1
|
Dimelow R, Liefaard L, Green Y, Tomlinson R. Extrapolation of the Efficacy and Pharmacokinetics of Belimumab to Support its Use in Children with Lupus Nephritis. Clin Pharmacokinet 2024; 63:1313-1326. [PMID: 39320441 PMCID: PMC11450137 DOI: 10.1007/s40262-024-01422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2024] [Indexed: 09/26/2024]
Abstract
BACKGROUND AND OBJECTIVE Lupus nephritis (LN), a severe manifestation of systemic lupus erythematosus, has greater severity in children versus adults. Belimumab is approved for systemic lupus erythematosus treatment in patients aged ≥ 5 years, and for active LN in adults in the European Union, China, Japan and Latin America, and patients aged ≥ 5 years in the USA. Low prevalence of paediatric active LN makes conducting a clinical study within a reasonable period unfeasible. We describe a model-based extrapolation of belimumab efficacy and pharmacokinetics from adults to children with LN to support US Food and Drug Administration approval of intravenous belimumab 10 mg/kg (administered every 4 weeks after the loading dose) in children (aged 5-17 years) with active LN. METHODS This concept assumed that disease progression, response to belimumab, exposure-response, and the target belimumab exposure for efficacy are similar across adult and paediatric systemic lupus erythematosus and LN, evaluated against the published literature for paediatric LN and belimumab systemic lupus erythematosus and LN clinical trial data in adults and children. A two-compartmental population pharmacokinetic model, previously developed for adults with LN, was used to extrapolate belimumab pharmacokinetics to children with LN. RESULTS The model captured the dependence of time-varying proteinuria on belimumab clearance, and therefore exposure. Sufficient target exposures for efficacy were achieved in children with active LN. A small proportion of children aged 5-11 years are predicted to have exposures below adult levels but no impact to efficacy is expected. CONCLUSIONS Our model demonstrated that intravenous belimumab 10 mg/kg every 4 weeks is appropriate for children aged 5-17 years with active LN.
Collapse
Affiliation(s)
- Richard Dimelow
- GSK, Clinical Pharmacology Modelling and Simulation, Gunnels Wood Rd, Stevenage , Hertfordshire, SG1 2NY, UK.
| | - Lia Liefaard
- GSK, Clinical Pharmacology Modelling and Simulation, Gunnels Wood Rd, Stevenage , Hertfordshire, SG1 2NY, UK
| | - Yulia Green
- GSK, Clinical Development, Brentford, Middlesex, UK
| | | |
Collapse
|
2
|
Chan EYH, Lai FFY, Ma ALT, Chan TM. Managing Lupus Nephritis in Children and Adolescents. Paediatr Drugs 2024; 26:145-161. [PMID: 38117412 DOI: 10.1007/s40272-023-00609-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/21/2023]
Abstract
Lupus nephritis is an important manifestation of systemic lupus erythematosus, which leads to chronic kidney disease, kidney failure, and can result in mortality. About 35%-60% of children with systemic lupus erythematosus develop kidney involvement. Over the past few decades, the outcome of patients with lupus nephritis has improved significantly with advances in immunosuppressive therapies and clinical management. Nonetheless, there is a paucity of high-level evidence to guide the management of childhood-onset lupus nephritis, because of the relatively small number of patients at each centre and also because children and adolescents are often excluded from clinical trials. Children and adults differ in more ways than just size, and there are remarkable differences between childhood- and adult-onset lupus nephritis in terms of disease severity, treatment efficacy, tolerance to medications and most importantly, psychosocial perspective. In this article, we review the 'art and science' of managing childhood-onset lupus nephritis, which has evolved in recent years, and highlight special considerations in this specific patient population.
Collapse
Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong.
| | - Fiona Fung-Yee Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tak Mao Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, School of Clinical Medicine, Pok Fu Lam, Hong Kong.
| |
Collapse
|
3
|
Chan EYH, Wong SW, Lai FFY, Ho TW, Tong PC, Lai WM, Ma ALT, Yap DYH. Long-term outcomes with rituximab as add-on therapy in severe childhood-onset lupus nephritis. Pediatr Nephrol 2023; 38:4001-4011. [PMID: 37358717 DOI: 10.1007/s00467-023-06025-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/14/2023] [Accepted: 05/04/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Long-term data pertaining to rituximab as add-on therapy in childhood-onset lupus nephritis (cLN) is scarce. METHODS A retrospective cohort study was conducted on all patients with proliferative cLN, diagnosed ≤ 18 years and between 2005 and 2021, who received rituximab for LN episodes that were life/organ threatening and/or treatment resistant to standard immunosuppression. RESULTS Fourteen patients with cLN (female, n = 10) were included, with median follow-up period of 6.9 years. LN episodes (class III, n = 1; class IV, n = 11; class IV + V, n = 2) requiring rituximab occurred at 15.6 years (IQR 12.8-17.3), urine protein:creatinine ratio was 8.2 mg/mg (IQR 3.4-10.1) and eGFR was 28 mL/min/1.73 m2 (IQR 24-69) prior to rituximab treatment. Ten and four patients received rituximab at 1500 mg/m2 and 750 mg/m2, which were given at 46.5 days (IQR 19-69) after commencement of standard therapies. Treatment with rituximab resulted in improvements in proteinuria (ps < 0.001), eGFR (ps < 0.01) and serological parameters, including haemoglobin levels, complement 3 levels and anti-dsDNA antibodies, compared with baseline. Rates of complete/partial remission at 6-, 12- and 24-month post-rituximab were 28.6/42.8%, 64.2/21.4% and 69.2/15.3%. All three patients who required acute kidney replacement therapy became dialysis-free after rituximab. Relapse rate following rituximab was 0.11 episodes/patient-year. There was no lethal complication or severe infusion reaction. Hypogammaglobulinaemia was the most frequent complication (45%) but was mostly asymptomatic. Neutropenia and infections were observed in 20% and 25% of treatments. Upon last follow-up, three (21%) and two (14%) patients developed chronic kidney disease (stage 2, n = 2; stage 4; n = 1) and kidney failure, respectively. CONCLUSION Add-on rituximab is an effective and safe rescue therapy for cLN patients with life-/organ-threatening manifestations or treatment-resistance. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR.
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR.
| | - Sze-Wa Wong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Fiona Fung-Yee Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Tsz-Wai Ho
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Pak-Chiu Tong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Wai-Ming Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR.
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR.
| | - Desmond Yat-Hin Yap
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon Bay, Hong Kong SAR.
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong School of Clinical Medicine, Pokfulam, Hong Kong SAR.
| |
Collapse
|
4
|
Biswas D, Dasgupta D, Pal P, Sinha R. Presentation and outcome of pediatric lupus nephritis from a large single centre contemporary cohort in Eastern India. Lupus 2023; 32:1440-1446. [PMID: 37707867 DOI: 10.1177/09612033231202843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND We present clinical, biochemical, and histopathological characteristics and treatment outcomes of biopsy proven childhood lupus nephritis (LN) from a low/middle income setting treated in the current era of increased use of Mycophenolate Mofetil (MMF) and biologics. METHODS Retrospective observational study of children (1-18 years) with biopsy proven LN treated from 01.01.2010 to 31.01.2020. RESULTS 60 children met our inclusion criteria (80%, n = 48 were females). The median age at diagnosis was 11 (IQR: 9-12) years. The most common extra-renal manifestation was mucocutaneous (n = 54, 90%) and the most common kidney manifestation was edema (n = 50, 83.3%). The median 24-h urinary protein excretion was 1117.8 (IQR: 795.4-1941.7) mg/m2/day with 67% (n = 40) having nephrotic range proteinuria (>1000 mg/m2/day). 75% (n = 45) children had eGFR <90 mL/min/1.73 m2 (median eGFR = 71; IQR: 56-90 mL/min/1.73 m2). Anti-Nuclear Antibody was positive in all, both complement three and four were low in 82% (n = 49) and anti-double stranded DNA antibodies were positive in 63% (n = 38). 85% (n = 51) had proliferative LN with majority being class IV (57%, n = 34). All children received steroids for induction therapy. MMF was given as the sole induction agent in 48% (n = 29) and cyclophosphamide in 27% (n = 16). Rituximab was added in 17% (n = 10) as a rescue agent. Median follow up duration was 50 (IQR: 28-82) months. Six children (10%) died as a result of serious infections and none of them had shown complete response (CR). Out of the 52 children who had a follow up duration of at least 2 years, CR was achieved in 46 children (88%) and partial response (PR) or no response (NR) in three children (6%) each. Although children who were in CR/PR at last follow up had lower proteinuria, higher eGFR, and lower histopathology activity index at onset; low numbers in the NR group precluded us from subjecting them to any statistical correlation tests. 36% (n = 22) of children developed 36 episodes of renal flares with overall incidence of 0.14/person-year. CONCLUSION Our study on a contemporary cohort of childhood LN highlights the importance of achieving CR and its feasibility.
Collapse
Affiliation(s)
- Debopoma Biswas
- Pediatric Rheumatology, Institute of Child Health, Kolkata, India
| | | | - Priyankar Pal
- Pediatric Rheumatology, Institute of Child Health, Kolkata, India
| | - Rajiv Sinha
- Pediatric Nephrology, Institute of Child Health, Kolkata, India
| |
Collapse
|
5
|
Khandelwal P, Govindarajan S, Bagga A. Management and outcomes in children with lupus nephritis in the developing countries. Pediatr Nephrol 2023; 38:987-1000. [PMID: 36255555 DOI: 10.1007/s00467-022-05769-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/14/2022] [Accepted: 09/05/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lupus nephritis (LN) has variable prevalence, severity, and outcomes across the world. OBJECTIVES This review compares the outcomes of childhood LN in low- and middle-income countries (LMICs) and high-income countries (HICs) and aims to summarize long-term outcomes of pediatric LN from LMICs. DATA SOURCES A systematic literature search, conducted in PubMed, EMBASE, and Cochrane database in the last 30-years from January 1992, published in the English language, identified 113 studies including 52 from lower (n = 1336) and upper MICs (n = 3014). STUDY ELIGIBILITY CRITERIA Cohort studies or randomized controlled trials, of patients ≤ 18 years of age (or where such data can be separately extracted), with > 10 patients with clinically or histologically diagnosed LN and outcomes reported beyond 12 months were included. PARTICIPANTS AND INTERVENTIONS Patients ≤ 18 years of age with clinically or histologically diagnosed LN; effect of an intervention was not measured. STUDY APPRAISAL AND SYNTHESIS METHODS Two authors independently extracted data. We separately analyzed studies from developed countries (high income countries; HIC) and developing countries (LMICs). Middle-income countries were further classified as lower and upper MICs. Meta-analyses of data were performed by calculating a pooled estimate utilizing the random-effects model. Test for heterogeneity was applied using I2 statistics. Publication bias was assessed using funnel plots. RESULTS Kidney remission was similar across MICs and HICs with 1-year pooled complete remission rates of 59% (95% CI 51-67%); one third of patients had kidney flares. The pooled 5-year survival free of stage 5 chronic kidney disease (CKD5) was lower in MICs, especially in lower MICs compared to HICs (83% vs. 93%; P = 0.002). The pooled 5-year patient survival was significantly lower in MICs than HICs (85% vs. 94%; P < 0.001). In patients with class IV LN, the 5-and 10-year respective risk of CKD5 was 14% and 30% in MICs; corresponding risks in HICs were 8% and 17%. Long-term data from developing countries was limited. Sepsis (48.8%), kidney failure (14%), lupus activity (18.1%), and intracranial hemorrhage/infarct (5.4%) were chief causes of death; mortality due to complications of kidney failure was more common in lower MICs (25.6%) than HICs (6.4%). LIMITATIONS The review is limited by heterogenous approach to diagnosis and management that has changed over the period spanning the review. World Bank classification based on income might not correlate with the standards of medical care. The overall quality of evidence is low since included studies were chiefly retrospective and single center. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Challenges in LMICs include limited access to pediatric nephrology care, dialysis, increased risk of infection-induced mortality, lack of frequent monitoring, and non-compliance due to cost of therapy. Attention to these issues might update the existing data and improve patient follow-up and outcomes. SYSTEMATIC REVIEW REGISTRATION NUMBER PROSPERO 2022 number: CRD42022359002, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022359002.
Collapse
Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Srinivasavaradan Govindarajan
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029, India.
| |
Collapse
|
6
|
Chan EYH, Yap DYH, Wong WT, Wong WHS, Wong SW, Lin KYK, Hui FYW, Yee-ming J, Lam SSY, Wong JKY, Lai FFY, Ho TW, Tong PC, Lai WM, Chan TM, Ma ALT. Long-Term Outcomes of Children and Adolescents With Biopsy-Proven Childhood-Onset Lupus Nephritis. Kidney Int Rep 2022; 8:141-150. [PMID: 36644360 PMCID: PMC9831948 DOI: 10.1016/j.ekir.2022.10.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Long-term data pertaining to childhood-onset lupus nephritis (cLN) remain extremely scarce. Methods We conducted a retrospective cohort study of biopsy-proven cLN with onset age <18 years diagnosed from 2001 to 2020 to ascertain the long-term patient and kidney survival rates, and the incidence of advanced chronic kidney disease (CKD) (estimated glomerular filtration rate [eGFR] <60 ml/min per 1.73 m2). Results A total of 92 subjects (78 female; age 13.7 ± 3.3 years; all Chinese) were included, with follow-up duration of 10.3 years (interquartile range, 5.8-15.9). Of these, 83 children (90%) had proliferative lupus nephritis (LN) (Class III/IV ± V). Mycophenolate was used for induction in 36%, whereas 34% received cyclophosphamide (CYC); 55% received mycophenolate as maintenance immunosuppression. The rates of complete remission (CR) and partial remission (PR) at 6 months and 12 months, respectively, were 65% and 20% and 78% and 8%. Two patients died (mortality rate 2.1/1000 patient-years), with a standardized mortality ratio of 22.3. Three patients (3.2%) developed end-stage kidney disease (ESKD), and advanced CKD occurred in 5 patients (5.4%). Survival rates without advanced CKD, ESKD, or death were 96.7%, 94.2%, 92.7%, 83.2% and 83.2% at 1 year, 5 years, 10 years, 15 years, and 20 years, respectively. Multivariate analysis revealed that severe kidney failure necessitating dialysis at presentation (adjusted hazard ratio 37.7, 95% confidence interval [CI] 4.0-355.6, P = 0.002), nonresponse (NR) after 12 months of treatment (adjusted hazard ratio 11.2, 95% CI 2.3-54.9, P = 0.003), and multiple nephritis flares (adjusted hazard ratio 2.6, 95% CI 1.1-6.2, P = 0.03) were predictive of advanced CKD, ESKD, or death. Other adverse outcomes included infections (2.9 episodes/100 patient-years), osteopenia (32%), hypertension (17%), short stature (14%), and avascular necrosis (7%). Conclusion The long-term outcomes of cLN appeared to have improved in the present era with effective immunosuppression, cautious drug tapering, and assurance of medication adherence. There is still an unacceptably high prevalence of adverse outcomes.
Collapse
Affiliation(s)
- Eugene Yu-hin Chan
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Desmond Yat-hin Yap
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wing-tung Wong
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Wilfred Hing-sang Wong
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong
| | - Sze-wa Wong
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Kyle Ying-kit Lin
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Felix Yan-wai Hui
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Jennifer Yee-ming
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | | | | | | | - Tsz-wai Ho
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Pak-chiu Tong
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Wai-ming Lai
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong
| | - Tak Mao Chan
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong,Correspondence: Tak Mao Chan, Paediatric Nephrology Centre, Hong Kong Children's Hospital; Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong.
| | - Alison Lap-tak Ma
- Paediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong,Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong,Alison Lap-tak Ma, Pediatric Nephrology Center, Hong Kong Children’s Hospital, Hong Kong.
| |
Collapse
|
7
|
Li C, Han Y, Zhang L, Chen Z, Jin M, Sun S. Endocapillary hypercellularity levels are associated with early complete remission in children with class IV lupus nephritis as the initial presentation of SLE. BMC Nephrol 2022; 23:296. [PMID: 36008770 PMCID: PMC9413905 DOI: 10.1186/s12882-022-02921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background Endocapillary hypercellularity (ECHC) is commonly seen in class IV lupus nephritis (LN), the most common and severe LN in children. Factors influencing early complete remission (CR) in pediatric class IV LN have been poorly described. We investigated the relationship between ECHC levels and early CR in pediatric class IV LN. Methods Patients with newly, simultaneously diagnosed systemic lupus erythematosus (SLE) and class IV LN by renal biopsy from 2012 to 2021 were studied. In this retrospective study, two pathologists who were blind to clinical information reviewed all pathological data retrospectively and classified glomerular lesions according to the revised criteria of the International Society of Nephrology and the Renal Pathology Society (ISN/RPS). The demographics, baseline clinical characteristics, laboratory parameters, renal histopathological findings, treatment regimen and CR at 6 months after immunosuppressive therapy were analyzed. ECHC was categorized as: > 50% (group A), 25–50% (group B) and < 25% (group C). CR was defined as absence of clinical symptoms, 24-hour urinary protein < 0.15 g, and normal levels of serum creatinine and albumin. Results Sixty-four patients were identified: 23, 15 and 26 in groups A, B and C, respectively. Group A had significantly higher levels of D-dimer, urine protein, and SLE disease activity index (SLEDAI) than groups B and C. Group C had a markedly higher estimated glomerular filtration rate (eGFR) than groups A and B. A substantially greater proportion of patients in group A had glomerular microthrombi and basement membrane thickening than in groups B and C. At 6 months post treatment, CR was achieved in 19 (82.6%), 5 (33.3%) and 11 (42.3%) in groups A, B and C, respectively (p < 0.05, group A vs groups B and C). Multiple logistic regression analysis revealed that ECHC and urine protein levels were significantly associated with CR. Conclusion ECHC and urine protein levels may be valuable biomarkers for predicting early CR in pediatric class IV LN.
Collapse
Affiliation(s)
- Chunzhen Li
- Department of Pediatrics, Hebei Medical University, Shijiazhuang, China.,Department of Pediatric Nephrology and Immunology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Yanan Han
- Department of Pediatric Nephrology and Immunology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Lili Zhang
- Department of Pathology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Zhiguo Chen
- Department of Pediatric Thoracic Surgery, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Mei Jin
- Department of Pediatric Neurology, Children's Hospital of Hebei Province, 133 Jianhua South Street, Shijiazhuang, 050031, Hebei Province, China
| | - Suzhen Sun
- Department of Pediatrics, Hebei Medical University, Shijiazhuang, China. .,Department of Pediatric Neurology, Children's Hospital of Hebei Province, 133 Jianhua South Street, Shijiazhuang, 050031, Hebei Province, China.
| |
Collapse
|
8
|
Yadav S, Balakrishnan C, Kothari J. Long-term outcome and predictors of long-term outcome in patients with lupus nephritis managed at a tertiary hospital in Mumbai. Lupus 2022; 31:1191-1201. [PMID: 35658736 DOI: 10.1177/09612033221106607] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM Study the long-term outcome of the patients with LN and identify the baseline factors that can predict the long-term outcome of these patients. METHODS All biopsy-proven LN patients who attended our regular 'lupus nephritis' clinic from 2013 to 2021 were studied. Data of these patients were collected from the hospital patient records. Standard therapy was given as per the KDIGO guidelines, and the renal response was evaluated according to KDIGO outcome criteria. Cox' regression analysis was used to determine predictors of chronic kidney disease (persistent doubling of serum creatinine with creatinine ≥1.5 mg%). Kaplan-Meier analysis was used for renal survival. RESULTS Eighty patients with at least 1 year of follow-up were included. Median age of onset was 24 years (IQR18-35). Median follow up was 6.5 years (IQR 3-10). World Health Organisation renal biopsy profile was Class I 1(1.2 %), Class II 6(7.5 %), Class III 9(11.2 %), Class IV 36(45 %), Class V 18(22.5 %) and Mixed Class IV + V 10 (12%). Complete remission was achieved in 63.75%, 70 % and 66.6% patients at 1, 2 and 5 years, respectively. Survival with normal renal function was 88.5 %, 85.8% and 60 % at 5, 10 and 15 years, respectively. Risk factors for poor outcome on univariate analysis were presence of Raynaud's phenomena-hazard ratio(HR) 7.78 (CI 1.944-31.207; p < .004), baseline hypertension-HR 5.356 (CI 1.479-19.403; p < .011), tubulointerstitial involvement-HR 1.076 (CI 1.032-1.222; p < .001), time to complete response-HR 1.036 (CI 1.036-1.067; p < .02 ), serum creatinine at 6 months HR 10.51 (CI 2.19-50.39; p < .003), failure to achieve complete response at 2 years HR 6.271 (CI 1.567-25.092; p < .009) and the number of nephritic flares HR 1.868(CI 1.103-3.164 ; p < .02). Renal relapses were quite common, with 1.8 flares per 10 patient-years of follow up. Infection was the most common cause of death, with bacterial lower respiratory infections and pulmonary tuberculosis being the most common. CONCLUSIONS Apart from conventional risk factors, other predictive factors like the presence of Raynaud's phenomenon, tubulointerstitial fibrosis and tubular atrophy on kidney biopsy, and initial response to induction therapy by 6 months have a significant impact on the long-term outcome in patients with LN.
Collapse
Affiliation(s)
- Sandeep Yadav
- Department of Rheumatology, 29537P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - C Balakrishnan
- Department of Rheumatology, 29537P.D. Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | - Jatin Kothari
- Department of Nephrology, 29537PD Hinduja National Hospital and Medical Research Centre, Khar Mumbai, India.,Apex Kidney Foundation, Mumbai, India.,Apex Kidney Care - Dialysis Networks, Mumbai, India.,Nanavati Max Hospital, Mumbai, India
| |
Collapse
|
9
|
Wenderfer SE, Orjuela A, Bekheirnia MR, Pereira M, Muscal E, Braun MC, De Guzman M. Lupus Nephritis, Autoantibody Production and Kidney Outcomes in Males with Childhood-Onset Systemic Lupus Erythematosus. Pediatr Rep 2022; 14:220-232. [PMID: 35645367 PMCID: PMC9149811 DOI: 10.3390/pediatric14020030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 02/04/2023] Open
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) only represents 20% of all SLE patients, and males with SLE only represent 10%. To study this rare SLE subset, males diagnosed with cSLE over a 30-year period were identified. Organ involvement, autoantibody production, hypocomplementemia, and kidney biopsy findings were compared to cSLE females. Outcomes were assessed using SLE Disease Activity Index scores, Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index, and Childhood Arthritis and Rheumatology Research Alliance definitions for nephritis responsiveness. Of 95 males and 545 females with cSLE, 62% and 57% developed nephritis, respectively. Median age of cSLE onset was 14 years in both genders. Among males, 80% of non-Hispanic whites, 64% of blacks, 59% of Hispanics, and 50% of Asians developed nephritis. The prevalence of pure and mixed class V membranous nephritis was 33%. Median follow-up was 3.2 years (range 0.1-18). Complete kidney responses were seen in 70% after a median 24 months; however, relapse rates were 46%. Kidney disease flares were 56% nephritic and 44% proteinuric. Males and females with cSLE present with comparable rates and nephritis class. While overall and kidney response rates are favorable, kidney disease relapses are common among males.
Collapse
Affiliation(s)
- Scott E. Wenderfer
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- British Columbia Children’s Hospital, Vancouver, BC V6H 3V4, Canada
| | - Alvaro Orjuela
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Mir Reza Bekheirnia
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Maria Pereira
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Eyal Muscal
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| | - Michael C. Braun
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (A.O.); (M.R.B.); (M.C.B.)
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
| | - Marietta De Guzman
- Texas Children’s Hospital, Houston, TX 77030, USA; (M.P.); (E.M.); (M.D.G.)
- Division of Rheumatology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
| |
Collapse
|
10
|
Boussetta A, Louati D, Jellouli M, Gaied H, Mabrouk S, Maalej B, Zouaghi K, Goucha R, Gargah T. Lupus Nephritis in Tunisian Children: Predictive Factors of Poor Outcomes. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:440-448. [PMID: 37843146 DOI: 10.4103/1319-2442.385968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disorder of unknown etiology. Lupus nephritis (LN) is one of the most severe clinical manifestations observed in patients with SLE; it is more frequent and more severe in children than in adults. The aim of our study was to assess the predictive factors of poor outcomes in Tunisian children with LN. This was a multicenter retrospective observational study on 40 pediatric patients with biopsy-proven LN from five nephrology departments in Tunisia. The patients were 12.33 ± 3.3 years of age at the time of their kidney biopsy. Eleven patients developed end-stage renal disease (ESRD) (27.5%), and seven patients died. Overall, 18 (45%) patients reached our composite endpoint (ESRD or death). An age at diagnosis of more than 14 years, elevated serum creatinine at the time of the kidney biopsy, the existence of wire loops, thromboembolic complications as well as infectious complications are the most important clinical features associated with an increased risk of ESRD. Predictive factors of death were a baseline creatinine level of more than 2.26 mg/dL, a high proteinuria at baseline, fibrous crescents determined by renal biopsy, thromboembolic complications, infectious compli-cations, and ESRD. In summary, our results suggest that early and appropriate management is the best guarantee of a good renal outcome in children with LN.
Collapse
Affiliation(s)
- Abir Boussetta
- Department of Pediatric Nephrology, Charles Nicolle Hospital; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Dalia Louati
- Department of Pediatrics Hedi Chaker Hospital, Sfax, Tunisia
| | - Manel Jellouli
- Department of Pediatric Nephrology, Charles Nicolle Hospital; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | - Hanen Gaied
- Faculty of Medicine of Tunis, University of Tunis El Manar; Department of Nephrology, Mongi Slim Hospital, Tunis, Tunisia
| | - Sameh Mabrouk
- Department of Pediatrics, Sahloul Hospital, Sousse, Tunisia
| | - Bayen Maalej
- Department of Pediatrics Hedi Chaker Hospital, Sfax, Tunisia
| | - Karim Zouaghi
- Faculty of Medicine of Tunis, University of Tunis El Manar; Department of Nephrology, Rabta Hospital, Tunis, Tunisia
| | - Rym Goucha
- Faculty of Medicine of Tunis, University of Tunis El Manar; Department of Nephrology, Mongi Slim Hospital, Tunis, Tunisia
| | - Tahar Gargah
- Department of Pediatric Nephrology, Charles Nicolle Hospital; Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
| |
Collapse
|
11
|
G B, Janarthanan M, S IT, Balasubramanian S, Geminiganesan S. Analysis of Clinicopathological Characteristics and Its Correlation With the Prognosis of Pediatric Lupus Nephritis: A Tertiary Care Center Experience. Cureus 2022; 14:e21862. [PMID: 35265405 PMCID: PMC8897966 DOI: 10.7759/cureus.21862] [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] [Accepted: 02/03/2022] [Indexed: 11/17/2022] Open
Abstract
Aim To study the various pathological patterns of pediatric lupus nephritis (LN) by renal biopsies and to correlate the histopathological data with the clinical and biochemical outcomes. Methods This is a retrospective study in children between 1 month and 18 years of age with renal biopsy-proven lupus nephritis, conducted between January 2015 and December 2019. Various pathological and clinical parameters were compared between the groups with lupus nephritis activity and those without activity. Results Of 38 biopsy-proven lupus nephritis cases, 30 (78.9%) were in the adolescent age group, and the female gender was predominantly affected (n=30; 78.9%). Class IV proliferative lupus nephritis (n=17, 44.7%) was the most common biopsy finding, and the activity score for endocapillary hypercellularity, neutrophil infiltration, fibrinoid necrosis, hyaline deposits, and interstitial inflammation was significantly high in classes III and IV. Overall, attaining remission was less, and the risk of progression of chronic kidney disease (CKD) was higher in class IV (n=3; 7.8%). Mortality was reported in 1 out of 38 (2.6%) children. Conclusion Light microscopy and immunofluorescence studies play an important role in defining the extent of renal damage in the form of activity and chronicity indices, which are the key factors in the decision-making of lupus nephritis treatment. The prognostic relevance of the histological scoring has been evaluated, and it is evident that the activity index and chronicity index go a long way in therapeutic intervention.
Collapse
|
12
|
Mittal A, Bamnawat H, Nalwa A, Vishwajeet V, Kumar P, Didel S, Goel AD, Singh K. Pediatric onset lupus nephritis in western India-is it different from the rest of the country? Lupus 2021; 30:2008-2016. [PMID: 34558344 DOI: 10.1177/09612033211045069] [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: 11/16/2022]
Abstract
AIM To determine the clinicopathological characteristics and outcomes of children diagnosed with lupus nephritis in a tertiary hospital in western Rajasthan and compare it with the data available from other parts of India. MATERIAL AND METHODS A retrospective review of children presenting to a tertiary care center in western Rajasthan, India, with a diagnosis of pediatric Systemic Lupus Erythematosus (p SLE), between July 2017 and July 2020 was done. Comparisons of pediatric lupus in western India to other parts of country were done. RESULTS 19 children with SLE with Renal involvement were enrolled and followed up. The median age at presentation was 15 years (IQR-16-9.5) (73% females). 8/19 (42%) children presented with AKI, of which 62% children presented as rapidly progressive renal failure. Six (37.5%) patients required dialysis at presentation. 84.21% of children were evaluated with renal biopsy, 16 biopsies were done in 19 children, among which class II, III, and IV lupus nephritis were reported in 21%,42%, and 35% respectively(4 crescentic). Antiphospholipid antibodies were positive in 8/15(53%), children which is much higher than a reported incidence of 30% in other Indian studies. Ten patients (52%) had neurological involvement, with seizures being the most common form of presentation (60%). Seven patients (36%) developed hepatitis. We noted many uncommon presentations in the small group like Autoimmune Pancreatitis, Mononeuritis multiplex, and peripheral digital gangrene. Cyclophosphamide was used in 10 out of 19 patients for inducing remission with class 3 and 4 nephritis and MMF in 8 children. 55% patients attained remission (after completing induction), of which 4 relapsed during the follow up. Four patients were lost to follow-up. A total of 27% patients died and 10% patients developed end stage renal failure. It was seen that those who died had more cardiac and neurological involvement at presentation, higher grade of proteinuria, lower GFR, and need for dialysis at admission. CONCLUSION We found a more severe form of clinical manifestation in pediatric SLE patients at the time of the first presentation in the form of severe renal and extrarenal manifestation compared to other parts of the country.
Collapse
Affiliation(s)
- Aliza Mittal
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| | - Harshita Bamnawat
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| | - Aasma Nalwa
- Department of Pathology, 410730All India Institute of Medical Sciences, Jodhpur, Rajasthan
| | - Vikarn Vishwajeet
- Department of Pathology, 410730All India Institute of Medical Sciences, Jodhpur, Rajasthan
| | - Prawin Kumar
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| | - Siyaram Didel
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| | - Akhil Dhanesh Goel
- Department of Community Medicine and Family Medicine, 410730All India Institute of Medical Sciences, Jodhpur, Rajasthan
| | - Kuldeep Singh
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| |
Collapse
|
13
|
Szymanik-Grzelak H, Barabasz M, Wikiera-Magott I, Banaszak B, Wieczorkiewicz-Płaza A, Bieniaś B, Drożynska-Duklas M, Tkaczyk M, Pańczyk-Tomaszewska M. Retrospective analysis of clinical and pathomorphological features of lupus nephritis in children. Adv Med Sci 2021; 66:128-137. [PMID: 33545446 DOI: 10.1016/j.advms.2021.01.004] [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: 07/21/2020] [Revised: 12/08/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of the study was to evaluate the clinical course and pathomorphological correlations in Polish children with the diagnosis of lupus nephritis (LN). METHODS We retrospectively analyzed the medical records of 39 children hospitalized due to LN in 7 pediatric nephrology units in Poland between 2010 and 2019. Demographic data, clinical symptoms at the onset of LN and laboratory parameters were reviewed. We analyzed Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), histological LN findings with the activity (IA) and chronicity index (IC). RESULTS We examined 32 girls and 7 boys, median age at LN onset was 14.75 (IQR 13.0-16.0) years, SLEDAI of 22.0 (IQR 18.0-27.0) points; LN histological class: IV (59.4%), III (18.9%), III/V (10.8%), IV/V (8.1%), VI (2.7%); IA 8.0 (IQR 6.0-11.0) points, IC 1.05 (IQR 0-2.0) points. Children with nephrotic (n = 22) and non-nephrotic (n = 17) proteinuria differed in median Hb level (9.55, IQR 8.3-11.2 vs 10.9, IQR 10.1-11.6 g/L; P < 0.05), albumin level (2.5, IQR 2.1-3.19 vs 3.6, IQR 3.4-4.1 g/dL; P < 0.001), proteinuria (5.76, IQR 3.0-7.5 vs 1.08, IQR 0.53-1.50 g/day; P < 0.0001), eGFR (53.9, IQR 27.0-68.8 vs 96.7, IQR 73.8-106.2 mL/min/1.73 m2; P < 0.01) and occurrence of hypertension (77% vs 23%; P < 0.01). In multivariate analysis Hb level (β = 8.0; 95%CI, 1.90-14.11) was the significant predictor of eGFR<90 mL/min/1.73 m2. CONCLUSIONS Proliferative forms of LN in children may have a varying clinical presentation. Children with LN with nephrotic range proteinuria have lower Hb level, lower eGFR and higher occurrence of hypertension. Hb level is the significant predictor of eGFR<90 mL/min/1.73 m2 in children with LN.
Collapse
|
14
|
Abstract
Systemic lupus erythematosus is a rare lifelong multi-systemic autoimmune condition. Juvenile-onset SLE (JSLE) is recognized to have a more active disease course when compared with adult-onset disease and patients have a worse long-term survival. Kidney involvement occurs in over 50% of children and treatment decisions are guided by the histological classification. Several international groups have produced treatment protocols that rely on an intense period of immunosuppression to halt the acute kidney inflammatory process, followed by maintenance therapy with close observation for disease improvement and prompt evaluation of disease flares. A reduced glomerular filtration rate at presentation is predictive of later stage chronic kidney disease (CKD) in multivariate analysis. Kidney remission remains suboptimal with only 40-60% of patients achieving complete remission. Kidney flares are seen in over a third of patients. The rate of CKD 5 is reported to be up to 15% and the presence of lupus nephritis (LN) has an established link with an associated increase in mortality. In established kidney failure, transplantation seems to be the optimal kidney replacement modality for this group of patients, ideally after a period of disease quiescence. Modified outcome measures in clinical trials have demonstrated that biologic agents can be effective in this disease. Current biologic agents under investigation include obinutuzimab, belimumab, atacicept, anifrolumab, tocilizumab, eculizumab, dapirolizumab, and abatacept. Future research should focus on discovering early disease biomarkers, including surrogates for later cardiovascular disease, and evaluating biological agents as adjuncts to improve the rates of complete remission and subsequently influence the kidney outcome. The aim of this review article is to summarize the current kidney outcomes for this disease with a view to identifying key areas that may help to reduce the risk of long-term CKD.
Collapse
|
15
|
Zhang CX, Cai L, Zhou ZY, Mao YY, Huang H, Yin L, Chen TX, Zhou W. Clinical manifestations, immunological features and prognosis of Chinese pediatric systemic lupus erythematosus: A single-center study. Int J Rheum Dis 2019; 22:1070-1076. [PMID: 30957986 DOI: 10.1111/1756-185x.13547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 02/15/2019] [Accepted: 02/17/2019] [Indexed: 11/30/2022]
Abstract
AIM Since there are only a few reports on pediatric systemic lupus erythematosus (pSLE) in Chinese populations, therefore we retrospectively report the clinical and immunological features as well as renal outcome in Chinese pSLE. METHODS Patients diagnosed with pSLE at Shanghai Children's Medical Center between 2001 and 2016 were evaluated and clinical data were retrospectively collected. RESULTS A total of 102 pSLE patients were analyzed. Renal disorder including proteinuria (81.37%) and hematuria (65.69%) were most commonly identified. Class IV was the most common finding on renal biopsy. In lupus nephritis (LN), 67.21%, 78.0%, 86.0% and 94.55% achieved complete remission within 6, 12, 18 and 24 months, respectively. Furthermore, 16.67% of LN patients suffered at least one renal flare. Antinuclear antibodies were detected in nearly all patients (97.62%), followed by anti-double-stranded DNA (anti-dsDNA) antibodies (70.0%) and anti-Sjögren's syndrome A (anti-SSA) antibodies (60.64%). Oral corticosteroid (93.14%) and mycophenolate mofetil (64.71%) was used in the majority of patients. Infection (32.35%) was the main side effect caused by the medications. CONCLUSIONS Our population-based pSLE cohort indicated that compared to other international cohorts, there was a higher prevalence of LN in Chinese pSLE. Proteinuria was the most frequent manifestation both at disease onset and during the entire clinical course. Class IV LN was the dominant renal pathological type. Nevertheless, there was a favorable renal remission rate and relatively low incidence of renal flare in our cohort. Apart from antinuclear antibodies and anti-dsDNA antibodies, anti-SSA antibodies were most frequently detected. Infection was the leading complication caused by the medications.
Collapse
Affiliation(s)
- Chen-Xing Zhang
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Division of Immunology, Institute of Pediatric Translational Medicine, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Li Cai
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Division of Immunology, Institute of Pediatric Translational Medicine, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Zheng-Yu Zhou
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - You-Ying Mao
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hua Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Lei Yin
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Tong-Xin Chen
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Division of Immunology, Institute of Pediatric Translational Medicine, Shanghai Jiaotong University School of Medicine, Shanghai, China.,Department of Allergy and Immunology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Zhou
- Department of Nephrology and Rheumatology, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai, China
| |
Collapse
|
16
|
Shaharir SS, Kadir WDA, Nordin F, Bakar FA, Ting MWH, Jamil A, Mohd R, Wahab AA. Systemic lupus erythematosus among male patients in Malaysia: how are we different from other geographical regions? Lupus 2018; 28:137-144. [PMID: 30458692 DOI: 10.1177/0961203318812676] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Systemic lupus erythematosus (SLE) is an autoimmune disease which predominantly affects females. The disease characteristics in male SLE patients are reported to be distinct and may vary across ethnicities and geographical regions. OBJECTIVE To determine and compare the clinical phenotype and organ damage between male and female patients with SLE in Malaysia. METHODOLOGY This was a cross-sectional study involving SLE patients from Universiti Kebangsaan Malaysia Medical Centre from June 2016 until June 2017. Information on their socio-demographics and disease characteristics were obtained from the clinical records. Disease damage was assessed using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index (SDI) scores. The disease characteristics, autoantibody profiles and organ damage were compared between male and female patients, and multivariable analysis using male sex as dependent variable was then performed. RESULTS A total of 418 patients were recruited and a total of 59 (14.1%) patients were male. Male patients presented with lower SLE ACR criteria at initial presentation but a significantly higher number of them had renal involvement (lupus nephritis) (78.0% versus 63.8%, p = 0.04). Male patients had less musculoskeletal involvement (45.8% versus 63.0%, p = 0.02) and tended to have lesser mucocutaneous involvement. Immunologic profile revealed that a lower number of male patients had positive anti-Ro antibody (22.7% versus 44.7%, p = 0.04) and they tended to have positive lupus anticoagulant antibody (27.6% versus 14.3%, p = 0.06). Presence of organ damage (SDI score ≥ 1) was significantly higher among males (55.9% versus 39.6%, p = 0.02) with higher renal damage (25.4% versus 9.2%, p = 0.004) and cardiovascular event of ischaemic heart disease or stroke (20.3% versus 7.0%, p = 0.004). They were also inclined to develop damage much earlier as compared to female patients, 3 (interquartile range (IQR) 7.5) versus 5 (IQR 7) years, p = 0.08. The occurrence of disease damage was independently associated with male gender with odds ratio of 1.9 (95% confidence interval 1.1-3.5), p = 0.02. CONCLUSION Male patients with SLE have more severe disease with renal damage and cardiovascular event.
Collapse
Affiliation(s)
- S S Shaharir
- 1 Rheumatology Unit, Department of Internal Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
| | - W D Abdul Kadir
- 2 Department of Internal Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
| | - F Nordin
- 1 Rheumatology Unit, Department of Internal Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
| | - F Abu Bakar
- 2 Department of Internal Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
| | - M W H Ting
- 2 Department of Internal Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
| | - A Jamil
- 3 Dermatology Unit, Department of Internal Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
| | - R Mohd
- 4 Nephrology Unit, Department of Internal Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
| | - A Abdul Wahab
- 5 Department of Immunology and Microbiology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur
| |
Collapse
|
17
|
Mohapatra A, Kakde S, Annapandian VM, Valson AT, Duhli N, Korula A, Matthai SM, Pulimood AB, David VG, Alexander S, Jacob S, Varughese S, Basu G, Tamilarasi V, John GT. Spectrum of biopsy proven renal disease in South Asian children: Two decades at a tropical tertiary care centre. Nephrology (Carlton) 2018; 23:1013-1022. [PMID: 28846194 PMCID: PMC7615900 DOI: 10.1111/nep.13160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2017] [Indexed: 11/29/2022]
Abstract
AIM We report findings from a large single centre paediatric renal biopsy cohort in South Asia. METHODS We analyzed all renal biopsies performed on children aged ≤18 years between 1996 and 2015 at our centre. The clinical characteristics and histological diagnosis pertaining to each case, distribution of renal diseases in children with various clinical presentations, and changes in the pattern of kidney disease during the study period were analyzed. RESULTS A total of 1740 paediatric kidney biopsies were performed during the study period. The mean age was 12.8 ± 4.9 years (8 months to 18 years) and the male: female ratio was 1.5:1. The most common indication for renal biopsy was nephrotic syndrome (63.2%) followed by acute nephritic syndrome (13%). Minimal change disease was the most common cause of nephrotic syndrome while endocapillary proliferative glomerulonephritis (65.7% infection related), remained the commonest cause of acute nephritic syndrome. IgA nephropathy was the commonest cause of chronic kidney disease. Contrary to trends in European paediatric cohorts, the frequency of lupus nephritis increased over the two decades of the study, while that of endocapillary proliferative glomerulonephritis did not show any appreciable decline. CONCLUSION This study provides the largest data on biopsy proven renal disease in children from South Asia published till date and highlights important differences in the spectrum and trends of kidney disease compared to data from other regions.
Collapse
Affiliation(s)
- Anjali Mohapatra
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
| | - Shailesh Kakde
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
| | - Vellaichamy M Annapandian
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
- Academic Research Department, Narayana Hrudayalaya Foundations, Bangalore, India
| | - Anna T Valson
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
| | - Neelaveni Duhli
- Department of Pathology, Christian Medical College and Hospital, Vellore, India
| | - Anila Korula
- Department of Pathology, Christian Medical College and Hospital, Vellore, India
| | - Smita Mary Matthai
- Central Electron Microscopy Unit, Christian Medical College and Hospital, Vellore, India
| | - Anna B. Pulimood
- Central Electron Microscopy Unit, Christian Medical College and Hospital, Vellore, India
| | - Vinoi G David
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
| | - Suceena Alexander
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
| | - Shibu Jacob
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
| | - Gopal Basu
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
- Department of Nephrology, Central Northern Adelaide Renal and Transplant Service, Adelaide, Australia
| | - Veerasamy Tamilarasi
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
| | - George T John
- Department of Nephrology, Christian Medical College and Hospital, Vellore, India
- Department of Renal Medicine, Royal Brisbane and Women’s Hospital, Queensland, Australia
| |
Collapse
|
18
|
Aggarwal A, Phatak S, Srivastava P, Lawrence A, Agarwal V, Misra R. Outcomes in juvenile onset lupus: single center cohort from a developing country. Lupus 2018; 27:1867-1875. [DOI: 10.1177/0961203318791046] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction About 10–20% of systemic lupus erythematosus (SLE) patients have onset in childhood and have more severe organ involvement. Survival of juvenile SLE patients is improving worldwide. Long-term data of childhood onset SLE from developing countries is scarce. Methods Clinical and laboratory data at initial presentation and follow-up visits were retrieved from clinic files, hospital information system and personal interviews. Treatment received, complications, flares, outcomes and death were recorded. Survival was calculated using Kaplan–Meier survival curves and regression analysis was done for predictors of mortality. Results Children with SLE ( n = 273, 250 girls) had a median age at onset of 14 years and duration of illness prior to diagnosis at our hospital of 1 year. Fever and arthritis were the most common presenting manifestations. Renal disease was seen in 60.5% and central nervous system (CNS) disease in 29%. The median follow-up period in 248 patients was 3.5 years. Fourteen children died, and 10 of these had active disease at the time of death. The mean actuarial survival was 24.5 years and survival rates at 1, 5 and 10 years were 97.9%, 95% and 89% respectively. Fever, CNS disease, anti-dsDNA levels and serious infections predicted death on univariate and multivariate analysis. Infections were seen in 72 children (26.3%), and 38 of these infections were serious. One-third of the patients had damage on the last follow-up. Flares were seen in 120 children, the majority being major flares. Conclusion Outcomes of pediatric SLE in North Indian children are similar to those seen in developed countries. Infections pose a major challenge in these patients.
Collapse
Affiliation(s)
- A Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - S Phatak
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - P Srivastava
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - A Lawrence
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - V Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - R Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
19
|
George J, Sankaramangalam KP, Sinha A, Hari P, Dinda AK, Bagga A. Lupus Nephritis in Indian Children: Flares and Refractory Illness. Indian Pediatr 2018. [DOI: 10.1007/s13312-018-1337-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
|
20
|
Samanta M, Nandi M, Mondal R, Hazra A, Sarkar S, Sabui T, Kundu CK, Biswas A. Childhood lupus nephritis: 12 years of experience from a developing country's perspective. Eur J Rheumatol 2017; 4:178-183. [PMID: 29163999 DOI: 10.5152/eurjrheum.2017.16117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/12/2017] [Indexed: 12/18/2022] Open
Abstract
Objective To assess the long-term outcome of lupus nephritis in children with systemic lupus erythematosus followed up over 12 years at a tertiary care teaching hospital in Eastern India. Material and Methods This is a retrospective observational study of the clinicopathological presentation, management, and outcome in 46 children with lupus nephritis over a period of 12 years at a tertiary teaching hospital in Eastern India. Mortality was compared between different lupus classes and therapy groups with Kaplan-Meier analysis and log-rank test. Results The incidence of lupus nephritis was 58.97% [95% confidence interval (CI) 48.06%-59.89%] with the mean age at presentation being 10.2±2.43 years (range 5.5-14.5) years. Majority belonged to class IV (30.43%), followed by class II (26.91%), class III (23.91), and class V (8.70%). Outcome analysis of children with lupus nephritis over 12 years revealed that 24 (52.17%) achieved complete remission of disease activity, 5 attained partial remission, 4 continued to have active disease, 5 developed end-stage renal disease (ESRD), and 8 died. Overall mortality thus observed was 17.39% with septicemia in the background of ESRD being the commonest cause. No significant difference in mortality was observed between different lupus nephritis classes or therapy arm groups. Conclusion The study throws light on various aspects of lupus nephritis and their long-term outcome patterns in children from developing countries such as India.
Collapse
Affiliation(s)
- Moumita Samanta
- Department of Pediatrics, NRS Medical College, Kolkata, India
| | - Madhumita Nandi
- Department of Pediatrics, NRS Medical College, Kolkata, India
| | - Rakesh Mondal
- Department of Pediatrics, Medical College and Hospital, Kolkata, India
| | - Avijit Hazra
- Department of Pharmacology, IPGME&R SSKM Hospital, Kolkata, India
| | - Sumatra Sarkar
- Department of Pediatrics, IPGME&R SSKM Hospital, Kolkata, India
| | - Tapas Sabui
- Department of Pediatrics, RGKAR Medical College, Kolkata, India
| | | | - Arnab Biswas
- Department of Pediatrics, NRS Medical College, Kolkata, India
| |
Collapse
|
21
|
Srivastava P, Abujam B, Misra R, Lawrence A, Agarwal V, Aggarwal A. Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years. Lupus 2015; 25:547-57. [PMID: 26637291 DOI: 10.1177/0961203315619031] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 11/02/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Childhood SLE (cSLE) has a higher prevalence of lupus nephritis (LN), and there are ethnic variations in response to treatment as well as outcome of LN. There are limited data on long-term outcome of LN in cSLE from the Indian subcontinent. METHODS Retrospective analysis of case records of patients with cSLE (satisfying revised American College of Rheumatology (ACR) 1997 criteria for diagnosis) and age of onset <18 years was conducted from 1989 to 2013. Data on clinical features, renal involvement and biopsy findings, treatment, renal outcome, damage accrual and mortality were collected. End-stage renal disease (ESRD) was defined as the need for renal replacement therapy. Actuarial ESRD-free survival was studied as the primary outcome measure using Kaplan-Meier analysis. RESULTS Among 205 children with cSLE, 134 (121 girls) had evidence of LN. The mean age at disease onset was 13.7 ± 3.5 years and the mean disease duration at presentation was 1.9 ± 2.5 years. Kidney biopsy was available for 92 patients, and histology included: 13 (14.2%) Class II, 24 (26%) Class III, 43 (46.7%) Class IV and 12 (13.1%) Class V LN. The mean follow-up period was 6.75 ± 5.7 years. At last visit, 81 (60.4%) children were in complete remission, 28 (20.9%) were in partial remission, 15 (11.2%) still had active nephritis and 10 (7.4%) had progressed to ESRD. Almost two-thirds (62.9%) of patients experienced lupus flares, and mean flare rate was 0.09 flares/patient follow-up year. Fifty-six (43.8%) children accrued damage and the mean Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage score was 0.79 ± 1.13. Actuarial ESRD-free survival at five, 10 and 15 years was 91.1%, 79% and 76.2%, and five-, 10- and 15-year renal survival was 93.8%, 87.1% and 84%, respectively. Although multiple factors individually predicted poor outcome (death/ESRD), only raised serum creatinine at onset (R square = 0.65, p ≤ 0.0001) and damage accrual (R square = 0.62, p ≤ 0.0001) remained significant on multivariate analysis. Eleven (8.2%) children died during the follow-up period, and infections were the leading cause of mortality. CONCLUSIONS Long-term outcome of LN in cSLE in our cohort was better than previous reports from India. However, a high rate of major infection still remains the leading cause of mortality.
Collapse
Affiliation(s)
- P Srivastava
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - B Abujam
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - R Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A Lawrence
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - V Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
22
|
Fatemi A, Matinfar M, Saber M, Smiley A. The association between initial manifestations of childhood-onset systemic lupus erythematosus and the survival. Int J Rheum Dis 2015; 19:974-980. [PMID: 26632491 DOI: 10.1111/1756-185x.12807] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Childhood-onset systemic lupus erythematosus (cSLE) comprises 15-20% of patients with SLE. Although several studies have reported the outcomes of adult-onset SLE, few investigations have been conducted on cSLE in the Middle East. METHODS In a retrospective study, all children with SLE admitted to our tertiary referral center between 1992 and 2011 were recruited. The clinical and laboratory data at the time of onset were recorded and analyzed. Kaplan-Meier analysis was used to calculate the survival rates. Cox regression analysis was applied to assess the predictors of mortality. RESULTS One hundred and eighty-eight children diagnosed with SLE were enrolled during the study period. Nine patients were censored due to loss to follow-up (6) and incomplete data (3 cases). Mean age of patients at the time of onset was 14.4 (3.05) years. Only 22 (11.8%) children were younger than 10 years at the time of disease onset. In total, 20 patients (11%) died, all after the first decade of life. The most common cause of death was lupus nephritis (10 patients, 50% of deaths) followed by infections (35%), cerebrovascular accidents (10%) and alveolar hemorrhage (5%). Cumulative survival rate after 5, 10, 15 and 20 years was 91, 87, 85, and 79%, respectively. Having hematuria or pleurisy at the time of SLE onset had a negative effect on survival in multivariate analysis. CONCLUSION cSLE survival in Iran was comparable to that in other developing countries. Baseline presentation with hematuria predominantly increased the mortality rate in cSLE. Prospective and larger studies in future may unfold other aspects of cSLE.
Collapse
Affiliation(s)
| | | | - Mina Saber
- Department of Dermatology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Smiley
- Department of Epidemiology, School of Public Health, Indiana University, Bloomington, Indiana, USA
| |
Collapse
|
23
|
Sui M, Ye X, Ma J, Yu C, Zhao S, Liu X, Li L, Cao J, Jia X, Xie R. Epidemiology and risk factors for chronic kidney disease in Chinese patients with biopsy-proven lupus nephritis. Intern Med J 2015; 45:1167-72. [PMID: 26109241 DOI: 10.1111/imj.12840] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 06/09/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lupus nephritis (LN) is one of the most serious complications of systemic lupus erythematosus (SLE). It is the most common secondary glomerulonephritis leading to end-stage renal disease. AIM The purpose of this study is to evaluate the epidemiology and risk factors of chronic kidney disease (CKD) in Chinese patients with LN. METHODS Clinical, laboratory, renal histopathology, treatment and outcome data were collected and retrospectively analysed in LN patients with or without CKD. RESULTS At the end of the study, 94 (45.63%) patients were identified as having CKD among 206 individuals with renal biopsy-proven LN. Renal function, represented by serum creatinine and estimated glomerular filtration rate, was significantly decreased in the CKD patients (P = 0.008 and P < 0.001, respectively) at the time of the kidney biopsy. Compared with the non-CKD group, significantly increased proportions of hypertension (P < 0.001), serositis (P = 0.042) and anti-histone antibody positivity (P = 0.004) were detected in the CKD patients. Renal pathological activity and chronicity index scores were significantly increased in the CKD group (P < 0.001 for all). Finally, hypertension (hazard ratio (HR) 2.432, 95% confidence interval (CI) 1.575-3.754, P < 0.001), anti-histone antibody (HR 2.907, 95% CI 1.837-4.600, P < 0.001), and tubular atrophy (HR 1.248, 95% CI 1.007-1.547, P = 0.043) were independent risk factors for CKD. CONCLUSIONS Hypertension, anti-histone antibody and tubular atrophy are independent risk factors for CKD in Chinese LN patients.
Collapse
Affiliation(s)
- M Sui
- Department of Nephrology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - X Ye
- Department of Haematology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - J Ma
- Department of Nephrology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - C Yu
- Department of Cardiology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - S Zhao
- Department of Nephrology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - X Liu
- Department of Nephrology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - L Li
- Department of Nephrology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - J Cao
- Endemic Disease Control, Harbin Center for Disease Prevention and Control, Harbin, China
| | - X Jia
- Department of Nephrology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - R Xie
- Department of Nephrology, First Affiliated Hospital of Harbin Medical University, Harbin, China
| |
Collapse
|
24
|
Singh S, Abujam B, Gupta A, Suri D, Rawat A, Saikia B, Minz RW, Joshi K, Nada R. Childhood lupus nephritis in a developing country-24 years' single-center experience from North India. Lupus 2015; 24:641-7. [PMID: 25712249 DOI: 10.1177/0961203315570166] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/07/2015] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Data on outcome of childhood lupus nephritis from developing countries are sparse. This study looks at outcome in children with lupus nephritis from a federal government-funded teaching hospital in North India. METHODS This study included children less than 14 years of age with lupus nephritis who presented to a single center during a period of 24 years (1991 to 2013). Data on clinical characteristics and outcome were extracted from medical records. The primary outcome was actuarial survival (time-to-death) and secondary outcome was actuarial renal survival using Kaplan-Meier analysis. A worst-case scenario that assumed children who were lost to follow-up as having either died or gone into end-stage renal disease was also calculated. Log-rank test and Cox-regression were used to assess difference in survival by histological class and predictors of poor outcome, respectively. RESULTS This study included 72 children, with a female:male ratio of 3:1, mean (±SD) age at onset of lupus 9.3 (±2.4) years and mean (±SD) time from onset-to-nephritis being 9.4 (±12.6) months. Renal biopsy was conducted in 53 children. The most common histological class was class IV (35 children). Mortality occurred in 22 children (30%), with half of these occurring at presentation. The two important causes of death were infection and end-stage renal disease. Actuarial survival was 81%, 67% and 59% at one, five and 10 years, respectively. In the worst-case scenario, actuarial survival was 72%, 53% and 38%, respectively. Renal survival was 96%, 89% and 78% (worst-case scenario 86%, 73% and 52%) at one, five and 10 years, respectively. There was no difference in survival by histological class. On univariate analysis, serum creatinine at presentation (hazard ratio = 2.2 (95% CI 1.3-3.9)) and serious infection (hazard ratio 7.9 (95% CI 2.6-23.5)) were statistically significant predictors of time-to-death. CONCLUSION Outcome of children with lupus nephritis from India is worse than developed countries. Nearly one-third of the children died, half at presentation, with common causes being infection and end-stage renal disease.
Collapse
Affiliation(s)
- S Singh
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre
| | - B Abujam
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre
| | - A Gupta
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre
| | - D Suri
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre
| | - A Rawat
- Pediatric Allergy Immunology Unit, Advanced Pediatrics Centre
| | | | | | - K Joshi
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
25
|
Vijay Y, Parveen B. Clinical and immunological profile of systemic lupus erythematosus in a pediatric population in North India. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2014. [DOI: 10.4103/1110-161x.147354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
26
|
Batinić D, Milošević D, Čorić M, Topalović-Grković M, Jelušić M, Turudić D. Lupus nephritis in Croatian children: clinicopathologic findings and outcome. Lupus 2014; 24:307-14. [DOI: 10.1177/0961203314563133] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report clinical and histopathological features, treatment and outcome of 37 Croatian children with biopsy-proven lupus nephritis seen over a 30-year period. The mean age at lupus nephritis presentation was 12.11 ± 2.59 years (range 4.66–17.0). The most frequent histopathological finding was class IV (37.8%), followed by class III (35.1%), class V (16.2 %) and class II (10.8 %) lupus nephritis. Compared with other classes there were more boys among patients with class IV lupus nephritis, and hypertension, nephrotic syndrome and decreased estimated glomerular filtration rate at presentation were more common. The median histopathological activity and total scores were highest in class IV lupus nephritis patients. The mean follow-up was 7.14 ± 4.71 years, ranging from 1.1 years to 21.0 years. Kaplan–Meier estimates of patient and kidney (without renal failure) survival rates were 90.5% and 87 % at five years. The renal survival rate of class IV lupus nephritis patients was found significantly lower compared with other histological classes combined. Decreased estimated glomerular filtration rate at the time of diagnosis, class IV lupus nephritis versus other lupus nephritis classes, and high total histological score were the parameters significantly associated with adverse outcome. The therapy with cyclophosphamide showed as superior to the therapy with azathioprine.
Collapse
Affiliation(s)
- D Batinić
- Clinical Hospital Centre Zagreb, University Zagreb School of Medicine, Department of Paediatric Nephrology, Zagreb, Croatia
| | - D Milošević
- Clinical Hospital Centre Zagreb, University Zagreb School of Medicine, Department of Paediatric Nephrology, Zagreb, Croatia
| | - M Čorić
- Clinical Hospital Centre Zagreb, University Zagreb School of Medicine, Department of Pathology and Cytology, Zagreb, Croatia
| | - M Topalović-Grković
- Clinical Hospital Centre Zagreb, University Zagreb School of Medicine, Department of Anaesthesiology and Intensive Care, Zagreb, Croatia
| | - M Jelušić
- Clinical Hospital Centre Zagreb, University Zagreb School of Medicine, Department of Paediatric Rheumatology, Zagreb, Croatia
| | - D Turudić
- University Zagreb School of Medicine, Zagreb, Croatia
| |
Collapse
|
27
|
Qin H, Guo Q, Shen N, Huang X, Wu H, Zhang M, Bao C, Chen S. Chest imaging manifestations in lupus nephritis. Clin Rheumatol 2014; 33:817-23. [PMID: 24696368 DOI: 10.1007/s10067-014-2586-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 02/21/2014] [Accepted: 03/18/2014] [Indexed: 10/25/2022]
Abstract
The purpose of this study was to analyze the association between renal histopathological features and chest computed tomography (CT) findings in lupus nephritis (LN) patients. We retrospectively reviewed the medical records and chest thin-section CT findings of 152 patients with an established diagnosis of LN based on renal biopsy and 93 systemic lupus erythematosus (SLE) patients without LN between April 2009 and March 2012. The 64-detector row CT images were retrospectively evaluated by an experienced thoracic radiologist without knowledge of the patients' clinical information except that all patients had SLE. Lupus nephritis patients have a significantly higher incidence of lung/plural disease than those without LN (61.8 versus 44.0%, p<0.05). The patients in LN group were more prone to ground glass opacity, interlobular septal thickening, reticular opacities, pleural effusions, and consolidation on CT images than in non-LN group (p<0.05). Class I, class III, and class IV lupus nephritis were associated with traction bronchiectasis, ground glass opacity, and pleural effusions, respectively (p<0.05). The presence of cord on chest CT scans was significantly associated with renal interstitial lesion and interstitial inflammation/fibrosis (p<0.05). Ground glass opacity and reticular opacities on chest CT scans were also related to renal hyaline thrombi (p<0.05). There was a significant association between pleural effusions and cellular/fibrous crescents, interstitial lesion, or interstitial inflammation/fibrosis (p<0.05). It was shown that hyaline thrombi in renal biopsy was an independent risk factor of the presence of ground glass opacity on CTs with logistic regression analysis (Wald=4.124, p=0.042). LN patients were more likely to suffer from lung/pleural disease. The patients with hyaline thrombi in renal biopsy were more prone to have ground glass opacity on CTs.
Collapse
Affiliation(s)
- Hui Qin
- Department of Rheumatology and Respiratory, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Hematopoietic Stem Cell Transplantation in Children with Autoimmune Connective Tissue Diseases. Arch Immunol Ther Exp (Warsz) 2014; 62:319-27. [DOI: 10.1007/s00005-014-0279-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 11/15/2013] [Indexed: 12/29/2022]
|
29
|
Wu JY, Yeh KW, Huang JL. Early predictors of outcomes in pediatric lupus nephritis: focus on proliferative lesions. Semin Arthritis Rheum 2013; 43:513-20. [PMID: 23972330 DOI: 10.1016/j.semarthrit.2013.07.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 06/20/2013] [Accepted: 07/08/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Studies regarding the clinical features and outcomes of pediatric lupus nephritis are limited, and risk factors of poor outcome in the more severe form of renal involvement, proliferative lupus nephritis (PLN), are poorly understood. This study analyzed the data from a large prospective cohort of childhood systemic lupus erythematosus to determine such risk factors. METHODS Subjects younger than 18 years at onset with biopsy-proven lupus nephritis were enrolled. Data on baseline presentations and laboratory values, response to treatment, and outcomes were collected. Primary outcome measures were death or end-stage renal disease (ESRD). Survival analysis was done and predictors were approached. RESULTS One hundred four patients with mean age of 12.4 ± 2.5 years (range, 4.0-17.2 years) and the female-to-male ratio of 5.94:1 were included. Among them, 81 patients had PLN and 23 had non-proliferative lupus nephritis. Those with PLN had significantly lower GFR, more proteinuria, more urine sediment, more hypertension, and poor early response to treatment (within 6 months). There was no significant difference in extra-renal manifestations. All poor outcomes happened in the PLN group. The prognostic factors were high baseline SLEDAI-2k >20 (HR, 6.76; p = 0.002), baseline GFR <60ml/min/m² (HR, 3.88; p = 0.022), and early responder (HR, 0.19; p = 0.013). CONCLUSIONS Patients with pediatric lupus nephritis and high risk factor can be identified early by concomitantly considering their baseline features and early response, which provides a novel hint in decision for management decisions.
Collapse
Affiliation(s)
- Jhong-Yong Wu
- Department of Pediatrics, Division of Allergy, Asthma and Rheumatology, Chang Gung Memorial Hospital at Linkuo, Chang Gung University, 5, Fu-Hsin St, Taoyuan, Taiwan
| | - Kuo-Wei Yeh
- Department of Pediatrics, Division of Allergy, Asthma and Rheumatology, Chang Gung Memorial Hospital at Linkuo, Chang Gung University, 5, Fu-Hsin St, Taoyuan, Taiwan
| | - Jing-Long Huang
- Department of Pediatrics, Division of Allergy, Asthma and Rheumatology, Chang Gung Memorial Hospital at Linkuo, Chang Gung University, 5, Fu-Hsin St, Taoyuan, Taiwan.
| |
Collapse
|
30
|
Clinical and immunological profile of systemic lupus erythematosus. Indian Pediatr 2013; 50:405-7. [DOI: 10.1007/s13312-013-0115-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 07/19/2012] [Indexed: 10/26/2022]
|
31
|
Sircar D, Sircar G, Waikhom R, Raychowdhury A, Pandey R. Clinical features, epidemiology, and short-term outcomes of proliferative lupus nephritis in Eastern India. Indian J Nephrol 2013; 23:5-11. [PMID: 23580798 PMCID: PMC3621239 DOI: 10.4103/0971-4065.107187] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Race and ethnicity are important predictors of prognosis in lupus nephritis. This study was conducted to determine the clinical features, epidemiological profile, and short-term outcomes in patients of lupus nephritis from a single center in Eastern India. A total of 86 patients of class III/IV lupus nephritis were studied. Seventy-eight of them received cyclophosphamide for induction and eight of them received mycophenolate. The patients were evaluated for response, estimated glomerular filtration rate (eGFR), and proteinuria at 6 months. About 44% patients had a partial or complete response at 6 months and 64% at 1 year. The factors correlating with response at 6 months were older age at diagnosis, hypertension, activity, and chronicity indices and duration of symptoms prior to therapy. Chronicity index and hypertension were the predictors of response by logistic regression at 6 months. Compared to the Caucasian and African American patients, patients with proliferative lupus in Eastern India presented with a lower eGFR, lower proteinuria, and higher chronicity scores. Older age at diagnosis, hypertension, activity, chronicity indices, and duration of symptoms correlated with response. Short-term outcomes were similar to those described in Caucasian patients.
Collapse
Affiliation(s)
- D Sircar
- Department of Nephrology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | | | | | | | | |
Collapse
|
32
|
Silva CA, Avcin T, Brunner HI. Taxonomy for systemic lupus erythematosus with onset before adulthood. Arthritis Care Res (Hoboken) 2013; 64:1787-93. [PMID: 22730317 DOI: 10.1002/acr.21757] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 05/29/2012] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To propose a common nomenclature to refer to individuals who fulfill the American College of Rheumatology classification criteria for systemic lupus erythematosus (SLE) during childhood or adolescence. METHODS The medical literature was reviewed for studies conducted in the target population between 1960 and December 2011 to obtain information about the terms used to refer to such children and adolescents. We reviewed the threshold ages used and disease features considered to discriminate these individuals from patients with onset of SLE during adulthood. Furthermore, the nomenclature used in other chronic diseases with onset during both childhood and adulthood was assessed. RESULTS There was an astonishing variability in the age cutoffs used to define SLE onset prior to adulthood, ranging from 14-21 years, but most studies used age 18 years. The principal synonyms in the medical literature were SLE without reference to the age at onset of disease, childhood-onset SLE, juvenile SLE, and pediatric (or paediatric) SLE. CONCLUSION Based on the definition of childhood, in analogy with other complex chronic diseases commencing prior to adulthood, and given the current absence of definite genetic variations that discriminate adults from children, the term childhood-onset SLE is proposed when referring to individuals with onset of SLE prior to age 18 years.
Collapse
|
33
|
Ruggiero B, Vivarelli M, Gianviti A, Benetti E, Peruzzi L, Barbano G, Corona F, Ventura G, Pecoraro C, Murer L, Ghiggeri GM, Pennesi M, Edefonti A, Coppo R, Emma F. Lupus nephritis in children and adolescents: results of the Italian Collaborative Study. Nephrol Dial Transplant 2013; 28:1487-96. [DOI: 10.1093/ndt/gfs589] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
34
|
Gulati A, Bagga A. Management of lupus nephritis. INDIAN JOURNAL OF RHEUMATOLOGY 2012. [DOI: 10.1016/s0973-3698(12)60031-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
|
35
|
Dhir V, Aggarwal A, Lawrence A, Agarwal V, Misra R. Long-term outcome of lupus nephritis in Asian Indians. Arthritis Care Res (Hoboken) 2012; 64:713-20. [PMID: 22232126 DOI: 10.1002/acr.21597] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
36
|
Sato VAH, Marques IDB, Goldenstein PT, Carmo LPF, Jorge LB, Titan SMO, Barros RT, Woronik V. Lupus nephritis is more severe in children and adolescents than in older adults. Lupus 2012; 21:978-83. [PMID: 22451604 DOI: 10.1177/0961203312443421] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate clinicopathological features and treatment response in patients with lupus nephritis (LN), comparing the childhood- and late-onset forms of the disease. METHODS We retrospectively analyzed clinical presentation, treatment and evolution in patients diagnosed with LN by renal biopsy between 1999 and 2008. Patients were grouped by age-≤18 years (n = 23); and ≥50 years (n = 13)-and were followed for the first year of treatment. RESULTS The baseline features of the childhood- and late-onset groups, respectively, were as follows: mean age, 15 ± 2 and 54 ± 5 years; female gender, 87% and 92%; hypertension, 87% and 77%; Systemic Lupus Erythematosus Disease Activity Index, 29 ± 9 and 17 ± 7 (p = 0.002); estimated glomerular filtration rate (eGFR), 86 ± 66 and 70 ± 18 ml/min; concurrent SLE/LN diagnosis, 90% and 15% (p < 0.001); crescents on biopsy, 74% and 30% (p = 0.02); activity index on biopsy, 4.8 ± 2.6 and 3.3 ± 1.9 (p = 0.10); and interstitial fibrosis (>10%), 39% and 61% (p = 0.08). Treatment consisted mainly of methylprednisolone, prednisone and intravenous cyclophosphamide, average cumulative doses being similar between the groups. After 12 months of treatment, the eGFR in the younger and older patients was 116 ± 62 and 78 ± 20 ml/min, respectively (p = 0.005). Three of the younger patients progressed to dialysis at 12 months, compared with none of the older patients. CONCLUSION Childhood-onset LN seems to be more severe than is late-onset LN.
Collapse
Affiliation(s)
- V A H Sato
- Nephrology Division, University of São Paulo, School of Medicine, São Paulo, Brazil.
| | | | | | | | | | | | | | | |
Collapse
|
37
|
Jaybhaye AP, Sutay NR, Chate SV, Rathod TN. Juvenile systemic lupus erythematosus: A diagnostic dilemma. J Nat Sci Biol Med 2012; 2:229-31. [PMID: 22346244 PMCID: PMC3276022 DOI: 10.4103/0976-9668.92319] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Juvenile systemic lupus erythematosus is an autoimmune disorder characterized by inflammatory damage to joints, kidney, central nervous system, and hematopoietic system in the form of fever, cutaneous lesion including skin rash, arthritis, anemia, and fatigue. We report a case in which the patient had features mimicking idiopathic thrombocytopenic purpura and juvenile dermatomyositis, but on a detailed Hematological investigation and kidney biopsy patient was diagnosed as juvenile SLE.
Collapse
Affiliation(s)
- Amol P Jaybhaye
- Department of Paediatrics, Grant Medical College and Sir J.J. Group of Hospitals, Mumbai, India
| | | | | | | |
Collapse
|
38
|
Papadimitraki ED, Isenberg DA. Childhood- and adult-onset lupus: an update of similarities and differences. Expert Rev Clin Immunol 2010; 5:391-403. [PMID: 20477036 DOI: 10.1586/eci.09.29] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multifactorial autoimmune rheumatic disease. Although its highest prevalence is among women of childbearing age, the disease is not confined within this population. A total of 15-20% of cases of SLE are diagnosed in children younger than 16 years (childhood-onset lupus). Although there have been few studies directly comparing childhood- to adult-onset lupus, there is substantial evidence to suggest that pediatric lupus patients display some differences in their disease profile compared with adult-onset populations. Overall, an increased male-to-female ratio, a higher prevalence of nephritis and CNS involvement necessitating a more sustained need for steroids and immnosuppressive drugs, and a higher prevalence of progression to end-stage renal disease are distinguishing features of childhood-onset lupus. In contrast, a higher prevalence of pulmonary involvement, arthritis and discoid lupus are reported in adult-onset SLE patients. Furthermore, childhood-onset lupus patients may experience a serious negative impact on their psychosocial and physical development, issues that pose extra challenges to healthcare providers. Growth delay, osteoporosis, the psychological effect of steroid-induced alterations of the physical image, and often poor treatment compliance are the issues that need to be addressed in pediatric lupus populations. In this review, we compare the epidemiological, clinical and laboratory features, and treatment options of childhood- and adult-onset lupus, and comment on the applicability of the instruments that measure activity, severity and cumulative disease damage in childhood-onset disease. In addition, we highlight special issues of concern for pediatric lupus patients, discussing the significance in the transition from pediatric to adult rheumatology care.
Collapse
Affiliation(s)
- Eva D Papadimitraki
- Department of Rheumatology, 3rd floor, University College Hospital, 250 Euston Road, London NW1 2PG, UK
| | | |
Collapse
|
39
|
Abstract
OBJECTIVES To summarize the clinical presentation, histological features, treatment, and outcome of minimal change nephropathy (MCN) in patients with systemic lupus erythematosus (SLE). METHODS We performed a systematic review of cases of MCN in SLE patients reported in the English literature from January 1985 to May 2009 by a Medline search. RESULTS The estimated prevalence of MCN in biopsy-proven lupus nephritis is 2.3% in childhood and 1.1% in adults. There are 13 individual cases (12 women, one man) of SLE-related MCN reported in the literature. The mean age of nephritis onset was 32.7 years. In six (46%) patients, MCN was the initial manifestation of SLE. All patients presented with nephrotic syndrome and two (15%) had active urinary sediments. Renal function was impaired in eight (62%) patients and six (46%) patients had active lupus serology. All patients responded promptly to high-dose glucocorticoids but four (31%) had relapse of proteinuria during their course of SLE. None of the patients developed thromboembolic or infective complications. CONCLUSIONS MCN is an uncommon histological class of lupus nephritis. Typically, patients present with heavy proteinuria, and transient renal dysfunction is common. The prognosis of MCN in SLE appears to be good because of its rapid response to glucocorticoids. Relapses of proteinuria may be reduced by the use of maintenance immunosuppression. Alkylating agents, calcineurin inhibitors, mycophenolate mofetil, and rituximab can be considered in glucocorticoid-dependent or refractory cases of SLE-related MCN.
Collapse
Affiliation(s)
- C C Mok
- Department of Medicine, Tuen Mun Hospital and Centre for Assessment and Treatment of Rheumatic Diseases, Pok Oi Hospital, Hong Kong, China.
| | | | | |
Collapse
|