Clinical features, disease activity and outcomes of Malaysian children with paediatric systemic lupus erythematosus: A cohort from a tertiary centre

Childhood-Onset Systemic Lupus Erythematosus Presenting With Concomitant Gastrointestinal Manifestation and Antiphospholipid Syndrome

Childhood-onset systemic lupus erythematosus is a rare disease that is more prevalent in Southeast Asian children than in Western children. It is characterised by a peripubertal onset and a female predominance that rises with age. Haematological, renal, and mucocutaneous are among the frequently involved organs upon diagnosis. Some of the typical symptoms include cutaneous vasculitis, malar rash, and fever. Patients frequently had proliferative class IV lupus nephritis, which increases disease activity and kidney damage. We reported a child presented with fever associated with multiple joint pain, skin rashes over the fingers of the right hand, and generalised abdominal pain.

The differential panorama of clinical features of lupus erythematosus patients with different onset ages: a cross-sectional multicenter study from China

OBJECTIVES

This study aims to compare the differences among patients of different onset ages in various subtypes of lupus erythematosus (LE) and to draw a panorama of the clinical characteristics of patients with different onset ages.

METHOD

Subjects were recruited from the Lupus Erythematosus Multicenter Case-control Study in Chinese populations (LEMCSC), grouped by the age of onset (childhood-onset: onset < 18 years, adult-onset: onset 18-50 years, late-onset: onset > 50 years). The data collected included demographic characteristics, LE-related systemic involvement, LE-related mucocutaneous manifestations, and laboratory results. All included patients were assigned into three groups: systemic LE (SLE) group (with systemic involvement, with or without mucocutaneous lesions), cutaneous LE (CLE) group (patients who were accompanied by any type of LE-specific cutaneous manifestations), and isolated cutaneous LE (iCLE) group (patients who were in CLE group without systemic involvements). Data were analyzed using R version 4.0.3.

RESULTS

A total of 2097 patients were involved, including 1865 with SLE and 232 with iCLE. We also identified 1648 patients with CLE among them, as there was some overlap between the SLE population and CLE population (patients with SLE and LE-specific cutaneous manifestations). Later-onset lupus patients seemed to be less female predominance (p < 0.001) and have less systemic involvement (except arthritis), lower positive rates of autoimmune antibodies, less ACLE, and more DLE. Moreover, childhood-onset SLE patients presented a higher risk of LE family history (p = 0.002, vs adult-onset SLE). In contrast to other LE-nonspecific manifestations, the self-reported photosensitivity history decreased with the age of onset in SLE patients (51.8%, 43.4%, and 39.1%, respectively) but increased in iCLE patients (42.4%, 64.9%, and 89.2%, respectively). There was also a gradual increase in self-reported photosensitivity from SLE, CLE, to iCLE in both adult-onset and late-onset lupus patients.

CONCLUSIONS

A negative correlation was suggested between the age of onset and the likelihood of systemic involvement, except for arthritis. As the age of onset increases, patients have a greater propensity to exhibit DLE compared to ACLE. Moreover, the presence of rapid response photodermatitis (i.e., self-reported photosensitivity) was associated with a lower rate of systemic involvement.

TRIAL REGISTRATION

This study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2100048939) on July 19, 2021, retrospectively registered. Key Points • We confirmed some phenomena that have been found in patients with SLE, such as the highest proportion of females of reproductive age, the higher risk of LE family history in childhood-onset SLE patients, and the less self-reported photosensitivity in the late-onset SLE group. We also compared the similarities and differences of these phenomena in patients with CLE or iCLE for the first time. • In patients with SLE, the proportion of females peaked in adult-onset patients, but this phenomenon disappeared in iCLE patients: the female-male ratio tends to decrease from childhood-onset iCLE, adult-onset iCLE, to late-onset iCLE. • Patients with early-onset lupus are more likely to have acute cutaneous lupus erythematosus (ACLE), and patients with late-onset lupus are more likely to have discoid lupus erythematosus (DLE). • In contrast to other LE-nonspecific manifestations, the incidence of rapid response photodermatitis (i.e., self-reported photosensitivity) decreased with the age of onset in SLE patients but increased with the age of onset in iCLE patients.

A Preliminary Predictive Model for Proliferative Lupus Nephritis in Juvenile Systemic Lupus Erythematosus

Proliferative lupus nephritis, which is diagnosed by renal biopsy, has significant impact on the treatment choices and long-term prognosis of juvenile SLE (jSLE). Renal biopsies are however not always possible or available, thus leading to an ongoing search for alternative biomarkers. This study aimed to develop a clinical predictive machine learning model using routine standard parameters as an alternative tool to evaluate the probability of proliferative lupus nephritis (ISN/RPS Class III or IV). Data were collected retrospectively from jSLE patients seen at Selayang Hospital from 2004 to 2021. A total of 22 variables including demographic, clinical and laboratory features were analyzed. A recursive feature elimination technique was used to identify factors to predict pediatric proliferative lupus nephritis. Various models were then used to build predictive machine learning models and assessed for sensitivity, specificity and accuracy. There were 194 jSLE patients (165 females), of which 111 had lupus nephritis (54 proliferative pattern). A combination of 11 variables consisting of gender, ethnicity, fever, nephrotic state, hypertension, urine red blood cells (RBC), C3, C4, duration of illness, serum albumin, and proteinuria demonstrated the highest accuracy of 79.4% in predicting proliferative lupus nephritis. A decision-tree model performed the best with an AROC of 69.9%, accuracy of 73.85%, sensitivity of 78.72% and specificity of 61.11%. A potential clinically useful predictive model using a combination of 11 non-invasive variables to collectively predict pediatric proliferative lupus nephritis in daily practice was developed.

Outcomes of achieving lupus low disease activity state and damage accrual in childhood-onset systemic lupus erythematosus

INTRODUCTION

At present, the treat-to-target approach has been proposed with the lupus low disease activity state (LLDAS) as an achievable target.

OBJECTIVES

To determine damage accrual and baseline clinical characteristics associated with achieving LLDAS within 12 months of treatment in patients with childhood-onset systemic lupus erythematosus (c-SLE).

METHODS

This retrospective cohort study was conducted at the largest university-based tertiary referral center in Thailand. Data of c-SLE patients (≤ 18 years) at diagnosis who were followed ≥ 12 months during January 2009 to December 2019 were collected. SLE disease status was categorized into LLDAS and non-optimally controlled state. SLEDAI-2K score was used to assess disease activity. Damage accrual was assessed by a pediatric version of the SLICC/ACR damage index.

RESULTS

A total of 232 c-SLE patients (85.8% female) were included. At 12 months of treatment, 109 (47%) patients achieved LLDAS. Damage accrual was observed in 93 (40.1%) patients at the mean follow-up time of 6.2 ± 3.7 years. Damage accrual was significantly lower in patients who achieved LLDAS within 12 months than in those non-optimally controlled (p = 0.002). The median time to achieving LLDAS was 12.6 months (95%CI: 11.19-13.97). The median time to achieving LLDAS was significantly shorter in those without renal involvement (10.8 months, 95%CI: 9.62-12.00 vs. 15.6 months, 95%CI: 13.76-17.52, respectively; p = 0.044). Multivariable logistic regression analysis revealed absence of renal involvement as the predictor of achieving LLDAS within 12 months of treatment (aOR: 2.430, 95%CI: 1.420-4.158; p = 0.001).

CONCLUSIONS

Achieving LLDAS within 12 months of treatment was associated with lower damage accrual. Absence of renal involvement was the predictor of achieving LLDAS within 12 months of treatment. Key Points • LLDAS is a promising and achievable treatment target in c-SLE. • Achieving LLDAS within 12 months of treatment is associated with lower damage accrual. • Absence of renal involvement is the predictor of achieving LLDAS within 12 months of treatment.

Clinical and histopathological study of renal biopsy in Nepalese children: A single center experience

BACKGROUND

Glomerular diseases are important causes of morbidity and mortality among children in developing countries. Renal biopsy is the gold standard for determining histological diagnosis, prognosis, and therapy options. This study aimed to investigate the clinical, histopathological, and direct immunofluorescence findings of renal biopsy results in Nepalese children under 18 years old.

METHODS

In this retrospective cross-sectional study, the available data from children who had undergone kidney biopsy between 2016 and the end of 2020 were evaluated. Demographic data, indications of biopsy, histopathologic findings, and direct immunofluorescence findings were collected and presented.

RESULTS

The mean age of the patients was 12.14 ± 4.07 years. Male/female ratio was 1:1. The majority of biopsy cases were aged between 11-15 years of age. The most common indication for biopsy in children was nephrotic syndrome (68.25%). Lupus nephritis with 28 cases (22.22%) had the highest frequency in overall renal biopsies. Minimal change disease (MCD) with 22 cases (17.46%) followed by Ig A nephropathy with 16 cases (12.69%) were the most frequent primary glomerulonephritis. Lupus nephritis showed full house positivity, and MCD showed full house negativity in all Direct immunofluorescence (DIF) parameters, whereas immunoglobulin A nephropathy showed 100% positivity in Ig A in DIF.

CONCLUSIONS

Nephrotic syndrome was the most common indication for renal biopsy. The most common primary glomerulonephritis was MCD, while secondary glomerulonephritis was lupus nephritis. Clinical data, light microscopy, and direct DIF played an integral role in the overall final diagnosis.

Pregnancy-related complications in systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a systemic autoimmune inflammatory disease that predominantly affects women of childbearing age and results in various adverse pregnancy outcomes (APOs). Pregnancy was formerly discouraged in patients with SLE because of unstable disease activity during the gestation period, increased thrombosis risk, severe organ damage, and inevitable side effects of immunosuppressive agents. Currently, most patients with SLE have successful pregnancies due to preconception counselling, strict monitoring, and improved therapy with minimised complications for both the mother and foetus. Hydroxychloroquine (HCQ) is extensively used and is beneficial for improving pregnancy outcomes. However, pregnant women with SLE have a high-risk of APOs, such as disease flare, preterm birth, intrauterine growth restriction (IUGR), preeclampsia, and pregnancy loss. Better understanding of the changes in maternal immunity and serum biomarkers, as well as their relationships with SLE-related APOs progression, would facilitate the investigation of molecular mechanisms for triggering and ameliorating APOs. Furthermore, it would enable us to explore and develop novel and effective therapeutic strategies to prevent disease activation. Therefore, this review briefly introduces the interaction between pregnancy outcomes and SLE, elucidates pathophysiological and immunological changes during SLE pregnancy. Furthermore, this review systematically expounds on the effective predictors of APOs and the molecular mechanisms underlying the SLE-related APOs to provide a solid foundation for the advanced management of lupus pregnancy.

Sex and gender differences in chronic kidney disease and access to care around the globe

The difference between sex, the biological construct, and gender, the social construct, may be most evident in settings of vulnerability. Globally, chronic kidney disease is more prevalent among women, but the prevalence of end-stage kidney failure, and especially receipt of kidney replacement therapy, is higher in men. These differences likely reflect a combination of physiological and social/structural risk factors that independently modulate kidney disease and/or its progression. The distribution of the most common risk factors such as hypertension and obesity differ between men and women and may impact disease risk differentially. Social and structural gender-related inequities remain stark across the globe. More women live in poverty, receive less education, and are more dependent on others for health care decision making, but men may have a higher risk of injury, occupational exposures, and less access to screening, prevention, and primary care. In this article, we explore how social determinants of health affect kidney disease risk and access to care differentially across genders, and differently across the globe. We also describe specific challenges experienced by boys and girls with kidney disease, how culture and geography may impact kidney care in places where resources are particularly limited such as sub-Saharan Africa, and give examples of social and structural circumstances that place young men and women at high risk of kidney disease in Mexico and Central America, illustrated by case vignettes. The coronavirus disease-2019 pandemic has raised awareness of pervasive gender-based inequities within all societies. This applies to kidney disease and is not new. The nephrology community must add its voice to the calls for action, for a more just society overall, and for the recognition of the roles of sex and gender as modulators of kidney disease risk and access to care.

A Review on Secondary Immune Thrombocytopenia in Malaysia

Immune thrombocytopenia (ITP) is an acquired autoimmune disease that occurs in adults and children. In Malaysia, the clinical practice guideline (CPG) for the management of ITP was issued in 2006, which focused almost exclusively on primary ITP (pITP), and only a few secondary ITP (sITP) forms were addressed. All published (twenty-three) sITP articles among children and adults in Malaysia, identified on the academic databases were retrieved. The articles were published between 1981 and 2019, at a rate of 0.62 publications per year. The publications were considered low and mainly focused on rare presentation and followed-up of secondary diseases. This review revealed that sITP in Malaysia is commonly associated with autoimmune diseases (Evan’s syndrome, SLE and WAS), malignancy (Kaposi’s sarcoma and breast cancer) and infection (dengue haemorrhagic fever, Helicobacter pylori and hepatitis C virus). The relationship between ITP and autoimmune diseases, malignancy and infections raise the question concerning the mechanism involved in these associations. Further studies should be conducted to bridge the current knowledge gap, and the further information is required to update the existing CPG of management of ITP in Malaysia.

Childhood-Onset Systemic Lupus Erythematosus: Southeast Asian Perspectives

Childhood onset systemic lupus erythematosus is a rare disease that is more common amongst Southeast Asian children compared to the West. It is typified by a peripubertal onset and a female preponderance, which increases with advancing age. Organs commonly involved at diagnosis include haematological, renal, and mucocutaneous. Fever, malar rash, and cutaneous vasculitis are common. Lupus nephritis is typically proliferative especially Class IV and contributes to both disease activity and damage. Antinuclear antibody and anti-dsDNA positivity are both prevalent in this region. Disease activity is higher than Western cohorts at onset but responds to therapy reducing to low disease activity by six months. However, organ damage occurs early and continues to accumulate over the time, a consequence of both active disease (neurological and renal systems) and steroid-related complications especially in the eye (cataract and glaucoma) and musculoskeletal systems (avascular necrosis). Infections remain the leading cause of death and mortality in this region is highly variable contributed by the heterogeneity in social economic status, healthcare access, and availability of paediatric rheumatology expertise in the region.