1
|
Williams CEC, Lamond M, Marro J, Chetwynd AJ, Oni L. A narrative review of potential drug treatments for nephritis in children with IgA vasculitis (HSP). Clin Rheumatol 2023; 42:3189-3200. [PMID: 37755547 PMCID: PMC10640478 DOI: 10.1007/s10067-023-06781-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/28/2023]
Abstract
Immunoglobulin A (IgA) vasculitis (IgAV, also known as Henoch-Schoenlein purpura, HSP) is the most common vasculitis of childhood. It usually presents with a simple, self-limiting disease course; however, a small subset of patients may develop kidney involvement (IgAV-N) which occurs 4-12 weeks after disease onset and is the biggest contributor to long-term morbidity. Treatment currently targets patients with established kidney involvement; however; there is a desire to work towards early prevention of inflammation during the window of opportunity between disease presentation and onset of significant nephritis. There are no clinical trials evaluating drugs which may prevent or halt the progression of nephritis in children with IgAV apart from the early use of corticosteroids which have no benefit. This article summarises the latest scientific evidence and clinical trials that support potential therapeutic targets for IgAV-N that are currently being developed based on the evolving understanding of the pathophysiology of IgAV-N. These span the mucosal immunity, B-cell and T-cell modulation, RAAS inhibition, and regulation of complement pathways, amongst others. Novel drugs that may be considered for use in early nephritis include TRF-budesonide; B-cell inhibiting agents including belimumab, telitacicept, blisibimod, VIS649, and BION-1301; B-cell depleting agents such as rituximab, ofatumumab, and bortezomib; sparsentan; angiotensin converting enzyme inhibitors (ACE-Is); and complement pathway inhibitors including avacopan, iptacopan, and narsoplimab. Further clinical trials, as well as pre-clinical scientific studies, are needed to identify mechanistic pathways as there may be an opportunity to prevent nephritis in this condition. Key Points • Kidney involvement is the main cause of long-term morbidity and mortality in IgA vasculitis despite the current treatment recommendations. • The evolving understanding of the pathophysiology of IgA vasculitis is allowing exploration of novel treatment options which target underlying immune pathways. • Novel treatments currently being trialled in IgA nephropathy may have benefit in IgA vasculitis due to the similarities in the underlying pathophysiology, such as TRF-budesonide, B-cell modulators, and complement inhibitors. • Further studies, including clinical trials of novel drugs, are urgently needed to improve the long-term outcomes for children with IgA vasculitis nephritis.
Collapse
Affiliation(s)
- Chloe E C Williams
- Royal Liverpool and Broadgreen University Hospital Trusts, Liverpool, UK
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Megan Lamond
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Julien Marro
- School of Medicine, University of Liverpool, Liverpool, UK
| | - Andrew J Chetwynd
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Centre for Proteome Research, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Louise Oni
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Paediatric Nephrology, Institute in the Park Building, University of Liverpool, Alder Hey Children's NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP, UK.
| |
Collapse
|
2
|
Machura E, Krakowczyk H, Bąk-Drabik K, Szczepańska M. SARS-CoV-2 Infection as a Possible Trigger for IgA-Associated Vasculitis: A Case Report. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020344. [PMID: 36832473 PMCID: PMC9955818 DOI: 10.3390/children10020344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/15/2023] [Accepted: 02/08/2023] [Indexed: 02/12/2023]
Abstract
BACKGROUND IgA-associated vasculitis (IgAV), formerly known as Henoch-Schönlein purpura (HSP) disease, is the most common type of systemic vasculitis observed during developmental age. Available published studies associate the outbreak of the disease with streptococci, adenovirus, parvovirus, mycoplasma, respiratory syncytial virus (RSV), and influenza infection in approximately 50% of patients with HSP, while some emerging reports have described a few cases of COVID-19 infection being associated with HSP in both adults and children. CASE PRESENTATION a 7-year-old girl was diagnosed with HSP, fulfilling the four required clinical criteria (palpable purpura and abdominal pain, arthralgia and edema, and periodic renal involvement). Infection with SARS-CoV-2 was confirmed via the presence of IgM and IgG antibodies. The disclosure of the Henoch-Schönlein purpura (HSP) disease was preceded by a mild, symptomatically treated infection of the upper respiratory tract. High levels of inflammatory markers were observed during hospitalization, including leukocytosis, an increased neutrophil count and a high neutrophil-to-lymphocyte ratio (NLR). All of these markers are associated with IgAV gastrointestinal bleeding, which was also associated with rotavirus diarrhea observed in the patient. CONCLUSIONS This case presented by us and similar cases presented by other authors indicate the possible role of SARS-CoV-2 in the development of HSP, but this assumption requires further research and evidence-based verification.
Collapse
|
3
|
Jain A, Johnson MH. ET-traps offer a potential therapeutic tool for use in different autoimmune diseases. Drug Discov Today 2020; 25:1142-1145. [PMID: 32325125 DOI: 10.1016/j.drudis.2020.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/07/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
Research shows that endothelin (ET)-traps are a potential therapy for diabetes. Given that type 1 diabetes mellitus (T1DM) is an autoimmune disorder, ET-traps could also have an efficacious, therapeutic effect on other autoimmune diseases associated with pathologically elevated ET-1. Here, we describe those different autoimmune diseases that might benefit from a tool such as ET-traps, which potently sequester these elevated levels of ET-1. We also discuss the current use of ET receptor (ETR) antagonists and the associated adverse effects, and how ET-traps are associated with no toxicity and potentially offer a superior alternative. ET-traps could be used against different autoimmune diseases and, therefore, are a novel therapeutic tool for such conditions.
Collapse
Affiliation(s)
- Arjun Jain
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK; Accelerate Cambridge, Judge Business School, University of Cambridge, Cambridge, UK.
| | - Martin H Johnson
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
| |
Collapse
|
4
|
Serum levels of selected cytokines [interleukin (IL)-17A, IL-18, IL-23] and chemokines (RANTES, IP10) in the acute phase of immunoglobulin A vasculitis in children. Rheumatol Int 2019; 39:1945-1953. [PMID: 31468124 PMCID: PMC7575498 DOI: 10.1007/s00296-019-04415-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/03/2019] [Indexed: 01/08/2023]
Abstract
The pathogenesis of the immunoglobulin A vasculitis (IgAV) is still unknown. The available data shows that interleukin (IL)-17, IL-18, IL-23, regulated on activation, normal T cell expressed and secreted (CCL 5, RANTES), and interferon (IFN)-γ-inducible protein 10 (IP10) participate in the pathogenesis of IgAV by influencing the recruitment of leukocytes to the site of inflammation. The aim of this study was to analyze the serum concentration of IL-17A, IL-18, IL-23, RANTES, and IP10 in patients with acute IgAV compared to healthy children. Moreover, we wanted to assess the suitability of the levels of tested cytokines to predict the severity of the disease. All children with IgAV hospitalized in our institution between 2012 and 2017 were included in the study. Cytokines levels were determined in a serum sample secured at admission to the hospital. Basic laboratory tests have also been analyzed. IL-17A, IL-18, and IL-23 were significantly higher in whole IgAV group (52.25 pg/ml; 164.1 pg/ml and 700 pg/ml, respectively) than in the control group (27.92 pg/ml; 140.1 pg/ml and 581.5 pg/ml, respectively). The receiver operating characteristic (ROC) curve analysis revealed the largest area under the curve (AUC 0.979, p < 0.001) for the IL-17A with 95.1% sensitivity and 91.7% specificity. There were no significant differences in cytokine levels depending on the severity of the IgAV. Although the serum levels of the IL-17A, IL-18, and IL-23 increase significantly in the acute phase of the IgAV, they cannot be used as indicators of predicting the course of the disease. IL-17A seems to be a good predictor of IgAV occurrences.
Collapse
|
5
|
Analysis of neutrophil to lymphocyte ratio, platelet to lymphocyte ratio and mean platelet volume to platelet count ratio in children with acute stage of immunoglobulin A vasculitis and assessment of their suitability for predicting the course of the disease. Rheumatol Int 2019; 39:869-878. [DOI: 10.1007/s00296-019-04274-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/06/2019] [Indexed: 12/15/2022]
|
6
|
Mahajan N, Kapoor D, Bisht D, Singh S, Minz RW, Dhawan V. Levels of interleukin-18 and endothelin-1 in children with Henoch-Schönlein purpura: a study from northern India. Pediatr Dermatol 2013; 30:695-9. [PMID: 24111610 DOI: 10.1111/pde.12222] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Henoch-Schönlein purpura (HSP) is an acute systemic vasculitis with unknown etiology, although several studies have found HSP to be related to cytokines such as tumor necrosis factor α, interleukin (IL)-1, and adhesion molecules. In the present study we determined the levels of cytokines such as IL-18 and endothelin-1 (ET-1) in children with HSP. Subjects were divided into three groups (group 1, 20 subjects with HSP; group 2, 10 subjects belonging to group 1 during their follow-up 4 to 6 months later; and group 3, 16 controls who were healthy siblings of the subjects). IL-18 and ET-1 levels were determined using enzyme immunoassay and expressed as mean ± standard deviation. We observed higher IL-18 levels in children with HSP (767.6 ± 145.1 pg/mL) than in controls (614.6 ± 66.54 pg/mL, p > 0.05), but IL-18 levels were found to be significantly lower in subjects with HSP in remission (502.7 ± 60.81 pg/mL) than in those who were in an active phase (1,050 ± 244.5 pg/mL, p < 0.05, n = 10). ET-1 levels were found to be significantly higher in subjects with HSP (1.93 ± 0.19 pg/mL) than in controls (1.10 ± 0.13 pg/mL, p < 0.05), although no significant difference was observed in ET-1 levels between subjects in group 1 (1.88 ± 0.30 pg/mL) and group 2 (1.91 ± 0.120, p > 0.05, n = 10). A positive correlation was observed between IL-18 and ET-1 levels in subjects with HSP (correlation coefficient [r] = 0.5254, p < 0.01). These results suggest that levels of IL-18 and ET-1 are worth monitoring during the clinical course of the disease, but caution must be exercised in extrapolating data based on small study samples.
Collapse
Affiliation(s)
- Nitin Mahajan
- Department of Experimental Medicine and Biotechnology, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | | | | | | | | | | |
Collapse
|
7
|
Hosgood SA, Hunter JP, Nicholson ML. Early Urinary Biomarkers of Warm and Cold Ischemic Injury in an Experimental Kidney Model. J Surg Res 2012; 174:e85-90. [DOI: 10.1016/j.jss.2011.10.024] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Revised: 09/23/2011] [Accepted: 10/18/2011] [Indexed: 11/25/2022]
|
8
|
Hosgood SA, Bagul A, Nicholson ML. Minimising cold ischaemic injury in an experimental model of kidney transplantation. Eur J Clin Invest 2011; 41:233-40. [PMID: 20955220 DOI: 10.1111/j.1365-2362.2010.02396.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Cold ischaemic (CI) injury is associated with reduced renal graft function and survival. However, there is little evidence on the benefits of reducing CI injury within a 24 h period in donation after cardiac death (DCD) kidney transplantation. METHODS Porcine kidneys subjected to 10-min warm ischaemia were retrieved and flushed with hyperosmolar citrate (HOC) preservation solution at 4 °C. They were stored on ice for periods of 2, 6, 18 or 24 h (n = 6). Renal function and injury were assessed during 3 h of ex-vivo reperfusion with oxygenated autologous blood. RESULTS Area under the curve (AUC) serum creatinine (Cr) levels were significantly higher in the 18- and 24-h groups and creatinine clearance (CrCl) lower compared to the 2-h group (P = 0·001, 0·003). Urinary biomarkers of ischaemic damage (Endothelin-1, Total nitric oxide) and renal and tubular cell function significantly correlated with the duration of CI time (r = 0·726, 0·642; P ≤ 0·001). CONCLUSIONS This study demonstrated the progressive effects of CI injury in DCD porcine kidneys over a 24 h hypothermic storage period. This highlights the need to minimise the cold storage period to improve graft function in DCD kidney transplantation.
Collapse
Affiliation(s)
- Sarah A Hosgood
- Department of Infection, Immunity and Inflammation, Transplant Group, University of Leicester, Leicester General Hospital, LE5 4PW, UK.
| | | | | |
Collapse
|
9
|
Abstract
Systemic vasculitis is a group of disorders with multiorgan involvement. These disorders have diverse clinical manifestations associated with significant morbidity and mortality. The most common vasculitides in children--Henoch-Schönlein purpura and Kawasaki disease--are self-limiting conditions. The lifelong and chronic vasculitides (eg, giant cell arteritis, Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome, polyarteritis nodosa, and Takayasu arteritis) are rarely seen in children. Therefore, the outcome in general is more favorable in children. This article offers an overview of the epidemiologic, etiologic, pathophysiologic, and clinical features of vasculitis in children, with emphasis on common conditions.
Collapse
|
10
|
Chen T, Guo ZP, Zhang YH, Gao Y, Liu HJ, Li JY. Elevated serum heme oxygenase-1 and insulin-like growth factor-1 levels in patients with Henoch-Schonlein purpura. Rheumatol Int 2009; 31:321-6. [PMID: 20013271 DOI: 10.1007/s00296-009-1254-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Accepted: 11/28/2009] [Indexed: 02/05/2023]
Abstract
The aim of this study is to investigate the levels of heme oxygenase-1 (HO-1), insulin-like growth factor-1 (IGF-1) and oxidative stress parameters including malondialdehyde (MDA), total antioxidant capacity (T-AOC) and the activities of total superoxide dismutase (SOD), glutathione peroxidase (GSH-PX), catalase (CAT) for exploring the correlations between these biological indexes and the clinical manifestations in Henoch-Schonlein purpura (HSP) patients. 36 patients with different phases of HSP and 16 age- and sex-matched controls were enrolled. MDA level, T-AOC and the activities of SOD, GSH-PX and CAT were measured by spectrophotometry. HO-1 and IGF-1 levels were detected by enzyme-linked immunosorbent assay. Significant higher MDA level, lower T-AOC, SOD, GSH-PX activities were shown in active phase of HSP, respectively, compared with those in early resolution phase of HSP (p < 0.001, <0.001, 0.017, <0.001, respectively) and the control subjects (p < 0.001, <0.001, 0.01, 0.008, respectively). HO-1 (both p < 0.001) and IGF-1 (p < 0.001, 0.009, respectively) levels in active phase and early resolution phase of HSP were significantly higher than those in normal controls. The changes of HO-1 and IGF-1 levels were coincident with overall clinical scores (r = 0.71, p < 0.001; r = 0.615, p < 0.001, respectively). The HO-1 level was found as positive correlation with MDA levels (r = 0.395, p = 0.017), but negative correlations with T-AOC (r = -0.409, p = 0.013) and SOD activities (r = -0.352, p = 0.035). HO-1 and IGF-1 were possibly involved in the pathogenesis of HSP; they could be the marker for evaluating the severity of the disease.
Collapse
Affiliation(s)
- Tao Chen
- Department of Dermatovenereology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | | | | | | | | | | |
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW To examine recent advances in the pathophysiology and therapy of pediatric vasculitis. RECENT FINDINGS The past 2 years have been marked by significant progress in extending novel techniques to the investigation of the two most common pediatric vasculitis syndromes, Henoch-Schonlein purpura and Kawasaki disease. Study of other vasculitides, such as Wegener granulomatosis, Churg-Strauss syndrome, and microscopic polyangiitis, is impeded by the small number of pediatric patients. Nonetheless, national and international registries are beginning to provide the foundation for generation of testable hypotheses regarding pathogenesis and optimal treatment. Thus, recent data from the study of children suggest that disorders in the control of inflammation, such as those that underlie familial Mediterranean fever and other autoinflammatory diseases, may predispose to vasculitis. Improved knowledge of mechanisms of disease, in turn, should pave the way for more targeted, effective, and tolerable therapies for children with systemic vasculitis. SUMMARY International collaboration to study rare disorders such as pediatric vasculitis are demonstrating disorders of inflammatory regulation that predispose to these diseases and may point toward new treatment approaches.
Collapse
|
12
|
|