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Biswas D, Dasgupta D, Pal P, Sinha R. Presentation and outcome of pediatric lupus nephritis from a large single centre contemporary cohort in Eastern India. Lupus 2023; 32:1440-1446. [PMID: 37707867 DOI: 10.1177/09612033231202843] [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] [Indexed: 09/15/2023]
Abstract
BACKGROUND We present clinical, biochemical, and histopathological characteristics and treatment outcomes of biopsy proven childhood lupus nephritis (LN) from a low/middle income setting treated in the current era of increased use of Mycophenolate Mofetil (MMF) and biologics. METHODS Retrospective observational study of children (1-18 years) with biopsy proven LN treated from 01.01.2010 to 31.01.2020. RESULTS 60 children met our inclusion criteria (80%, n = 48 were females). The median age at diagnosis was 11 (IQR: 9-12) years. The most common extra-renal manifestation was mucocutaneous (n = 54, 90%) and the most common kidney manifestation was edema (n = 50, 83.3%). The median 24-h urinary protein excretion was 1117.8 (IQR: 795.4-1941.7) mg/m2/day with 67% (n = 40) having nephrotic range proteinuria (>1000 mg/m2/day). 75% (n = 45) children had eGFR <90 mL/min/1.73 m2 (median eGFR = 71; IQR: 56-90 mL/min/1.73 m2). Anti-Nuclear Antibody was positive in all, both complement three and four were low in 82% (n = 49) and anti-double stranded DNA antibodies were positive in 63% (n = 38). 85% (n = 51) had proliferative LN with majority being class IV (57%, n = 34). All children received steroids for induction therapy. MMF was given as the sole induction agent in 48% (n = 29) and cyclophosphamide in 27% (n = 16). Rituximab was added in 17% (n = 10) as a rescue agent. Median follow up duration was 50 (IQR: 28-82) months. Six children (10%) died as a result of serious infections and none of them had shown complete response (CR). Out of the 52 children who had a follow up duration of at least 2 years, CR was achieved in 46 children (88%) and partial response (PR) or no response (NR) in three children (6%) each. Although children who were in CR/PR at last follow up had lower proteinuria, higher eGFR, and lower histopathology activity index at onset; low numbers in the NR group precluded us from subjecting them to any statistical correlation tests. 36% (n = 22) of children developed 36 episodes of renal flares with overall incidence of 0.14/person-year. CONCLUSION Our study on a contemporary cohort of childhood LN highlights the importance of achieving CR and its feasibility.
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Affiliation(s)
- Debopoma Biswas
- Pediatric Rheumatology, Institute of Child Health, Kolkata, India
| | | | - Priyankar Pal
- Pediatric Rheumatology, Institute of Child Health, Kolkata, India
| | - Rajiv Sinha
- Pediatric Nephrology, Institute of Child Health, Kolkata, India
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Das J, Kalita P, Dey B, Raphael V, Mishra J, Khonglah Y, Marbaniang E, Handique G, Saurabh A. Clinicopathological, Immunological, and Laboratory Parameters of Childhood Lupus Nephritis: A Study from Northeast India. J Lab Physicians 2023; 15:361-364. [PMID: 37564220 PMCID: PMC10411078 DOI: 10.1055/s-0043-1768168] [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] [Indexed: 08/12/2023] Open
Abstract
Background Lupus nephrtis in children is associated with high morbidity and mortality. The incidence of childhood systemic lupus erythematosus (SLE) ranges from 3.3 to 8.8/100000 children with a higher Asian preponderance. The predominance of SLE in female pediatric patients increases gradually with age to the values observed in adults. Objectives To assess the clinical, immunological, and histopathological spectrum of childhood lupus nephritis in northeast India and explore the relationship between clinical, biochemical, serological, and histopathological findings. Materials and Methods A retrospective descriptive study was performed over 8 years. Histopathology slides were reviewed by two pathologists, whereas other details were collected from patients' records. Statistical Analysis Statistical analysis was based on the chi-square test and a p -value < 0.05 was considered statistically significant. Results Fifty-three cases of lupus nephritis were included in the study. The patients' age ranged from 5 to 18 years with a mean age of 14.5 years and a female: male ratio of 6.5:1. Edema and hypertension were the commonest clinical presentations, whereas proteinuria was the commonest presenting laboratory parameter. Amongst all the immunological markers, dsDNA was the commonest. Histopathologically, predominantly study population belonged to class IV lupus nephritis. The patients with class IV showed a statistically significant correlation with proteinuria and hematuria at the time of diagnosis. Immunological markers, namely, ANA and anti-ds-DNA positivity were significantly associated with advanced renal histopathology. Conclusion cSLE in northeast India presents mostly as Class IV LN presenting mostly with deranged laboratory parameters and preponderance of various immunological markers and clinical presentations.
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Affiliation(s)
- Jonali Das
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Pranjal Kalita
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Biswajit Dey
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Vandana Raphael
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Jaya Mishra
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Yookarin Khonglah
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Evarisalin Marbaniang
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Gauranga Handique
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
| | - Animesh Saurabh
- Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, India
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Wang X, Fu S, Yu J, Tang D, Wu H, Xu Z. Renal C4d is a potential biomarker of disease activity and severity in pediatric lupus nephritis patients. Front Pediatr 2023; 11:1193917. [PMID: 37325343 PMCID: PMC10268246 DOI: 10.3389/fped.2023.1193917] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Background Systemic lupus erythematosus (SLE), a multisystemic autoimmune disease, is very aggressive in pediatric-onset patients as they are prone to develop lupus nephritis (LN). Although renal C4d positivity is correlated with the activity of renal disease and SLE in adult-onset LN patients, available information for pediatric-onset patients is limited. Methods To evaluate the potential diagnostic significance of renal C4d staining in pediatric LN patients, we retrospectively detected C4d staining by immunohistochemistry on renal biopsy specimens from 58 pediatric LN patients. The clinical and laboratory data at the time of the kidney biopsy and the renal disease activity of histological injury were analyzed according to the C4d staining status. Results Glomerular C4d (G-C4d)-positive staining was detected in all 58 cases of LN. Patients with a G-C4d score of 2 displayed more severe proteinuria than those with a G-C4d score of 1 (24-h urinary protein: 3.40 ± 3.55 g vs. 1.36 ± 1.24 g, P < 0.05). Peritubular capillary C4d (PTC-C4d) positivity was found in 34 of 58 LN patients (58.62%). The PTC-C4d-positive patient groups (patients with a PTC-C4d score of 1 or 2) had higher serum creatinine and blood urea nitrogen levels as well as renal pathological activity index (AI) and SLE disease activity index (SLEDAI) scores; however, they had lower serum complement C3 and C4 levels compared to PTC-C4d-negative patients (P < 0.05). In addition, there was positive tubular basement membrane C4d (TBM-C4d) staining in 11 of 58 LN patients (18.96%), and a higher proportion of TBM-C4d-positive patients than TBM-C4d-negative patients (63.63% vs. 21.27%) had hypertension. Conclusion Our study revealed that G-C4d, PTC-C4d, and TMB-C4d were positively correlated with proteinuria, disease activity and severity, and hypertension, respectively, in pediatric LN patients. These data suggest that renal C4d is a potential biomarker for disease activity and severity in pediatric LN patients, providing insights into the development of novel identification and therapeutic approaches for pediatric-onset SLE with LN.
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Affiliation(s)
- Xueyao Wang
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Shaojie Fu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Jinyu Yu
- Department of Renal Pathology, The First Hospital of Jilin University, Changchun, China
| | - Daru Tang
- Medical Student, Bethune Medical College, Jilin University, Changchun, China
| | - Hao Wu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Zhonggao Xu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
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Mittal A, Bamnawat H, Nalwa A, Vishwajeet V, Kumar P, Didel S, Goel AD, Singh K. Pediatric onset lupus nephritis in western India-is it different from the rest of the country? Lupus 2021; 30:2008-2016. [PMID: 34558344 DOI: 10.1177/09612033211045069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM To determine the clinicopathological characteristics and outcomes of children diagnosed with lupus nephritis in a tertiary hospital in western Rajasthan and compare it with the data available from other parts of India. MATERIAL AND METHODS A retrospective review of children presenting to a tertiary care center in western Rajasthan, India, with a diagnosis of pediatric Systemic Lupus Erythematosus (p SLE), between July 2017 and July 2020 was done. Comparisons of pediatric lupus in western India to other parts of country were done. RESULTS 19 children with SLE with Renal involvement were enrolled and followed up. The median age at presentation was 15 years (IQR-16-9.5) (73% females). 8/19 (42%) children presented with AKI, of which 62% children presented as rapidly progressive renal failure. Six (37.5%) patients required dialysis at presentation. 84.21% of children were evaluated with renal biopsy, 16 biopsies were done in 19 children, among which class II, III, and IV lupus nephritis were reported in 21%,42%, and 35% respectively(4 crescentic). Antiphospholipid antibodies were positive in 8/15(53%), children which is much higher than a reported incidence of 30% in other Indian studies. Ten patients (52%) had neurological involvement, with seizures being the most common form of presentation (60%). Seven patients (36%) developed hepatitis. We noted many uncommon presentations in the small group like Autoimmune Pancreatitis, Mononeuritis multiplex, and peripheral digital gangrene. Cyclophosphamide was used in 10 out of 19 patients for inducing remission with class 3 and 4 nephritis and MMF in 8 children. 55% patients attained remission (after completing induction), of which 4 relapsed during the follow up. Four patients were lost to follow-up. A total of 27% patients died and 10% patients developed end stage renal failure. It was seen that those who died had more cardiac and neurological involvement at presentation, higher grade of proteinuria, lower GFR, and need for dialysis at admission. CONCLUSION We found a more severe form of clinical manifestation in pediatric SLE patients at the time of the first presentation in the form of severe renal and extrarenal manifestation compared to other parts of the country.
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Affiliation(s)
- Aliza Mittal
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| | - Harshita Bamnawat
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| | - Aasma Nalwa
- Department of Pathology, 410730All India Institute of Medical Sciences, Jodhpur, Rajasthan
| | - Vikarn Vishwajeet
- Department of Pathology, 410730All India Institute of Medical Sciences, Jodhpur, Rajasthan
| | - Prawin Kumar
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| | - Siyaram Didel
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
| | - Akhil Dhanesh Goel
- Department of Community Medicine and Family Medicine, 410730All India Institute of Medical Sciences, Jodhpur, Rajasthan
| | - Kuldeep Singh
- Department of Pediatrics, 410730All India Institute of Medical Sciences Jodhpur, Jodhpur, Rajasthan
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Association Between Hypoalbuminemia, Degree of Proteinuria, and Lupus Nephritis Class: A Single-Center Cross-sectional Biopsy Study. Nephrourol Mon 2021. [DOI: 10.5812/numonthly.112883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The current study intended to determine whether serum albumin level and urine protein/creatinine rate (uPCR) are appropriate predictors of severe lupus nephritis in childhood-onset SLE. Objectives: Following a cross-sectional single-center design, 85 LN children referred to the National Children Hospital, Ha Noi, Viet Nam, from 6/2019 to 6/2020 were recruited. Renal biopsy was performed for all participants. Methods: Following a cross-sectional single-center design, 85 LN children referred to the National Children Hospital, Ha Noi, Viet Nam, from 6/2019 to 6/2020 were recruited. Renal biopsy was performed for all participants. Results: The mean SLEDAI score of all patients was 14.69. The proportion of patients with high and very high SLEDAI was 61.2 and 17.6%, respectively. The mean concentration of serum albumin was 28.55 g/L, and the proportion of decreased albumin concentration was 55.3%. The median uPCR was 446.6 mg/mmol in which 76.5% of values were ≥ 200 mg/mmol. Pathological morphology of LN class from I to VI was observed in 0%, 17.6%, 37.6 %, 37.6%, 7.1%, and 0%, respectively. Serum albumin level and uPCR presented the predictive value for severe and active LN (class IV and V); (AUC: 0.725 P < 0.001 for both). Conclusions: Serum albumin and uPCR were appropriate predictors for severe and active LN in Vietnamese children.
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Szymanik-Grzelak H, Barabasz M, Wikiera-Magott I, Banaszak B, Wieczorkiewicz-Płaza A, Bieniaś B, Drożynska-Duklas M, Tkaczyk M, Pańczyk-Tomaszewska M. Retrospective analysis of clinical and pathomorphological features of lupus nephritis in children. Adv Med Sci 2021; 66:128-137. [PMID: 33545446 DOI: 10.1016/j.advms.2021.01.004] [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: 07/21/2020] [Revised: 12/08/2020] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE The aim of the study was to evaluate the clinical course and pathomorphological correlations in Polish children with the diagnosis of lupus nephritis (LN). METHODS We retrospectively analyzed the medical records of 39 children hospitalized due to LN in 7 pediatric nephrology units in Poland between 2010 and 2019. Demographic data, clinical symptoms at the onset of LN and laboratory parameters were reviewed. We analyzed Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), histological LN findings with the activity (IA) and chronicity index (IC). RESULTS We examined 32 girls and 7 boys, median age at LN onset was 14.75 (IQR 13.0-16.0) years, SLEDAI of 22.0 (IQR 18.0-27.0) points; LN histological class: IV (59.4%), III (18.9%), III/V (10.8%), IV/V (8.1%), VI (2.7%); IA 8.0 (IQR 6.0-11.0) points, IC 1.05 (IQR 0-2.0) points. Children with nephrotic (n = 22) and non-nephrotic (n = 17) proteinuria differed in median Hb level (9.55, IQR 8.3-11.2 vs 10.9, IQR 10.1-11.6 g/L; P < 0.05), albumin level (2.5, IQR 2.1-3.19 vs 3.6, IQR 3.4-4.1 g/dL; P < 0.001), proteinuria (5.76, IQR 3.0-7.5 vs 1.08, IQR 0.53-1.50 g/day; P < 0.0001), eGFR (53.9, IQR 27.0-68.8 vs 96.7, IQR 73.8-106.2 mL/min/1.73 m2; P < 0.01) and occurrence of hypertension (77% vs 23%; P < 0.01). In multivariate analysis Hb level (β = 8.0; 95%CI, 1.90-14.11) was the significant predictor of eGFR<90 mL/min/1.73 m2. CONCLUSIONS Proliferative forms of LN in children may have a varying clinical presentation. Children with LN with nephrotic range proteinuria have lower Hb level, lower eGFR and higher occurrence of hypertension. Hb level is the significant predictor of eGFR<90 mL/min/1.73 m2 in children with LN.
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Abstract
Systemic lupus erythematosus is a rare lifelong multi-systemic autoimmune condition. Juvenile-onset SLE (JSLE) is recognized to have a more active disease course when compared with adult-onset disease and patients have a worse long-term survival. Kidney involvement occurs in over 50% of children and treatment decisions are guided by the histological classification. Several international groups have produced treatment protocols that rely on an intense period of immunosuppression to halt the acute kidney inflammatory process, followed by maintenance therapy with close observation for disease improvement and prompt evaluation of disease flares. A reduced glomerular filtration rate at presentation is predictive of later stage chronic kidney disease (CKD) in multivariate analysis. Kidney remission remains suboptimal with only 40-60% of patients achieving complete remission. Kidney flares are seen in over a third of patients. The rate of CKD 5 is reported to be up to 15% and the presence of lupus nephritis (LN) has an established link with an associated increase in mortality. In established kidney failure, transplantation seems to be the optimal kidney replacement modality for this group of patients, ideally after a period of disease quiescence. Modified outcome measures in clinical trials have demonstrated that biologic agents can be effective in this disease. Current biologic agents under investigation include obinutuzimab, belimumab, atacicept, anifrolumab, tocilizumab, eculizumab, dapirolizumab, and abatacept. Future research should focus on discovering early disease biomarkers, including surrogates for later cardiovascular disease, and evaluating biological agents as adjuncts to improve the rates of complete remission and subsequently influence the kidney outcome. The aim of this review article is to summarize the current kidney outcomes for this disease with a view to identifying key areas that may help to reduce the risk of long-term CKD.
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Abstract
This chapter describes the musculoskeletal (MSK) context in children and young people as an important contributor to the global non-communicable disease burden. Through selected MSK conditions, we describe the impact on patients, families and communities and highlight the challenges that need to be addressed. We focus on opportunities for better working together and describe exemplar initiatives to raise awareness, workforce capacity building, models of care and research agendas to have a greater global context.
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Smith EMD, Lythgoe H, Midgley A, Beresford MW, Hedrich CM. Juvenile-onset systemic lupus erythematosus: Update on clinical presentation, pathophysiology and treatment options. Clin Immunol 2019; 209:108274. [PMID: 31678365 DOI: 10.1016/j.clim.2019.108274] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 10/12/2019] [Accepted: 10/13/2019] [Indexed: 12/25/2022]
Abstract
Juvenile-onset systemic lupus erythematosus (jSLE) accounts for up to 20% of all SLE patients. Key differences between juvenile- and adult-onset (aSLE) disease include higher disease activity, earlier development of damage, and increased use of immunosuppressive treatment in jSLE suggesting (at least partial) infectivity secondary to variable pathomechanisms. While the exact pathophysiology of jSLE remains unclear, genetic factors, immune complex deposition, complement activation, hormonal factors and immune cell dysregulation are involved to variable extents, promising future patient stratification based on immune phenotypes. Though less effective and potentially toxic, jSLE patients are treated based upon evidence from studies in aSLE cohorts. Here, age-specific clinical features of jSLE, underlying pathomechanisms, treatment options and disease outcomes will be addressed. Future directions to improve the care of jSLE patients, including implementation of the Single Hub and Access point for pediatric Rheumatology in Europe (SHARE) recommendations, biomarkers, treat to target and personalized medicine approaches are discussed.
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Affiliation(s)
- Eve Mary Dorothy Smith
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK.
| | - Hanna Lythgoe
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK
| | - Angela Midgley
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK
| | - Michael William Beresford
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK
| | - Christian Michael Hedrich
- Department of Women's & Children's Health, Institution of Translational Medicine, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Rd, Liverpool L12 2AP, UK.
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