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Aggarwal A, Fernandes TAP, Migowa A, Smith EMD, Hanif M, Webb K, Lewandowski LB. Childhood-Onset Systemic Lupus Erythematosus (cSLE): An International Perspective. Curr Allergy Asthma Rep 2024; 24:559-569. [PMID: 39145903 PMCID: PMC11377481 DOI: 10.1007/s11882-024-01169-3] [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] [Accepted: 07/25/2024] [Indexed: 08/16/2024]
Abstract
PURPOSE OF REVIEW Childhood-onset systemic lupus erythematosus (cSLE) is a severe and potentially life-threatening chronic autoimmune disease. cSLE is more aggressive and has poorer outcomes than adult-onset disease. The global burden of cSLE is poorly understood, with most publications on cSLE originating from high-resourced settings. The reports from less resourced settings indicate high morbidity and mortality in these populations. RECENT FINDINGS In this article, we review the disparities in global access to rheumatology care and research for patients with cSLE. We highlight recent cSLE advances from all regions of the globe. We describe current obstacles to cSLE clinical care and research in all settings. Finally, we propose a path forward for high quality, equitable and accessible care to individuals with cSLE everywhere. Individuals with cSLE are at risk for morbidity and death, yet patients worldwide face challenges to adequate access to care and research. Sustained, collaborative efforts are needed to create pathways to improve care and outcomes for these patients.
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Affiliation(s)
- Amita Aggarwal
- Department of Clinical Immunology & Rheumatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Taciana A P Fernandes
- Department of Pediatrics, Medical School, São Paulo State University (UNESP), Botucatu, Sao Paulo, Brazil
| | - Angela Migowa
- Department of Paediatrics and Child Health, Aga Khan University, 3Rd Parklands Avenue, P.O.BOX 30270 00100 GPO, Nairobi, Kenya
| | - Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Maria Hanif
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Kate Webb
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Laura B Lewandowski
- Lupus Genomics and Global Health Disparities Unit, Systemic Autoimmunity Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA.
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Lin KYK, Chan EYH, Mak YF, To MC, Wong SW, Lai FFY, Ho TW, Tong PC, Lai WM, Yap DYH, Ma ALT. Renal vascular lesions in childhood-onset lupus nephritis. Pediatr Nephrol 2024:10.1007/s00467-024-06498-z. [PMID: 39249126 DOI: 10.1007/s00467-024-06498-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 08/03/2024] [Accepted: 08/05/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND This study aimed to determine the clinical significance of renal vascular lesions (RVLs) in childhood-onset lupus nephritis (cLN). METHODS We retrospectively reviewed all children with biopsy-proven cLN between 2004-2020 to evaluate the prevalence of RVLs on kidney biopsy and its associated factors and long-term outcomes. The composite kidney outcome was defined as advanced chronic kidney disease (CKD) stage 3-5, kidney failure and death. RESULTS 107 biopsies from 84 Chinese patients were analysed. RVLs were observed in 19 patients (22.6%), including non-inflammatory necrotizing vasculopathy (NNV, n = 6), thrombotic microangiopathy (TMA, n = 4), arterial sclerosis (AS, n = 3), concurrent NNV with AS (n = 4), concurrent NNV with TMA (n = 1) and concurrent true renal vasculitis with AS (n = 1). The presence of RVLs was associated with lower estimated glomerular filtration rate (eGFR) (66.9 ± 40.3 vs. 95.6 ± 39.4 ml/min/1.73m2, p = 0.005), haemoglobin level (9.1 ± 1.9 vs. 10.4 ± 1.9 g/dL, p = 0.008) and platelet count (150.1 ± 96.4 vs. 217.2 ± 104.8 × 109/L, p = 0.01). LN classes and activity/chronicity indices were similar. Patients with RVLs had poorer composite kidney outcomes, though not reaching statistical significance (log-rank test, p = 0.06). The presence of NNV was associated with inferior survival free from composite kidney outcome (log-rank test, p = 0.0018), compared to other forms of RVLs and those without RVLs. Univariate analysis revealed NNV (HR 7.08, 95% CI 1.67-30.03) was predictive of composite kidney outcome. CONCLUSION RVLs are present in one-fifth of cLN patients and are associated with severe presentation. NNV is associated with worse long-term kidney outcome. Routine evaluation of RVLs is warranted and should be incorporated into future classification criteria.
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Affiliation(s)
- Kyle Ying-Kit Lin
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong, Hong Kong, SAR
| | - Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong, Hong Kong, SAR.
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong, Hong Kong, SAR.
| | - Yuen-Fun Mak
- Department of Pathology, Princess Margaret Hospital, Hong Kong, Hong Kong, SAR
| | - Ming-Chun To
- Department of Pathology, Princess Margaret Hospital, Hong Kong, Hong Kong, SAR
| | - Sze-Wa Wong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong, Hong Kong, SAR
| | - Fiona Fung-Yee Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong, Hong Kong, SAR
| | - Tsz-Wai Ho
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong, Hong Kong, SAR
| | - Pak-Chiu Tong
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong, Hong Kong, SAR
| | - Wai-Ming Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong, Hong Kong, SAR
| | - Desmond Yat-Hin Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong, SAR
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Hong Kong, Hong Kong, SAR
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Hong Kong, Hong Kong, SAR
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Li H, Chen C, Yang H, Tu J. Efficacy and safety of belimumab combined with the standard regimen in treating children with lupus nephritis. Eur J Pediatr 2024; 183:3987-3995. [PMID: 38940925 PMCID: PMC11322259 DOI: 10.1007/s00431-024-05662-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 06/29/2024]
Abstract
The purpose of this study is to evaluate the efficacy and safety of belimumab combined with the standard regimen in treating children with active lupus nephritis. This single-center, retrospective cohort study used clinical data of children with newly active lupus nephritis hospitalized in the Department of Nephrology between December 2004 and February 2023. Patients were divided into a belimumab or traditional treatment group according to whether or not they received belimumab. Renal remission and recurrence rates and glucocorticoid dose were compared between groups. Forty-seven children (median age 11 years) were enrolled, including 30 and 17 children in the traditional treatment and belimumab groups, respectively. The Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2000) score of children in the belimumab group (23.59 ± 7.78) was higher than that in the traditional treatment group (19.13 ± 6.10) (P = 0.035). The two groups showed no significant difference in the frequency of pyuria, gross hematuria, and the levels of 24-h proteinuria and estimated glomerular filtration rate. The complement C3/C4 in the belimumab group recovered faster than that in the traditional treatment group (P < 0.05). There were no between-group differences in the complete renal remission rate at 6 or 12 months (P = 0.442, P = 0.759). There were no between-group differences in 1-year recurrence rate (P = 0.303). Furthermore, 6 and 12 months after treatment, glucocorticoid doses were lower in the belimumab than the traditional treatment group (17.87 ± 6.96 mg/d vs. 27.33 ± 8.40 mg/d, P = 0.000; 10.00 (5.3) mg/d vs. 13.75 (10.0) mg/d, P = 0.007), respectively. CONCLUSION With an equivalent renal remission rate, belimumab combined with the standard traditional regimen might promote the tapering of glucocorticoids, and the incidence of adverse events is low. WHAT IS KNOWN • Belimumab is documented as an adjunctive treatment with systemic lupus erythematosus (c-SLE) LN with efficacy. • Due to the paucity of studies, its effects and side effects in children with LN remain unclear. WHAT IS NEW • This single-center, retrospective cohort study evaluated the efficacy and safety of belimumab combined with the standard regimen in treating children with proliferative LN. • Belimumab combined with the standard traditional treatment might promote the tapering of glucocorticoids, while exhibiting a low occurrence of adverse events.
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Affiliation(s)
- Huarong Li
- Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China
| | - Chaoying Chen
- Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China.
| | - Hongxian Yang
- Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China
| | - Juan Tu
- Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, 100020, China
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Chan EYH, Lai FFY, Ma ALT, Chan TM. Managing Lupus Nephritis in Children and Adolescents. Paediatr Drugs 2024; 26:145-161. [PMID: 38117412 DOI: 10.1007/s40272-023-00609-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2023] [Indexed: 12/21/2023]
Abstract
Lupus nephritis is an important manifestation of systemic lupus erythematosus, which leads to chronic kidney disease, kidney failure, and can result in mortality. About 35%-60% of children with systemic lupus erythematosus develop kidney involvement. Over the past few decades, the outcome of patients with lupus nephritis has improved significantly with advances in immunosuppressive therapies and clinical management. Nonetheless, there is a paucity of high-level evidence to guide the management of childhood-onset lupus nephritis, because of the relatively small number of patients at each centre and also because children and adolescents are often excluded from clinical trials. Children and adults differ in more ways than just size, and there are remarkable differences between childhood- and adult-onset lupus nephritis in terms of disease severity, treatment efficacy, tolerance to medications and most importantly, psychosocial perspective. In this article, we review the 'art and science' of managing childhood-onset lupus nephritis, which has evolved in recent years, and highlight special considerations in this specific patient population.
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Affiliation(s)
- Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong.
| | - Fiona Fung-Yee Lai
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
| | - Alison Lap-Tak Ma
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Tak Mao Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong.
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, School of Clinical Medicine, Pok Fu Lam, Hong Kong.
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Pennesi M, Benvenuto S. Lupus Nephritis in Children: Novel Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1841. [PMID: 37893559 PMCID: PMC10607957 DOI: 10.3390/medicina59101841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Childhood-onset systemic lupus erythematosus is an inflammatory and autoimmune condition characterized by heterogeneous multisystem involvement and a chronic course with unpredictable flares. Kidney involvement, commonly called lupus nephritis, mainly presents with immune complex-mediated glomerulonephritis and is more frequent and severe in adults. Despite a considerable improvement in long-term renal prognosis, children and adolescents with lupus nephritis still experience significant morbidity and mortality. Moreover, current literature often lacks pediatric-specific data, leading clinicians to rely exclusively on adult therapeutic approaches. This review aims to describe pediatric lupus nephritis and provide an overview of the novel perspectives on the pathogenetic mechanisms, histopathological classification, therapeutic approach, novel biomarkers, and follow-up targets in children and adolescents with lupus nephritis.
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Affiliation(s)
- Marco Pennesi
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Simone Benvenuto
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
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How common is chronic kidney disease in children with lupus nephritis? Pediatr Nephrol 2022; 38:1701-1705. [PMID: 36525081 DOI: 10.1007/s00467-022-05848-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
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