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Lin W, Xie X, Luo Z, Chen X, Cao H, Fang X, Song Y, Yuan X, Liu X, Du R. Early identification of macrophage activation syndrome secondary to systemic lupus erythematosus with machine learning. Arthritis Res Ther 2024; 26:92. [PMID: 38725078 PMCID: PMC11080238 DOI: 10.1186/s13075-024-03330-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVE The macrophage activation syndrome (MAS) secondary to systemic lupus erythematosus (SLE) is a severe and life-threatening complication. Early diagnosis of MAS is particularly challenging. In this study, machine learning models and diagnostic scoring card were developed to aid in clinical decision-making using clinical characteristics. METHODS We retrospectively collected clinical data from 188 patients with either SLE or the MAS secondary to SLE. 13 significant clinical predictor variables were filtered out using the Least Absolute Shrinkage and Selection Operator (LASSO). These variables were subsequently utilized as inputs in five machine learning models. The performance of the models was evaluated using the area under the receiver operating characteristic curve (ROC-AUC), F1 score, and F2 score. To enhance clinical usability, we developed a diagnostic scoring card based on logistic regression (LR) analysis and Chi-Square binning, establishing probability thresholds and stratification for the card. Additionally, this study collected data from four other domestic hospitals for external validation. RESULTS Among all the machine learning models, the LR model demonstrates the highest level of performance in internal validation, achieving a ROC-AUC of 0.998, an F1 score of 0.96, and an F2 score of 0.952. The score card we constructed identifies the probability threshold at a score of 49, achieving a ROC-AUC of 0.994 and an F2 score of 0.936. The score results were categorized into five groups based on diagnostic probability: extremely low (below 5%), low (5-25%), normal (25-75%), high (75-95%), and extremely high (above 95%). During external validation, the performance evaluation revealed that the Support Vector Machine (SVM) model outperformed other models with an AUC value of 0.947, and the scorecard model has an AUC of 0.915. Additionally, we have established an online assessment system for early identification of MAS secondary to SLE. CONCLUSION Machine learning models can significantly improve the diagnostic accuracy of MAS secondary to SLE, and the diagnostic scorecard model can facilitate personalized probabilistic predictions of disease occurrence in clinical environments.
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Affiliation(s)
- Wenxun Lin
- Department of Rheumatology, Union hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xi Xie
- Department of Rheumatology and Immunology, the Second Xiangya Hospital, Central South University, Changsha, Hunan, P.R. China
- Clinical Medical Research Center for Systemic Autoimmune Diseases in Hunan Province, Changsha, Hunan, P.R. China
| | - Zhijun Luo
- Department of Rheumatology, Union hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoqi Chen
- Department of Rheumatology, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Heng Cao
- Department of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xun Fang
- Department of Rheumatology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, China
| | - You Song
- Department of Rheumatology, Union hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xujing Yuan
- Department of Rheumatology, Union hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaojing Liu
- Department of Rheumatology, Union hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rong Du
- Department of Rheumatology, Union hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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tabei Y, Ohtsu Y, Shimada M, Wada A, Hamajima E, Osawa Y, Takizawa T. FGF23-related hypophosphatemic rickets preceding the onset of systemic lupus erythematosus: A juvenile case. Clin Case Rep 2024; 12:e8420. [PMID: 38223518 PMCID: PMC10784849 DOI: 10.1002/ccr3.8420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/19/2023] [Accepted: 12/24/2023] [Indexed: 01/16/2024] Open
Abstract
Key Clinical Message This case report describes the clinical course of a juvenile female with FGF23-related hypophosphatemic rickets preceding the onset of SLE. Our study demonstrates the possibility of hypophosphatemic rickets as an early symptom of SLE. Abstract Fibroblast growth factor 23 (FGF23)-related hypophosphatemic rickets is observed in both genetic and acquired disorders. Various reports describe FGF23-related hypophosphatemia with systemic lupus erythematosus (SLE), although FGF23-related hypophosphatemia preceding the onset of SLE has never been described. Here, we report the case of a 9-year-old female with FGF23-related hypophosphatemic rickets preceding the onset of SLE. The patient presented to us with arthralgia in the lower extremities and abnormality of gait lasting for 8 months. She was diagnosed with FGF23 hypophosphatemic rickets due to the presence of hypophosphatemic rickets symptoms and high serum levels of FGF23. Additional examination excluded hereditary diseases and tumor-induced osteomalacia. Three months after diagnosis of FGF23-related hypophosphatemic rickets, she developed nephritis and was diagnosed with SLE. She was treated with prednisolone, hemodialysis, and disease-modifying drugs, as well as oral sodium phosphate to improve hypophosphatemia. Serum anti-double-stranded DNA antibody (dsDNAab) and plasma tumor necrosis factor-α (TNF-α) were elevated at FGF23-related hypophosphatemic rickets diagnosis. During the clinical course, serum FGF23 correlated with dsDNAab and TNF-α serum levels, which are involved in SLE disease activity. In this case, FGF23-related hypophosphatemic rickets without hereditary diseases or tumor-induced osteomalacia occurred before the appearance of juvenile SLE symptoms, and serum FGF23 represented disease activity in SLE.
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Affiliation(s)
- Yoko tabei
- Department of Pediatrics, Graduate School of MedicineGunma UniversityMaebashiJapan
| | - Yoshiaki Ohtsu
- Department of Pediatrics, Graduate School of MedicineGunma UniversityMaebashiJapan
| | - Masaharu Shimada
- Department of Pediatrics, Graduate School of MedicineGunma UniversityMaebashiJapan
| | - Aya Wada
- Department of Pediatrics, Graduate School of MedicineGunma UniversityMaebashiJapan
| | - Emi Hamajima
- Department of Pediatrics, Graduate School of MedicineGunma UniversityMaebashiJapan
| | - Yoshimitsu Osawa
- Department of Pediatrics, Graduate School of MedicineGunma UniversityMaebashiJapan
| | - Takumi Takizawa
- Department of Pediatrics, Graduate School of MedicineGunma UniversityMaebashiJapan
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Vukomanovic V, Krasic S, Prijic S, Ninic S, Popovic S, Petrovic G, Ristic S, Simic R, Cerovic I, Nesic D. Recent Experience: Corticosteroids as a First-line Therapy in Children With Multisystem Inflammatory Syndrome and COVID-19-related Myocardial Damage. Pediatr Infect Dis J 2021; 40:e390-e394. [PMID: 34260481 PMCID: PMC8505156 DOI: 10.1097/inf.0000000000003260] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cardiovascular complications with myocarditis in multisystem inflammatory syndrome in children (MIS-C) associated with severe acute respiratory syndrome coronavirus 2 infection have been reported, but the optimal therapeutic strategy remains unknown. METHODS A retrospective cohort study included 19 patients with acute left ventricular systolic dysfunction associated with MIS-C, average years of age 13.2 ± 3.8, treated from April 2020 to April 2021. RESULTS Treatment failure (TF) was observed in 8 patients (in the intravenous immunoglobulin [IVIG] group 7/10; in the corticosteroid [CS] group 1/9). The independent risk factor for TF was IVIG treatment (odds ratio [OR] 18.6, 95% confidence interval [CI] 1.6-222.93, P = 0.02). Patients initially treated with CS became afebrile during in-hospital day 1 (1.5, interquartile range [IQR] 1-2), while IVIG-treated patients became afebrile on in-hospital day 4 (IQR 2-4.25), after CS was added. The C-reactive protein (CRP) significantly declined in CS-treated patients on day 2 (P = 0.01), while in the IVIG group, CRP decreased significantly on the fourth day (P = 0.04). Sodium and albumin levels were higher on third in-hospital day in the CS group than in the IVIG group (P = 0.015, P = 0.03). A significant improvement and normalization of ejection fraction (EF) during the first 3 days was observed only in the CS group (P = 0.005). ICU stays were shorter in the CS group (4, IQR 2-5.5) than in the IVIG group (IVIG group 7, IQR 6-8.5) (P = 0.002). CONCLUSIONS Among children with MIS-C with cardiovascular involvement, treatment with CS was associated with faster normalization of LV EF, fever, laboratory analysis, and shorter ICU than IVIG-treated patients.
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Affiliation(s)
- Vladislav Vukomanovic
- From the Cardiology Department, Mother and Child Health Institute of Serbia
- School of Medicine, University of Belgrade
| | - Stasa Krasic
- From the Cardiology Department, Mother and Child Health Institute of Serbia
| | - Sergej Prijic
- From the Cardiology Department, Mother and Child Health Institute of Serbia
- School of Medicine, University of Belgrade
| | - Sanja Ninic
- From the Cardiology Department, Mother and Child Health Institute of Serbia
| | - Sasa Popovic
- From the Cardiology Department, Mother and Child Health Institute of Serbia
| | - Gordana Petrovic
- Immunology Department, Mother and Child Health Institute of Serbia
| | - Snezana Ristic
- Intensive Care Unit, Mother and Child Health Institute of Serbia
| | - Radoje Simic
- Surgery Department, Mother and Child Health Institute of Serbia
| | - Ivana Cerovic
- From the Cardiology Department, Mother and Child Health Institute of Serbia
| | - Dejan Nesic
- School of Medicine, University of Belgrade
- Immunology Department, Mother and Child Health Institute of Serbia
- Intensive Care Unit, Mother and Child Health Institute of Serbia
- Surgery Department, Mother and Child Health Institute of Serbia
- Institute of Medical Physiology "Rihard Burian", Belgrade, Serbia
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Diarrassouba A. [Immunity and tubular dysfunction in case of systemic disease]. Nephrol Ther 2021; 17:149-159. [PMID: 33753012 DOI: 10.1016/j.nephro.2020.12.005] [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: 04/16/2020] [Revised: 11/22/2020] [Accepted: 12/16/2020] [Indexed: 10/21/2022]
Abstract
The immune renal tubular diseases are known since five decades, but their prevalence remains to be defined. They are caused by humoral and cellular effectors of innate and adaptative immunities on several targets of the renal tubule: protein channels, co or counter transporters, luminal or cytosolic enzymes, tight junctions. Genetic or epigenetic variations are also involved. Clinical manifestations are various and make the diagnosis difficult. They can precede the causal affection and they worsen the prognosis. The classical model consists in hypokalemic tubular distal acidosis observed in Sjögren's syndrome which illustrates the auto-immune epithelitis concept. Cellular immunity can act through other ways, like tertiary lymphoid neogenesis in systemic lupus. Humoral immunity through autoantibodies targets several membrane, cytosolic or nuclear proteins, causing specific tubular dysfonctions. It is also implied in the epithelial-mesenchymal transition of tubular cells. Innate immunity through cytokines may be involved. Treatment consists in electrolytic disorders correction and immunosupppressive medication: the choice should be guided at best by physiopathology.
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Affiliation(s)
- Assétou Diarrassouba
- Service néphrologie-médecine A, Centre hospitalier de Verdun, 2, rue d'Anthouard, 55107 Verdun, France.
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Hodax JK, Bialo SR, Yalcindag A. SIADH in Systemic JIA Resolving After Treatment With an IL-6 Inhibitor. Pediatrics 2018; 141:peds.2016-4174. [PMID: 29242269 DOI: 10.1542/peds.2016-4174] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 11/24/2022] Open
Abstract
Interleukin-6 (IL-6) is implicated in the pathogenesis of both systemic juvenile idiopathic arthritis (SJIA) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH), but the 2 have not been previously described as occurring together. We report a case of a 6-year-old girl with symptoms of arthralgia, daily fevers, evanescent rash, lymphadenopathy, and laboratory evaluation showing elevated inflammatory markers, consistent with SJIA. At presentation, the patient had hyponatremia with a sodium level of 128 mEq/L. She had low serum osmolality with elevated urine osmolality, consistent with SIADH. Hyponatremia improved temporarily during times of fluid restriction as expected in SIADH, but did not resolve until SJIA was treated successfully with tocilizumab, an IL-6 receptor antibody that inhibits IL-6 activity. The positive response to treatment with tocilizumab supports the role of IL-6 in the pathogenesis of both SJIA and SIADH. Patients with SJIA should be monitored for SIADH to avoid complications of untreated hyponatremia.
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Affiliation(s)
| | | | - Ali Yalcindag
- Pediatric Rheumatology, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Assari R, Ziaee V, Mirmohammadsadeghi A, Moradinejad MH. Dynamic Changes, Cut-Off Points, Sensitivity, and Specificity of Laboratory Data to Differentiate Macrophage Activation Syndrome from Active Disease. DISEASE MARKERS 2015; 2015:424381. [PMID: 26063955 PMCID: PMC4430633 DOI: 10.1155/2015/424381] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Revised: 04/03/2015] [Accepted: 04/07/2015] [Indexed: 11/23/2022]
Abstract
PURPOSE To compare the laboratory data and changes in these data between patients with MAS and patients with flare-up of the autoimmune diseases. METHODS In a prospective study, the static laboratory data and dynamic changes in the selected data in 17 consecutive patients with MAS and 53 patients with active disease of SJIA, PJIA, Kawasaki disease, and SLE were compared. The ROC curve analysis was used to evaluate cut-off points, sensitivity, and specificity of the static and dynamic laboratory data to differentiate between MAS and active disease. RESULTS In the MAS group, the mean CRP3, ALT, AST, total bilirubin, ferritin, LDH, PT, PTT, and INR were significantly higher and the mean WBC2, PMN2, Lymph2, Hgb1, 2, 3, ESR2, serum albumin, and sodium were significantly lower than in control group. Some of the important cut-off points were PLT2 < 209000/microliter, AST > 38.5, ALT > 38, WBC < 8200 × 103/UL, ferritin > 5277 ng/mL. CONCLUSION The dynamic changes in some laboratory data, especially PLT, can differentiate between MAS and active disease. The changes in WBC, PMN, and ESR and the levels of the liver enzymes may also be helpful in the early differentiation. Very high levels of ferritin may also help the diagnosis along with other clinical and laboratory signs.
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Affiliation(s)
- Raheleh Assari
- Children's Medical Center, Pediatrics Center of Excellence, Tehran, Iran
| | - Vahid Ziaee
- Pediatric Rheumatology Research Group, Rheumatology Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad-Hassan Moradinejad
- Children's Medical Center, Pediatrics Center of Excellence, Tehran, Iran
- Department of Pediatrics, Tehran University of Medical Sciences, Tehran, Iran
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Eirin A, Irazabal MV, Fervenza FC, Sethi S. Histiocytic glomerulopathy associated with macrophage activation syndrome. Clin Kidney J 2015; 8:157-60. [PMID: 25815171 PMCID: PMC4370310 DOI: 10.1093/ckj/sfv010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 01/27/2015] [Indexed: 12/13/2022] Open
Abstract
We present an interesting case of a 37-year old man with acute renal failure following a febrile illness. Laboratory results showed features of macrophage activation syndrome (MAS) with anemia, thrombocytopenia, hypofibrinogenemia and elevated ferritin levels. Renal biopsy was then done to determine the cause of renal failure and showed unique glomerular findings with massive histiocytic infiltration ('histiocytic glomerulopathy') and evidence of endothelial injury. Recognizing that the histiocytic infiltrate and endothelial injury is a part of MAS is important because early recognition and treatment is of utmost importance since the disease can be fatal.
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Affiliation(s)
- Alfonso Eirin
- Division of Nephrology and Hypertension, Department of Internal Medicine , Mayo Clinic , Rochester, MN , USA
| | - Maria V Irazabal
- Division of Nephrology and Hypertension, Department of Internal Medicine , Mayo Clinic , Rochester, MN , USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Internal Medicine , Mayo Clinic , Rochester, MN , USA
| | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology , Mayo Clinic , Rochester, MN , USA
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Ito N, Wijenayaka AR, Prideaux M, Kogawa M, Ormsby RT, Evdokiou A, Bonewald LF, Findlay DM, Atkins GJ. Regulation of FGF23 expression in IDG-SW3 osteocytes and human bone by pro-inflammatory stimuli. Mol Cell Endocrinol 2015; 399:208-18. [PMID: 25458698 DOI: 10.1016/j.mce.2014.10.007] [Citation(s) in RCA: 131] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 09/19/2014] [Accepted: 10/11/2014] [Indexed: 12/16/2022]
Abstract
Fibroblast growth factor-23 (FGF23), produced by osteocytes, is the key physiological regulator of phosphate homeostasis. Sepsis patients often experience transient hypophosphataemia, suggesting the regulation of FGF23 levels by pro-inflammatory factors. Here, we used the osteocyte-like cell line IDG-SW3 to investigate the effect of pro-inflammatory stimuli on FGF23 production. In differentiated IDG-SW3 cultures, basal Fgf23 mRNA was dose-dependently up-regulated by pro-inflammatory cytokines TNF, IL-1β and TWEAK, and bacterial LPS. Similar effects were observed in human bone samples. TNF- and IL-1β-induced Fgf23 expression was NF-κB-dependent. Conversely, mRNA encoding negative regulators of FGF23, Phex, Dmp1 and Enpp1, were suppressed by TNF, IL-1β, TWEAK and LPS, independent of NF-κβ signalling. Galnt3, the protein product of which protects intact FGF23 protein from furin/furin-like proprotein convertase cleavage, increased in response to these treatments. C-terminal FGF23 and intact FGF23 protein levels also increased, the latter only in the presence of Furin inhibitors, suggesting that enzymatic cleavage exerts critical control of active FGF23 secretion by osteocytes. Our results demonstrate in principle that pro-inflammatory stimuli are capable of increasing osteocyte secretion of FGF23, which may contribute to hypophosphataemia during sepsis and possibly other inflammatory conditions.
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Affiliation(s)
- Nobuaki Ito
- Bone Cell Biology Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Asiri R Wijenayaka
- Bone Cell Biology Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Matthew Prideaux
- Bone Cell Biology Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Masakazu Kogawa
- Bone Cell Biology Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Renee T Ormsby
- Bone Cell Biology Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Andreas Evdokiou
- Discipline of Surgery, Breast Cancer Research Unit, Basil Hetzel Institute, The University of Adelaide, Woodville, SA 5011, Australia
| | - Lynda F Bonewald
- Department of Oral Biology, University of Missouri-Kansas City School of Dentistry, Kansas, MO 64108, United States
| | - David M Findlay
- Bone Cell Biology Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA 5005, Australia
| | - Gerald J Atkins
- Bone Cell Biology Group, Centre for Orthopaedic & Trauma Research, The University of Adelaide, Adelaide, SA 5005, Australia.
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Incidence and aetiology of renal phosphate loss in patients with hypophosphatemia in the intensive care unit. Intensive Care Med 2013; 39:1785-91. [DOI: 10.1007/s00134-013-2970-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 05/18/2013] [Indexed: 10/26/2022]
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10
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Bennett TD, Fluchel M, Hersh AO, Hayward KN, Hersh AL, Brogan TV, Srivastava R, Stone BL, Korgenski EK, Mundorff MB, Casper TC, Bratton SL. Macrophage activation syndrome in children with systemic lupus erythematosus and children with juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2013; 64:4135-42. [PMID: 22886474 DOI: 10.1002/art.34661] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 07/31/2012] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To describe patient demographics, interventions, and outcomes in hospitalized children with macrophage activation syndrome (MAS) complicating systemic lupus erythematosus (SLE) or juvenile idiopathic arthritis (JIA). METHODS We performed a retrospective cohort study using data recorded in the Pediatric Health Information System (PHIS) database from October 1, 2006 to September 30, 2010. Participants had International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes for MAS and either SLE or JIA. The primary outcome was hospital mortality (for the index admission). Secondary outcomes included intensive care unit (ICU) admission, critical care interventions, and medication use. RESULTS A total of 121 children at 28 children's hospitals met the inclusion criteria, including 19 children with SLE and 102 children with JIA. The index admission mortality rate was 7% (8 of 121 patients). ICU admission (33%), mechanical ventilation (26%), and inotrope/vasopressor therapy (26%) were common. Compared to children with JIA, those with SLE had a similar mortality rate (6% versus 11%, respectively; exact P = 0.6). More patients with SLE than those with JIA received ICU care (63% versus 27%; P = 0.002), received mechanical ventilation (53% versus 21%; P = 0.003), and had cardiovascular dysfunction (47% versus 23% received inotrope/vasopressor therapy; P = 0.02). Children with SLE and those with JIA received cyclosporine at similar rates, but more children with SLE received cyclophosphamide and mycophenolate mofetil, and more children with JIA received interleukin-1 antagonists. CONCLUSION Organ system dysfunction is common in children with rheumatic diseases complicated by MAS, and more organ system support is required in children with underlying SLE than in children with JIA. Current treatment of pediatric MAS varies based on the underlying rheumatic disease.
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Affiliation(s)
- Tellen D Bennett
- Pediatric Critical Care, University of Utah, Salt Lake City, UT 84158-1289, USA.
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Development of Severe Hyponatremia due to Salt-Losing Nephropathy after Esophagectomy for Esophageal Cancer. Case Rep Med 2009; 2009:241283. [PMID: 19888422 PMCID: PMC2771150 DOI: 10.1155/2009/241283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 09/07/2009] [Indexed: 11/24/2022] Open
Abstract
A 72-year-old woman was admitted to our hospital for esophagectomy for esophageal cancer. On the third postoperative day, she developed polyuria (3.8 L/day), massive natriuresis, hyponatremia (112 mEq/L), hyperkalemia (5.6 mEq/L), and decreased central venous pressure, which was refractory to isotonic saline infusion. Laboratory findings indicated proximal tubular injury (high urinary β2-microglobulin, coexistence of hypouricemia) together with reduced aldosterone action at the cortical collecting duct. A diagnosis of salt-losing nephropathy was made and sodium correction was done with 3% saline and fludrocortisone. She responded well to therapy. The cause of hyponatremia was considered renal tubular dysfunction together with elevated antidiuretic hormone level. Postoperatively, it is important to look for the development of salt-losing nephropathy.
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Abstract
PURPOSE OF REVIEW Hemophagocytic lymphohistiocytoses represent a rare but biologically and clinically important group of disorders. This review focuses on the clinical, pathophysiologic and genetic manifestations of these disorders along with critical aspects of timely and appropriate treatment. RECENT FINDINGS Detailed laboratory investigations have led to significant advances in our understanding of the molecular and pathophysiologic features of hemophagocytic lymphohistiocytoses. These studies have provided new diagnostic tools and potential new therapeutic targets for future development. Parallel to these laboratory studies have been enormous advances in the treatment and improved clinical outcomes of patients with both primary and secondary hemophagocytic lymphohistiocytoses. The eventual merging of the improved understanding of the molecular pathway with novel gene therapy approaches may prove to be the final frontier in the optimal curative treatment of these disorders. SUMMARY Several key molecular events have been defined which lead to a final common etiologic pathway of natural killer cell dysfunction leading to the hemophagocytic lymphohistiocytosis syndromes. In part through international clinical trials, effective curative therapies for about half of patients with severe forms of hemophagocytic lymphohistiocytosis have been developed. Although a significant advance, the fact that about 50% of patients are still not able to be cured with currently used approaches challenges physician-scientists to develop more innovative and effective diagnostic and therapeutic approaches.
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