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Xi L, Sun Y, Chen Y, Yang X, Su H, Ren X. Clinicopathological features and prognosis of IgA vasculitis nephritis with nephrotic-range proteinuria in children. Pediatr Nephrol 2024:10.1007/s00467-024-06441-2. [PMID: 38980322 DOI: 10.1007/s00467-024-06441-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND To investigate the clinical features, kidney pathology, treatment regimens, and clinical outcomes of IgA vasculitis nephritis (IgAVN) with nephrotic-range proteinuria in children. METHODS A retrospective review of children diagnosed with IgAVN between January 2019 and December 2022 was conducted. Participants were divided into two groups based on their urine protein/creatinine (UPCR) levels. Biodata, clinical characteristics, laboratory findings, pathologic features, treatment regimens, and outcomes were abstracted from case records and analyzed. RESULTS A total of 255 children were identified, 94 with nephrotic-range proteinuria (UPCR ≥ 200 mg/mmol) and 161 with non-nephrotic proteinuria (UPCR < 200 mg/mmol). Patients in the nephrotic-range proteinuria group were significantly younger and had worse grades of glomerular and acute tubulointerstitial injury compared to those in the non-nephrotic proteinuria group. Higher levels of blood urea nitrogen (BUN), D-dimer (DD), and fibrin degradation products (FDP), and lower levels of total protein (TP), albumin (ALB), urine creatinine (Cr), prothrombin time (PT), activated partial thromboplastin time (APTT), IgG, CD3 + cells, and CD4 + cells were found in patients in the nephrotic-range proteinuria group. Clinical outcome of patients with nephrotic-range proteinuria was significantly associated with ISKDC grading, proportion of glomerular crescents and severity of acute tubulointerstitial injury. CONCLUSIONS Children with nephrotic-range proteinuria exhibit more severe disordered immunologic function, hypercoagulability, glomerular and tubulointerstitial pathological damage, and have worse outcomes than those with lower proteinuria levels. Clinicians should pay great attention to the kidney injury and more extensive studies are required to identify optimal treatment regimens to improve outcomes in patients.
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Affiliation(s)
- Leying Xi
- Department of Pediatrics, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Yuying Sun
- Department of Pediatrics, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Yawei Chen
- Department of Oncology, Nanjing Drum Tower Hospital, School of Chemistry and Chemical Engineering, Nanjing University, Nanjing, Jiangsu, China
| | - Xiaoqing Yang
- Department of Pediatrics, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Hang Su
- Department of Pediatrics, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, China
| | - Xianqing Ren
- Department of Pediatrics, The First Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, China.
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Di Ludovico A, Rinaldi M, Lauriola F, Ciarelli F, La Bella S, Gualdi G, Chiarelli F, Bailey K, Breda L. The Diagnostic Role of Skin Manifestations in Rheumatic Diseases in Children: A Critical Review of Paediatric Vasculitis. Int J Mol Sci 2024; 25:7323. [PMID: 39000430 PMCID: PMC11242831 DOI: 10.3390/ijms25137323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 06/25/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024] Open
Abstract
Skin lesions are frequently observed in children with rheumatic diseases, particularly in conditions such as IgA vasculitis (IgAV) and Kawasaki disease (KD). In paediatric vasculitis, the presence of skin lesions serves as an early indicator, emphasising the importance of timely diagnosis to prevent complications, such as cardiac or renal involvement. Conversely, autoinflammatory disorders like juvenile systemic lupus erythematosus (SLE) and juvenile dermatomyositis (DM) may manifest with cutaneous manifestations either at the onset of disease or during its progression. Identifying these skin lesions prior to the appearance of systemic symptoms offers an opportunity for early diagnosis and treatment, which has a positive influence on the outcomes. Additionally, it is noteworthy that specific rheumatological conditions, such as acute rheumatic fever (ARF) or oligoarticular or polyarticular forms of juvenile idiopathic arthritis (JIA), may exhibit occasional, but significant skin involvement, which is strongly correlated with an unfavourable prognosis. The assessment of skin is important in the holist approach to assessing patients for potentially systemic/multisystem disorder and helps distinguish discrete conditions.
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Affiliation(s)
- Armando Di Ludovico
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.)
| | - Marta Rinaldi
- Paediatric Department, Buckinghamshire Healthcare NHS Trust, Aylesbury-Thames Valley Deanery, Oxford HP21 8AL, UK
| | - Federico Lauriola
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.)
| | - Francesca Ciarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.)
| | - Saverio La Bella
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.)
| | - Giulio Gualdi
- Dermatology Clinic, Department of Medicine and Aging Science, University G D’Annunzio Chieti-Pescara, 66100 Chieti, Italy
| | - Francesco Chiarelli
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.)
| | - Kathryn Bailey
- Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, UK
| | - Luciana Breda
- Paediatric Department, University of Chieti “G. D’Annunzio”, 66100 Chieti, Italy; (A.D.L.)
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Pan M, Li M, Li N, Mao J. Predicting renal damage in children with IgA vasculitis by machine learning. Pediatr Nephrol 2024:10.1007/s00467-024-06432-3. [PMID: 38916780 DOI: 10.1007/s00467-024-06432-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 05/25/2024] [Accepted: 06/07/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Children with IgA Vasculitis (IgAV) may develop renal complications, which can impact their long-term prognosis. This study aimed to build a machine learning model to predict renal damage in children with IgAV and analyze risk factors for IgA Vasculitis with Nephritis (IgAVN). METHODS 50 clinical indicators were collected from 217 inpatients at our hospital. Six machine learning algorithms-Logistic Regression, Linear Discriminant Analysis, K-Nearest Neighbor, Support Vector Machine, Decision Trees, and Random Forest-were utilized to select the model with the highest predictive performance. A simplified model was developed through feature importance ranking and validated by an additional cohort with 46 patients. RESULTS The random forest model had the highest accuracy, precision, recall, F1 score, and area under the curve, with values of 0.91, 0.98, 0.70, 0.79 and 0.94, respectively. The top 11 features according to the importance ranking were anti-streptolysin O, corticosteroids therapy, antihistamine therapy, absolute eosinophil count, immunoglobulin E, anticoagulant therapy, C-reactive protein, prothrombin time, age at onset, D-dimer, recurrence of rash ≥ 3 times. A simplified model using these features demonstrated optimal performance with an accuracy of 84.2%, a sensitivity of 89.4%, and a specificity of 82.5% in external validation. Finally, we provided a web tool based on the simplified model, whose code was published on https://github.com/mulanruo/IgAVN_Prediction . CONCLUSION The model based on the random forest algorithm demonstrates good performance in predicting renal damage in children with IgAV, providing a basis for early clinical diagnosis and decision-making.
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Affiliation(s)
- Mengen Pan
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Ming Li
- College of Computer Science and Technology, Zhejiang University, Hangzhou, Zhejiang, China
| | - Na Li
- Zhejiang University School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jianhua Mao
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, National Children's Regional Medical Center, Hangzhou, Zhejiang, China.
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4
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Batnozic Varga M, Held M, Wagner J, Arvaj N, Sestan M, Sapina M, Kifer N, Grguric D, Crkvenac Gornik K, Gagro A, Frkovic M, Jelusic M. The Association of HMGB1 and RAGE Gene Polymorphisms with IgA Vasculitis. Biochem Genet 2024; 62:2268-2278. [PMID: 37902913 DOI: 10.1007/s10528-023-10536-0] [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: 06/03/2023] [Accepted: 09/22/2023] [Indexed: 11/01/2023]
Abstract
High-mobility group box 1 (HMGB1) is a pleiotropic cytokine that propagates inflammation by its extracellular action of interacting with the receptor for advanced glycation end products (RAGE). Both HMGB1 and RAGE play multiple roles in the pathogenesis of a variety of inflammatory and autoimmune diseases. We investigated the association of five single-nucleotide polymorphisms (SNPs) of the HMGB1 gene (rs1412125, rs2249825, rs1045411, rs1060348, rs41369348) and four SNPs of the RAGE gene (rs1800624, rs1800625, rs2070600, rs3134940) with the susceptibility and clinical features of paediatric patients with IgA vasculitis (IgAV), also known as Henoch-Schönlein's purpura. This case‒control study included 103 children with IgAV (experimental group) and 150 age-matched healthy individuals (control group). The strength of the association between different groups and alleles or genotypes of HMGB1 and RAGE was estimated using odds ratios (ORs) and 95% confidence intervals (CIs). The HMGB1 polymorphisms rs41369348, rs1045411, rs2249825 and rs1412125 were associated with the development of generalized purpuric rash, and rs1412125 was associated with IgAV nephritis (IgAVN). The RAGE polymorphism rs2070600 might be linked to the development of arthritis in IgAV patients. There was no statistically significant association between the analysed polymorphisms and susceptibility to IgAV. This is the first study to propose an association between several HMGB1 and RAGE polymorphisms and different phenotypes in the clinical course of IgAV in a paediatric population. Further research on other polymorphisms of HMGB1 and RAGE should be conducted in a larger number of patients.
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Affiliation(s)
- Mateja Batnozic Varga
- Department of Paediatrics, Josip Juraj Strossmayer University of Osijek, Faculty of Medicine Osijek, University Hospital Centre Osijek, Osijek, Croatia
| | - Martina Held
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Paediatrics, University of Zagreb School of Medicine, 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
| | - Jasenka Wagner
- Department of Medical Biology and Genetics, Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Nena Arvaj
- Department of Medical Biology and Genetics, Faculty of Medicine Osijek, Josip Juraj Strossmayer University of Osijek, Osijek, Croatia
| | - Mario Sestan
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Paediatrics, University of Zagreb School of Medicine, 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
| | - Matej Sapina
- Department of Paediatrics, Josip Juraj Strossmayer University of Osijek, Faculty of Medicine Osijek, University Hospital Centre Osijek, Osijek, Croatia
| | - Nastasia Kifer
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Paediatrics, University of Zagreb School of Medicine, 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
| | - Danica Grguric
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Paediatrics, University of Zagreb School of Medicine, 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
| | - Kristina Crkvenac Gornik
- Department of Laboratory Diagnostics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Alenka Gagro
- Department of Paediatrics, Children's Hospital Zagreb, Zagreb, Croatia
| | - Marijan Frkovic
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Paediatrics, University of Zagreb School of Medicine, 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
| | - Marija Jelusic
- Division of Clinical Immunology, Rheumatology and Allergology, Department of Paediatrics, University of Zagreb School of Medicine, 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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Held M, Kozmar A, Sestan M, Turudic D, Kifer N, Srsen S, Gagro A, Frkovic M, Jelusic M. Insight into the Interplay of Gd-IgA1, HMGB1, RAGE and PCDH1 in IgA Vasculitis (IgAV). Int J Mol Sci 2024; 25:4383. [PMID: 38673968 PMCID: PMC11050592 DOI: 10.3390/ijms25084383] [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: 02/26/2024] [Revised: 04/11/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
The pathogenesis of IgAV, the most common systemic vasculitis in childhood, appears to be complex and requires further elucidation. We aimed to investigate the potential role of galactose-deficient immunoglobulin A1 (Gd-IgA1), high-mobility group box 1 (HMGB1), receptor for advanced glycation end products (RAGE) and protocadherin 1 (PCDH1) in the pathogenesis of IgAV. Our prospective study enrolled 86 patients with IgAV and 70 controls. HMGB1, RAGE, Gd-IgA1 and PCDH1 in serum and urine were determined by the enzyme-linked immunosorbent assay (ELISA) method at the onset of the disease and after a six-month interval in patients and once in the control group. Serum concentrations of HMGB1, RAGE and PCDH1 and urinary concentrations of HMGB1, RAGE, Gd-IgA1 and PCDH1 were significantly higher in patients with IgAV than in the control group (p < 0.001). Concentrations of HMGB1 (5573 pg/mL vs. 3477 pg/mL vs. 1088 pg/mL, p < 0.001) and RAGE (309 pg/mL vs. 302.4 pg/mL vs. 201.3 pg/mL, p = 0.012) in the serum of patients remained significantly elevated when the disease onset was compared with the six-month follow-up interval, and thus could be a potential marker of disease activity. Urinary concentration of HMGB1 measured in the follow-up period was higher in patients with nephritis compared to IgAV without nephritis (270.9 (146.7-542.7) ng/mmol vs. 133.2 (85.9-318.6) ng/mmol, p = 0.049) and significantly positively correlated with the urine albumine to creatinine ratio (τ = 0.184, p < 0.05), the number of erythrocytes in urine samples (τ = 0.193, p < 0.05) and with the outcome of nephritis (τ = 0.287, p < 0.05); therefore, HMGB1 could be a potential tool for monitoring patients with IgAV who develop nephritis. Taken together, our results imply a possible interplay of Gd-IgA1, HMGB1, RAGE and PCDH1 in the development of IgAV. The identification of sensitive biomarkers in IgAV may provide disease prevention and future therapeutics.
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Affiliation(s)
- Martina Held
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (M.H.); (M.S.); (D.T.); (N.K.); (M.F.)
| | - Ana Kozmar
- Department of Laboratory Diagnostics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia;
| | - Mario Sestan
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (M.H.); (M.S.); (D.T.); (N.K.); (M.F.)
| | - Daniel Turudic
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (M.H.); (M.S.); (D.T.); (N.K.); (M.F.)
| | - Nastasia Kifer
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (M.H.); (M.S.); (D.T.); (N.K.); (M.F.)
| | - Sasa Srsen
- Department of Pediatrics, University of Split School of Medicine, University Hospital Centre Split, 21000 Split, Croatia;
| | - Alenka Gagro
- Children’s Hospital Zagreb, Medical Faculty Osijek, Josip Juraj Strossmayer University of Osijek, 10000 Zagreb, Croatia;
| | - Marijan Frkovic
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (M.H.); (M.S.); (D.T.); (N.K.); (M.F.)
| | - Marija Jelusic
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, 10000 Zagreb, Croatia; (M.H.); (M.S.); (D.T.); (N.K.); (M.F.)
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Chatpaitoon B, Rianthavorn P, Chanakul A, Khaosut P. Clinical characteristics and risk factors for kidney involvement in children with immunoglobulin A vasculitis. Pediatr Int 2024; 66:e15781. [PMID: 38863300 DOI: 10.1111/ped.15781] [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: 07/21/2023] [Revised: 02/09/2024] [Accepted: 04/08/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Immumoglobulin A (IgA) vasculitis (IgAV), formerly known as Henoch-Schönlein purpura (HSP), is a self-limiting systemic vasculitis in children. Kidney involvement is associated with a long-term unfavorable outcome and can lead to significant morbidity. This study was conducted to describe the clinical and laboratory characteristics of childhood IgAV with kidney involvement and to identify risk factors associated with IgAV nephritis (IgAVN). METHODS This was an ambidirectional descriptive study of 77 children with IgAV. All demographic data, clinical features, and laboratory tests were collected from electronic medical records from January 2010 to December 2022. Risk factors for kidney involvement in IgAV were assessed using multivariate logistic regression. Kaplan-Meier survival analysis was used to calculate the time to commencement of kidney involvement. RESULTS Twenty-five children (32.4% of the IgAV patients) developed IgAVN. The common findings in IgAV with kidney involvement were microscopic hematuria (100%), nephrotic range proteinuria (44%), and non-nephrotic range proteinuria (40%). Multivariate logistic regression showed that age greater than 10 years (adjusted hazard ratio, AHR 4.66; 95% confidence interval, CI, 1.91-11.41; p = 0.001), obesity (body mass index, BMI, z-score ≥ +2 standard deviations, SDs) (AHR 3.59; 95% CI 1.41-9.17; p = 0.007), and hypertension at onset (AHR 4.78; 95% CI 1.76-12.95; p = 0.002) were associated significantly with kidney involvement. During follow up, most IgAV patients developed nephritis within the first 9 months. CONCLUSION Age greater than 10 years, obesity, and hypertension at presentation were predictive factors for IgAVN. Our study emphasized that IgAV patients with risk factors should be closely monitored for at least 1 year after the onset of the disease.
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Affiliation(s)
- Boonyapohn Chatpaitoon
- Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pornpimol Rianthavorn
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Ankanee Chanakul
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Parichat Khaosut
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Faculty of Medicine, Center of Excellence for Allergy and Clinical Immunology, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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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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8
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Stone HK, Mitsnefes M, Dickinson K, Burrows EK, Razzaghi H, Luna IY, Gluck CA, Dixon BP, Dharnidharka VR, Smoyer WE, Somers MJ, Flynn JT, Furth SL, Bailey C, Forrest CB, Denburg M, Nehus E. Clinical course and management of children with IgA vasculitis with nephritis. Pediatr Nephrol 2023; 38:3721-3733. [PMID: 37316676 PMCID: PMC10514113 DOI: 10.1007/s00467-023-06023-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/25/2023] [Accepted: 05/04/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND IgA vasculitis is the most common vasculitis in children and is often complicated by acute nephritis (IgAVN). Risk of chronic kidney disease (CKD) among children with IgAVN remains unknown. This study aimed to describe the clinical management and kidney outcomes in a large cohort of children with IgAVN. METHODS This observational cohort study used the PEDSnet database to identify children diagnosed with IgAV between January 1, 2009, and February 29, 2020. Demographic and clinical characteristics were compared among children with and without kidney involvement. For children followed by nephrology, clinical course, and management patterns were described. Patients were divided into four categories based on treatment: observation, renin-angiotensin-aldosterone system (RAAS) blockade, corticosteroids, and other immunosuppression, and outcomes were compared among these groups. RESULTS A total of 6802 children had a diagnosis of IgAV, of whom 1139 (16.7%) were followed by nephrology for at least 2 visits over a median follow-up period of 1.7 years [0.4,4.2]. Conservative management was the most predominant practice pattern, consisting of observation in 57% and RAAS blockade in 6%. Steroid monotherapy was used in 29% and other immunosuppression regimens in 8%. Children receiving immunosuppression had higher rates of proteinuria and hypertension compared to those managed with observation (p < 0.001). At the end of follow-up, 2.6 and 0.5% developed CKD and kidney failure, respectively. CONCLUSIONS Kidney outcomes over a limited follow-up period were favorable in a large cohort of children with IgAV. Immunosuppressive medications were used in those with more severe presentations and may have contributed to improved outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Hillarey K Stone
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7022, Cincinnati, OH, 45229, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Kimberley Dickinson
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Evanette K Burrows
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ingrid Y Luna
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Caroline A Gluck
- Division of Pediatric Nephrology, Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Vikas R Dharnidharka
- Division of Pediatric Nephrology, Washington University School of Medicine, Saint Louis, MO, USA
| | - William E Smoyer
- Center for Clinical and Translational Research, Abigail Wexner Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Michael J Somers
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph T Flynn
- Division of Nephrology, Department of Pediatrics, Seattle Children's Hospital and University of Washington School of Medicine, Seattle, WA, USA
| | - Susan L Furth
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Charles Bailey
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle Denburg
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Edward Nehus
- Department of Pediatrics, West Virginia University Charleston Campus, Charleston, WV, USA
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9
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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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10
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YILDIRIM S, ERGÜVEN M. Reporting the clinical spectrum of children with IgAV in a retrospective 24-year cohort: Influences of age and sex on clinical presentation. Turk J Med Sci 2023; 53:1339-1347. [PMID: 38813037 PMCID: PMC10763743 DOI: 10.55730/1300-0144.5700] [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: 09/20/2022] [Revised: 10/26/2023] [Accepted: 08/11/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim Immunoglobulin A vasculitis (IgAV) is one of the most common types of vasculitis in children. The aims of this study were to investigate the clinical characteristics of the disease, and the effects of age and sex on the clinical course in children with IgAV. Materials and methods This was a retrospective study including pediatric patients diagnosed with IgAV who attended follow-ups at the pediatric rheumatology department of a tertiary healthcare institution between January 1997 and December 2020. The patients were grouped and compared according to sex and age at diagnosis (<7 years vs. ≥7 years). Results The study included 709 children with IgAV, 392 (55.3%) of whom were male. The mean age at diagnosis was 7.9 ± 3.2 years. The most common disease onset season was autumn (31.2%). Upper respiratory infections (27.8%) were the most common predisposing factors. Gastrointestinal system (GIS), joint, and renal involvement were observed in 52.8%, 47.5%, and 17.5% of patients, respectively. Renal involvement, GIS involvement, and disease relapse were significantly more common among those diagnosed after 7 years of age compared to those diagnosed before the age of 7 (p < 0.001, p = 0.033, and p < 0.001, respectively). Scrotal involvement and subcutaneous edema were more common among those diagnosed at younger than 7 years compared to those aged ≥7 years at diagnosis (p < 0.001 and p = 0.016, respectively). GIS involvement was more frequently seen in males compared to females (p = 0.046). Conclusion It was demonstrated that being ≥7 years of age at diagnosis or being a male were associated with higher likelihood of renal and GIS involvement in children with IgAV.
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Affiliation(s)
- Sema YILDIRIM
- Department of Pediatric, Göztepe Prof. Dr. Süleyman Yalçın City Hospital, İstanbul,
Turkiye
| | - Müferet ERGÜVEN
- Department of Pediatric Rheumatology, Faculty of Medicine, Düzce University, Düzce,
Turkiye
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11
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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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12
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Zhu Y, Dong Y, Li Y, Jin J, Ma Y. Adding Methylprednisolone and Cyclophosphamide Pulse Therapy Provides No Benefit in Pediatric IgAV Nephritis Grade III. Clin Pediatr (Phila) 2023; 62:615-621. [PMID: 36475327 DOI: 10.1177/00099228221142782] [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: 12/13/2022]
Abstract
Although immunoglobulin (Ig) A vasculitis (IgAV) nephritis is a common form of secondary pediatric glomerulonephritis, there is no consensus on an appropriate therapeutic regimen for moderate-to-severe pediatric IgAV nephritis grade III or the effectiveness of aggressive immunosuppressive therapy. The objective is to evaluate the efficacy and renal outcomes of methylprednisolone pulse therapy with or without cyclophosphamide pulse therapy for grade III IgAV nephritis in children. This retrospective, single-center study included 115 children with IgAV nephritis grade III. The primary endpoint was proteinuria reduction from moderate or severe levels to a normal level. The secondary endpoint was stable renal function, that is, an increase of less than 25% from the baseline creatinine level over the 4-month follow-up period. Among 115 children with IgAV nephritis grade III, 59 received methylprednisolone and cyclophosphamide double-pulse treatment; methylprednisolone and cyclophosphamide double-pulses did not significantly improve proteinuria remission. Proteinuria improvement did not show any difference with or without cyclophosphamide treatment. Furthermore, methylprednisolone pulse therapy showed no benefit over steroid therapy alone. The demographic and baseline disease characteristics among the treatment groups were well-balanced. The rates of complete remission in 24-hour proteinuria excretion over the 4-month follow-up period in the methylprednisolone and cyclophosphamide double-pulse, methylprednisolone plus oral prednisolone, and oral prednisolone-only groups were 91.52%, 92.31%, and 100%, respectively. Renal function remained stable in all the patients. Most patients with IgAV nephritis grade III showed a good prognosis. However, the addition of methylprednisolone and/or cyclophosphamide pulses did not offer benefits over steroid-only therapy.
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Affiliation(s)
- Yaju Zhu
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yu Dong
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yufeng Li
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jing Jin
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yifei Ma
- Department of Pediatric Nephrology, Rheumatology and Immunology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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13
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Batnožić Varga M, Šestan M, Wagner J, Crkvenac Gornik K, Kifer N, Frković M, Stefinovec L, Vučemilović Jurić V, Grgurić D, Pušeljić S, Jelušić M. ASSOCIATION BETWEEN HIGH MOBILITY GROUP BOX 1 PROTEIN GENE (rs41369348) POLYMORPHISM AND IMMUNOGLOBULIN A VASCULITIS IN CHILDREN. Acta Clin Croat 2023; 62:25-35. [PMID: 38304371 PMCID: PMC10829956 DOI: 10.20471/acc.2023.62.01.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
Immunoglobulin A vasculitis (IgAV) or Henoch-Schönlein purpura is the most prevalent systemic small vessel vasculitis in childhood. High mobility group box 1 protein (HMBG1) is a pleiotropic cytokine that functions as a pro-inflammatory signal, important for the activation of antigen-presenting cells and propagation of inflammation. HMGB1 is implicated in the pathophysiology of a variety of inflammatory diseases. The aim of this study was to investigate the role of single nucleotide polymorphism rs41369348 for HMGB1 gene in the susceptibility and clinical features of patients meeting the classification criteria for IgAV. DNA was extracted from blood cells of 76 children with IgAV and 150 age-matched healthy controls. Clinical data and laboratory parameters were collected for all IgAV patients. Although there was a higher frequency of heterozygous A/delA genotype of this gene polymorphism in IgAV group as compared with control group, no genotype difference was observed between these two groups. No statistically significant genotype differences were disclosed when patients with different IgAV clinical features were compared. In conclusion, in this study, polymorphism rs41369348 for HMGB1 was not associated with increased susceptibility to childhood IgAV, its severity or different clinical manifestations.
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Affiliation(s)
- Mateja Batnožić Varga
- Department of Pediatrics, Josip Juraj Strossmayer University of Osijek, Osijek Faculty of Medicine, Osijek University Hospital Center, Osijek, Croatia
| | - Mario Šestan
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb University Hospital Center, Zagreb, Croatia
| | - Jasenka Wagner
- Department of Medical Biology and Genetics, Josip Juraj Strossmayer University of Osijek, Osijek Faculty of Medicine, Osijek, Croatia
| | - Kristina Crkvenac Gornik
- Clinical Department of Laboratory Diagnostics, University of Zagreb School of Medicine, Zagreb University Hospital Center, Zagreb, Croatia
| | - Nastasia Kifer
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb University Hospital Center, Zagreb, Croatia
| | - Marijan Frković
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb University Hospital Center, Zagreb, Croatia
| | - Laura Stefinovec
- Department of Pediatrics, Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek University Hospital Center, Osijek, Croatia
| | - Valentina Vučemilović Jurić
- Department of Medical Biology and Genetics, Josip Juraj Strossmayer University of Osijek, Osijek Faculty of Medicine, Osijek, Croatia
| | - Danica Grgurić
- Department of Pediatrics, Zagreb University Hospital Center, Zagreb, Croatia
| | - Silvija Pušeljić
- Department of Pediatrics, Josip Juraj Strossmayer University of Osijek, Osijek Faculty of Medicine, Osijek University Hospital Center, Osijek, Croatia
| | - Marija Jelušić
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb University Hospital Center, Zagreb, Croatia
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14
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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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15
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Popov H, Koleva T, Stoyanov GS. Bullous Henoch-Schönlein Purpura and Associated Nephritis: A Pathological Case Report. Cureus 2023; 15:e35051. [PMID: 36942172 PMCID: PMC10024341 DOI: 10.7759/cureus.35051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/18/2023] Open
Abstract
Henoch-Schönlein purpura (HSP) is the most common vasculitis in childhood, presenting with purpura, predominantly of the lower extremities and occasionally with renal involvement as well. Although associated with childhood, HSP, although rarely, can also develop in adults as well. Here we present a patient in his sixties, presenting with a myriad of rash units on his lower extremities, including bullous ones, and a constellation of chronic kidney failure. Skin and renal biopsy specimens revealed morphological changes and immune depositions representative of HSP. Despite treatment, the patient's kidney failure slowly progressed, and he expired eight months after his presentation due to associated complications. Although rare, the bullous form of HSP can be viewed as a more aggressive form of the disease, as seen by the presentation constellation and rapid progression in our case.
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Affiliation(s)
- Hristo Popov
- General and Clinical Pathology, Forensic Medicine and Deontology, Medical University of Varna, Varna, BGR
| | | | - George S Stoyanov
- General and Clinical Pathology, St. Marina University Hospital, Varna, BGR
- General and Clinical Pathology, Forensic Medicine and Deontology, Medical University of Varna, Varna, BGR
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16
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Proskura MV, Petrosyan EK, Povilaitite PE, Kushnir BL. A modern approach to the morphological assessment of nephritis in Henoch–Schonlein purpura (IgA-vasculitis). ROSSIYSKIY VESTNIK PERINATOLOGII I PEDIATRII (RUSSIAN BULLETIN OF PERINATOLOGY AND PEDIATRICS) 2023. [DOI: 10.21508/1027-4065-2022-67-6-75-82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The authors analyzed clinical and morphological correlations between the manifestations and outcome in nephritis with Henoch– Schönlein purpura and assessed the effect of morphological data on achieving remission as per ISKDC, SQC, MEST-C classification.Patients and methods. 32 patients with nephritis in Henoch–Schönlein purpura (15 girls and 17 boys) were enrolled into retrospective longitudinal single-center study, median of primary admission to the nephrological department was 9.0 y. o. [5; 12 y.]. Clinical features of the onset (age, form of onset, glomerular filtration rate, daily proteinuria, hematuria, serum IgA level) and the course of the disease were analyzed in all children. The morphological data were assessed using such morphological classifications as ISKDC, SQC, MEST-C. A search for statistically significant relationships between clinical and morphological data and a comparative analysis of the influence of each morphological classification on the achievement of remission were carried out.Results. The sum of the SQC scores had a statistically significant effect on the outcome (p=0.006): in patients with complete remission, on average, 4 points were obtained, patients who did not achieve remission had 2 points more. When assessing the likelihood of detecting remission depending on the total score of the Oxford scale using the ROC-analysis, a statistically significant model was obtained (p=0.012). If the total MEST-C score was less than or equal to 3, remission was predicted (=0.032). The sensitivity and specificity of the method were both 75%.Conclusions. The practical application of the Oxford MEST-C classification and the new semi-quantitative SQC classification in comparison with the ISKDC classification for children with nephritis in Henoch–Schönlein purpura is promising for predicting an unfavorable renal outcome.
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Affiliation(s)
| | | | | | - B. L. Kushnir
- Pirogov Russian National Research Medical University
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17
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Girao A, Fernandes JA, Mira FS, Pina R. Immunoglobulin a (IgA) Vasculitis in the Elderly. Cureus 2023; 15:e34422. [PMID: 36874655 PMCID: PMC9978861 DOI: 10.7759/cureus.34422] [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: 01/30/2023] [Indexed: 02/02/2023] Open
Abstract
IgA vasculitis is a small vessel vasculitis mediated by the deposition of IgA immune complexes. It mostly occurs in children and is rare in adults, with increased severity and mortality in the latter. Its aetiology remains largely unknown, and its prognosis depends primarily on the extent of renal involvement. We present the case of a 71-year-old woman with purpuric lesions in both lower and upper limbs associated with fever, abdominal pain, vomiting and blood in her stools for the past month. The patient was diagnosed with IgA vasculitis and the full systemic involvement (renal, dermatological, intestinal, and cerebral) of the disease was identified with excellent response to parenteral corticotherapy.
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Affiliation(s)
- Adriana Girao
- Internal Medicine Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - José A Fernandes
- Internal Medicine Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Filipe S Mira
- Nephrology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
| | - Rui Pina
- Internal Medicine Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, PRT
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18
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Zhang X, Che R, Xu H, Ding G, Zhao F, Huang S, Zhang A. Hemoperfusion and intravenous immunoglobulins for refractory gastrointestinal involvement in pediatric Henoch-Schönlein purpura: a single-center retrospective cohort study. BMC Pediatr 2022; 22:692. [PMID: 36460986 PMCID: PMC9716741 DOI: 10.1186/s12887-022-03709-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/25/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) with refractory gastrointestinal (GI) symptoms is always difficult to handle because of its resistance to supportive therapies and glucocorticoid. This study aimed to evaluate the efficacy of hemoperfusion (HP) and intravenous immunoglobulins (IVIG) therapies in this population. METHODS Sixty-four HSP patients with refractory GI involvement (R-GI group) and 64 cases with mild GI symptoms (control group) were retrospectively analyzed in our center from March 2016 to October 2019. In R-GI group, 42 cases (subgroup A) were treated with IVIG and steroid, 13 cases (subgroup B) used HP and steroid, 9 cases (subgroup C) executed a combination of IVIG, HP and steroid. Demographic characteristics, clinical features, laboratory indexes and treatment outcomes were recorded. t-test, One-way ANOVA, Mann-Whitney U test, and multivariate logistic regression were used in comparing differences among subgroups and predicting independent risk factors. RESULTS Compared with the control group, R-GI cases experienced higher risk of renal involvement (P = 0.000), more steroid exposure (P = 0.000), six times expenses (P = 0.000) and 2.3 times length of hospitalization (P = 0.000). The independent risk factors of R-GI group were elevated neutrophils (OR 1.250 [95% CI 1.130-1.383]) and the percentage of B lymphocytes (OR 1.100 [95% CI 1.026-1.179]) as well as decreased IgG (OR 0.847 [95% CI 0.732-0.98]). In R-GI group, increased age (OR 1.039 [95% CI 1.016-1.062]) and IgM (OR 5.994 [95% CI 1.403-27.611]) were verified to be risk factors of HSP nephritis. All three subgroups could alleviate the symptoms effectively. Compared with those in subgroup A, patients in subgroup B were elder (P = 0.004), had less relapse (P = 0.002), steroid exposure (P = 0.033) and expenses (P = 0.031), more significant decrease of WBC (P = 0.026) after treatment. CONCLUSION The HSP with refractory GI involvement had much higher risk of medical burden and renal involvement. Both IVIG and HP therapies could ameliorate refractory GI symptoms efficiently. HP therapy tended to reduce the relapse, costs and steroid exposure in its audiences who were cooperated and with stable hemodynamics, while IVIG had better use in younger children.
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Affiliation(s)
- Xiaolu Zhang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Ruochen Che
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Haisheng Xu
- grid.452511.6Department of Emergency Medicine, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Guixia Ding
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Fei Zhao
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Songming Huang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China ,grid.452511.6Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Aihua Zhang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China ,grid.452511.6Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
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19
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Kaneta KA, Adler R. Purpuric Vesiculobullous Rash in IgA Vasculitis (IgAV). J Pediatr 2022; 251:217-218. [PMID: 35970238 DOI: 10.1016/j.jpeds.2022.08.006] [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: 07/26/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Kelli A Kaneta
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California
| | - Robert Adler
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California; University of Southern California, Los Angeles, California
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20
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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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21
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Kallash M, Vogt BA, Zeid A, Khin E, Najjar M, Aldughiem A, Benoit E, Stotter B, Rheault M, Warejko JK, Daga A. The scope of treatment of pediatric IgA vasculitis nephritis and its outcome: a Pediatric Nephrology Research Consortium study. Pediatr Nephrol 2022; 37:2687-2697. [PMID: 35233641 DOI: 10.1007/s00467-022-05496-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND IgA vasculitis (IgAV) is the most common type of vasculitis in children. There is a lack of consensus for management of significant IgAV nephritis (IgAVN). This study was designed to identify the most used treatment options and describe their efficacy. METHODS This is a multicenter retrospective study of children age 1-21 years with IgAVN who were managed for at least 6 months by a nephrologist. Subjects with at least microscopic hematuria and proteinuria and/or decreased kidney function were enrolled. Kidney outcome was assessed by eGFR and urine protein/creatinine (UPC) ratios at 2-4 weeks, 3, 6, and 12 months post-diagnosis. RESULTS A total of 128 subjects with median age of 7 years (range 2-18) were included. Of these, 69 subjects had kidney biopsy with crescents detected in 53%. AKI (P = 0.039), nephrosis (P = 0.038), and crescents on biopsy (P = 0.013) were more likely in older patients. Patients with UPC > 1 mg/mg were more likely to get a kidney biopsy (P < 0.001) and to be treated with steroids ± immunosuppressive (IS) agents (P = 0.001). Sixty-six percent of patients were treated with steroids and/or IS agents for variable durations. Anti-metabolite agents were the most common IS agents used with variability in dosing and duration. At 12 months, most subjects had a normal eGFR (79%) (median 123, range 68-207 mL/min/1.73 m2) and no proteinuria (median UPC 0.15, range 0.01-4.02 mg/mg). CONCLUSIONS IS agents are frequently used in managing IgAVN associated with heavy proteinuria, nephrosis, and/or AKI. Prospective studies are needed to determine indications and needed duration of IS therapy. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Mahmoud Kallash
- Section of Pediatric Nephrology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Beth A Vogt
- Section of Pediatric Nephrology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ahmed Zeid
- Section of Pediatric Nephrology, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ei Khin
- Section of Pediatric Nephrology, Texas Tech University Health Science Center El Paso, El Paso, TX, USA
| | - Mohammed Najjar
- Section of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Ahmad Aldughiem
- Section of Pediatric Nephrology, Dayton Children's Hospital, Dayton, OH, USA
| | - Elizabeth Benoit
- Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Stotter
- Division of Nephrology, Hypertension, and Pheresis, Department of Pediatrics, Washington University School of Medicine and St. Louis Children's Hospital, St. Louis, MO, USA
| | - Michelle Rheault
- Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Jillian K Warejko
- Section of Pediatric Nephrology, Yale University School of Medicine, New Haven, CT, USA
| | - Ankana Daga
- Pediatric Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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22
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Wang K, Sun X, Jing S, Lin L, Cao Y, Peng X, Qiao L, Dong L. Development and validation of nomogram prediction model for severe kidney disease in children with Henoch–Schönlein purpura: A prospective analysis of two independent cohorts—forecast severe kidney disease outcome in 2,480 hospitalized Henoch–Schönlein purpura children. Front Immunol 2022; 13:999491. [PMCID: PMC9597459 DOI: 10.3389/fimmu.2022.999491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
This study aimed to develop and validate a nomogram to forecast severe kidney disease (SKD) outcomes for hospitalized Henoch–Schönlein purpura (HSP) children. The predictive model was built based on a primary cohort that included 2,019 patients with HSP who were diagnosed between January 2009 and December 2013. Another cohort consisting of 461 patients between January 2014 and December 2016 was recruited for independent validation. Patients were followed up for 24 months in development/training and validation cohorts. The data were gathered at multiple time points after HSP (at 3, 6, 12, and 24 months) covering severe kidney disease as the severe outcome after HSP. The least absolute shrinkage and selection operator (LASSO) regression model was utilized to decrease data dimension and choose potentially relevant features, which included socioeconomic factors, clinical features, and treatments. Multivariate Cox proportional hazards analysis was employed to establish a novel nomogram. The performance of the nomogram was assessed on the aspects of its calibration, discrimination, and clinical usefulness. The nomogram comprised serious skin rash or digestive tract purpura, severe gastrointestinal (GI) manifestations, recurrent symptoms, and renal involvement as predictors of SKD, providing favorable calibration and discrimination in the training dataset with a C-index of 0.751 (95% CI, 0.734–0.769). Furthermore, it demonstrated receivable discrimination in the validation cohort, with a C-index of 0.714 (95% CI, 0.678–0.750). With the use of decision curve analysis, the nomogram was proven to be clinically useful. The nomogram independently predicted SKD in HSP and displayed favorable discrimination and calibration values. It could be convenient to promote the individualized prediction of SKD in patients with HSP.
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Affiliation(s)
- Ke Wang
- Division of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- National Center for Birth Defects Monitoring of China, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- National Health Council Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Xiaomei Sun
- Division of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- National Health Council Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Shuolan Jing
- Division of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- National Health Council Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Li Lin
- Division of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- National Health Council Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Yao Cao
- Division of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- National Health Council Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Xin Peng
- Division of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- National Health Council Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
| | - Lina Qiao
- Division of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- National Health Council Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
- *Correspondence: Liqun Dong, ; Lina Qiao,
| | - Liqun Dong
- Division of Pediatric Pulmonology and Immunology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, China
- National Health Council Key Laboratory of Chronobiology, Sichuan University, Chengdu, China
- *Correspondence: Liqun Dong, ; Lina Qiao,
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23
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Carucci NS, La Barbera G, Peruzzi L, La Mazza A, Silipigni L, Alibrandi A, Santoro D, Chimenz R, Conti G. Time of Onset and Risk Factors of Renal Involvement in Children with Henoch-Schönlein Purpura: Retrospective Study. CHILDREN 2022; 9:children9091394. [PMID: 36138703 PMCID: PMC9497900 DOI: 10.3390/children9091394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 11/27/2022]
Abstract
Background: Henoch-Schönlein purpura (HSP) is a common systemic vasculitis in children, involving the skin, musculoskeletal system, gastrointestinal tract and kidneys. Some studies in children have shown possible risk factors linked with the development and severity of HSP Nephritis (HSPN). The aim of this study was to research predicting factors for the development of HSPN. Methods: We retrospectively evaluated 132 pediatric patients with HSP, according to EULAR/PRINTO/PRESS criteria. All patients were screened for HSPN by urinalysis. Finally, we compared demographic, clinical and laboratory data in HSP patients with and without nephritis. Results: The median age at HSP diagnosis [6.2 (2.6–17.5) vs. 5.5 (0.8–15.4) years, p = 0.03] and the incidence of abdominal pain (48 vs. 27%, p = 0.01) were significantly higher in HSPN patients. No differences were evidenced regarding gender, allergic diseases, skin recurrences, gastrointestinal involvement, musculoskeletal involvement, scrotal involvement, and laboratory data (white blood cell count, neutrophil count, lymphocyte count, platelet count, C-reactive protein, erythrocyte sedimentation rate, and blood concentration of IgA). Conclusions: The age at diagnosis and abdominal pain were independent risk factors for renal involvement in HSP patients. However, due to the retrospective nature of this study, further long-term and prospective studies will be necessary.
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Affiliation(s)
- Nicolina Stefania Carucci
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, 98125 Messina, Italy
| | - Giulia La Barbera
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, 98125 Messina, Italy
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Department, Azienda Ospedaliero-Universitaria Città Della Salute E Della Scienza, 10126 Torino, Italy
- Correspondence:
| | - Antonella La Mazza
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, 98125 Messina, Italy
| | - Lorena Silipigni
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, 98125 Messina, Italy
| | - Angela Alibrandi
- Unit of Statistical and Mathematical Sciences, Department of Economics, University of Messina, 98125 Messina, Italy
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Roberto Chimenz
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, 98125 Messina, Italy
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, 98125 Messina, Italy
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24
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Affiliation(s)
- Clement D Lee
- From the Children's Hospital of Philadelphia, Philadelphia
| | - Evan Shirey
- From the Children's Hospital of Philadelphia, Philadelphia
| | | | - Chén C Kenyon
- From the Children's Hospital of Philadelphia, Philadelphia
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25
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Nagai S, Horinouchi T, Ninchoji T, Kondo A, Aoto Y, Ishiko S, Sakakibara N, Nagano C, Yamamura T, Kaito H, Tanaka R, Shima Y, Fujimura J, Kamiyoshi N, Ishimori S, Nakanishi K, Yoshikawa N, Iijima K, Nozu K. Use of renin-angiotensin system inhibitors as initial therapy in children with Henoch-Schönlein purpura nephritis of moderate severity. Pediatr Nephrol 2022; 37:1845-1853. [PMID: 35015121 DOI: 10.1007/s00467-021-05395-z] [Citation(s) in RCA: 4] [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: 08/21/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cases of Henoch-Schönlein purpura nephritis (HSPN) with moderate severity were demonstrated to achieve good prognosis after treatment with renin-angiotensin system (RAS) inhibitors. However, some patients required additional treatment for recurrence after remission. This study aimed to clarify the effect of RAS inhibitors in HSPN cases with moderate severity, including the proportion of cases with recurrence and their response to additional treatment. METHODS Among 126 patients diagnosed with HSPN between 1996 and 2019, 71 patients with clinicopathologically diagnosed HSPN of moderate severity, defined as ISKDC grade II-IIIa and serum albumin ≥ 2.5 g/dL, were investigated. RESULTS Proteinuria became negative after RAS inhibitor treatment alone in all 71 cases. However, 16 (22.5%) had recurrence. Eleven recurrent cases achieved negative proteinuria again following additional treatment. At the last follow-up (median 46.5 months; IQR, 23.2-98.2), 5 patients had persistent mild proteinuria; no patients had estimated glomerular filtration rate < 90 mL/min/1.73 m2. The pathological findings in all recurrent cases were ISKDC grade IIIa. The 16 recurrent cases had significantly higher proportions of glomeruli with global/segmental sclerosis (25.0 vs. 0%, P < 0.001) and tubular atrophy/interstitial fibrosis (37.5 vs. 12.7%, P =0.0 24) than 55 cases without recurrence. CONCLUSIONS Japanese childhood HSPN cases with moderate severity had good outcomes without need for corticosteroids or immunosuppressants, when prescribed RAS inhibitor treatment. Even in recurrent cases, abnormal proteinuria was transient, and prognosis was excellent. 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, Kobe, 650-0017, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Atsushi Kondo
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yuya Aoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinya Ishiko
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Nana Sakakibara
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - China Nagano
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, 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, Kakogawa, 675-8611, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Japanese Red Cross Society Himeji Hospita, 1-12-1 Shimoteno, Himeji, 670-8540, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki, 569-1192, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Nakagami-gun, Okinawa, 903-0125, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki, 569-1192, 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, Kobe, 650-0017, Japan
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26
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Yang X, Li Q, He Y, Zhu Y, Yang R, Zhu X, Zheng X, Xiong W, Yang Y. Individualized medication based on pharmacogenomics and treatment progress in children with IgAV nephritis. Front Pharmacol 2022; 13:956397. [PMID: 35935867 PMCID: PMC9355498 DOI: 10.3389/fphar.2022.956397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/27/2022] [Indexed: 11/13/2022] Open
Abstract
Immunoglobulin A vasculitis (IgAV) nephritis, also known as Henoch-Schönlein purpura nephritis (HSPN), is a condition in which small blood vessel inflammation and perivascular IgA deposition in the kidney caused by neutrophil activation, which more often leads to chronic kidney disease and accounts for 1%–2% of children with end-stage renal disease (ESRD). The treatment principles recommended by the current management guidelines include general drug treatment, support measures and prevention of sequelae, among which the therapeutic drugs include corticosteroids, immunosuppressive agents and angiotensin system inhibitors. However, the concentration range of immunosuppressive therapy is narrow and the individualized difference is large, and the use of corticosteroids does not seem to improve the persistent nephropathy and prognosis of children with IgAV. Therefore, individualized maintenance treatment of the disease and stable renal prognosis are still difficult problems. Genetic information helps to predict drug response in advance. It has been proved that most gene polymorphisms of cytochrome oxidase P450 and drug transporter can affect drug efficacy and adverse reactions (ADR). Drug therapy based on genetics and pharmacogenomics is beneficial to providing safer and more effective treatment for children. Based on the pathogenesis of IgAV, this paper summarizes the current therapeutic drugs, explores potential therapeutic drugs, and focuses on the therapeutic significance of corticosteroids and immunosuppressants in children with IgAV nephritis at the level of pharmacogenomics. In addition, the individualized application of corticosteroids and immunosuppressants in children with different genotypes was analyzed, in order to provide a more comprehensive reference for the individualized treatment of IgAV nephritis in children.
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Affiliation(s)
- Xuerong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Qi Li
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yuanyuan He
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Yulian Zhu
- Department of Pharmacy, Ziyang People’s Hospital, Ziyang, China
| | - Rou Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiaoshi Zhu
- Department of Pediatrics, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
| | - Xi Zheng
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Wei Xiong
- Department of Hepatobiliary Surgery, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China
- *Correspondence: Wei Xiong, ; Yong Yang,
| | - Yong Yang
- Department of Pharmacy, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
- *Correspondence: Wei Xiong, ; Yong Yang,
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27
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A boy with purpura and generalized edema: Answers. Pediatr Nephrol 2022; 37:1321-1323. [PMID: 35084564 DOI: 10.1007/s00467-021-05408-x] [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: 11/22/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
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ASLAN C, GOKNAR N, KELESOGLU E, UCKARDES D, CANDAN C. Long-term Results in Children with Henoch-Schönlein Nephritis. Medeni Med J 2022; 37:159-164. [PMID: 35735000 PMCID: PMC9234360 DOI: 10.4274/mmj.galenos.2022.92331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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29
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Carmona-Cruz SA, Durán-McKinster LC, García-Romero MT. Atypical purpura and other features associated with unfavorable outcomes of IgA vasculitis (Henoch-Schönlein purpura) in children: A retrospective study. Pediatr Dermatol 2022; 39:369-371. [PMID: 35178758 DOI: 10.1111/pde.14927] [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: 08/24/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022]
Abstract
The prognosis of IgA vasculitis (also known as Henoch-Schönlein purpura) is determined by renal or other organ involvement. We conducted a retrospective study to identify the initial features of 106 children with IgA vasculitis and their association with unfavorable outcomes. Location of purpura above the waist and an altered urinalysis at diagnosis predicted a more aggressive course of disease.
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30
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Marro J, Chetwynd AJ, Wright RD, Dliso S, Oni L. Urinary Protein Array Analysis to Identify Key Inflammatory Markers in Children with IgA Vasculitis Nephritis. CHILDREN 2022; 9:children9050622. [PMID: 35626799 PMCID: PMC9139281 DOI: 10.3390/children9050622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/16/2022]
Abstract
Chronic kidney disease is a recognised complication of immunoglobulin A vasculitis, (IgAV; formerly Henoch–Schonlein purpura—HSP). The pathophysiology of IgAV and why some patients develop significant renal involvement remains largely unknown. Identifying urinary inflammatory markers could direct targets for earlier intervention. The aim of this cross-sectional exploratory study was to perform a large protein array analysis to identify urinary markers to provide insight into the mechanisms of kidney inflammation in children with established IgAV nephritis (IgAVN). Determination of the relative levels of 124 key proteins was performed using commercially available proteome profiler array kits. Twelve children were recruited: IgAVN, n = 4; IgAV without nephritis (IgAVwoN), n = 4; healthy controls (HCs), n = 4. The urinary concentrations of twenty proteins were significantly different in IgAVN compared to IgAVwoN. The largest fold changes were reported for B-cell activating factor (BAFF), Cripto-1, sex-hormone-binding globulin and angiotensinogen. The urinary levels of complement components C5/C5a and factor D were also significantly elevated in patients with IgAVN. A total of 69 urinary proteins significantly raised levels in comparisons made between IgAVN vs. HCs and nine proteins in IgAVwoN vs. HCs, respectively. This study identified key urinary proteins potentially involved in IgAVN providing new insight into the pathophysiology. Further longitudinal studies with larger cohorts are needed to quantitatively analyse these biomarkers.
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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 L12 2AP, UK; (J.M.); (A.J.C.); (R.D.W.)
| | - Andrew J. Chetwynd
- Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L12 2AP, UK; (J.M.); (A.J.C.); (R.D.W.)
| | - Rachael D. Wright
- Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L12 2AP, UK; (J.M.); (A.J.C.); (R.D.W.)
| | - Silothabo Dliso
- NIHR Alder Hey Clinical Research Facility, Clinical Research Division, Alder Hey Children’s NHS Foundation Trust, Liverpool L14 5AB, UK;
| | - Louise Oni
- Department of Women’s and Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L12 2AP, UK; (J.M.); (A.J.C.); (R.D.W.)
- Department of Paediatric Nephrology, Alder Hey Children’s NHS Foundation Trust Hospital, Liverpool L14 5AB, UK
- Correspondence: ; Tel.: +44-(0)151-252-5441
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31
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Deki S, Hamada R, Mikami N, Terano C, Harada R, Hamasaki Y, Ishikura K, Honda M, Hataya H. Half of children with IgA vasculitis-associated nephritis with nephrotic state spontaneously recover. Nephrology (Carlton) 2022; 27:681-689. [PMID: 35362228 DOI: 10.1111/nep.14041] [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: 10/16/2021] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND The clinical spectrum of Henoch-Schönlein purpura nephritis (HSPN), now known as IgA vasculitis-associated nephritis (IgAVN), ranges from isolated microscopic haematuria to nephrotic syndrome, progressive glomerulonephritis, and kidney failure. The outcome also varies, and the management of IgAVN is controversial. The presence of nephrotic state at disease onset is thought to be a risk factor of a poor prognosis. However, not all patients with nephrotic state have a poor prognosis, and it is unclear whether they need early treatment. METHODS We herein retrospectively examined the clinical course of paediatric IgAVN cases with nephrotic state (serum albumin [sAlb]<3.0g/dL and urine protein-creatinine ratio of >2.0 g/ gCr) without kidney injury treated at our hospital between 2010 and 2018. RESULTS Of the 216 patients with IgAVN identified, 17 met the inclusion criteria. The median follow-up period from disease onset to the last observation was 40.5 months (IQR:31.0-74.2). Eleven patients were male, the median age at onset was 5 years, the minimum serum Alb level was 1.9 g/dL, the maximum proteinuria value was 12.3 g/gCr, and the median minimum eGFR was 86.0 mL/min/1.73 m2 in the acute phase. Eight patients (47%) achieved resolution of nephrotic state within three months and complete remission without treatment by the last observation. The patients with spontaneous resolution of nephrotic state had less severe hypoalbuminaemia (Alb<2.0g/dL) and tended to show a quick increase in the serum albumin level. CONCLUSIONS Our study found that half of paediatric patients with IgAVN with nephrotic state achieved spontaneous resolution without treatment and enjoyed a favorable short-term outcome. Consideration of the duration of nephrotic state and trends in the serum albumin level in children with IgAVN may allow unnecessary kidney biopsies and immunosuppressive therapy to be avoided. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Saori Deki
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Pediatrics, Yokohama City University Medical Center, Kanagawa, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Naoaki Mikami
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Chikako Terano
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Ryoko Harada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
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32
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Yazılıtaş F, Çakıcı EK, Kurt Şükür ED, Özdel S, Güngör T, Bağlan E, Çelikkaya E, Karakaya D, Orhan D, Bülbül M. Clinical spectrum of immunoglobulin A vasculitis in children and determining the best timing of urine examination to predict renal involvement. Postgrad Med 2022; 134:441-447. [PMID: 35354357 DOI: 10.1080/00325481.2022.2061165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Immunoglobulin A (IgA) vasculitis (also known as Henoch-Schonlein purpura) is the most common small vessel vasculitis of childhood. The long-term prognosis depends on renal involvement. The aim of this study was to evaluate the risk factors associated with renal involvement in children with IgA vasculitis and to investigate the best timing of urine examination to predict the presence of renal involvement at the sixth month after the diagnosis. METHODS In this prospective observational study, medical records, demographic data, clinical findings, laboratory tests, and urine microscopic examinations of pediatric patients diagnosed with IgA vasculitis were evaluated to identify potential risk factors associated with renal involvement. RESULTS A total of 178 patients with a median age of 6 years were involved in the study. Renal involvement was found in 24 (13.5%) patients. Most of the patients (85.7%), whose urine examination was found to be abnormal at the sixth month after the diagnosis, also had abnormalities in the first month urine examination. Factors significantly associated with renal involvement were as follows: older age, presence of hematuria and or proteinuria in the first month urine examination and patients who presented the disease in the spring season. Multivariate logistic regression analysis showed age ≥8 years (p = 0.005), the season of onset (p = 0.025), serum creatinine levels (p = 0.016), and abnormal urine examinations at the first-month visits (p = 0.005) significantly increased the risk of renal involvement. CONCLUSION This study has demonstrated that the optimal date to predict the presence of hematuria and/or proteinuria in the sixth month is the urine examination performed in the first month of the disease. Therefore, we think that patients with IgA vasculitis who show a presence of hematuria and/or proteinuria in the first-month urine examination should be followed more closely.
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Affiliation(s)
- Fatma Yazılıtaş
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Evrim Kargın Çakıcı
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Eda Didem Kurt Şükür
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Semanur Özdel
- Department of Pediatric Rheumatology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Tülin Güngör
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Esra Bağlan
- Department of Pediatric Rheumatology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Evra Çelikkaya
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Deniz Karakaya
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Diclehan Orhan
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehmet Bülbül
- Department of Pediatric Nephrology and Rheumatology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
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33
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Lectin and alternative complement pathway activation in cutaneous manifestations of IgA-vasculitis: A new target for therapy? Mol Immunol 2022; 143:114-121. [DOI: 10.1016/j.molimm.2022.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 11/18/2022]
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34
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Avramescu M, Lahoche A, Hogan J, Salomon R, Roussey G, Bacchetta J, Decramer S, Ulinski T, Barbe C, Pietrement C. To biopsy or not to biopsy: Henoch-Schönlein nephritis in children, a 5-year follow-up study. Pediatr Nephrol 2022; 37:147-152. [PMID: 34224002 DOI: 10.1007/s00467-021-05086-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/24/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The prognosis of Henoch-Schönlein purpura (HSP), IgA vasculitis, depends on kidney involvement. There is no consensus on the initiation of treatment for HSP nephritis (HSPN). Some centres start treatment before performing a kidney biopsy (KB) while in others, treatment is dictated by the importance of the clinical, biological and histological signs. The aim of this study was to evaluate which of these two approaches is associated with a better kidney outcome at 5-year follow-up. METHODS This multicentre, retrospective, nonrandomised study included children treated for HSPN between 2006 and 2010 in a French paediatric nephrology unit. One group had an early KB at diagnosis (before starting treatment or in the 15 following days). In the second group, initial treatment was decided without performing a KB. RESULTS Among the 107 children included, 63.5% had an early KB at diagnosis. Follow-up at 5 years was completed in 44 children (28 KB at diagnosis, 16 no KB at diagnosis). Median urine protein/creatinine at 5 years was 2.5 mg/mmol in the early biopsy diagnosis group and 12.5 mg/mmol in the non-biopsy group. An antiproteinuric treatment was given, at 5 years, to 35.7% of the early biopsy at diagnosis children and in 62.5% of the non-biopsied children. CONCLUSIONS Children with early KB at diagnosis seem to have a better renal outcome at 5 years compared to those without an early biopsy at diagnosis or biopsied later. However, this is a small patient cohort and data are missing. Further work is needed to build consensual guidelines on the management of HSPN in children.
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Affiliation(s)
- Marina Avramescu
- Service de Néphrologie Pédiatrique, AP-HP, Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Annie Lahoche
- Service de Néphrologie Pédiatrique, Hôpital Jeanne de Flandre, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Julien Hogan
- Service de Néphrologie Pédiatrique, AP-HP, Hôpital Universitaire Robert Debré, Paris, France
| | - Rémi Salomon
- Service de Néphrologie Pédiatrique, AP-HP, Hôpital Universitaire Necker-Enfants Malades, Paris, France
| | - Gwenaëlle Roussey
- Service de Néphrologie Pédiatrique, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Justine Bacchetta
- Service de Néphrologie Pédiatrique, Hôpital Femme Mère Enfants, Bron, Lyon, France
| | - Stéphane Decramer
- Service de Néphrologie Pédiatrique, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Tim Ulinski
- Service de Néphrologie Pédiatrique, AP-HP, Hôpital Universitaire Armand Trousseau, Paris, France
| | - Coralie Barbe
- Néphrologie Pédiatrique, CHU Reims, 45 rue Cognacq Jay, 51092, Reims CEDEX, France.,Centre de recherche et d'investigation clinique, CHU Reims, Reims, France
| | - Christine Pietrement
- Néphrologie Pédiatrique, CHU Reims, 45 rue Cognacq Jay, 51092, Reims CEDEX, France.
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35
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Kang Z, Xun M, Li Z, Yang Z. Association of the clinicopathological characteristics and proteinuria remission of pediatric IgAV with nephrotic-range proteinuria: A retrospective cohort study. Front Pediatr 2022; 10:959212. [PMID: 36340706 PMCID: PMC9634576 DOI: 10.3389/fped.2022.959212] [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: 07/12/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND IgA vasculitis (IgAV) combined with nephrotic-range proteinuria is uncommon, and nephrotic-range proteinuria is considered a risk factor for poor prognosis in children with IgAV. There are few clinical studies with large samples. METHODS Children with IgAV and nephrotic-range proteinuria who were hospitalized at the Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, from March 2008 to January 2020 were retrospectively studied; the patients were aged ≤18 years and were followed up for ≥12 months. We analyzed clinical characteristics, pathological changes, treatment responses, and their relationships in patients with IgAV combined with nephrotic-range proteinuria. RESULTS Two hundred seventy-seven children with an average age at onset of IgAV with nephritis (IgAVN) of 8.0 years (interquartile range (IQR), 6.0-10.0) were enrolled; 65.7% were aged 6-10 years. The male-to-female ratio was 1.35:1. All children had both nephrotic-range proteinuria and hematuria, 49 (17.7%) had hypoalbuminemia, and 9 (3.2%) had estimated glomerular filtration rate < 90 (mL/min/1.73 m2). All included children were followed up for at least 1 year. At 3, 6, and 12 months of follow-up, the remission rates of proteinuria in children with IgAV combined with nephrotic-range proteinuria were 27.8%, 62.1%, and 83.0%, respectively, and the remission rates of hematuria were 1.4%, 8.7%, and 35.7%, respectively. In addition, children with age at onset of IgAV with nephrotic-range proteinuria ≥10 years, who were female, who had proteinuria ≥100 mg/kg/24 h, and who had a pathological grade III or above had lower remission rates of hematuria and proteinuria (P < 0.05). Multivariate factor analysis was performed by logistic regression and showed age at onset of IgAVN ≥ 10 years and crescents to be risk factors for nonremission of proteinuria at 12 months of follow-up (P < 0.05). CONCLUSIONS Age at onset of IgAVN, sex, proteinuria level, pathological grade, and crescents significantly affect proteinuria remission in children with IgAV combined with nephrotic-range proteinuria.
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Affiliation(s)
- Zhijuan Kang
- Department of Pediatrics, Third Xiangya Hospital of Central South University, Changsha, China.,Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Mai Xun
- Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Zhihui Li
- Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Zuocheng Yang
- Department of Pediatrics, Third Xiangya Hospital of Central South University, Changsha, China
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36
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Jelusic M, Sestan M, Giani T, Cimaz R. New Insights and Challenges Associated With IgA Vasculitis and IgA Vasculitis With Nephritis-Is It Time to Change the Paradigm of the Most Common Systemic Vasculitis in Childhood? Front Pediatr 2022; 10:853724. [PMID: 35372148 PMCID: PMC8965283 DOI: 10.3389/fped.2022.853724] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 02/21/2022] [Indexed: 12/29/2022] Open
Abstract
What are the challenges ahead and how have we responded so far when it comes to the non-granulomatous systemic vasculitis, characterized mainly by deposits of IgA immune complexes in the endothelium of small blood vessels-IgA vasculitis (IgAV)? That is the question to which we tried to answer. We summarized existing knowledge about epidemiology, pathogenesis, genetics, diagnostic tests and therapy in this somewhat neglected entity in pediatric rheumatology. Since etiopathogenesis of IgA vasculitis is complex, with factors other than galactose-deficient IgA1-containing immune complexes also being important, and may involve numerous interactions between environmental and genetic factors, genomics alone cannot explain the entirety of the risk for the disease. The incidence of IgAV and nephritis varies worldwide and may be a consequence of overlapping genetic and environmental factors. In addition to the role of the HLA class II genes, some studies have pointed to the importance of non-HLA genes, and modern geostatistical research has also indicated a geospatial risk distribution, which may suggest the strong influence of different environmental factors such as climate, pathogen load, and dietary factors. The application of modern geostatistical methods until recently was completely unknown in the study of this disease, but thanks to the latest results it has been shown that they can help us a lot in understanding epidemiology and serve as a guide in generating new hypotheses considering possible environmental risk factors and identification of potential genetic or epigenetic diversity. There is increasing evidence that an integrative approach should be included in the understanding of IgA vasculitis, in terms of the integration of genomics, proteomics, transcriptomics, and epigenetics. This approach could result in the discovery of new pathways important for finding biomarkers that could stratify patients according to the risk of complications, without an invasive kidney biopsy which is still the gold standard to confirm a diagnosis of nephritis, even if biopsy findings interpretation is not uniform in clinical practice. Ultimately, this will allow the development of new therapeutic approaches, especially important in the treatment of nephritis, for which there is still no standardized treatment.
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Affiliation(s)
- Marija Jelusic
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mario Sestan
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Teresa Giani
- Department of Clincial Sciences and Community Health, University of Milan, Milan, Italy
| | - Rolando Cimaz
- Department of Clincial Sciences and Community Health, University of Milan, Milan, Italy.,ASST Pini-CTO, Milan, Italy
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Cao Y, Shen T, Li Y, Shuai L, Chen Q, Mo S, Li C, Li X, Wang Y, Wu X. A retrospective study on the characteristics of renal pathological grades in HSPN children with mild to moderate proteinuria. Front Pediatr 2022; 10:1029520. [PMID: 36467482 PMCID: PMC9718029 DOI: 10.3389/fped.2022.1029520] [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: 08/27/2022] [Accepted: 11/02/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate the characteristics of renal pathological grades in Henoch-Schönlein purpura nephritis (HSPN) children with mild to moderate proteinuria and the correlation between pathological grade and severity of proteinuria among this population. METHODS HSPN children who were presented with mild (150 mg <24 h urinary protein <25 mg/kg) to moderate (25 mg/kg ≤24 h urinary protein <50 mg/kg) proteinuria and performed renal biopsy without steroid ± immunosuppressant treatment in the Second Xiangya Hospital between January 2010 and March 2021 were involved. We retrospectively analyzed the correlation between age, disease course, degree of proteinuria, type of immunoglobulin deposits, C3 deposits in glomeruli and renal pathological grade. RESULTS (1) 72 HSPN children including 46 boys and 26 girls were included, with a mean age of onset of 9.01 ± 2.65 years old. The majority of these patients (62.5%) had a disease course between 1 week to 1 month. 51 patients presented with mild proteinuria and 21 patients with moderate proteinuria. (2) Renal biopsy results showed that ISKDC Grade IIIa were both predominant in mild proteinuria group (25, 49%) and moderate proteinuria group (11, 52.4%). 32 patients had grade II (44.4%), 2 had grade IIIb (2.8%), 1 had grade IV (1.4%), and 1 had grade VI (1.4%). There was no correlation between age, disease course and renal pathological grade (p > 0.05). (3) In patients with mild proteinuria (n = 51), 27 (52.9%) HSPN children had a pathological grade ≥ grade III. In patients with moderate proteinuria (n = 21), 13 (61.9%) HSPN children had grade ≥ III. There was no significant difference in the proportion of renal pathological grade between the 2 groups (p > 0.05). (4) There was no significant correlation between glomerular C3 deposits or immunoglobulin deposit types and renal pathological grade (p = 0.776 and p = 0.056 respectively). CONCLUSION In HSPN children with mild to moderate proteinuria, longer disease course or heavier urinary protein level is not completely parallel with higher renal pathological grade. ISKDC grade IIIa is the most common pathological grade. Clinicians should pay great attention to the renal injury in patients with mild to moderate proteinuria.
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Affiliation(s)
- Yan Cao
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Tian Shen
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yongzhen Li
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Lanjun Shuai
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiaoping Chen
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Shuanghong Mo
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Canlin Li
- Department of Digestive Nutrition, Hunan Children's Hospital, Changsha, China
| | - Xiaoyan Li
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ying Wang
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaochuan Wu
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
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38
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Dawood SA, Abodiah AM, Alqahtani SM, Shati AA, Alqahtani YA, Alshehri MA, Mahmood SE. Clinico-Epidemiological Profile and Outcome of Children with IgA Vasculitis in Aseer Region, Southwestern Saudi Arabia. Healthcare (Basel) 2021; 9:1694. [PMID: 34946420 PMCID: PMC8701005 DOI: 10.3390/healthcare9121694] [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] [Received: 11/09/2021] [Revised: 12/02/2021] [Accepted: 12/04/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction: Immunoglobulin A (IgA) vasculitis is one of the most common forms of primary vasculitis in children; it typically has a benign course but can be aggressive and require intervention. Aim of the work: The aim of this retrospective study was to evaluate the epidemiological and clinical profile and treatment modalities used for children with IgA vasculitis in the southwestern region of Saudi Arabia. Material and Methods: We reviewed the medical records of 89 children admitted to Abha Maternity and Children Hospital in the southwestern region of Saudi Arabia from January 2016 to December 2020 with a confirmed diagnosis of IgA vasculitis according to the European League Against Rheumatism/Paediatric Rheumatology International Trials Organisation/Pediatric Rheumatology European Society criteria. Results: Eighty-nine children had a confirmed diagnosis of IgA vasculitis, with 50 boys (56.2%) and 39 girls (43.8%; male-to-female ratio of 1.28:1) and a mean age at diagnosis of 5.87 ± 2.81 years. The mean hospital stay duration was 5.66 ± 4.72 days. Infections preceded 29.2% of the cases, with upper respiratory tract infections comprising 24.7%. Approximately 31.5% of the cases were diagnosed in summer, followed by autumn in 28% of the cases. Rash was present in 100%, arthritis in 72.2%, gastrointestinal tract involvement in 60.7%, and renal involvement in 23.5% of cases. Thrombocytosis and leukocytosis were found in 35% and 46% of all cases, and 52.3% and 47.6.25% of cases with renal involvement, respectively (OR = 2.035, 95% CI: 0.75-5.52 and OR = 1.393, 95% CI: 0.522-1.716, respectively). Approximately 26% of cases experienced relapses. Treatment was conservative in 23.6%, oral prednisolone in 23.6%, and pulse steroid in 45% of cases. Abdominal pain with lower gastrointestinal tract bleeding was the primary indication for initiating pulse steroid treatment. Conclusions: There were similarities and differences in the epidemiology and frequency of clinical manifestations of patients with IgA vasculitis compared to previous studies. Children presenting with such epidemiological and clinical profile need to be closely monitored and long-term follow-up is recommended to improve the outcomes.
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Affiliation(s)
- Samy A. Dawood
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Abdoh M. Abodiah
- Pediatric Rheumatology Unit, Department of Pediatrics, Abha Maternity and Children Hospital, Abha 62562, Saudi Arabia;
| | - Saleh M. Alqahtani
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Ayed A. Shati
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Youssef A. Alqahtani
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Mohammed A. Alshehri
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Syed E. Mahmood
- Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia;
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Cannon L, Wu EY. Recent Advances in Pediatric Vasculitis. Rheum Dis Clin North Am 2021; 47:781-796. [PMID: 34635304 DOI: 10.1016/j.rdc.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This article provides an overview of the clinical presentation and diagnosis of select pediatric primary systemic vasculitides. Important advances in understanding the pathogenesis of these rare diseases also are discussed and efforts to harmonize treatment through consensus-based guidelines and multicenter and international collaborations highlighted.
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Affiliation(s)
- Laura Cannon
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, 2301 Erwin Road, DUMC Box 3212, Durham, NC 27710, USA
| | - Eveline Y Wu
- Division of Pediatric Rheumatology, Department of Pediatrics, The University of North Carolina Chapel Hill, 030 MacNider Hall, CB #7231, Chapel Hill, NC 27599, USA; Division of Allergy/Immunology, Department of Pediatrics, The University of North Carolina Chapel Hill, Chapel Hill, NC.
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Mizerska-Wasiak M, Turczyn A, Cichoń-Kawa K, Małdyk J, Miklaszewska M, Drożdż D, Bieniaś B, Sikora P, Drożyńska-Duklas M, Żurowska A, Szczepańska M, Pańczyk-Tomaszewska M. IgA vasculitis nephritis clinical course and kidney biopsy - national study in children. Pediatr Rheumatol Online J 2021; 19:150. [PMID: 34620183 PMCID: PMC8495907 DOI: 10.1186/s12969-021-00616-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 07/20/2021] [Indexed: 11/12/2022] Open
Abstract
UNLABELLED The aim of the study was to investigate the relationship between the severity of typical clinical symptoms, severity of histopathological lesions in kidney biopsies in IgA vasculitis nephritis (IgAVN) and to propose indications for kidney biopsy in children. MATERIAL AND METHODS This retrospective study enrolled 106 patients, included in the IgAVN registry of Polish children, diagnosed by kidney biopsy. Renal and extrarenal symptoms at onset of the disease were analyzed. Biopsy results were assessed using Oxford classifications (MEST-C). The patients were divided into 3 groups depending on the severity of proteinuria: A-nephrotic proteinuria with hematuria; B-non-nephrotic proteinuria with hematuria; C-isolated hematuria. RESULTS The first symptoms of nephropathy were observed at the 0.7 (1-128.4) months from the onset of extrarenal symptoms. Kidney biopsy was performed on 39 (6-782) days after the onset of nephropathy symptoms. MEST-C score 4 or 5 was significantly more frequent in children from group A than in groups B and C. Significantly higher mean MEST-C score was found in patients with abdominal symptoms than without. In group A: S0 and T0 we found in significantly shorter time to kidney biopsy than in S1, T1-2 p < 0.05) and in group B the significantly shorter time in T0 compare to T1-2 p < 0.05). The ROC analysis shows that S1 changes appear in kidney biopsies in group A with cut off 21 days (AUC 0,702, p = 0.004, sensitivity 0.895 specificity 0.444) T1-2 changes after 35 days (AUC 0.685, p = 0.022, sensitivity 0.750, specificity 0.615), and in goupn B T1-2 cut off is 74 days (AUC 0,738, p = 0.002, sensitivity 0.667, specificity 0.833). CONCLUSIONS In childhood IgAVN, the severity of changes in the urine is clearly reflected in the result of a kidney biopsy. The biopsy should be performed in patients with nephrotic proteinuria no later than 3 weeks after the onset of this symptom in order to promptly apply appropriate treatment and prevent disease progression. Accompanying abdominal symptoms predispose to higher MESTC score.
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Affiliation(s)
| | - Agnieszka Turczyn
- grid.13339.3b0000000113287408Department of Paediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland
| | - Karolina Cichoń-Kawa
- grid.13339.3b0000000113287408Department of Paediatrics and Nephrology, Medical University of Warsaw, Warsaw, Poland
| | - Jadwiga Małdyk
- grid.13339.3b0000000113287408Department of Pathomorphology, Medical University of Warsaw, Warsaw, Poland
| | - Monika Miklaszewska
- grid.5522.00000 0001 2162 9631Department of Pediatric Nephrology, Jagiellonian University, Collegium Medicum, Cracow, Poland
| | - Dorota Drożdż
- grid.5522.00000 0001 2162 9631Department of Pediatric Nephrology, Jagiellonian University, Collegium Medicum, Cracow, Poland
| | - Beata Bieniaś
- grid.411484.c0000 0001 1033 7158Department of Pediatric Nephrology, Medical University of Lublin, Lublin, Poland
| | - Przemysław Sikora
- grid.411484.c0000 0001 1033 7158Department of Pediatric Nephrology, Medical University of Lublin, Lublin, Poland
| | - Magdalena Drożyńska-Duklas
- grid.11451.300000 0001 0531 3426Department of Paediatrics, Nephrology and Hypertension, Medical University of Gdańsk, Gdansk, Poland
| | - Aleksandra Żurowska
- grid.11451.300000 0001 0531 3426Department of Paediatrics, Nephrology and Hypertension, Medical University of Gdańsk, Gdansk, Poland
| | - Maria Szczepańska
- grid.411728.90000 0001 2198 0923Department of Paediatrics, Medical University of Silesia, Zabrze, Poland
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Association of kidney biopsy findings with short- and medium-term outcomes in children with moderate-to-severe IgA vasculitis nephritis. Eur J Pediatr 2021; 180:3209-3218. [PMID: 33934234 DOI: 10.1007/s00431-021-04065-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/31/2021] [Accepted: 04/04/2021] [Indexed: 10/21/2022]
Abstract
Assessing the initial severity of immunoglobulin A vasculitis nephritis (IgAV-N) is important due to its determining effect on kidney management and outcomes. This paper describes a multicentre paediatric cohort of IgAV-N patients and discusses relationships among clinical presentation, histological features, and kidney outcome. We retrospectively studied a cohort of 170 children with biopsy-proven IgAV-N, diagnosed between 2007 and 2017. One-quarter of the cohort (27%) presented with initial nephrotic syndrome (NS). Kidney biopsy revealed International Study of Kidney Disease (ISKDC) grade II or grade III in 83% of cases. Endocapillary proliferation was observed in 73% of patients, and chronic lesions were observed in 25%. Data analysis showed a significant association between NS at onset and endocapillary proliferation and cellular crescents. After a median follow-up of 21 months (IQR 12-39), 30% of patients had persistent proteinuria or decreased eGFR. At the end of follow-up, kidney impairment was more often observed in patients with NS at onset and those with cellular crescents and chronic lesions on initial kidney biopsy.Conclusion: This study highlights the relationship between the clinical and histological presentation of IgAV-N and the factors that affect kidney outcome. The ISKDC classification may be improved by including lesions that are more discriminating for disease severity and prognosis. What is Known: • Nephrotic syndrome (NS) or kidney failure at diagnosis and cellular crescents in more than 50% of the glomeruli are recognized as risk factors for poor kidney outcome in immunoglobulin A vasculitis nephritis (IgAV-N). • The reference histological classification of the International Study of Kidney Disease in Children (ISKDC) is primarily based on the presence and number of affected glomeruli (mesangial proliferation, cellular crescents). The updated Oxford classification, which emphasizes tubular atrophy and interstitial fibrosis, is also used to group pathological features of IgAV-N. Both classifications have limitations. What is New: • Medical treatment should not be postponed in patients with IgAV-N and NS until after biopsy, as NS at diagnosis is associated with initial histological severity and poorer kidney outcome. This proposal needs to be verified in further studies. • Endocapillary proliferation is associated with the initial severity of IgAV-N at diagnosis, while chronic glomerular changes and interstitial fibrosis are associated with poorer short- and medium-term kidney outcomes.
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Türe E, Yazar A, Akın F, Topcu C, Aydın A, Balasar M, Ataş B. Early kidney injury in immunoglobulin A vasculitis: Role of renal biomarkers. Pediatr Int 2021; 63:1218-1222. [PMID: 33423326 DOI: 10.1111/ped.14600] [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: 05/16/2020] [Revised: 12/07/2020] [Accepted: 01/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND We aimed to determine whether urine kidney injury molecule 1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) can be used as early noninvasive biomarkers of kidney injury in immunoglobulin A vasculitis. METHODS Patients who were diagnosed with immunoglobulin A vasculitis were included in the study. Urine samples were collected for determination of urine KIM-1 and NGAL levels. The control group consisted of age-matched healthy children. RESULTS Sixty-one patients who were diagnosed with immunoglobulin A vasculitis were included in the study; 37.7% of these patients were determined to have renal involvement. Median KIM-1 was found to be significantly higher in the patient group (69.59 pg/mL) than the control group (40.84 pg/mL) (P = 0.001). Median NGAL was determined to be statistically significantly higher in the patient group (59.87 ng/mL) compared with the control group (44.87 ng/mL) (P = 0.013). In 23.6% of the patients without renal involvement at admission renal involvement developed within the following 6 months. When median KIM-1 and NGAL at admission of these patients were compared with the control group, they were determined to be statistically significantly higher (P = 0.001, P = 0.003). CONCLUSIONS The fact that our patients with late-term nephropathy had no hematuria and / or proteinuria and that KIM-1 and NGAL levels were determined to be high indicates that these biomarkers might be potentially reliable, noninvasive and early determinants of kidney injury.
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Affiliation(s)
- Esra Türe
- Department of Pediatric Emergency, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Abdullah Yazar
- Department of Pediatric Emergency, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Fatih Akın
- Department of Pediatric Emergency, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Cemile Topcu
- Department of Medical Biochemistry, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Arif Aydın
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Mehmet Balasar
- Department of Urology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
| | - Bülent Ataş
- Department of Pediatric Nephrology, Meram Medical Faculty, Necmettin Erbakan University, Konya, Turkey
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IgA Vasculitis: a Review and Update on the Management of Renal and Extrarenal Disease, Highlighting What’s New for Biomarkers and Treatment. CURRENT PEDIATRICS REPORTS 2021. [DOI: 10.1007/s40124-021-00247-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Jelusic M, Sestan M. IgA vasculitis or Henoch-Schönlein purpura: genetics and beyond. Pediatr Nephrol 2021; 36:2149-2153. [PMID: 33591408 DOI: 10.1007/s00467-021-04987-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Marija Jelusic
- Department of Paediatrics, Division of Clinical Immunology, Rheumatology and Allergology, Centre of Reference for Paediatric and Adolescent Rheumatology of Ministry of Health of the Republic Croatia, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Kispaticeva 12, 10 000, Zagreb, Croatia.
| | - Mario Sestan
- Department of Paediatrics, Division of Clinical Immunology, Rheumatology and Allergology, Centre of Reference for Paediatric and Adolescent Rheumatology of Ministry of Health of the Republic Croatia, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Kispaticeva 12, 10 000, Zagreb, Croatia
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Koskela M, Nihtilä J, Ylinen E, Kolho KL, Nuutinen M, Ritari J, Jahnukainen T. HLA-DQ and HLA-DRB1 alleles associated with Henoch-Schönlein purpura nephritis in Finnish pediatric population: a genome-wide association study. Pediatr Nephrol 2021; 36:2311-2318. [PMID: 33591409 PMCID: PMC8260528 DOI: 10.1007/s00467-021-04955-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/18/2020] [Accepted: 01/19/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The pathophysiology of Henoch-Schönlein purpura (HSP) is still unclear, but several findings suggest that genetic factors may influence disease susceptibility. We aimed to perform a genome-wide association study (GWAS) in pediatric HSP patients with an emphasis on severe HSP nephritis. METHODS The study included 46 HSP patients, 42 of whom had undergone kidney biopsy. Forty-nine pediatric patients with an inflammatory bowel disease (IBD) served as an autoimmune disease control group while Finnish bone marrow and blood donors represented the general reference population (n = 18,757). GWAS was performed for HSP and IBD samples in a case-control manner against the reference population. The analysis also included imputation of human leukocyte antigen (HLA) alleles. RESULTS GWAS analysis in HSP revealed several polymorphisms from the HLA region that surpassed the genome-wide significance level. Three HLA class II alleles were also significantly more frequent in HSP than in the reference population: DQA1*01:01, DQB1*05:01, and DRB1*01:01. Haplotype DQA1*01:01/DQB1*05:01/DRB1*01:01 occurred in 43.5% of HSP patients, whereas its frequency was 8.2% in IBD patients and 15.0% in the reference population. HSP patients with this haplotype showed similar baseline clinical findings and outcome as HSP patients negative for the haplotype. In IBD patients, no polymorphism or HLA allele appeared significant at the genome-wide level. CONCLUSIONS Our results suggest that haplotype DQA1*01:01/DQB1*05:01/DRB1*01:01 is associated with susceptibility to HSP, but not with the severity of the kidney involvement. These HLA associations did not occur in IBD patients, suggesting that they are specific to HSP and not related to susceptibility to autoimmune diseases in general.
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Affiliation(s)
- Mikael Koskela
- Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland. .,Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, PO Box 347, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland.
| | - Julia Nihtilä
- University of Helsinki, Helsinki, Finland.,Finnish Red Cross Blood Service, Helsinki, Finland
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, PO Box 347, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland
| | - Kaija-Leena Kolho
- Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Matti Nuutinen
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.,PEDEGO Research Unit, Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology, Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Jarmo Ritari
- Finnish Red Cross Blood Service, Helsinki, Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, PO Box 347, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland
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Mizerska-Wasiak M, Winiarska M, Nogal K, Cichoń-Kawa K, Pańczyk-Tomaszewska M, Małdyk J. IgA Vasculitis Complicated by Both CMV Reactivation and Tuberculosis. Pediatr Rep 2021; 13:416-420. [PMID: 34449697 PMCID: PMC8396185 DOI: 10.3390/pediatric13030048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/13/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
Immunoglobulin A (IgA) vasculitis is the most common systemic vasculitis in the pediatric population. We present the case of a patient with IgA vasculitis with nephritis who developed cytomegalovirus (CMV) infection followed by Mycobacterium tuberculosis infection. In the literature, there are a few cases of IgA nephropathy accompanied by reactivation of CMV or tuberculosis. To the best of our knowledge, this is the first reported case of IgA vasculitis complicated by both CMV reactivation and tuberculosis. It is important to detect infections in patients with IgA vasculitis because they can induce and exacerbate the symptoms of the disease. Effective antimicrobial treatment facilitates the management of proteinuria and slows down the decline of renal function. Immunosuppressive therapy is a risk factor for reactivation of latent infections and makes patients more susceptible to its generalized and complicated course. This can be prevented by actively screening for hidden sites of infection.
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Affiliation(s)
- Małgorzata Mizerska-Wasiak
- Department of Pediatrics and Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.C.-K.); (M.P.-T.)
- Correspondence:
| | - Maria Winiarska
- Student’s Scientific Group at the Department of Pediatrics and Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.W.); (K.N.)
| | - Karolina Nogal
- Student’s Scientific Group at the Department of Pediatrics and Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland; (M.W.); (K.N.)
| | - Karolina Cichoń-Kawa
- Department of Pediatrics and Nephrology, Medical University of Warsaw, 02-091 Warsaw, Poland; (K.C.-K.); (M.P.-T.)
| | | | - Jadwiga Małdyk
- Department of Pathology, Medical University of Warsaw, 02-091 Warsaw, Poland;
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Sestan M, Kifer N, Frkovic M, Sapina M, Srsen S, Batnozic Varga M, Ovuka A, Held M, Gudelj Gracanin A, Kozmar A, Bulimbasic S, Coric M, Laskarin G, Gagro A, Jelusic M. Gastrointestinal involvement and its association with the risk for nephritis in IgA vasculitis. Ther Adv Musculoskelet Dis 2021; 13:1759720X211024828. [PMID: 34262620 PMCID: PMC8252396 DOI: 10.1177/1759720x211024828] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/24/2021] [Indexed: 01/29/2023] Open
Abstract
Background: We analysed clinical and biochemical parameters in predicting severe gastrointestinal (GI) manifestations in childhood IgA vasculitis (IgAV) and the risk of developing renal complications. Methods: A national multicentric retrospective study included children with IgAV reviewed in five Croatian University Centres for paediatric rheumatology in the period 2009–2019. Results: Out of 611 children, 281 (45.99%) had at least one GI manifestation, while 42 of 281 (14.95%) had the most severe GI manifestations. Using logistic regression several clinical risk factors for the severe GI manifestations were identified: generalized rash [odds ratio (OR) 2.09 (95% confidence interval (CI) 1.09–4.01)], rash extended on upper extremities (OR 2.77 (95% CI 1.43–5.34)] or face [OR 3.69 (95% CI 1.42–9.43)] and nephritis (IgAVN) [OR 4.35 (95% CI 2.23–8.50)], as well as lower values of prothrombin time (OR 0.05 (95% CI 0.01–0.62)], fibrinogen [OR 0.45 (95% CI 0.29–0.70)] and IgM [OR 0.10 (95% I 0.03–0.35)]] among the laboratory parameters. Patients with severe GI involvement more frequently had relapse of the disease [OR 2.14 (CI 1.04–4.39)] and recurrent rash [OR 2.61 (CI 1.27–5.38)]. Multivariate logistic regression found that the combination of age, GI symptoms at the beginning of IgAV and severity of GI symptoms were statistically significant predictors of IgAVN. Patients in whom IgAV has started with GI symptoms [OR 6.60 (95% CI 1.67–26.06)], older children [OR 1.22 (95% CI 1.02–1.46)] with severe GI form of IgAV (OR 5.90 (95% CI 1.12–31.15)] were particularly high-risk for developing IgAVN. Conclusion: We detected a group of older children with the onset of GI symptoms before other IgAV symptoms and severe GI form of the IgAV, with significantly higher risk for acute and chronic complications of IgAV.
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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
| | - Marijan Frkovic
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - 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
| | - Mateja Batnozic Varga
- Department of Paediatrics, Josip Juraj Strossmayer University of Osijek, Medical Faculty Osijek, University Hospital Centre Osijek, Osijek, Croatia
| | - Aleksandar Ovuka
- Department of Paediatrics, University of Rijeka, Faculty of Medicine, University Hospital Centre Rijeka, Rijeka, Croatia
| | - Martina Held
- Department of Paediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | | | - Ana Kozmar
- Clinical Department of Laboratory Diagnostics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Stela Bulimbasic
- Department of Pathology and Cytology, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marijana Coric
- Department of Pathology and Cytology, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | | | - Alenka Gagro
- Department of Paediatrics, Children's Hospital Zagreb, Zagreb, Croatia
| | - Marija Jelusic
- Department of Paediatrics, University of Zagreb School of Medicine, 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, Zagreb, 10 000, Croatia
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Pillebout E, Sunderkötter C. IgA vasculitis. Semin Immunopathol 2021; 43:729-738. [PMID: 34170395 DOI: 10.1007/s00281-021-00874-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
IgA vasculitis (IgAV) is an inflammation of small vessels caused by perivascular deposition of IgA and activation of neutrophils. It may present as systemic vasculitis (IgAV - Henoch-Schönlein purpura) or as a variant restricted to the skin (skin-limited IgAV), while IgA nephropathy presents a variant restricted to the kidneys. Systemic IgAV affects children more frequently than adults (150 to 200 for 1; incidence 1 in 1 million/year). In the latter, disease more often leads to chronic renal disease. The dominant clinical features include round or oval and retiform palpable purpura predominantly on the lower legs, arthralgia or arthritis, gastrointestinal bleeding or pain and glomerulonephritis with mesangial IgA deposits (IgAVN). Pulmonary, cardiac, genital and neurological involvement occurs, but is rare. Immune complexes containing galactose-deficient IgA1 play a pivotal role in the pathophysiology of IgAV; via the Fc alpha receptor (CD89), they induce neutrophilic inflammation around cutaneous vessels and mesangial proliferation and inflammation in the glomerulus. In case of self-limited disease, only symptomatic treatment is recommended. Treatment of severe IgAV, nephritis or gastrointestinal manifestations, is not established, but some studies reported a benefit of corticosteroids, combined with immunosuppressive drugs. Short-term outcome depends on the severity of gastrointestinal manifestations, while long-term prognosis depends on the severity of nephritis.
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Affiliation(s)
- Evangéline Pillebout
- Nephrology Unit, Saint Louis Hospital, INSERM 1149, CRI, 1 Av C. Vellefaux, 75010, Paris, France.
| | - Cord Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle/Saale, Germany
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Penile involvement of immunoglobulin a vasculitis/Henoch-Schönlein purpura. J Pediatr Urol 2021; 17:409.e1-409.e8. [PMID: 33558175 DOI: 10.1016/j.jpurol.2021.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 01/05/2021] [Accepted: 01/14/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Immunoglobulin A vasculitis/Henoch-Schönlein purpura (IgAV/HSP) is a leukocytoclasia vasculitis of childhood, predominantly affecting the skin, joints, gastrointestinal tract, and kidneys. The involvement of the penis is rare. OBJECTIVE We aimed to describe this rare manifestation of IgAV/HSP and to review the previous studies, including similar cases. METHODS Clinical data were reviewed for two children of penile involvement of IgAV/HSP in our hospital. More clinical cases were retrieved from the databases of PubMed/MEDLINE and Scopus from database inception to February 1, 2020. RESULTS We presented two boys aged three and five years both of whom had penile lesions after presenting with the typical rash of IgAV/HSP on lower extremities. The penile lesions improved entirely in a few days without treatment in one and with corticosteroid treatment in the other. The literature review revealed 12 articles describing 20 patients with penile involvement of IgAV/HSP. The penile findings were edema, erythema, ecchymosis, purpuric rash, edema, color change, stiffness of the shaft or prepuce, and tenderness. Penile lesions appeared before the purpuric rash of IgAV/HSP in three of 22 patients. The penile involvement could make the diagnosis challenging especially if the penile lesions appear before the typical rash of the disease. The lesions improved entirely in the short term in all patients; in five without treatment in fifteen after corticosteroid or immunosuppressive drug treatment. CONCLUSIONS It is important to raise awareness about this rare manifestation among health care providers. It is not clear whether corticosteroid treatment should be initiated for treatment since it seems as a self-limited feature. Treatment with corticosteroids could be considered in the treatment of selected cases especially with systemic involvement.
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Oni L, Gritzfeld JF, Jones C, Sinha MD, Wallace D, Stack M, Kurt-Sukur ED, Quinlan C, Ruggiero B, Raja M, Tullus K. Comment on: European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis-the SHARE initiative. Rheumatology (Oxford) 2021; 60:e179-e180. [PMID: 32337557 DOI: 10.1093/rheumatology/keaa159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 03/18/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Louise Oni
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool and Liverpool Health Partners
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool Health Partners, Liverpool
| | - Jenna F Gritzfeld
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool and Liverpool Health Partners
| | - Caroline Jones
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool Health Partners, Liverpool
| | - Manish D Sinha
- Department of Paediatric Nephrology, Evelina London Children's Hospital, London
| | - Dean Wallace
- Department of Paediatric Nephrology, Royal Manchester Children's Hospital, Manchester, UK
| | - Maria Stack
- Department of Paediatric Nephrology, Children's Health Ireland, Dublin, Ireland
| | - Eda Didem Kurt-Sukur
- Department of Paediatric Nephrology, Dr Sami Ulus Children's Hospital, Ankara, Turkey
| | - Catherine Quinlan
- Department of Paediatric Nephrology, The Royal Children's Hospital, Melbourne, Australia
| | - Barbara Ruggiero
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital and Research Institute, Rome, Italy
| | - Maduri Raja
- Department of Paediatric Nephrology, Southampton Children's Hospital, Southampton
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street NHS Foundation Trust Hospital, London, UK
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