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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.
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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.
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Association Between Hypoalbuminemia, Degree of Proteinuria, and Lupus Nephritis Class: A Single-Center Cross-sectional Biopsy Study. Nephrourol Mon 2021. [DOI: 10.5812/numonthly.112883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The current study intended to determine whether serum albumin level and urine protein/creatinine rate (uPCR) are appropriate predictors of severe lupus nephritis in childhood-onset SLE. Objectives: Following a cross-sectional single-center design, 85 LN children referred to the National Children Hospital, Ha Noi, Viet Nam, from 6/2019 to 6/2020 were recruited. Renal biopsy was performed for all participants. Methods: Following a cross-sectional single-center design, 85 LN children referred to the National Children Hospital, Ha Noi, Viet Nam, from 6/2019 to 6/2020 were recruited. Renal biopsy was performed for all participants. Results: The mean SLEDAI score of all patients was 14.69. The proportion of patients with high and very high SLEDAI was 61.2 and 17.6%, respectively. The mean concentration of serum albumin was 28.55 g/L, and the proportion of decreased albumin concentration was 55.3%. The median uPCR was 446.6 mg/mmol in which 76.5% of values were ≥ 200 mg/mmol. Pathological morphology of LN class from I to VI was observed in 0%, 17.6%, 37.6 %, 37.6%, 7.1%, and 0%, respectively. Serum albumin level and uPCR presented the predictive value for severe and active LN (class IV and V); (AUC: 0.725 P < 0.001 for both). Conclusions: Serum albumin and uPCR were appropriate predictors for severe and active LN in Vietnamese children.
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Ogbu EA, Chandrakasan S, Rouster-Stevens K, Greenbaum LA, Sanz I, Gillespie SE, Marion C, Okeson K, Prahalad S. Impact of autoimmune cytopenias on severity of childhood-onset systemic lupus erythematosus: A single-center retrospective cohort study. Lupus 2020; 30:109-117. [PMID: 33108953 DOI: 10.1177/0961203320969806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess whether children with autoimmune cytopenias prior to or at diagnosis of systemic lupus erythematosus (cSLE), differ phenotypically from other cSLE patients; and have a lower risk and severity of lupus nephritis (LN) as observed in prior adult studies. To assess the effect of prior immune therapy for autoimmune cytopenias on 2-year risk of LN. METHODS This was a retrospective cohort study of incident cSLE cases. We included patients aged less than 17 years at diagnosis. We excluded patients with LN at cSLE diagnosis. Our follow-up period was 2 years. We defined autoimmune cytopenias as either autoimmune hemolytic anemia, immune thrombocytopenia or Evan's syndrome. RESULTS Forty-three (33%) of the 130 patients had autoimmune cytopenias before or at cSLE diagnosis. Those with autoimmune cytopenias had significantly more neuropsychiatric symptoms and higher mean ESR but less arthritis, malar rash and myositis versus those without autoimmune cytopenias. They had lower 2-year incidence proportion of LN compared to other cSLE patients (7% vs 15%). Of the 16 patients who developed LN, those with autoimmune cytopenias had mostly class V (2 of 3 patients) versus mostly class III and IV in those without autoimmune cytopenias (6 of 12 patients). None of the 13 patients pre-treated for autoimmune cytopenias developed LN. CONCLUSION Patients with autoimmune cytopenias before or at cSLE diagnosis have intriguing differences from other cSLE patients. They may represent a unique sub-type of cSLE patients and should be further explored.
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Affiliation(s)
- Ekemini A Ogbu
- Department of Pediatrics, Division of Pediatric Allergy, Immunology and Rheumatology, Johns Hopkins University, Baltimore, USA
| | - Shanmuganathan Chandrakasan
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Emory University School of Medicine and Children's Healthcare of Atlanta, Georgia, USA
| | - Kelly Rouster-Stevens
- Department of Pediatrics, Division of Pediatric Rheumatology, Emory University School of Medicine and Children's Healthcare of Atlanta, Georgia, USA
| | - Larry A Greenbaum
- Department of Pediatrics, Division of Pediatric Nephrology, Emory University School of Medicine and Children's Healthcare of Atlanta, Georgia, USA
| | - Ignacio Sanz
- Department of Medicine, Division of Rheumatology, Emory University School of Medicine, Georgia, USA
| | - Scott E Gillespie
- Department of Pediatrics, Emory University School of Medicine, Georgia, USA
| | | | - Karli Okeson
- Department of Pediatrics, Emory University School of Medicine, Georgia, USA
| | - Sampath Prahalad
- Department of Pediatrics, Division of Pediatric Rheumatology, Emory University School of Medicine and Children's Healthcare of Atlanta, Georgia, USA
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Lim SC, Chan EWL, Tang SP. Clinical features, disease activity and outcomes of Malaysian children with paediatric systemic lupus erythematosus: A cohort from a tertiary centre. Lupus 2020; 29:1106-1114. [PMID: 32631203 DOI: 10.1177/0961203320939185] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Paediatric systemic lupus erythematosus is a rare autoimmune disease with a wide spectrum of clinical presentation in different populations. We present a cohort of paediatric systemic lupus erythematosus in Malaysia where the disease features and outcomes are still largely unknown. METHODS A retrospective review of all paediatric systemic lupus erythematosus patients with at least 6 months follow-up at Selayang Hospital from 2004 to 2016. Epidemiological, clinical and outcome data were collected and analysed. RESULTS A total of 141 paediatric systemic lupus erythematosus patients, 87.9% females, were followed up for a median 6.3 years (interquartile range 3.6-9.0). The median age at diagnosis was 10.8 years (interquartile range 9.0-12.0 years), positive family history of systemic lupus erythematosus was present in 12.1% and the majority (61.7%) were of Malay ethnicity. Common presentations included fever (87.2%), vasculitic rash (72.3%) and lethargy (69.5%). At diagnosis, leukopenia (51.1%), thrombocytopenia (41.8%) and cutaneous lupus (56%) predominate with significant renal involvement (39.7%). Renal (45.4%), liver (26%) and the central nervous system (17%) were important major organs involved during the course of the disease. At diagnosis, almost all (99.3%) patients had high disease activity (mean Systemic Lupus Erythematosus Disease Activity Index score 20.1 ± 9.6). The majority (62.4%) achieved remission or low disease activity after 6 months, maintained over the next 10 years. Damage occurred early (39.1% at 1 year) and increased with time. Ocular damage was the most common side effect (29%) and was predominantly corticosteroid related (93%). Growth retardation was significant (38.2%) with no gonadal failure or secondary malignancies. End-stage renal disease occurred in 3.1% patients whereas 53.1% had sustained renal remission. Overall mortality was 1.4%. CONCLUSION Despite high disease activity at diagnosis, the majority had good sustained response to treatment with low overall mortality. However, there was progressive accrual of organ damage, highlighting the need for further research and refinements into therapies for paediatric systemic lupus erythematosus.
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Affiliation(s)
- Sern Chin Lim
- Department of Paediatrics, Universiti Teknologi MARA, Jalan Hospital, Sungai Buloh, Malaysia
| | - Elaine Wan Ling Chan
- Institute for Research, Development and Innovation, International Medical University, Bukit Jalil, Malaysia
| | - Swee Ping Tang
- Paediatric Rheumatology Unit, Selayang Hospital, Batu Caves, Malaysia
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Abdulrahman MA, Sallam DE. Treatment response and progression to end stage renal disease in adolescents and young adults with lupus nephritis: A follow up study in an Egyptian cohort. THE EGYPTIAN RHEUMATOLOGIST 2020. [DOI: 10.1016/j.ejr.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Hao GX, Song LL, Zhang DF, Su LQ, Jacqz-Aigrain E, Zhao W. Off-label use of tacrolimus in children with glomerular disease: Effectiveness, safety and pharmacokinetics. Br J Clin Pharmacol 2020; 86:274-284. [PMID: 31725919 DOI: 10.1111/bcp.14174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022] Open
Abstract
Glomerular diseases are leading causes of end-stage renal disease in children. Tacrolimus is frequently used off-label in the treatment of glomerular diseases. The effectiveness, safety and pharmacokinetic data of tacrolimus in the treatment of glomerular diseases in children are reviewed in this paper to provide evidence to support its rational use in clinical practice. The remission rates in previously published studies were different. In 19 clinical trials on children with nephrotic syndrome, the overall remission rate was 52.6-97.6%. In four clinical trials on children with lupus nephritis, the overall remission rate was 81.8-89.5%. In a pilot study with paediatric Henoch-Schönlein purpura nephritis patients, the overall remission rate was 100.0%. Infection, nephrotoxicity, gastrointestinal symptoms and hypertension are the most common adverse events. Body weight, age, CYP3A5 genotype, cystatin-C and daily dose of tacrolimus may have significant effects on the pharmacokinetics of tacrolimus in children with glomerular disease. More prospective controlled trials with long follow-up are needed to demonstrate definitely the effectiveness, safety and pharmacokinetics of tacrolimus in children with glomerular diseases.
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Affiliation(s)
- Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Lin-Lin Song
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Dong-Feng Zhang
- Department of Pediatric Nephrology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Le-Qun Su
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
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Falasinnu T, O'Shaughnessy MM, Troxell ML, Charu V, Weisman MH, Simard JF. A review of non-immune mediated kidney disease in systemic lupus erythematosus: A hypothetical model of putative risk factors. Semin Arthritis Rheum 2019; 50:463-472. [PMID: 31866044 DOI: 10.1016/j.semarthrit.2019.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/08/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022]
Abstract
About half of patients with systemic lupus erythematosus (SLE) are diagnosed with lupus nephritis (LN). Patients with SLE are also at increased risk for diabetes, hypertension and obesity, which together account for >70% of end-stage renal disease in the general population. The frequencies of non-LN related causes of kidney disease, and their contribution to kidney disease development and progression among patients with SLE have been inadequately studied. We hypothesize that a substantial, and increasing proportion of kidney pathology in patients with SLE might not directly relate to LN but instead might be explained by non-immune mediated factors such as diabetes, hypertension, and obesity. The goal of the manuscript is to draw attention to hypertension, diabetes and obesity as potential alternative causes of kidney damage in patients with SLE. Further, we suggest that misclassification of kidney disease etiology in patients with SLE might have important ramifications for clinical trial recruitment, epidemiologic investigation, and clinical care. Future studies aiming to elucidate and distinguish discrete causes of kidney disease - both clinically and histologically - among patients with SLE are desperately needed as improved understanding of disease mechanisms is paramount to advancing therapeutic discovery. Collaboration among rheumatologists, pathologists, nephrologists, and endocrinologists, and the availability of dedicated research funding, will be critical to the success of such efforts.
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Affiliation(s)
- Titilola Falasinnu
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane Stanford, Palo Alto, CA 94305, United States
| | | | - Megan L Troxell
- Department of Pathology, Stanford University Medical Center, Palo Alto, CA. United States
| | - Vivek Charu
- Department of Pathology, Stanford University Medical Center, Palo Alto, CA. United States
| | - Michael H Weisman
- Division of Rheumatology, Cedars-Sinai Medical Center, David Geffen School of Medicine, UCLA, United States
| | - Julia F Simard
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane Stanford, Palo Alto, CA 94305, United States; Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, United States.
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Pinheiro SVB, Dias RF, Fabiano RCG, Araujo SDA, Silva ACSE. Pediatric lupus nephritis. ACTA ACUST UNITED AC 2018; 41:252-265. [PMID: 30465590 PMCID: PMC6699445 DOI: 10.1590/2175-8239-jbn-2018-0097] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 09/05/2018] [Indexed: 12/18/2022]
Abstract
Involvement of the kidneys by lupus nephritis (LN) is one of the most severe
clinical manifestations seen in individuals with systemic lupus erythematosus
(SLE). LN is more frequent and severe in pediatric patients and has been
associated with higher morbidity and mortality rates. This narrative review
aimed to describe the general aspects of LN and its particularities when
affecting children and adolescents, while focusing on the disease's
etiopathogenesis, clinical manifestations, renal tissue alterations, and
treatment options.
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Affiliation(s)
- Sergio Veloso Brant Pinheiro
- Universidade Federal de Minas Gerais, Hospital das Clínicas, Unidade de Nefrologia Pediátrica, Belo Horizonte, MG, Brasil
| | - Raphael Figuiredo Dias
- Universidade Federal de Minas Gerais, Hospital das Clínicas, Unidade de Nefrologia Pediátrica, Belo Horizonte, MG, Brasil
| | | | - Stanley de Almeida Araujo
- Universidade Federal de Minas Gerais, Hospital das Clínicas, Unidade de Nefrologia Pediátrica, Belo Horizonte, MG, Brasil
| | - Ana Cristina Simões E Silva
- Universidade Federal de Minas Gerais, Hospital das Clínicas, Unidade de Nefrologia Pediátrica, Belo Horizonte, MG, Brasil
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Jongvilaikasem P, McNeil EB, Dissaneewate P, Vachvanichsanong P. Improvement of survival rates in the last decade in Thai childhood-onset systemic lupus erythematosus. Pediatr Rheumatol Online J 2018; 16:62. [PMID: 30268135 PMCID: PMC6162941 DOI: 10.1186/s12969-018-0274-5] [Citation(s) in RCA: 9] [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: 05/21/2018] [Accepted: 09/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Morbidity and mortality in childhood onset systemic lupus erythematosus (SLE) is more severe than adult onset SLE. Long-term follow up is needed to determine the prognosis. The objectives of this study are to describe the mortality of childhood SLE in a single tertiary care centre over three decades, compare trends in survival over time, and determine predictors for survival. METHODS We retrospectively reviewed the medical records of children aged < 18 years who were diagnosed with SLE at the Department of Pediatrics, Songklanagarind Hospital, Thailand, from 1985 to 2016. RESULTS There were 331 children (272 girls, 59 boys) with a mean age at presentation of 11.5 ± 2.6 years. The mean follow-up duration was 7.0 ± 5.0 (range 1-28) years, 77 children (23.3%) died, 28.6% within the first year after diagnosis. The overall mortality rate was 3.3 per 100 person-years. Survival rates at 1, 5 and 10 years were 93.4%, 83.1% and 72.6%, respectively. Ten-year survival rates for the children diagnosed in the decades 1985-1996, 1997-2006 and 2007-2016 were 67.4%, 63.4% and 82.8%, respectively (p < 0.001). Boys had worse survival than girls (hazard ratio = 2.3, 95% CI: 1.4-3.7) even after adjusting for decade of diagnosis. Lupus nephritis (LN) class IV had similar survival compared to LN classes II/III/V combined (hazard ratio = 1.0, 95% CI: 0.6-1.7). CONCLUSION In our setting, the survival rate of childhood onset SLE has improved during the past 10 years, but mortality is still high compared to developed countries, particularly in boys.
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Affiliation(s)
- Pondtip Jongvilaikasem
- 0000 0004 0470 1162grid.7130.5Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110 Thailand
| | - Edward B. McNeil
- 0000 0004 0470 1162grid.7130.5Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla Thailand
| | - Pornsak Dissaneewate
- 0000 0004 0470 1162grid.7130.5Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110 Thailand
| | - Prayong Vachvanichsanong
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
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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]
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Jin SY, Huang DL, Dang XQ, Yi ZW. Lupus glomerulonephritis in 788 Chinese children: a multi-centre clinical and histopathological analysis based on 549 renal biopsies. Paediatr Int Child Health 2017; 37:286-291. [PMID: 28463080 DOI: 10.1080/20469047.2017.1309337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND System lupus erythematosus (SLE) is a severe multisystem autoimmune disease. OBJECTIVE To describe the clinical and pathological features, treatment, and renal outcome in children under 18 years with lupus nephritis (LN). METHODS The study was undertaken by a questionnaire completed in 26 Grade 3A hospitals' paediatric renal units in China. The study comprised 788 children (619 girls, 169 boys) diagnosed with SLE by the American College of Rheumatology criteria (1997) during 2005-2010. Results of renal biopsies were classified according to the guidelines of The International Association of Nephrology and the Renal Pathology Society (2003). Guidelines by the Chinese Society of Paediatric Nephrology were applied for the diagnosis and treatment (for trial implementation) in 2010 to determine inclusion. The data included the prevalence of acute kidney injury (AKI), SLE disease activity index (SLEDAI), renal histopathology and the induction of therapy mode. RESULTS The mean (SD) age of onset of SLE was 10.9 (2.90) years (range 1-18) and at diagnosis was 11.3 (2.9) years. The mean (SD) SLEDAI score was 13.5 (5.53). The clinical classification was as follows: about 36 (4.6%) patients had isolated haematuria, 99 (12.6%) isolated proteinuria, 60 (7.6%) isolated haematuria and proteinuria, 157 (19.9%) acute glomerulonephritis, 392 (49.7%) nephrotic syndrome, 20 (2.5%) rapidly progressive glomerulonephritis, 15 (1.9%) chronic nephritis, 2 (0.3%) tubule-interstitial damage and 7 (0.9%) subclinical LN. A total of 549 children (69.7%) underwent renal biopsy. The most frequent renal histopathological findings of LN were Class IV, followed by Class II and Class V + IV. There were no significant differences between the age groups in either renal pathological types or prognosis. In 242 (30.7%) patients, LN was complicated by AKI. Those with AKI had an older mean (SD) age at onset than the non-AKI patients [11.5 (2.8) years vs 10.7 (2.9) years, respectively, p < 0.0001] and a higher SLEDAI score [14.3 (5.8) vs 13.1 (5.4), respectively, p = 0.003]. In the induction phase, cyclophosphamide (CTX) and mycophenolate mofetil (MMF) were equally effective in the patients with the same pathological type. Follow-up records were only available for 482 (61.2%) patients, with a mean (SD) follow-up time of 21.5 (18.4) months. Six of the 35 patients who deteriorated required dialysis and seven died. CONCLUSION In LN, AKI is a risk factor for poor outcome. Owing to different times of onset and remission, the pathological types of LN cannot be estimated by clinical manifestation alone, and therefore renal biopsy should be undertaken in all LN children with AKI. In the induction phase, there was no significant difference in efficacy between CTX and MMF. Follow-up of children with LN in China needs to be improved.
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Affiliation(s)
- Si-Yan Jin
- a Division of Paediatric Nephrology, Department of Paediatrics , Central South University , Changsha , P. R. China
| | - Dan-Lin Huang
- a Division of Paediatric Nephrology, Department of Paediatrics , Central South University , Changsha , P. R. China
| | - Xi-Qiang Dang
- a Division of Paediatric Nephrology, Department of Paediatrics , Central South University , Changsha , P. R. China
| | - Zhu-Wen Yi
- a Division of Paediatric Nephrology, Department of Paediatrics , Central South University , Changsha , P. R. China
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Turnier JL, Fall N, Thornton S, Witte D, Bennett MR, Appenzeller S, Klein-Gitelman MS, Grom AA, Brunner HI. Urine S100 proteins as potential biomarkers of lupus nephritis activity. Arthritis Res Ther 2017; 19:242. [PMID: 29065913 PMCID: PMC5655804 DOI: 10.1186/s13075-017-1444-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 09/27/2017] [Indexed: 11/17/2022] Open
Abstract
Background Improved, noninvasive biomarkers are needed to accurately detect lupus nephritis (LN) activity. The purpose of this study was to evaluate five S100 proteins (S100A4, S100A6, S100A8/9, and S100A12) in both serum and urine as potential biomarkers of global and renal system-specific disease activity in childhood-onset systemic lupus erythematosus (cSLE). Methods In this multicenter study, S100 proteins were measured in the serum and urine of four cSLE cohorts and healthy control subjects using commercial enzyme-linked immunosorbent assays. Patients were divided into cohorts on the basis of biospecimen availability: (1) longitudinal serum, (2) longitudinal urine, (3) cross-sectional serum, and (4) cross-sectional urine. Global and renal disease activity were defined using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) and the SLEDAI-2K renal domain score. Nonparametric testing was used for statistical analysis, including the Wilcoxon signed-rank test, Kruskal-Wallis test, Mann-Whitney U test, and Spearman’s rank correlation coefficient. Results All urine S100 proteins were elevated in patients with active LN compared with patients with active extrarenal disease and healthy control subjects. All urine S100 protein levels decreased with LN improvement, with S100A4 demonstrating the most significant decrease. Urine S100A4 levels were also higher with proliferative LN than with membranous LN. S100A4 staining in the kidney localized to mononuclear cells, podocytes, and distal tubular epithelial cells. Regardless of the S100 protein tested, serum levels did not change with cSLE improvement. Conclusions Higher urine S100 levels are associated with increased LN activity in cSLE, whereas serum S100 levels do not correlate with disease activity. Urine S100A4 shows the most promise as an LN activity biomarker, given its pronounced decrease with LN improvement, isolated elevation in urine, and positive staining in resident renal cells. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1444-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jessica L Turnier
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
| | - Ndate Fall
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Sherry Thornton
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - David Witte
- Department of Pathology and Laboratory Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Michael R Bennett
- Department of Nephrology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Simone Appenzeller
- State University of Campinas, Barão Geraldo, Campinas, SP, 13083-970, Brazil
| | - Marisa S Klein-Gitelman
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Chicago, IL, 60611, USA
| | - Alexei A Grom
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
| | - Hermine I Brunner
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, MLC 4010, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA
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Tanaka H, Joh K, Imaizumi T. Treatment of pediatric-onset lupus nephritis: a proposal of optimal therapy. Clin Exp Nephrol 2017; 21:755-763. [PMID: 28258497 DOI: 10.1007/s10157-017-1381-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 01/05/2017] [Indexed: 02/01/2023]
Abstract
Lupus nephritis (LN) is one of the major clinical manifestations of systemic lupus erythematosus (SLE) which occurs frequently in the early stages of pediatric-onset cases. Since SLE is a chronic disease associated with frequent disease flares and effective and safe maintenance therapy is required for achieving a favorable outcome, optimal treatment for LN in pubertal patients is a great challenge that remains to be overcome. Although its etiology remains unclear, it has been reported that the innate and adaptive immune systems have been reported to play an important role in the pathogenesis of SLE. However, studies of drugs that have been useful in controlling inflammatory pathways mediated by the innate and adaptive immune systems are now underway. In clinical practice, recent advances in the management of LN, together with earlier renal biopsy and selective use of aggressive immunosuppressive therapy, have contributed to a favorable outcome in children and adolescents with LN. However, the balance of the efficacy of treatment in terms of long-term prognosis and its adverse effects should be weighed in determining the treatment strategy.
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Affiliation(s)
- Hiroshi Tanaka
- Department of School Health Science, Faculty of Education, Hirosaki University, Hirosaki, 036-8650, Japan. .,Department of Pediatrics, Hirosaki University Hospital, Hirosaki, 036-8563, Japan.
| | - Kensuke Joh
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, 980-8575, Japan
| | - Tadaatsu Imaizumi
- Department of Vascular Biology, Graduate School of Medicine, Hirosaki University, Hirosaki, 036-8562, Japan
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Fatemi A, Matinfar M, Smiley A. Childhood versus adult-onset systemic lupus erythematosus: long-term outcome and predictors of mortality. Clin Rheumatol 2016; 36:343-350. [PMID: 28012055 DOI: 10.1007/s10067-016-3509-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 11/23/2016] [Accepted: 12/07/2016] [Indexed: 12/20/2022]
Abstract
The aim of this study was to compare survival of childhood-onset systemic lupus erythematosus (c-SLE) and adult-onset SLE (a-SLE) according to initial manifestations. This was a retrospective cohort study. All patients were categorized into c-SLE (≤18 years) and a-SLE (>18 years). The clinical and serological data at the time of diagnosis were recorded and compared. Kaplan-Meier curves were used to compare survival rates between the two groups. Predictors of mortality were obtained by a backward Cox regression. One hundred eighty patients with c-SLE and 394 patients with a-SLE were enrolled. The female/male ratio was higher in c-SLE (P = 0.0001). Lupus nephritis (P = 0.002) and valvular heart disease (P = 0.025) were more common in c-SLE and a-SLE, respectively. In a 23-year follow-up, 20 patients (11.1%) with c-SLE and 35 patients (8.9%) with a-SLE died. Mortality was not significantly different between them (P = 0.4). The main causes of death were nephritis (50% in c-SLE vs. 29% in a-SLE), infections (40% in c-SLE vs. 29% in a-SLE), and circulatory disease (10% in c-SLE vs. 37% in a-SLE). The difference was not significant (P = 0.08). Cumulative survival rates after 5, 10, 15, and 20 years were 91, 87, 85, and 78% in c-SLE and 93, 90, 90, and 83% in a-SLE, respectively. By multivariate analysis, seizure, proteinuria, and nephritis in c-SLE and seizure, hematuria, and pericarditis in a-SLE had negative prognostic effect on survival. Both c-SLE and a-SLE patients with seizure or renal involvement should be monitored more carefully to prevent ominous outcomes.
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Affiliation(s)
- Alimohammad Fatemi
- Department of Rheumatology, Alzahra Hospital, Sofe Street, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Mohammad Matinfar
- Department of Internal Medicine, Alzahra Hospital, Sofe Street, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abbas Smiley
- Department of Epidemiology and Biostatistics, School of Public Health, Indiana University, Bloomington, IN, USA
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Srivastava P, Abujam B, Misra R, Lawrence A, Agarwal V, Aggarwal A. Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years. Lupus 2015; 25:547-57. [PMID: 26637291 DOI: 10.1177/0961203315619031] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 11/02/2015] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Childhood SLE (cSLE) has a higher prevalence of lupus nephritis (LN), and there are ethnic variations in response to treatment as well as outcome of LN. There are limited data on long-term outcome of LN in cSLE from the Indian subcontinent. METHODS Retrospective analysis of case records of patients with cSLE (satisfying revised American College of Rheumatology (ACR) 1997 criteria for diagnosis) and age of onset <18 years was conducted from 1989 to 2013. Data on clinical features, renal involvement and biopsy findings, treatment, renal outcome, damage accrual and mortality were collected. End-stage renal disease (ESRD) was defined as the need for renal replacement therapy. Actuarial ESRD-free survival was studied as the primary outcome measure using Kaplan-Meier analysis. RESULTS Among 205 children with cSLE, 134 (121 girls) had evidence of LN. The mean age at disease onset was 13.7 ± 3.5 years and the mean disease duration at presentation was 1.9 ± 2.5 years. Kidney biopsy was available for 92 patients, and histology included: 13 (14.2%) Class II, 24 (26%) Class III, 43 (46.7%) Class IV and 12 (13.1%) Class V LN. The mean follow-up period was 6.75 ± 5.7 years. At last visit, 81 (60.4%) children were in complete remission, 28 (20.9%) were in partial remission, 15 (11.2%) still had active nephritis and 10 (7.4%) had progressed to ESRD. Almost two-thirds (62.9%) of patients experienced lupus flares, and mean flare rate was 0.09 flares/patient follow-up year. Fifty-six (43.8%) children accrued damage and the mean Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage score was 0.79 ± 1.13. Actuarial ESRD-free survival at five, 10 and 15 years was 91.1%, 79% and 76.2%, and five-, 10- and 15-year renal survival was 93.8%, 87.1% and 84%, respectively. Although multiple factors individually predicted poor outcome (death/ESRD), only raised serum creatinine at onset (R square = 0.65, p ≤ 0.0001) and damage accrual (R square = 0.62, p ≤ 0.0001) remained significant on multivariate analysis. Eleven (8.2%) children died during the follow-up period, and infections were the leading cause of mortality. CONCLUSIONS Long-term outcome of LN in cSLE in our cohort was better than previous reports from India. However, a high rate of major infection still remains the leading cause of mortality.
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Affiliation(s)
- P Srivastava
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - B Abujam
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - R Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A Lawrence
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - V Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - A Aggarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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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.
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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
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Dandolo A, Prajs N, Lizop M. [Nephropathy due to Puumala hantavirus]. Arch Pediatr 2014; 21:1334-8. [PMID: 25449445 DOI: 10.1016/j.arcped.2014.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 01/30/2014] [Accepted: 09/21/2014] [Indexed: 11/18/2022]
Abstract
Hemorrhagic fever with renal syndrome (HFRS) is due to an infection by the virus of the Hantavirus genus. Rodent hosts of Hantavirus are present in restricted areas in France; consequently, there are ecological niches and microepidemics of human Hantavirus infections. A HFRS case was diagnosed in the Paris region. The 11-year-old child had an acute debut fever-persistent despite antipyretic medication-asthenia, headache, abdominal pain, myalgia, thrombocytopenia, as well as renal failure with proteinuria. The diagnosis was made with a relevant clinical history and the specific serology of Puumala hantavirus. Therefore, a kidney biopsy was not necessary. What was interesting was the diagnostic approach because of the difference between the place and time of contamination and where the child became ill and developed the symptoms. The child was infected by Puumala hantavirus in Les Ardennes, a high-risk area, but became ill in the Paris region, an area with no prevalence. We review Hantavirus infections in France and its differential diagnosis.
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Affiliation(s)
- A Dandolo
- Service des urgences, institut hospitalier Franco-Britannique, 92300 Levallois-Perret, France.
| | - N Prajs
- Service de pédiatrie, institut hospitalier Franco-Britannique, 92300 Levallois-Perret, France
| | - M Lizop
- Service de pédiatrie, institut hospitalier Franco-Britannique, 92300 Levallois-Perret, France
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