Diagnostic and Management Strategies of IgA Vasculitis Nephritis/Henoch-Schönlein Purpura Nephritis in Pediatric Patients: Current Perspectives

IPNA clinical practice recommendations for the diagnosis and management of children with IgA nephropathy and IgA vasculitis nephritis

IgA nephropathy and IgA vasculitis with nephritis, albeit rare, represent two relatively frequent glomerular conditions in childhood. Compared to adults, pediatric IgA nephropathy has a more acute presentation, most frequently with synpharyngitic macrohematuria and histologically with more intense inflammation and less intense chronic damage. Management of these conditions is controversial and supported by little high-quality evidence. The paucity of evidence is due to the disease heterogeneity, its inter-ethnic variability, and the difficulty of extrapolating data from adult studies due to the peculiarities of the condition in children. IgA vasculitis with nephritis is a kidney manifestation of a systemic disorder, typical of the pediatric age, in which both the diagnosis of kidney involvement and its management are poorly defined, and an interdisciplinary approach is crucial. Both conditions can have a profound and long-lasting impact on kidney function and the global health of affected children. The International Pediatric Nephrology Association has therefore convened a diverse international group of experts from different disciplines to provide guidance on the recommended management of these conditions in children and to establish common definitions and define priorities for future high-quality, evidence-based collaborative studies for the benefit of children.

Predictive Laboratory Markers for Gastrointestinal Complications in Children with Henoch-Schönlein Purpura

Background

Henoch-Schönlein Purpura (HSP) is a common systemic vasculitis in children that often involves the gastrointestinal system (GIS). Identifying reliable predictive markers for GIS complications is crucial for early intervention and improved patient outcomes.

Objective

This study aims to identify laboratory markers predictive of GIS complications in children with HSP using a machine learning approach.

Methods

This retrospective study included children diagnosed with HSP and a control group from May 2020 to January 2024. Detailed demographic and laboratory data, including WBC count, lymphocyte count, neutrophil count, platelet count, hemoglobin, NLR, PLR, MPV, MPR, C-reactive protein, ESR, albumin, BUN, creatinine, sodium, potassium, calcium, IgA, PT, aPTT, and INR, were collected. GIS complications was classified based on clinical symptoms and diagnostic findings. Patients were categorized into groups without GIS complications, with mild GIS complications, and with severe GIS complications. We compared laboratory parameters across these groups to identify significant differences associated with GIS complications. Furthermore, a predictive model was developed by a Random Forest classifier to identify key markers and assess their ability to distinguish between patients with and without GIS complications.

Results

Significant differences were observed in several laboratory parameters between HSP patients and the control group, and between patients with and without GIS complications. Key predictive markers identified included neutrophil count, NLR, WBC count, PLR, and platelet count. The RandomForest model achieved an accuracy of 91% and an AUC of 0.90.

Conclusion

Our findings highlight the importance of specific laboratory markers in predicting GIS complications in HSP. The use of machine learning models can enhance the early identification and management of high-risk patients, potentially improving clinical outcomes.

The coincidence of multiple sclerosis and primary vasculitis; from the bench of pathology to the bedside of treatment: a systematic review of case reports

INTRODUCTION

Multiple sclerosis (MS) is a chronic, disabling neurodegenerative disease, leads to reduced quality of life. The increasing prevalence of MS around the world and its comorbidities increase its burden. Primary vasculitis subtypes, one of autoimmune diseases with different prevalence in different ages and genders, should be considered one of the important differential diagnosis in patients with MS. This study aims to verify the relationship between MS and primary vasculitis by conducting a systematic review.

METHOD

We searched PubMed, Scopus, EMBASE, Web of Science, and Google Scholar, from January 1974 to July 2023. We included original articles that reported characteristics of patients involved with any type of Primary Vasculitis with MS.

RESULT

From an initial 816 publications, 18 studies consisting of 18 individual patients from 14 countries with confirmed MS and one of different subtypes of primary vasculitis met the inclusion criteria. The female/male ratio was 0.38:1, the mean (SD) age was 40.44 (14.37) years with the range of 16 to 70 years old, and the relapsing/progressive ratio was 1.57:1. Most of them, 14 (77%) experienced MS before vasculitis, and mostly received Corticosteroids, interferon, cyclophosphamide, Glatiramer acetate as MS treatment. The concurrence of Takayasu Arteritis (2 cases), Polyarteritis Nodosa (2 cases), Churg-Strauss Syndrome (1 case), Wegener's Granulomatosis (2 cases), Microscopic Polyangiitis (1 case), Cutaneous leukocytoclastic vasculitis (5 cases), Good pasture's disease (5 cases) were reported with MS.

CONCLUSION

Our study suggested that different primary vasculitis can be an important comorbidity of MS and can mimic its symptoms and MRI. Any atypical syndrome for PwMS, whether clinical or radiological, must be evaluated in terms of other differential diagnoses including vasculitis.

Effects of Child-Friendly Music Nursing in the Ward on Mental Health of Children with Henoch-Schönlein Purpura Nephritis: A Retrospective Study

OBJECTIVE

This study aims to improve the clinical nursing model by exploring the effects of child-friendly music nursing in the ward on the mental health of children with Henoch-Schönlein purpura nephritis (HSPN).

METHODS

This study retrospectively analyzed the clinical data of 105 children with HSPN treated at our hospital from January 2022 to December 2023. Five cases were excluded, resulting in the inclusion of 100 cases. Based on different nursing methods, the children were divided into the reference group (routine nursing, n = 52) and the observation group (child-friendly music nursing plus routine nursing, n = 48). A comparison was made between the two groups regarding the levels of anxiety and depression, inflammatory and immune function indexes [C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and immunoglobulin A (IgA)], and renal function indexes [serum creatinine (Scr), blood urea nitrogen (BUN), and hemoglobin (HB)].

RESULTS

Before nursing, there were no significant differences between the two groups in terms of levels of anxiety and depression, inflammatory and immune function indexes (such as CRP, IL-6, TNF-α, and IgA), and renal function indexes (such as Scr, BUN, and HB, P > 0.05). After nursing, the observation group demonstrated significantly lower levels of anxiety, depression, CRP, IL-6, TNF-α, and IgA (P < 0.05) compared to the the reference group, while no significant differences were observed in Scr, BUN, and HB (P > 0.05).

CONCLUSIONS

Child-friendly music nursing can improve the inflammatory level and immune function of children with HSPN to a certain extent. At the same time, it can also improve the anxiety and depression of children. Therefore, child-friendly music nursing in the ward is helpful for the recovery of the physical and mental health of children with HSPN, with a potential clinical application value.

Immunoglobulin A vasculitis with periorbital edema and severe renal involvement: A case report

Immunoglobulin A (IgA) vasculitis, or Henoch-Schonlein purpura, is the most common systemic vasculitis in children, clinically presenting as palpable purpura in combination with arthritis, gastrointestinal involvement, or kidney injury. Subcutaneous edema is reported in patients with IgA vasculitis, and it commonly affects the lower extremities, especially around joints. Here, we report a case of IgA vasculitis with a rare presentation of edema isolated to the periorbital area in a 7-year-old boy, who subsequently developed crescentic glomerulonephritis with nephrotic range proteinuria. Isolated periorbital edema is an uncommon cutaneous feature of IgA vasculitis.

Characterization of non-IgA vasculitis: Demographic, clinical, and treatment-related features in a retrospective analysis of 28 biopsy-confirmed cases from a German university hospital

Non-IgA vasculitis is a rare disease that belongs to the group of small-vessel vasculitides. Due to nomenclature and classification changes introduced in 2018, there are few published data under this name. The aim of this study is to characterize non-IgA vasculitis as an independent vasculitis entity in terms of demographic, clinical, and treatment-related features. A retrospective data analysis of patients with biopsy-confirmed non-IgA vasculitis treated at the Department of Dermatology at the University Medical Center Hamburg-Eppendorf between January 1, 2018, and December 31, 2022, was performed. A total of 28 patients with non-IgA vasculitis were included; 53.6% (15/28) were women and 42.9% (12/28) were older than 71 years. Previous infection as a possible triggering factor was found in 42.6% (12/28) of the cases. Palpable purpura was the most common skin finding (78.6%, 22/28) and 28.6% patients (8/28) had skin lesions above the waist. On direct immunofluorescence, C3 (89.3%, 25/28) was the most frequent deposition, followed by fibrinogen (71.4%, 20/28) and IgM (53.6%, 15/28). Hospitalization was required in 85.7% (24/28), with a mean hospital stay of 9.4 ± 4.1 days. No fatal courses were reported. This study is the first characterization of non-IgA vasculitis based on patient cases from Germany and contributes to a better understanding of non-IgA vasculitis as an independent entity. Non-IgA vasculitis primarily affects older patients of both sexes, with most cases having an identifiable trigger. Our results indicate that cutaneous manifestations often extend beyond the lower legs. Treatment is usually required in the inpatient setting and requires a longer stay than other dermatological conditions. With proper treatment, the disease is not expected to be fatal.

Clinical prediction model for progression from henoch-schönlein purpura to nephritis in pediatric patients

OBJECTIVE

To identify independent risk factors for Henoch-Schönlein purpura nephritis (HSPN) in pediatric patients.

METHODS

This study enrolled 180 pediatric patients (90 with HSP, 90 with HSPN) hospitalized at the 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army from December 2022 to October 2023, with a follow-up of at least six months. Clinical data were collected at the time of the first onset of HSP. Logistic regression analysis identified risk factors, which were subsequently evaluated using Receiver Operating Characteristic (ROC) curve analysis, a calibration plot, a nomogram, and decision curve analysis.

RESULTS

A predictive model was constructed based on serum cystatin C, serum creatinine, immunoglobulin M, and estimated glomerular filtration rate (eGFR). ROC curve analysis showed high predictive accuracy, with an AUC of 0.9444, sensitivity of 0.82, and specificity of 0.98 at the optimal cutoff point. The calibration curve indicated strong agreement between predicted and actual outcomes. Decision curve analysis suggested that the model provides significant net benefits across different risk thresholds.

CONCLUSION

This model effectively predicts the risk of HSPN, facilitating early intervention and improved patient outcomes.

Therapeutic effect of total glucosides of paeony on IgA vasculitis nephritis: progress and prospects

IgA vasculitis nephritis (IgAVN), a type of immune system disease characterized by the deposition of IgA in the mesangial area of the glomerulus, is most common in children. Corticosteroids and immunosuppressants agents are commonly prescribed for the clinical management of IgAVN; however, these therapies are associated with numerous adverse reactions. This necessitates the discovery of alternative, potential therapeutic agents that can offer a safer treatment option. Natural plants contain abundant total glucosides of paeony (TGP), which represent one of the most prevalent secondary metabolites found within these organisms. TGP has been proven to be a safe and desirable natural medicine, with the most central ingredient being polyphenolic. TGP, a naturally occurring and cost-effective compound, exerts its therapeutic influence on IgAVN via diverse pathways and targets, with minimal side effects. Its substantial clinical potential underscores the importance of delving deeper into its pharmacological mechanisms, which hold great promise for novel drug development. This review examines the multifaceted therapeutic mechanisms of TGP in IgAVN encompassing modulation of Wnt/β-catenin pathways and programmed cell death pathways, antioxidant and anti-inflammatory effects, and enhancement of vascular repair. Additionally, we provide an overview of recent advancements in enhancing the bioavailability of TGP and highlight crucial considerations that may inform future research endeavors.

IgA Vasculitis Associated With Levofloxacin Use in an Adult Female: A Case Report

Immunoglobulin A (IgA) vasculitis, once known as Henoch-Schönlein purpura in recognition of the physicians who first identified it, is an acute form of vasculitis, associated with a deposition of immune complexes, self-limited that affects small-caliber vessels. It usually occurs in children and rarely in adults. This disease can be induced by multiple factors such as exposure to certain infectious antigens such as viruses or bacteria, drugs, and toxins, and even genetic predisposition has been described. Although the use of some antibiotics is known as a risk factor for the development of IgA vasculitis, it may not be considered when approaching and treating an adult with a related clinical condition, since its frequency is rare. We present the case of a 26-year-old woman with a history of an upper respiratory tract infection who required treatment with levofloxacin and subsequently developed palpable purpura.

The relationship between the severity and complications of Henöch-Schönlein purpura in children and dietary inflammatory index: a retrospective cohort study

Purpose

To investigate the association between the Dietary Inflammatory Index (DII) and disease severity as well as complications in children diagnosed with Henöch-Schönlein purpura (HSP), shedding light on the potential influence of dietary factors on HSP.

Methods

A retrospective cohort study was conducted, enrolling children aged 2-14 years diagnosed with HSP. Participants were divided into low and Pro-inflammatory dietary groups based on their DII scores. Biomarkers, nutrient intake, blood lipid profiles and disease complications were compared between the two groups. Spearman correlation analysis was performed to assess the relationship between DII and complications.

Results

A total of 115 patients, including 56 patients with anti-inflammatory dietary and 59 with pro-inflammatory dietary, were included. The pro-inflammatory dietary group demonstrated significantly elevated of C-reactive protein, tumor necrosis factor-α, interleukin-6, erythrocyte sedimentation rate, white blood cell count, eosinophils, IgE, consumption of total calories, protein, carbohydrates, fiber, fat intake, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, VLDL cholesterol, complications of renal, skin, gastrointestinal, coagulation and respiratory in comparison to the anti-inflammatory dietary group. DII was positively correlated with renal, skin, gastrointestinal, coagulation and respiratory complications.

Conclusion

The study highlights the potential influence of dietary inflammatory potential, as quantified by the DII, on disease severity and complications in children with HSP. Understanding the interplay between dietary patterns and inflammatory responses in pediatric vasculitis has implications for the management of HSP, emphasizing the relevance of considering dietary interventions to optimize clinical outcomes and improve the overall well-being of affected children.

Association of Childhood IgA Vasculitis With Allergic Rhinitis and Chronic Rhinosinusitis

Introduction

Immunoglobulin A vasculitis (IgAV) is related to chronic inflammation; however, little is known about the associations between IgAV and allergic rhinitis (AR) or chronic rhinosinusitis (CRS). We evaluated the relationships among IgAV, AR, and CRS in children.

Methods

The clinical data of children with IgAV who were hospitalized from January to December 2019 were analyzed retrospectively. Four groups were created, the simple AR, simple CRS, AR + CRS, and non-AR or non-CRS groups, to explore the relationships among IgAV, AR, and CRS.

Results

We included 504 children with IgAV; and 357 (70.8%) were combined with AR or CRS, including 51 with simple AR, 70 with simple CRS, and 236 with AR + CRS. The incidences of renal involvement and recurrent rash were significantly higher in the simple AR group than in the non-AR or non-CRS group (P < 0.001). The incidences of renal involvement and recurrent rash were significantly higher in the AR + CRS group than in the non-AR or non-CRS group (P < 0.001). The incidences of renal involvement between the simple CRS group and non-AR or non-CRS group did not differ significantly, but that of recurrent rash was significantly higher than that in the other groups (P < 0.001). Age, abdominal pain, recurrent rash, simple AR, and AR combined with CRS were risk factors for renal involvement (all odds ratio [OR] > 1, P < 0.05).

Conclusion

Chronic rhinitis may be related to the pathogenesis of IgAV, and AR or CRS may be the triggering factors of IgAV. AR may be a risk factor for renal involvement and recurrent rash in patients with IgAV.

Analysis of the influencing factors of abdominal Henoch-Schonlein purpura in children with gastrointestinal bleeding and the clinical value of PLR

OBJECTIVE

To identify the influencing factors of gastrointestinal bleeding in children with abdominal-type Henoch-Schonlein purpura (HSP) and to assess the diagnostic value of PLR (platelet-to-lymphocyte ratio).

METHODS

We retrospectively analyzed the medical records of 112 children with abdominal HSP admitted to Northwest Women's and Children's Hospital from April 2021 to May 2023. Among them, 62 cases with gastrointestinal bleeding constituted the bleeding group, while the other 50 cases without gastrointestinal bleeding comprised the non-bleeding group. We compared PLR and related routine blood indicators between the two groups. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for gastrointestinal bleeding. HSP children with gastrointestinal bleeding were further categorized based on treatment efficacy, and the predictive value of PLR for treatment efficacy was analyzed.

RESULTS

The observation group exhibited significantly higher levels of WBC, NEU, PLT, MPV, C-reactive protein, and PLR, along with lower lymphocyte levels compared to the control group (all P < 0.05). Univariate analysis revealed associations between symptom onset, abdominal pain, vomiting, levels of WBC, NEU, LYM, PLT, PLR, C-reactive protein and gastrointestinal bleeding (all P < 0.05). Multivariate logistic analysis identified onset with abdominal pain, high WBC values, and elevated PLR ratios as risk factors for gastrointestinal bleeding. The ROC curve demonstrated an AUC of 0.914 for PLR in predicting gastrointestinal bleeding. Additionally, PLR was significantly lower in the good efficacy group compared to the poor efficacy group. The AUC of PLR in predicting treatment efficacy was 0.804, indicating high predictive value.

CONCLUSION

Elevated PLR may serve as a potential risk factor for gastrointestinal bleeding in children with abdominal-type allergic purpura. Monitoring changes in PLR could aid in diagnosis and improvements in treatment for this condition.

Efficacy and safety of mycophenolate mofetil versus cyclophosphamide therapy for Henoch schonlein purpura nephritis in children: A meta-analysis

OBJECTIVE

The objective of this meta-analysis was to compare the efficacy and safety between glucocorticoids combined with mycophenolate mofetil (MMF) versus glucocorticoids combined with cyclophosphamide (CTX) for henoch schonlein purpura nephritis (HSPN) in children.

METHODS

Databases including PubMed, EMbase, the Cochrane Library, China National Knowledge Infrastructure, and Wanfang database were searched from the inception to April 5th, 2024. Eligible studies comparing glucocorticoids combined with MMF versus glucocorticoids combined with CTX for HSPN in children were included. Data were analyzed using Review Manager Version 5.3.

RESULTS

Ten studies were included in the meta-analysis. Six randomized controlled trials (RCTs) and 4 non-randomized studies involving 675 patients were identified. Compared with CTX therapeutic schedule, MMF therapeutic schedule had a higher complete remission (CR) within the 6 months (OR 1.61, 95%CI 1.16-2.22, P = .004) and CR within the 12 months (OR 1.73, 95%CI 1.00-2.97, P = .05). However, there was no significant difference between MMF and CTX therapeutic schedule concerning total remission (TR) within the 6 months (OR 1.54, 95%CI 0.82-2.92, P = .18) and TR within the 12 months (OR 2.08, 95%CI 0.86-5.01, P = .10). In addition, incidences of gastrointestinal discomfort (OR 0.33, 95%CI 0.19-0.56, P < .0001), liver function injury (OR 0.28, 95%CI 0.09-0.87, P = .03), myelosuppression (OR 0.15, 95%CI 0.06-0.41, P = .0001), alopecia (OR 0.25, 95%CI 0.07-0.91, P = .03) in MMF therapeutic schedule were all lower than CTX therapeutic schedule. There was no statistically significant difference between the 2 therapeutic schedules concerning infection (OR 0.90, 95%CI 0.50-1.61, P = .72), rash (OR 0.38, 95%CI 0.07-2.04, P = .26).

CONCLUSION

Glucocorticoids combined with MMF had a higher CR and lower incidence of adverse effects compared with glucocorticoids combined with CTX in the treatment of HSPN in children.

Causal association of plasma circulating metabolites with nephritis: a Mendelian randomization study

Background

Nephritis is a pivotal catalyst in chronic kidney disease (CKD) progression. Although epidemiological studies have explored the impact of plasma circulating metabolites and drugs on nephritis, few have harnessed genetic methodologies to establish causal relationships.

Methods

Through Mendelian randomization (MR) in two substantial cohorts, spanning large sample sizes, we evaluated over 100 plasma circulating metabolites and 263 drugs to discern their causal effects on nephritis risk. The primary analytical tool was the inverse variance weighted (IVW) analysis. Our bioinformatic scrutiny of GSE115857 (IgA nephropathy, 86 samples) and GSE72326 (lupus nephritis, 238 samples) unveiled anomalies in lipid metabolism and immunological characteristics in nephritis. Thorough sensitivity analyses (MR-Egger, MR-PRESSO, leave-one-out analysis) were undertaken to verify the instrumental variables' (IVs) assumptions.

Results

Unique lipoprotein-related molecules established causal links with diverse nephritis subtypes. Notably, docosahexaenoic acid (DHA) emerged as a protective factor for acute tubulointerstitial nephritis (ATIN) (OR1 = 0.84, [95% CI 0.78-0.90], p1 = 0.013; OR2 = 0.89, [95% CI 0.82-0.97], p2 = 0.007). Conversely, multivitamin supplementation minus minerals notably increased the risk of ATIN (OR = 31.25, [95% CI 9.23-105.85], p = 0.004). Reduced α-linolenic acid (ALA) levels due to lipid-lowering drugs were linked to both ATIN (OR = 4.88, [95% CI 3.52-6.77], p < 0.001) and tubulointerstitial nephritis (TIN) (OR = 7.52, [95% CI 2.78-20.30], p = 0.042). While the non-renal drug indivina showed promise for TIN treatment, the use of digoxin, hydroxocobalamin, and liothyronine elevated the risk of chronic tubulointerstitial nephritis (CTIN). Transcriptome analysis affirmed that anomalous lipid metabolism and immune infiltration are characteristic of IgA nephropathy and lupus nephritis. The robustness of these causal links was reinforced by sensitivity analyses and leave-one-out tests, indicating no signs of pleiotropy.

Conclusion

Dyslipidemia significantly contributes to nephritis development. Strategies aimed at reducing plasma low-density lipoprotein levels or ALA supplementation may enhance the efficacy of existing lipid-lowering drug regimens for nephritis treatment. Renal functional status should also be judiciously considered with regard to the use of nonrenal medications.

Autoimmune diseases: targets, biology, and drug discovery

Autoimmune diseases (AIDs) arise from a breakdown in immunological self-tolerance, wherein the adaptive immune system mistakenly attacks healthy cells, tissues and organs. AIDs impose excessive treatment costs and currently rely on non-specific and universal immunosuppression, which only offer symptomatic relief without addressing the underlying causes. AIDs are driven by autoantigens, targeting the autoantigens holds great promise in transforming the treatment of these diseases. To achieve this goal, a comprehensive understanding of the pathogenic mechanisms underlying different AIDs and the identification of specific autoantigens are critical. In this review, we categorize AIDs based on their underlying causes and compile information on autoantigens implicated in each disease, providing a roadmap for the development of novel immunotherapy regimens. We will focus on type 1 diabetes (T1D), which is an autoimmune disease characterized by irreversible destruction of insulin-producing β cells in the Langerhans islets of the pancreas. We will discuss insulin as possible autoantigen of T1D and its role in T1D pathogenesis. Finally, we will review current treatments of TID and propose a potentially effective immunotherapy targeting autoantigens.

A Review of IgA Vasculitis (Henoch-Schönlein Purpura) Past, Present, and Future

The clinical association of purpura, arthralgia, and arthritis was first described in 1837 in a publication by Johann Lukas Schönlein, a German physician. In 1874, Eduard Henoch, a student of Schönlein, reported cases of children with purpura, abdominal pain, bloody diarrhea, and joint pain. IgA vasculitis, or Henoch-Schönlein purpura, is a systemic hypersensitivity vasculitis caused by the deposition of immune complexes in small blood vessels, including the renal glomeruli and mesangium. In the skin, the presentation is with non-thrombocytopenic purpura or urticaria. Worldwide, IgA nephropathy is the most common cause of primary glomerulonephritis. Detection of IgA deposition in small blood vessels and the renal glomeruli is diagnostic in most cases. This article aims to review the history, current classification, epidemiology, presentation, and diagnosis of IgA vasculitis and nephropathy, disease associations or trigger factors, including infections, vaccines, and therapeutic agents, and highlights some future approaches to improve diagnosis and clinical management.