testing can further refine the differential diagnosis, and renal biopsy can be used for definitive diagnosis. Treatment of GN can include supportive care, renin-angiotensin-aldosterone system blockade, immunomodulatory therapy, and renal transplant. Prognosis is largely dependent on the underlying cause of GN and can vary from a self-limited course to chronic kidney disease. This review focuses on lupus nephritis, IgA nephropathy, IgA vasculitis, and postinfectious GN.
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Yang K, Tang J, Li H, Zhang H, Ding J, Li Z, Luo J. LncRNAs in Kawasaki disease and Henoch-Schönlein purpura: mechanisms and clinical applications. Mol Cell Biochem 2023:10.1007/s11010-023-04832-x. [PMID: 37639198 DOI: 10.1007/s11010-023-04832-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/14/2023] [Indexed: 08/29/2023]
Abstract
Kawasaki disease (KD) and Henoch-Schönlein purpura (HSP) are the two most predominant types of childhood vasculitis. In childhood vasculitis, factors such as lack of sensitive diagnostic indicators and adverse effects of drug therapy may cause multiorgan system involvement and complications and even death. Many studies suggest that long noncoding RNAs (lncRNAs) are involved in the mechanism of vasculitis development in children and can be used to diagnose or predict prognosis by lncRNAs. In existing drug therapies, lncRNAs are also involved in drug-mediated treatment mechanisms and are expected to improve drug toxicity. The aim of this review is to summarize the link between lncRNAs and the pathogenesis of KD and HSP. In addition, we review the potential applications of lncRNAs in multiple dimensions, such as diagnosis, treatment, and prognosis prediction. This review highlights that targeting lncRNAs may be a novel therapeutic strategy to improve and treat KD and HSP.
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Affiliation(s)
- Kangping Yang
- Department of Pediatrics, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.
| | - Jiayao Tang
- School of Pharmacy, Nanchang University, Nanchang, China
| | - Haoying Li
- Queen Mary School of Nanchang University, Nanchang, China
| | - Hejin Zhang
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Jiatong Ding
- The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Zelin Li
- The First Clinical Medical College of Nanchang University, Nanchang, China
| | - Jinghua Luo
- Department of Pediatrics, The Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, China.
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27
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Marro J, Williams C, Pain CE, Oni L. A case series on recurrent and persisting IgA vasculitis (Henoch Schonlein purpura) in children. Pediatr Rheumatol Online J 2023; 21:85. [PMID: 37580746 PMCID: PMC10424434 DOI: 10.1186/s12969-023-00872-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND IgA vasculitis (IgAV) is a small vessel vasculitis that is more common in childhood. Very limited evidence exists on patients who experience an atypical disease course. The aim of this study was to describe a cohort of children diagnosed with recurrent or persisting IgAV to identify any themes associated with their disease course and areas of unmet needs. METHODS A single centre retrospective study of children diagnosed with recurrent or persisting IgAV at Alder Hey Children's Hospital (Liverpool, UK). Clinical data, including features at presentation and during follow up, potential triggers, abnormal laboratory and histology results, treatment and outcome at last clinical review were retrospectively collected. Key themes were identified. RESULTS A total of 13 children met the inclusion criteria (recurrent disease, n = 4; persisting disease, n = 9). Median age at first presentation was 10.2 years [2.6-15.5], female:male ratio 1.2:1. Children in the atypical cohort were significantly older than a larger cohort of children who followed a non-complicated disease course (median age 5.5 years (range [0.6-16.7], p = 0.003)). All children re-presented with a purpuric rash (either recurring or persisting), accompanied by joint involvement in 92% of patients (12/13). Disease-modifying anti-rheumatic drugs (DMARDs) were used in 8/13 (62%) children. The median time from first presentation to diagnosis of atypical disease was 18.4 months [5.3-150.8] and the time from first presentation to treatment was 24.1 months [1.8-95.4]. Use of corticosteroids was significantly higher in children with renal involvement (p = 0.026). During follow up, 8/13 (62%) children were admitted at least once, whilst 10/13 (77%) had re-presented at least once to the emergency department. Five (38%) children were referred to psychology services and 7 (54%) children reported feelings of frustration. CONCLUSIONS This series describes some characteristics of a small cohort of children with atypical IgAV. It also identifies unmet needs in children with atypical IgAV, which includes delays in diagnosis and lengthy waits for treatment, lack of high-quality evidence regarding treatment choices and a high unrecognised disease burden. Further research is needed to study this subgroup of children as evidence is lacking.
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Affiliation(s)
- Julien Marro
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Chloe Williams
- Royal Liverpool and Broadgreeen University Hospital Trusts, Liverpool, UK
| | - Clare E Pain
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Louise Oni
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Paediatric Nephrology, University of Liverpool Alder Hey Children's NHS Foundation Trust Hospital, Institute in the Park Building, Eaton Road, Liverpool, L12 2AP, UK.
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28
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Zhang S, Wang Q, Li Z, Guo Q. Testicular ischemia associated with IgA vasculitis in a child: a case report and literature review. Front Pediatr 2023; 11:1219878. [PMID: 37635796 PMCID: PMC10450908 DOI: 10.3389/fped.2023.1219878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
Testicular necrosis is a rare and severe complication of immunoglobulin A (IgA) vasculitis (IgAV). Herein, We report a case of a 10-year-old boy who was admitted to the hospital due to skin purpura and intermittent abdominal pain for 10 days and bilateral testicular pain for 2 days. Scrotal ultrasonography indicated right testicle ischemia, right epididymo-orchitis, and bilateral hydrocele of the testis. Scrotal surgical exploration revealed significant swelling and darkening of the right testicle. Conservative treatment led to improvement in his condition, and he was discharged. During 3 months of follow-up, there was no recurrence of skin purpura or pain, and the urine tests were normal. Color ultrasound indicated only partial blood flow signal to the right testicle tissue, which was slightly smaller than the left testicle. This case highlights the need for continuous attention from clinicians to the signs and symptoms of the reproductive system during the diagnosis and treatment of IgAV. Continuous monitoring with ultrasound can aid in early detection, diagnosis, and treatment of reproductive system lesions of IgA vasculitis.
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Affiliation(s)
- Shuya Zhang
- The First Clinical Medical College, Henan University of Chinese Medicine, Zhengzhou, China
| | - Qingwen Wang
- The First Clinical Medical College, Henan University of Chinese Medicine, Zhengzhou, China
| | - Ziwei Li
- The First Clinical Medical College, Henan University of Chinese Medicine, Zhengzhou, China
| | - Qingyin Guo
- Department of Pediatrics, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, China
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Sestan M, Kifer N, Sozeri B, Demir F, Ulu K, Silva CA, Campos RT, Batu ED, Koker O, Sapina M, Srsen S, Held M, Gagro A, Fonseca AR, Rodrigues M, Rigante D, Filocamo G, Baldo F, Heshin-Bekenstein M, Giani T, Kataja J, Frkovic M, Ruperto N, Ozen S, Jelusic M. Clinical features, treatment and outcome of pediatric patients with severe cutaneous manifestations in IgA vasculitis: Multicenter international study. Semin Arthritis Rheum 2023; 61:152209. [PMID: 37126983 DOI: 10.1016/j.semarthrit.2023.152209] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE IgA vasculitis (IgAV) (formerly Henoch-Schönlein Purpura, HSP) rarely causes severe skin lesions in children. The purpose of the research was to determine whether severe skin manifestations were associated with a more severe disease course. METHODS Severe cutaneous manifestations were defined as presence of hemorrhagic vesicles, bullae, ulcerations and/or necroses. Data were collected retrospectively from 12 international tertiary university medical centers. RESULTS A total of 64 patients with the most severe skin changes in IgAV/HSP and median (Q1, Q3) age of 8.08 (5.08, 11.92) years at the disease onset were compared with 596 IgAV/HSP patients without these manfiestations and median (Q1, Q3) age of 6.33 (4.50, 8.92) years. The patients with severe cutaneous manifestations were older in comparison to other patients with IgAV/HSP (p<0.001), they developed nephritis more frequently (40.6% vs. 20.6%, p = 0.001) with worse outcome of renal disease (p = 0.001). This group of patients also had higher frequencies of severe gastrointestinal complications like hematochezia, massive bleeding and/or intussusception (29.3% vs. 14.8%, p<0.001). d-dimer concentrations were significantly higher in these patients (4.60 mg/L vs. 2.72 mg/L, p = 0.003) and they had more frequent need for treatment with systemic glucocorticoids (84.4% vs. 37.2%, p<0.001) in comparison with the control group. Further multivariate analysis showed that severe cutaneous changes were associated with higher risk of developing nephritis [OR=3.1 (95%CI 1.04-9.21), p = 0.042] and severe gastrointestinal complications [OR=3.65 (95%CI 1.08-12.37), p = 0.038]. CONCLUSION Patients with IgAV/HSP and severe skin manifestations had a more severe clinical course and more frequently required glucocorticoids compared to classic IgAV/HSP patients.
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Affiliation(s)
- Mario Sestan
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nastasia Kifer
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Betul Sozeri
- University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Ferhat Demir
- University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Kadir Ulu
- University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Clovis A Silva
- Pediatric Rheumatology Unit, ICr-HC-FMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Reinan T Campos
- Pediatric Rheumatology Unit, ICr-HC-FMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ezgi Deniz Batu
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Oya Koker
- Department of Pediatric Rheumatology, Marmara University-Pendik Training and Research Hospital, Istanbul, Turkey
| | - Matej Sapina
- Department of Paediatrics, Josip Juraj Strossmayer University of Osijek, Medical Faculty and Faculty of Dental Medicine and Health Osijek, University Hospital Centre Osijek, Osijek, Croatia
| | - Sasa Srsen
- Department of Paediatrics, University of Split School of Medicine, University Hospital Centre Split, Split, Croatia
| | - Martina Held
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Alenka Gagro
- Department of Paediatrics, Children's Hospital Zagreb, University of Zagreb School of Medicine, Zagreb, Croatia; Josip Juraj Strossmayer University of Osijek, Medical Faculty Osijek, Osijek, Croatia
| | - Adriana Rodrigues Fonseca
- Universidade Federal do Rio de Janeiro, Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, Brazil
| | - Marta Rodrigues
- Universidade Federal do Rio de Janeiro, Instituto de Puericultura e Pediatria Martagão Gesteira, Rio de Janeiro, Brazil
| | - Donato Rigante
- Department of Life Sciences and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica Sacro Cuore, Rome, Italy
| | - Giovanni Filocamo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Baldo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Merav Heshin-Bekenstein
- Pediatric Rheumatology Service, Dana Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | | | - Janne Kataja
- Department of Paediatrics and Adolescents Medicine, Turku University Hospital, Turku, Finland
| | - Marijan Frkovic
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, UOSID centro trial, Genoa, Italy
| | - Seza Ozen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Marija Jelusic
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
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Stampa Ferro J, Fernández González B, Arzallus Marco T, Izagirre Arostegi A, Azcue Prieto B, Cavero Barreras L, Segués Merino NM, Alonso-Galán H. IgA vasculitis (Henoch- Schönlein purpura) with gastrointestinal involvement. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023; 115:468-469. [PMID: 36426858 DOI: 10.17235/reed.2022.9329/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
We present the case of a patient who was admitted due to jejunitis in the context of an IgA vasculitis, previously known as Schönlein-Henoch vasculitis.
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31
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Windpessl M, Odler B, Bajema IM, Geetha D, Säemann M, Lee JM, Vaglio A, Kronbichler A. Glomerular Diseases Across Lifespan: Key Differences in Diagnostic and Therapeutic Approaches. Semin Nephrol 2023; 43:151435. [PMID: 37945450 DOI: 10.1016/j.semnephrol.2023.151435] [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: 11/12/2023]
Abstract
Glomerular diseases are common causes of chronic kidney disease in childhood, adolescence, and adulthood. The epidemiology of glomerular diseases differs between different age groups, with minimal change disease being the leading cause of nephrotic syndrome in childhood, while membranous nephropathy and focal segmental glomerulosclerosis are more common in adulthood. IgA vasculitis is also more common in childhood. Moreover, there is a difference in disease severity with more children presenting with a relapsing form of nephrotic syndrome and a more acute presentation of antineutrophil cytoplasmic antibody-associated vasculitis and concomitant glomerulonephritis, as highlighted by the higher percentage of cellular crescents on kidney biopsy specimens in comparison with older patients. There is also a female preponderance in antineutrophil cytoplasmic antibody-associated vasculitis and more children present with tracheobroncholaryngeal disease. This article aims to summarize differences in the presentation of different glomerular diseases that are encountered commonly by pediatric and adult nephrologists and potential differences in the management.
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Affiliation(s)
- Martin Windpessl
- Section of Nephrology, Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria; Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Balazs Odler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria; Sigmund Freud University, Medical School, Vienna, Austria
| | - Jiwon M Lee
- Division of Rare Disease Management, Korea Disease Control and Prevention Agency, Cheongju-si, Republic of Korea
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Firenze, Nephrology Unit, Meyer Children's Hospital, Firenze, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria.
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Xie Y, Deng Q, Guo M, Li X, Xian D, Zhong J. Proanthocyanidins: A novel approach to Henoch‑Schonlein purpura through balancing immunity and arresting oxidative stress via TLR4/MyD88/NF‑κB signaling pathway (Review). Exp Ther Med 2023; 25:300. [PMID: 37229322 PMCID: PMC10203752 DOI: 10.3892/etm.2023.11999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 04/04/2023] [Indexed: 05/27/2023] Open
Abstract
Henoch-Schonlein purpura (HSP), a recurrent and immunoglobulin (Ig)A-mediated vasculitis, presents not only as skin lesions but also as systemic involvement that can be life-threatening. Although the etiology of HSP remains unknown, immune imbalance and oxidative stress (OS) are primary contributors to its pathogenesis, alongside the abnormal activation of Toll-like receptor (TLR)/myeloid differentiation primary response gene 88 (MyD88)/nuclear factor-κB (NF-κB) pathway. TLRs, especially TLR4, stimulate downstream signaling molecules such as NF-κB and proinflammatory cytokines, which are released when TLRs combine with the key adapter molecule MyD88. This leads to the activation of T helper (Th) cell 2/Th17 and overproduction of reactive oxygen species (ROS). The function of regulatory T (Treg) cells is suppressed in the process. Th17/Treg imbalance then produces various inflammatory cytokines to promote proliferation and differentiation of B cells and the secretion of antibodies. IgA is secreted, and it binds to vascular endothelial surface receptors where the complex induces injury of the vascular endothelial cells. Additionally, excessive ROS creates OS that leads to an inflammatory response and vascular cell apoptosis or necrosis, thereby contributing to vascular endothelial damage and HSP occurrence. Proanthocyanidins are active compounds naturally enriched in fruits, vegetables and plants. Proanthocyanidins have diverse properties, including anti-inflammatory, antioxidant, antibacterial, immunoregulatory, anticarcinogenic and vascular protective effects. Proanthocyanidins are used in the management of various diseases. Proanthocyanidins regulate T cells, equilibrate immunity and arrest OS by inhibiting the TLR4/MyD88/NF-κB signaling pathway. Considering the pathogenesis of HSP and the properties of proanthocyanidins, the present study hypothesized that these compounds may potentially lead to HSP recovery through modulating the immune equilibrium and preventing OS by inhibiting the TLR4/MyD88/NF-κB pathway. To the best of our knowledge, however, little is known about the positive effects of proanthocyanidins against HSP. The present review summarizes the potential of proanthocyanidins to treat HSP.
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Affiliation(s)
- Yuxin Xie
- Department of Dermatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Qiyan Deng
- Department of Dermatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Menglu Guo
- Department of Dermatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Xiaolong Li
- Department of Dermatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Deihai Xian
- Department of Neurobiology, Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Jianqiao Zhong
- Department of Dermatology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
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Lopez Castillo ER, Bhatty O. Immunoglobulin A Vasculitis: Contemplating Treatment for Gastrointestinal Involvement. Cureus 2023; 15:e39405. [PMID: 37362476 PMCID: PMC10287093 DOI: 10.7759/cureus.39405] [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] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
This is a case of a 30-year-old female with a history of recent cholecystectomy who presented with a chief complaint of diffuse rash, abdominal pain, vomiting, and diarrhea. Infectious and autoimmune tests were unrevealing, but a skin biopsy confirmed the presence of immunoglobulin A (IgA) vasculitis. Worsening gastrointestinal (GI) symptoms prompted the care team to pursue upper and lower endoscopies, which were suggestive of GI involvement of IgA vasculitis. The patient responded well to corticosteroids and later had a recurrence of diarrhea which improved with cholestyramine, raising the question of a co-existent post-cholecystectomy syndrome. This case highlights the importance of having broad differential diagnoses, and establishing the extent of organ involvement in IgA vasculitis, as this can dictate the type of treatment used.
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Affiliation(s)
| | - Osman Bhatty
- Rheumatology, Advocate Illinois Masonic Medical Center, Chicago, USA
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Liu L, Liu H, Zhu K, Zhang L, Yin X, Han L, Wang M, Gao S, Xiao X, Yang J, Huang C, Huang Y. Proteome analysis reveals novel serum biomarkers for Henoch-Schönlein purpura in Chinese children. J Proteomics 2023; 276:104841. [PMID: 36796721 DOI: 10.1016/j.jprot.2023.104841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 12/30/2022] [Accepted: 01/29/2023] [Indexed: 02/16/2023]
Abstract
PURPOSE Henoch-Schönlein purpura (HSP) is diagnosed based on characteristic skin changes. This study aimed to identify the serum biomarkers of HSP in children. EXPERIMENTAL DESIGN We performed proteomic analysis of serum samples from 38 paired pre- and posttherapy HSP patients and 22 healthy controls using a combination of magnetic bead-based weak cation exchange and MALDI-TOF MS. ClinProTools was used to screen the differential peaks. Then, LC-ESI-MS/MS was performed to identify the proteins. ELISA was used to verify the expression of whole protein in the serum of 92 HSP patients, 14 peptic ulcer disease (PUD) patients and 38 healthy controls, which were prospectively collected. Finally, logistic regression analysis was performed to analyze the diagnostic value of the above predictors and existing clinical indicators. RESULTS Seven potential HSP serum biomarker peaks (m/z:1228.95, m/z:1781.22, m/z:1468.43, m/z:1619.53, m/z:1868.41, m/z:1694.05, m/z:1743.25) with higher expression in the pretherapy group and one peak (m/z:1947.41) with lower expression in the pretherapy group were all identified as peptide regions of albumin (ALB), complement C4-A precursor (C4A), tubulin beta chain (TUBB), isoform 1 of fibrinogen alpha chain (FGA), and ezrin (EZR). The expression of identified proteins was validated by ELISA. Multivariate logistic regression analysis showed that serum C4A EZR and ALB were independent risk factors for HSP, serum C4A and lgA were independent risk factors for HSPN, and serum D-dimer was an independent risk factor for abdominal HSP. CONCLUSIONS AND CLINICAL RELEVANCE These findings revealed the specific etiology of HSP from the perspective of serum proteomics. The identified proteins might serve as potential biomarkers for HSP and HSPN diagnoses. SIGNIFICANCE Henoch-Schönlein purpura (HSP) is the most common systemic vasculitis in children, and its diagnosis depends primarily on characteristic skin changes. Early diagnosis of non-rash patients is difficult, especially for abdominal and renal types (Henoch-Schönlein purpura nephritis, HSPN). HSPN has poor outcomes, is diagnosed based on urinary protein and/or haematuria, and cannot be detected early in HSP. Patients with an earlier diagnosis of HSPN appear to have better renal outcomes. Our plasma proteomic analysis of HSP in children revealed that HSP patients could be distinguished from healthy controls and peptic ulcer disease patients using complement C4-A precursor (C4A), ezrin, and albumin. C4A and IgA could distinguish HSPN from HSP in the early stages, and D-dimer was a sensitive index used to distinguish abdominal HSP; identifying these biomarkers could promote the early diagnosis of HSP, especially pediatric HSPN and abdominal HSP, thereby improving precision therapy.
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Affiliation(s)
- Li Liu
- Department of Pediatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province 710061, PR China; Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an 710061, PR China.
| | - Hailing Liu
- Department of Pediatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province 710061, PR China; Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an 710061, PR China
| | - Kaili Zhu
- Department of Pediatrics, Xi'an No 3 People's Hospital, Xi'an, Shaanxi Province 71006, PR China
| | - Lingyu Zhang
- Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an 710061, PR China
| | - Xiaomei Yin
- Department of Pediatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province 710061, PR China
| | - Lin Han
- Key Laboratory of Environment and Genes Related to Diseases, Ministry of Education of China, Xi'an Jiaotong University, Xi'an 710061, PR China
| | - Miaomiao Wang
- Department of Clinical Laboratory, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province 710061, PR China
| | - Shanfeng Gao
- Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an 710061, PR China
| | - Xuan Xiao
- Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an 710061, PR China
| | - Juan Yang
- Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an 710061, PR China; Key Laboratory of Environment and Genes Related to Diseases, Ministry of Education of China, Xi'an Jiaotong University, Xi'an 710061, PR China
| | - Chen Huang
- Department of Cell Biology and Genetics, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an 710061, PR China; Key Laboratory of Environment and Genes Related to Diseases, Ministry of Education of China, Xi'an Jiaotong University, Xi'an 710061, PR China
| | - Yanping Huang
- Department of Pediatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi Province 710061, PR China.
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Kifer N, Bulimbasic S, Sestan M, Held M, Kifer D, Srsen S, Gudelj Gracanin A, Heshin-Bekenstein M, Giani T, Cimaz R, Gagro A, Frković M, Coric M, Jelusic M. Semiquantitative classification (SQC) and Oxford classifications predict poor renal outcome better than The International Study of Kidney Disease in Children (ISKDC) and Haas in patients with IgAV nephritis: a multicenter study. J Nephrol 2023; 36:441-449. [PMID: 36447124 DOI: 10.1007/s40620-022-01509-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 10/19/2022] [Indexed: 12/07/2022]
Abstract
INTRODUCTION Several histologic classifications are used in the evaluation of IgA vasculitis nephritis (IgAVN), however, to date, no studies have determined which one has the strongest association with the severity of IgAVN and, as a consequence, its outcomes. MATERIALS AND METHODS Patients included in the study were diagnosed with IgAV and IgAVN in seven tertiary university medical centers in Croatia, Italy and Israel. The International Study of Kidney Disease in Children (ISKDC), Haas, Oxford, and Semiquantitative classification (SQC) classifications were used in the analysis and description of renal biopsy. Time from biopsy to outcome evaluation was a statistically significant factor in outcome prediction that was used to define the base model, and was a covariate in all the tested models. RESULTS Sixty-seven patients were included in this study. The SQC classification proved to be the best one in outcome prediction, followed by the Oxford classification. The ISKDC and Haas classifications could not predict renal outcome. The Oxford parameters for mesangial hypercellularity and tubular atrophy, as well as the SQC parameters for cellular crescents showed an independent statistically significant contribution to outcome prediction. High level of twenty-four hour protein excretion was associated with a higher grade in the Oxford, SQC and ISKDC classifications. Endocapillary proliferation was positively associated with the Pediatric Vasculitis Activity Score (PVAS) at diagnosis, while tubular atrophy was negatively associated. CONCLUSION The SQC, followed by the Oxford classification were found to provide the best classifications of renal biopsy analysis in patients to predict the outcome in patients with IgAVN. Cellular crescents, mesangial hypercellularity and tubular atrophy showed significant contributions, indicating that active and chronic variables should be included in the estimation.
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Affiliation(s)
- Nastasia Kifer
- Division of Rheumatology and Immunology, Department of Pediatrics, Referral Centre for Pediatric and Adolescent Rheumatology Republic of Croatia, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Stela Bulimbasic
- Department of Pathology and Cytology, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mario Sestan
- Division of Rheumatology and Immunology, Department of Pediatrics, Referral Centre for Pediatric and Adolescent Rheumatology Republic of Croatia, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Martina Held
- Division of Rheumatology and Immunology, Department of Pediatrics, Referral Centre for Pediatric and Adolescent Rheumatology Republic of Croatia, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Domagoj Kifer
- Department of Biophysics, University of Zagreb Faculty of Pharmacy and Biochemistry, Zagreb, Croatia
| | - Sasa Srsen
- Division of Rheumatology and Immunology, Department of Paediatrics, University of Split School of Medicine, University Hospital Centre Split, Split, Croatia
| | - Ana Gudelj Gracanin
- Department of Internal Medicine, Clinical Hospital Holly Spirit, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Merav Heshin-Bekenstein
- Pediatric Rheumatology Service, Dana Dwek Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Teresa Giani
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- ASST Pini-CTO, Milan, Italy
| | - Alenka Gagro
- Children's Hospital Zagreb, University of Osijek, Medical Faculty Osijek, Osijek, Croatia
| | - Marijan Frković
- Division of Rheumatology and Immunology, Department of Pediatrics, Referral Centre for Pediatric and Adolescent Rheumatology Republic of Croatia, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Marijana Coric
- Department of Pathology and Cytology, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marija Jelusic
- Division of Rheumatology and Immunology, Department of Pediatrics, Referral Centre for Pediatric and Adolescent Rheumatology Republic of Croatia, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia.
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Crawshaw H, Janagan S, Austin K, Baker C, Day J, Robson JC. Patient-reported outcomes in vasculitis. Best Pract Res Clin Rheumatol 2023; 37:101829. [PMID: 37277246 DOI: 10.1016/j.berh.2023.101829] [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: 03/29/2023] [Revised: 04/21/2023] [Accepted: 04/23/2023] [Indexed: 06/07/2023]
Abstract
Systemic vasculitis encompasses a group of multisystem disorders; both the diseases and the treatment strategies can have a significant impact on a patient's health-related quality of life (HRQoL). Using patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) to evaluate the patient's view of their condition, treatments, and healthcare journey is essential to the patient-centered care approach. In this paper, we discuss the use of generic, disease-specific, and treatment-specific PROMs and PREMs in systemic vasculitis and future research goals.
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Affiliation(s)
- Helena Crawshaw
- Rheumatology Department Gloucestershire Royal Hospital NHS Trust, Great Western Road, Gloucester, Gloucestershire, GL1 3NN, UK.
| | - Shalini Janagan
- Rheumatology Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK.
| | - Keziah Austin
- Rheumatology Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK; Rheumatology Department, Royal National Hospital for Rheumatic Diseases, Combe Park, Bath, BA1 3NG, UK.
| | - Charlotte Baker
- Rheumatology Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK.
| | - Julia Day
- Rheumatology Department, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK.
| | - Joanna C Robson
- Centre for Health and Clinical Research, University of the West of England, Bristol, Room 5-054, Rheumatology Research B502, Bristol Royal Infirmary, Bristol, BS2 8HW, UK.
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Abstract
BACKGROUND IgA vasculitis (IgAV), previously known as Henoch-Schönlein purpura, is the most common vasculitis of childhood but may also occur in adults. This small vessel vasculitis is characterised by palpable purpura, abdominal pain, arthritis or arthralgia and kidney involvement. This is an update of a review first published in 2009 and updated in 2015. OBJECTIVES To evaluate the benefits and harms of different agents (used singularly or in combination) compared with placebo, no treatment or any other agent for (1) the prevention of severe kidney disease in people with IgAV with or without kidney involvement at onset, (2) the treatment of established severe kidney disease (macroscopic haematuria, proteinuria, nephritic syndrome, nephrotic syndrome with or without acute kidney failure) in IgAV, and (3) the prevention of recurrent episodes of IgAV-associated kidney disease. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 2 February 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing interventions used to prevent or treat kidney disease in IgAV compared with placebo, no treatment or other agents were included. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed the risk of bias and extracted data from each study. Statistical analyses were performed using the random-effects model, and the results were expressed as risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Twenty studies (1963 enrolled participants) were identified; one three-arm study has been assessed as two studies. Nine studies were at low risk of bias for sequence generation (selection bias), and nine studies were at low risk of bias for allocation concealment (selection bias). Blinding of participants and personnel (performance bias) and outcome assessment (detection bias) was at low risk of bias in four and seven studies, respectively. Nine studies reported complete outcome data (attrition bias), while 10 studies reported expected outcomes, so were at low risk of reporting bias. Five studies were at low risk of other bias. Eleven studies evaluated therapy to prevent persistent kidney disease in IgAV with or without kidney involvement at presentation. There was probably no difference in the risk of persistent kidney disease any time after treatment (5 studies, 746 children: RR 0.74, 95% CI 0.42 to 1.32) or at one, three, six and 12 months in children given prednisone for 14 to 28 days at presentation of IgAV compared with placebo or supportive treatment (moderate certainty evidence). There may be no differences in the risk of any persistent kidney disease with antiplatelet therapy (three studies) or heparin (two studies) in children with or without any kidney disease at study entry, although heparin may reduce the risk of proteinuria by three months compared with placebo or no specific treatment (2 studies, 317 children: RR 0.47, 95% CI 0.31 to 0.73). One study comparing montelukast with placebo found no differences in outcomes as assessed by severity scale scores. Nine studies examined the treatment of severe IgAV-associated kidney disease. In two studies (one involving 56 children and the other involving 54 adults), there may be no differences in efficacy outcomes or adverse effects with cyclophosphamide compared with placebo or supportive treatment. In two studies, there may be no differences in the numbers achieving remission of proteinuria with intravenous (IV) cyclophosphamide compared with mycophenolate mofetil (MMF) (65 children evaluated) or tacrolimus (142 children evaluated). In three small studies comparing cyclosporin with methylprednisolone (15 children), MMF with azathioprine (26 children), or MMF with leflunomide (19 children), it is unclear whether the treatment had any effect on the numbers in remission or the degree of proteinuria between treatment groups because of small numbers of included participants. In one study comparing plasmapheresis, cyclophosphamide and methylprednisolone with cyclophosphamide and methylprednisolone, there may be no difference in the numbers achieving remission. One study compared fosinopril with no specific therapy and reported fosinopril reduced the number of participants with proteinuria. No studies were identified that evaluated the efficacy of therapy on kidney disease in participants with recurrent episodes of IgAV. AUTHORS' CONCLUSIONS There are no substantial changes in conclusions from this update compared with the initial review or the previous update despite the addition of five studies. From generally low to moderate certainty evidence, we found that there may be little or no benefit in the use of corticosteroids or antiplatelet agents to prevent persistent kidney disease in children with IgAV in participants with no or minimal kidney involvement at presentation. We did not find any studies which evaluated corticosteroids in children presenting with IgAV and nephritic and/or nephrotic syndrome, although corticosteroids are recommended in such children in guidelines. Though heparin may be effective in reducing proteinuria, this potentially dangerous therapy is not justified to prevent serious kidney disease when few children with IgAV develop severe kidney disease. There may be no benefit of cyclophosphamide compared with no specific treatment or corticosteroids. While there may be no benefit in the efficacy of MMF or tacrolimus compared with IV cyclophosphamide in children or adults with IgAV and severe kidney disease, adverse effects, particularly infections, may be lower in MMF or tacrolimus-treated children. Because of small patient numbers and events leading to imprecision in results, it remains unclear whether cyclosporin, MMF or leflunomide have any role in the treatment of children with IgAV and severe kidney disease. We did not identify any studies which evaluated corticosteroids.
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Affiliation(s)
- Deirdre Hahn
- Department of Nephrology, The Children's Hospital at Westmead, Westmead, Australia
| | - Elisabeth M Hodson
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Viegas AF, Lopes A, Pereira S, Almeida CC, Costa ML, Tavares JP. IgA Vasculitis with scrotal involvement - a rare presentation in adults. Arch Clin Cases 2023; 10:1-6. [PMID: 36814677 PMCID: PMC9940281 DOI: 10.22551/2023.38.1001.10229] [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: 02/17/2023] Open
Abstract
IgA vasculitis (IgAV) is a small-vessel vasculitis common in children but rare in adults. It is usually an auto-limited disease in children but has a more severe course and worse prognosis in adults. The classical manifestations are non-thrombocytopenic purpura, arthralgias, gastrointestinal involvement and renal involvement. Herein we report a case of a 39-year-old man with a rash of the lower limbs associated with testicular and lower abdominal pain. The initial study revealed increased inflammatory biomarkers and enlarged left testis with bilateral ischemic areas on doppler ultrasound. A cutaneous biopsy later revealed leukocytoclastic vasculitis, confirming the diagnosis of IgAV with scrotal involvement. The patient started prednisolone, with improvement in the first week and sustained remission after two years of follow-up. This case report describes an adult with IgAV and scrotal involvement, which is rarely reported in adults and appears to be different from the one in children. The prevalence of scrotal involvement is presumably underestimated. In all men with IgAV, a scrotal examination should be performed and ultrasonography accordingly since it affects the treatment and follow-up. Recommendations for IgAV diagnosis and treatment in adults are still lacking and more research is needed.
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Affiliation(s)
- Ana Filipa Viegas
- Corresponding author: Ana Filipa Viegas, Centro Hospitalar Tondela-Viseu, Av. Rei Dom Duarte, 3504-509 Viseu, Portugal.
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Machura E, Krakowczyk H, Bąk-Drabik K, Szczepańska M. SARS-CoV-2 Infection as a Possible Trigger for IgA-Associated Vasculitis: A Case Report. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020344. [PMID: 36832473 PMCID: PMC9955818 DOI: 10.3390/children10020344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/15/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND IgA-associated vasculitis (IgAV), formerly known as Henoch-Schönlein purpura (HSP) disease, is the most common type of systemic vasculitis observed during developmental age. Available published studies associate the outbreak of the disease with streptococci, adenovirus, parvovirus, mycoplasma, respiratory syncytial virus (RSV), and influenza infection in approximately 50% of patients with HSP, while some emerging reports have described a few cases of COVID-19 infection being associated with HSP in both adults and children. CASE PRESENTATION a 7-year-old girl was diagnosed with HSP, fulfilling the four required clinical criteria (palpable purpura and abdominal pain, arthralgia and edema, and periodic renal involvement). Infection with SARS-CoV-2 was confirmed via the presence of IgM and IgG antibodies. The disclosure of the Henoch-Schönlein purpura (HSP) disease was preceded by a mild, symptomatically treated infection of the upper respiratory tract. High levels of inflammatory markers were observed during hospitalization, including leukocytosis, an increased neutrophil count and a high neutrophil-to-lymphocyte ratio (NLR). All of these markers are associated with IgAV gastrointestinal bleeding, which was also associated with rotavirus diarrhea observed in the patient. CONCLUSIONS This case presented by us and similar cases presented by other authors indicate the possible role of SARS-CoV-2 in the development of HSP, but this assumption requires further research and evidence-based verification.
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Acar BÇ, Tekin ZE, Güngörer V, Çelikel E, Kurt T, Tekgöz N, Sezer M, Karagöl C, Coşkun S, Kaplan MM, Polat MC, Öner N, Kuruç AI, Erten EE, Şenel E. Intussusception as a rare manifestation of immunoglobulin A vasculitis: Risk factors and treatment. J Paediatr Child Health 2023; 59:505-511. [PMID: 36692146 DOI: 10.1111/jpc.16335] [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: 11/15/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 01/25/2023]
Abstract
AIM To identify the risk factors associated with intussusception in children with immunoglobulin A vasculitis (IgAV)-gastrointestinal (GI) tract involvement and to evaluate the outcomes of medical treatment and surgical intervention and the course of patients with intussusception. METHODS This retrospective study was conducted in 157 patients under 18 years of age who were followed up with the diagnosis of IgAV-GI tract involvement between January 2015 and September 2022. The characteristics of the patients who developed intussusception were evaluated in detail. RESULTS One hundred and fifty-seven patients with GI tract involvement were included in the study. The mean age of patients with IgAV-GI tract involvement was 8.7 ± 3.7 years. The female-to-male ratio was 1:1.5. Intussusception was detected in 14 patients (8.9%). Two patients (14.3%) underwent surgery, and the remaining 12 patients (85.7%) had their medical therapy intensified. Patients with GI tract involvement were divided into two groups as with (n = 14) and without (n = 143) intussusception. There was a statistically significant difference between the groups in the time from the onset of the first symptom of IgAV to the onset of steroids (P = 0.001). There were no statistically significant differences between the groups in age at onset of IgAV, gender distribution, erythrocyte sedimentation rate and C-reactive protein levels. CONCLUSIONS The time from the onset of the first symptom of IgAV to the start of steroids is a risk factor for the development of intussusception in patients with IgAV-GI tract involvement. In these patients, medical treatment usually reduces intussusception without the need for surgical intervention.
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Affiliation(s)
- Banu Ç Acar
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Zahide E Tekin
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Vildan Güngörer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Elif Çelikel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Tuba Kurt
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Nilüfer Tekgöz
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Müge Sezer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Cüneyt Karagöl
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Serkan Coşkun
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Melike M Kaplan
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Merve C Polat
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Nimet Öner
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Aylin I Kuruç
- Department of Pediatrics, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Elif E Erten
- Department of Pediatric Surgery, University of Health Sciences, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Emrah Şenel
- Department of Pediatric Surgery, Ankara Yıldırım Beyazıt University, Ankara Bilkent City Hospital, Ankara, Turkey
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Viral Infections May Be Associated with Henoch-Schönlein Purpura. J Clin Med 2023; 12:jcm12020697. [PMID: 36675626 PMCID: PMC9862009 DOI: 10.3390/jcm12020697] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 01/17/2023] Open
Abstract
Henoch-Schönlein purpura or IgA vasculitis is the most common type of pediatric vasculitis that may affect adults as well. It is classified as a type of small-vessel vasculitis. It can cause cutaneous and systemic symptoms with a minority of patients developing kidney failure. Little is known about the specific pathophysiology of this disorder, except that it is believed to occur in individuals with abnormally glycosylated IgA1. Serum aberrant IgA1 may form large antigen-antibody complexes which, due to a defective clearance, are able to deposit in the small vessels of the skin, kidney, gut, and joints. A variety of factors, including infectious agents, drugs, and vaccines, have been identified as potential triggers. The majority of cases are preceded by upper respiratory tract infections, and seasonal variations suggest a link with many pathogens. The etiologic agent most frequently associated with IgA vasculitis historically have been group A β-hemolytic streptococcus and common respiratory tract viruses. However, during the current coronavirus pandemic, SARS-CoV-2 infection was identified as a main trigger factor. In addition, IgA vasculitis has been observed following COVID-19 immunization. This review provides insights into the state of the art on the relationship between viral infections, viral vaccines, and Henoch-Schönlein purpura.
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Sestan M, Jelusic M. Diagnostic and Management Strategies of IgA Vasculitis Nephritis/Henoch-Schönlein Purpura Nephritis in Pediatric Patients: Current Perspectives. Pediatric Health Med Ther 2023; 14:89-98. [PMID: 36915829 PMCID: PMC10008002 DOI: 10.2147/phmt.s379862] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/24/2023] [Indexed: 03/09/2023] Open
Abstract
IgA vasculitis (IgAV) or Henoch-Schönlein purpura (HSP) is the most common vasculitis in children, and nephritis (IgAVN or HSPN) is the most important and only chronic manifestation of the disease. Despite this, there are no diagnostic criteria and we rely on the European League Against Rheumatism/Paediatric Rheumatology International Trials Organization/Paediatric Rheumatology European Society-endorsed Ankara 2008 classification criteria in our daily practice. Basic investigations that should be done in every patient with IgAVN include blood pressure measurement, estimated glomerular filtration rate and urinalysis. Kidney biopsy is still the gold standard for the diagnosis of IgAVN since noninvasive confirmation of nephritis is still pending. According to the Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) recommendations, the first-line treatment for with mild forms of IgAVN is oral glucocorticoids, for patients with moderate IgAVN parenterally administrated glucocorticoids in pulsed doses, while initial treatment for patients with the most severe forms of IgAVN include pulsed doses of glucocorticoids in combination with intravenous cyclophosphamide pulses. New therapeutic options are currently being tested, aiming to reduce the production of galactose-deficient IgA1 and autoantibodies or suppress the alternative or lectin complement pathway and blocking mesangial cell activation.
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Affiliation(s)
- Mario Sestan
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marija Jelusic
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
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Coşkun S, Güngörer V, Ekici Tekin Z, Çelikel E, Kurt T, Tekgöz N, Sezer M, Karagöl C, Kaplan MM, Polat MC, Öner N, Acar BÇ. Preadolescent-versus adolescent-onset immunoglobulin A vasculitis: The impact of age on prognosis. Pediatr Int 2023; 65:e15426. [PMID: 36416667 DOI: 10.1111/ped.15426] [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: 09/30/2022] [Revised: 11/15/2022] [Accepted: 11/22/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to investigate the characteristics of patients with preadolescent- and adolescent-onset immunoglobulin A vasculitis (IgAV) and to determine whether age affects IgAV outcomes in adolescents. METHODS Demographic, clinical, and laboratory data of 333 patients diagnosed with IgAV at the Department of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, were evaluated retrospectively. The patients were classified into two groups: preadolescents (<10 years) and adolescents (10-19 years). Subgroup analyses were also performed by grouping the adolescent patients into early, middle, and late adolescent groups. RESULTS Of the 333 patients, 219 (65.8%) and 114 (34.2%) were preadolescents and adolescents. Palpable purpura, renal, joint, and gastrointestinal (GI) tract involvement were detected in 333 (100%), 78 (23.4%), 79 (23.7%), and 124 (37.2%) patients, respectively; testicular involvement was observed in 25 (13.3%) of 187 male patients. The frequency of renal involvement was significantly higher in the adolescent group than in the preadolescent group at the time of diagnosis (p = 0.030). Notably, joint involvement was significantly higher in the adolescent group (p = 0.001). The need for aggressive therapy was significantly higher in the adolescent group than in the preadolescent group (p = 0.003). There was no significant difference in clinical data, demographic characteristics, and laboratory findings between the adolescent subgroups (p > 0.05). CONCLUSIONS Immunoglobulin A vasculitis can occur at any age but the disease prognosis appears to worsen with age. The present study reported that joint involvement, kidney involvement, and the need for more aggressive treatment were higher in the adolescent group than in the preadolescent group.
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Affiliation(s)
- Serkan Coşkun
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Vildan Güngörer
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Zahide Ekici Tekin
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Elif Çelikel
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Tuba Kurt
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Nilüfer Tekgöz
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Müge Sezer
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Cüneyt Karagöl
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Melike Mehveş Kaplan
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Merve Cansu Polat
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Nimet Öner
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Banu Çelikel Acar
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Younger DS. Adult and childhood vasculitis. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:653-705. [PMID: 37562892 DOI: 10.1016/b978-0-323-98818-6.00008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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45
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Ly S, Nedosekin D, Wong HK. Review of an Anti-CD20 Monoclonal Antibody for the Treatment of Autoimmune Diseases of the Skin. Am J Clin Dermatol 2023; 24:247-273. [PMID: 36630066 PMCID: PMC9838371 DOI: 10.1007/s40257-022-00751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 01/12/2023]
Abstract
Biologic therapies targeting B-cells are emerging as an effective strategy to treat a variety of immune-mediated diseases. One of the most studied B-cell-targeted therapies is rituximab, an anti-CD20 monoclonal antibody that exemplifies B-cell depletion therapy and has served as the prototype for other anti-CD20 monoclonal antibodies and the development of biosimilars. While there are multiple studies on the use of rituximab in dermatology, a comprehensive review of rituximab therapy in autoimmune skin conditions is lacking. In this literature review, we summarize indications, treatment efficacy, and safety of rituximab among common autoimmune diseases of the skin: pemphigus vulgaris, cutaneous lupus erythematous, dermatomyositis, systemic sclerosis, thyroid dermopathy, autoimmune pemphigoid diseases, and cutaneous vasculitis diseases. Existing data on rituximab support the approach of rituximab, biosimilars, and newer B-cell-targeting therapies in immune-mediated cutaneous diseases. Overall, rituximab, which targets CD20, provides an effective alternative or concomitant option to traditional immunosuppressants in the management of various autoimmune diseases of the skin. Further studies are necessary to expand the understanding and possible utility of B-cell-targeted therapies among autoimmune skin diseases.
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Affiliation(s)
- Sophia Ly
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Dmitry Nedosekin
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Henry K. Wong
- grid.241054.60000 0004 4687 1637Department of Dermatology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot #576, Little Rock, AR 72205 USA
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46
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Dong W, Wu S, Zhou J. A rare association of invasive infective endocarditis due to Abiotrophia defectiva with ventricular septal defect and recurrent Henoch-Schonlein purpura in a child. J Cardiothorac Surg 2022; 17:320. [PMID: 36528593 PMCID: PMC9758810 DOI: 10.1186/s13019-022-02092-2] [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: 05/31/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Henoch-Schonlein purpura is the most common vasculitis in childhood, usually triggered by an upper respiratory tract infection and rarely observed in infective endocarditis patients. Abiotrophia defectiva is a rare causative agent of infective endocarditis associated with pre-existing heart disease, immunocompromised and prosthetic valves. Dental procedures are also a common predisposing factor. CASE PRESENTATION We present the first pediatric congenital heart disease case of infective endocarditis caused by Abiotrophia defectiva combined with recurrent Henoch-Schonlein purpura. A 10-year-old girl with uncorrected congenital heart defects and Henoch-Schonlein purpura developed a purple petechial rash again. Transthoracic echocardiography evaluation revealed multiple irregular vegetations on the right ventricular side of the ventricular septal defect and on the tricuspid valve leaflets. Blood cultures grew Abiotrophia defectiva. The girl received cardiac surgery for vegetation resection as well as congenital heart defect correction and tricuspid valve replacement. Five months after the surgery, the patient was in satisfactory condition without any signs of endocarditis or valve insufficiency and her purpuric rash disappeared. CONCLUSIONS The coexistence of recurrent Henoch-Schonlein purpura and infective endocarditis is possible. Abiotrophia defectiva belongs to the streptococcus with a high virulence. In addition, cardiovascular surgery is often required for pediatric infective endocarditis associated with Abiotrophia defectiva, and bioprosthetic valve replacement is considered feasible for irreparable tricuspid valve in children.
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Affiliation(s)
- Wenpeng Dong
- grid.412679.f0000 0004 1771 3402Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Shushan District, Hefei, 230032 China
| | - Shuibi Wu
- grid.412679.f0000 0004 1771 3402Department of Cardiovascular Surgery, The First Affiliated Hospital of Anhui Medical University, Jixi Road 218, Shushan District, Hefei, 230032 China
| | - Jing Zhou
- grid.460068.c0000 0004 1757 9645Department of Cardiovascular Surgery, The Third People’s Hospital of Chengdu, Chengdu, China
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Grewal MK, Adams MD, Valentini RP. Vasculitis and Kidney Disease. Pediatr Clin North Am 2022; 69:1199-1217. [PMID: 36880930 DOI: 10.1016/j.pcl.2022.07.009] [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] [Indexed: 11/16/2022]
Abstract
Pediatric vasculitis is a complex group of disorders that commonly presents with multisystem involvement. Renal vasculitis can be isolated to the kidneys or can occur as part of a broader multiorgan vasculitis. Depending on severity, renal vasculitis may present as acute glomerulonephritis (AGN) often associated with hypertension and sometimes with a rapidly deteriorating clinical course. Prompt diagnosis and initiation of therapy are key to preserving kidney function and preventing long-term morbidity and mortality. This review focuses on the clinical presentation, diagnosis, and treatment objectives for common forms of renal vasculitis seen in pediatric patients.
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Affiliation(s)
- Manpreet K Grewal
- Division of Nephrology and Hypertension, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Boulevard, MI, 48201, USA; Department of Pediatrics, Central Michigan University College of Medicine, 1280 East Campus Drive, Mount Pleasant, MI 48858, USA
| | - Matthew D Adams
- Department of Pediatrics, Wayne State University School of Medicine, 540 East Canfield Street, Detroit, MI 48201, USA
| | - Rudolph P Valentini
- Division of Nephrology and Hypertension, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Boulevard, MI, 48201, USA; Department of Pediatrics, Central Michigan University College of Medicine, 1280 East Campus Drive, Mount Pleasant, MI 48858, USA.
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48
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Aymonnier K, Amsler J, Lamprecht P, Salama A, Witko‐Sarsat V. The neutrophil: A key resourceful agent in immune‐mediated vasculitis. Immunol Rev 2022; 314:326-356. [PMID: 36408947 DOI: 10.1111/imr.13170] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The term "vasculitis" refers to a group of rare immune-mediated diseases characterized by the dysregulated immune system attacking blood vessels located in any organ of the body, including the skin, lungs, and kidneys. Vasculitides are classified according to the size of the vessel that is affected. Although this observation is not specific to small-, medium-, or large-vessel vasculitides, patients show a high circulating neutrophil-to-lymphocyte ratio, suggesting the direct or indirect involvement of neutrophils in these diseases. As first responders to infection or inflammation, neutrophils release cytotoxic mediators, including reactive oxygen species, proteases, and neutrophil extracellular traps. If not controlled, this dangerous arsenal can injure the vascular system, which acts as the main transport route for neutrophils, thereby amplifying the initial inflammatory stimulus and the recruitment of immune cells. This review highlights the ability of neutrophils to "set the tone" for immune cells and other cells in the vessel wall. Considering both their long-established and newly described roles, we extend their functions far beyond their direct host-damaging potential. We also review the roles of neutrophils in various types of primary vasculitis, including immune complex vasculitis, anti-neutrophil cytoplasmic antibody-associated vasculitis, polyarteritis nodosa, Kawasaki disease, giant cell arteritis, Takayasu arteritis, and Behçet's disease.
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Affiliation(s)
- Karen Aymonnier
- INSERM U1016, Institut Cochin, Université Paris Cité, CNRS 8104 Paris France
| | - Jennifer Amsler
- INSERM U1016, Institut Cochin, Université Paris Cité, CNRS 8104 Paris France
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology University of Lübeck Lübeck Germany
| | - Alan Salama
- Department of Renal Medicine, Royal Free Hospital University College London London UK
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Ivanchikov VV, Murashkin NN, Ambarchian ET, Kuzminova AD. Serum Sickness-Like Reaction Associated with Epstein – Barr Virus: Clinical Case. CURRENT PEDIATRICS 2022. [DOI: 10.15690/vsp.v21i5.2455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background. Annular dermatoses are a group of diseases with major clinical manifestation of rashes of relevant form. This manifestation pattern causes difficulties in diagnosis. The case of rarely diagnosed annular dermatosis is presented: serum siknesslike reaction (SSLR) triggered by the Epstein – Barr virus (EBV). Clinical case description. Patient D., 8 years old girl, noted abdominal pain 3 weeks before hospitalization, and later numerous polymorphic rashes (erythematous macules, urticarial elements), swelling and pain in joints. Self-treatment with non-steroidal anti-inflammatory and systemic antihistamines did not lead to any improvement. The patient was hospitalized in the pediatric department at the place of residence, where the diagnosis “Henoch-Schonlein purpura, mixed type” was established according to the results of physical, laboratory (double increase of ALT and AST, ESR up to 166 mm/h, IgM to EBV), and ultrasound (mesenteric lymph nodes hyperplasia) studies. Systemic glucocorticosteroids have led to improvement, however, few days after the end of the treatment there was relapse of rash and arthralgia. Thus, the girl was administrated to clinical diagnostic center. Patient’s general condition was satisfactory at the time of examination. There were numerous erythematous annular urticarial and macular elements (3–12 cm) on the skin of face, body and limbs. Some foci, as well as some resolved rashes had blue spots with indistinct boundaries that disappeared after compression. Mucous membranes, nails and hair were intact. Subjective symptoms — slight burning around rashes, at palpation — low-intensity pain in the left radiocarpal joint. Blood tests: C-reactive protein concentration increased up to 12 mg/L, ESR up to 26 mm/h, IgG to EBV up to 47.7. Conclusion. During differential diagnosis we should consider the possibility of SSLR development in all pediatric patients with annular rashes associated with arthralgia and/or arthritis, fever, history of drug use (most often beta-lactam antibiotics), recent vaccination or manifestations of viral infection, especially in case of cyanotic spots after rashes resolution and non-specific laboratory parameters.
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Affiliation(s)
- V. V. Ivanchikov
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery
| | - N. N. Murashkin
- National Medical Research Center of Children’s Health; Central State Medical Academy of Department of Presidential Affairs
| | - E. T. Ambarchian
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery
| | - A. D. Kuzminova
- Pediatrics and Child Health Research Institute in Petrovsky National Research Centre of Surgery
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50
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Liu Y, Zeng H, Wang B, Ji P. Intra-abdominal hemorrhage with shock in an adult patient with IgA vasculitis. Asian J Surg 2022; 46:1898-1899. [PMID: 36369135 DOI: 10.1016/j.asjsur.2022.10.090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/27/2022] [Indexed: 11/10/2022] Open
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