The pathogenesis and treatment of pediatric Henoch–Schönlein purpura nephritis

Correlation between the course of kidney injury and clinicopathology and prognosis of children with Henoch-Schönlein purpura nephritis

PURPOSE

Henoch-Schönlein purpura nephritis (HSPN) has a poor prognosis and variable pathophysiology. The present study aimed to analyze the kidney injury, clinicopathology, and prognosis of HSPN children.

METHODS

This retrospective study examined 249 children with HSPN. The patients' pathological and clinical data were collected. The patients were divided into the following groups according to the duration of their kidney injury: groups with disease duration of < 2 weeks, 2 weeks to 1 month, 1-2 months, 2-4 months, 4-6 months, and ≥ 6 months. The clinicopathological and prognostic relationships were examined between the groups.

RESULTS

We enrolled 249 children with HSPN (average age of 10.12 ± 3.01 years). There were 161 boys (64.66%) and 88 girls (35.34%). Altogether, 191 children (76.71%) developed kidney injury within 2 months. A total of 37 children (14.86%) showed recurrent renal damage after 6 months. Most patient groups exhibited hematuria and proteinuria, with type III pathology being the most common. During 2 weeks and 1 month of kidney injury, the acute pathology index peaked and then decreased; then, it increased again after 4 months as recurrence occurred. The chronic pathology index was the highest in the group with a disease duration of 2-4 months and it increased with increasing disease duration. The prognosis worsens with the disease duration.

CONCLUSION

Children with HSPN showed disease remission after a duration of 4-6 months. The acute and chronic pathology indexes peaked between 2 weeks to 1 month and 2-4 months, respectively. Patients with kidney injury occurring within a month had a much higher remission rate.

Erythrocyte Glutathione S-Transferase Activity as a Sensitive Marker of Kidney Function Impairment in Children with IgA Vasculitis

IgA vasculitis (IgAV) is the most common childhood vasculitis. The main cause of morbidity and mortality in children with IgAV is nephritis (IgAVN), but the risk of its development, severity, and chronicity remain unclear. Erythrocyte glutathione S-transferase (e-GST) activity has been previously detected as a sensitive marker of kidney function impairment in several diseases. We spectrophotometrically assessed and correlated e-GST activity between 55 IgAV patients without nephritis (IgAVwN), 42 IgAVN patients, and 52 healthy controls. At disease onset, e-GST activity was significantly higher in IgAVN patients (median (interquartile range)) (5.7 U/gHb (4.4-7.5)) than in IgAVwN patients (3.1 U/gHb (2.2-4.2); p < 0.001), and controls (3.1 U/gHb (1.9-4.2); p < 0.001). Therewithal, there were no differences between the IgAVwN patients and controls (p = 0.837). e-GST activity was also significantly higher in the IgAVN patients than in the IgAVwN patients after 3 months (5.0 U/gHb (4.2-6.2) vs. 3.3 U/gHb (2.3-4.1); p < 0.001) and 6 months (4.2 U/gHb (3.2-5.8) vs. 3.3 U/gHb (2.1-4.1); p < 0.001) since the disease onset. Consistent correlations between e-GST activity and serum creatinine, estimated glomerular filtration rate (eGFR), and proteinuria levels were not detected. In conclusion, increased e-GST activity can serve as a subtle indicator of kidney function impairment in children with IgAV.

Regulatory T and B cells in pediatric Henoch-Schönlein purpura: friends or foes?

BACKGROUND AND OBJECTIVES

Henoch-Schönlein purpura (HSP) is the most common immunoglobulin A-mediated systemic vasculitis in childhood. We studied immune dysregulation in HSP by analyzing regulatory T (Treg), T helper 3 (Th3), and regulatory B cell (Breg) subpopulations that might intervene in immune activation, IgA production, and HSP clinical manifestations.

METHODS

This prospective study included 3 groups of children: 30 HSP on acute phase, 30 HSP on remission, and 40 healthy controls (HCs) matched on age. Treg, Breg, and Th3 were analyzed by flow cytometry. Serum immunoglobulin and cytokine levels were quantified by ELISA and Luminex.

RESULTS

Treg frequencies were higher in acute HSP than in remitting HSP and HCs (6.53% [4.24; 9.21] vs. 4.33% [3.6; 5.66], p = 0.002, and vs. 4.45% [3.01; 6.6], p = 0.003, respectively). Activated Th3 cells (FoxP3 + Th3 cells) tend to be more abundant in HSP than in HCs (78.43% [50.62; 80.84] vs. 43.30% [40.20; 49.32], p = 0.135). Serum IgA, IL-17, and latency-associated peptide (a marker of the anti-inflammatory cytokine TGF-beta production) were significantly and inflammatory cytokines TNF-alpha, IL-1-beta, and IL-6 were non-significantly higher in HSP than HCs. Bregs were identical between the groups, but, in patients with renal impairment, Breg percentage was lower compared to those without. Treg removal in PBMC culture resulted in an increase in IgA production in HSP proving a negative regulatory role of Tregs on IgA production.

CONCLUSIONS

In pediatric HSP, immune activation persists in spite of an increase in Th3 and Tregs. Th3 could be involved in IgA hyperproduction, inefficiently downregulated by Tregs. Lack of Bregs appears linked to renal impairment.

Individualized medication based on pharmacogenomics and treatment progress in children with IgAV nephritis

Immunoglobulin A vasculitis (IgAV) nephritis, also known as Henoch-Schönlein purpura nephritis (HSPN), is a condition in which small blood vessel inflammation and perivascular IgA deposition in the kidney caused by neutrophil activation, which more often leads to chronic kidney disease and accounts for 1%–2% of children with end-stage renal disease (ESRD). The treatment principles recommended by the current management guidelines include general drug treatment, support measures and prevention of sequelae, among which the therapeutic drugs include corticosteroids, immunosuppressive agents and angiotensin system inhibitors. However, the concentration range of immunosuppressive therapy is narrow and the individualized difference is large, and the use of corticosteroids does not seem to improve the persistent nephropathy and prognosis of children with IgAV. Therefore, individualized maintenance treatment of the disease and stable renal prognosis are still difficult problems. Genetic information helps to predict drug response in advance. It has been proved that most gene polymorphisms of cytochrome oxidase P450 and drug transporter can affect drug efficacy and adverse reactions (ADR). Drug therapy based on genetics and pharmacogenomics is beneficial to providing safer and more effective treatment for children. Based on the pathogenesis of IgAV, this paper summarizes the current therapeutic drugs, explores potential therapeutic drugs, and focuses on the therapeutic significance of corticosteroids and immunosuppressants in children with IgAV nephritis at the level of pharmacogenomics. In addition, the individualized application of corticosteroids and immunosuppressants in children with different genotypes was analyzed, in order to provide a more comprehensive reference for the individualized treatment of IgAV nephritis in children.

Imbalanced Th17/Treg in peripheral blood of adult patients with immunoglobulin A vasculitis nephritis

Introduction

Adult immunoglobulin A vasculitis nephritis (IgAVN) was observed to be more severe than the disease in children because it tended to result in a poor prognosis. The present study analyzed the Th17/Treg cell axis in peripheral blood of adult IgAVN patients, aiming to provide new immunological viewpoints for the pathogenesis of adult IgAVN.

Material and methods

Th17 cell and Treg cell frequencies in peripheral blood of healthy subjects (n = 13) and adult IgAVN patients (n = 12) were analyzed by flow cytometry. Foxp3 mRNA in peripheral blood of healthy subjects and adult IgAVN patients was detected by RT-PCR. Interleukin (IL)-17 and IL-10 in peripheral blood serum of healthy subjects and adult IgAVN patients were examined by ELISA.

Results

The percentages of CD4⁺ Th17⁺ cells in peripheral blood of healthy subjects and adult IgAVN patients were 2.65 ±1.55% and 4.37 ±1.68% respectively. The percentages of Treg cells in peripheral blood of healthy subjects and adult IgAVN patients were 6.44 ±2.90% and 3.91 ±1.94% respectively. The ratio of Th17/Treg in adult IgAVN patients was significantly higher than that of healthy subjects (p = 0.0030). Meanwhile, the Foxp3 mRNA expression of adult IgAVN patients was significantly lower than that of healthy subjects. There was a significant difference in the ratio of IL-17/IL-10 between healthy subjects and adult IgAVN patients (p < 0.0001). A significant correlation between red blood cell distribution width (RDW) and the ratio of Th17/Treg in adult IgAVN patients was observed in Spearman correlation analysis (r = 0.6970, p = 0.0145).

Conclusions

Imbalanced Th17/Treg contributed to the complex pathogenesis of adult IgAVN.

Metagenomic profiling reveals dominance of gram-positive bacteria in the gut microbiome shifts associated with immunoglobulin A vasculitis (Henoch-Schönlein Purpura)

Objectives

Immunoglobulin A vasculitis (IgAV), previously known as Henoch-Schönlein purpura, is the most common vasculitis that has a classical skin manifestation of palpable purpuric rash. Factors pertinent to IgAV remain inadequately understood. Here, we aimed to examine the gut microbiome shifts associated with IgAV and its recovery.

Methods

Stool samples were collected from 10 children with IgAV (6-14 years old) before and after a multi-drug therapy, along with 9 age-matched healthy children. The samples were subjected to metagenomic analyses to investigate the taxonomic and functional shifts of the gut microbiome.

Results

The analyses revealed that compared with healthy controls, treatment-naïve patients exhibited substantial taxonomic and functional alterations of gut microbiota, including 104 IgAV-depleted species and 7 IgAV-elevated species (FDR < 0.05). After treatment, the IgAV patients displayed a partial restoration of the microbiota shifts, as the relative abundances of some biomarkers (e.g. 9 genera and 22 species) became comparable (FDR > 0.1) between the patients and healthy controls. The treatment-responsive features included Weissella, Faecalibacterium prausnitzii and Bifidobacterium pseudocatenulatum and three components of a putative glutamine transport system. Importantly, gram-positive bacteria accounted for over 85% of the numbers and total relative abundance of the species that were associated with IgAV and responsive to the treatment. In addition, of the 122 IgAV-depleted bacterial genes, 82 were mainly contributed by gram-positive bacteria and 12 by gram-negative bacteria.

Conclusions

Gram-positive bacteria are the main drivers underlying the gut microbiome shifts of IgAV, which may assist rational management of the disease.

Early kidney injury in immunoglobulin A vasculitis: Role of renal biomarkers

BACKGROUND

We aimed to determine whether urine kidney injury molecule 1 (KIM-1) and neutrophil gelatinase-associated lipocalin (NGAL) can be used as early noninvasive biomarkers of kidney injury in immunoglobulin A vasculitis.

METHODS

Patients who were diagnosed with immunoglobulin A vasculitis were included in the study. Urine samples were collected for determination of urine KIM-1 and NGAL levels. The control group consisted of age-matched healthy children.

RESULTS

Sixty-one patients who were diagnosed with immunoglobulin A vasculitis were included in the study; 37.7% of these patients were determined to have renal involvement. Median KIM-1 was found to be significantly higher in the patient group (69.59 pg/mL) than the control group (40.84 pg/mL) (P = 0.001). Median NGAL was determined to be statistically significantly higher in the patient group (59.87 ng/mL) compared with the control group (44.87 ng/mL) (P = 0.013). In 23.6% of the patients without renal involvement at admission renal involvement developed within the following 6 months. When median KIM-1 and NGAL at admission of these patients were compared with the control group, they were determined to be statistically significantly higher (P = 0.001, P = 0.003).

CONCLUSIONS

The fact that our patients with late-term nephropathy had no hematuria and / or proteinuria and that KIM-1 and NGAL levels were determined to be high indicates that these biomarkers might be potentially reliable, noninvasive and early determinants of kidney injury.

Renal biopsy in children with IgA vasculitis

Introduction

Henoch-Schönlein purpura nephritis (HSN) is defined as Henoch-Schönlein purpura with kidney involvement, including hematuria and/or proteinuria. The aim of this study was to evaluate the data of HSN patients who underwent renal biopsy, and compare the main clinical and laboratory parameters that may affect renal biopsy findings, treatment protocols, and short- and long-term outcome of those patients.

Methods

Biopsies performed in 72 HSN patients between January 2007 to January 2017 were retrospectively evaluated. They were divided into two groups according to renal biopsy classification of the International Study of Kidney Disease in Children. Renal outcome, clinical and laboratory parameters, treatment protocols, and outcome were compared between groups. Short- and long-term follow-up of patients were evaluated.

Results

Of 72 patients, 47 were male (65.3%) and 44 (61.1%) were ≤10 years of age. Neutrophil-lymphocyte ratio was found higher in patients with scrotal involvement (p=0.042). Short-term unfavorable outcome was significantly higher in patients with scrotal involvement (p=0.038). Patients with hypertension and decreased creatinine clearance were found to have more unfavorable outcomes in long-term follow-up (p=0.029, p=0.040).

Conclusion

Cyclosporin-A and cyclophosphamide could be effective in steroid unresponsive HSN patients. Patients with scrotal involvement, decreased creatinine clearance, and hypertension should be closely monitored for sequelae of HSN.

Association between Tfh and PGA in children with Henoch-Schönlein purpura

Objective

The aim of this study was to investigate the roles of follicular helper CD4⁺ T cells (Tfh) and serum anti-α-1,4-d-polygalacturonic acid (PGA) antibody in the pathogenesis of Henoch-Schönlein purpura (HSP).

Methods

ELISA was performed to determine serum PGA-IgA and PGA-IgG. Flow cytometry was utilized to determine the peripheral CD4⁺ CXCR5⁺ and CD4⁺ CXCR5⁺ ICOS⁺ Tfh cells. Real-time PCR was conducted to determine the expression of Bcl-6 gene. Then the change of Tfh cells was analyzed, together with the association with the anti-PGA antibody as well as the roles in the pathogenesis of HSP.

Results

Compared with the cases with acute respiratory infection and elective surgery, the proportion of CD4⁺ CXCR5⁺ and CD4⁺ CXCR5⁺ ICOS⁺ Tfh cells in the HSP group showed significant elevation (P < 0.001). A significant correlation was noticed between PGA-IgA and CD4⁺ CXCR5⁺ Tfh cells (r = 0.380 and P = 0.042) and CD4⁺ CXCR5⁺ ICOS⁺ Tfh cells (r = 0.906 and P < 0.001). The expression of Bcl-6 in the HSP group showed no statistical difference compared with that in the acute respiratory infection and the surgery control (P < 0.05).

Conclusion

Increased activity of Tfh cells, which is closely related to mucosal immunity, may be a major contributor in the elevation of PGA-IgA, and Tfh cells and PGA-IgA are closely related to the occurrence of HSP.

Henoch-Schönlein purpura in Saudi Arabia: characteristics and rare vital organ involvement

Henoch-Schönlein purpura (HSP) is the most common small vessel vasculitis in children with an annual incidence of between 10 and 30 per 100,000. It is an inflammation that affects many organs primarily in the skin, gastrointestinal (GI) tract, musculoskeletal, also vital organs like kidneys and lungs which may lead to chronic kidney disease and pulmonary hemorrhage. In this review, we are showing the characteristics of Saudi patients with HSP and the relation with preceding infections, gender, and seasonal variations in addition to the common and most severe systemic involvements. We found cases that were challenging to diagnose and others with unfortunate fetal complications.

Clinical manifestations and outcomes of 420 children with Henoch Schönlein Purpura from a single referral center from Turkey: A three-year experience

Objectives: Henoch Schönlein Purpura (HSP) is the most common systemic vasculitis in childhood. We aimed to evaluate the clinical features, seasonal variation, treatment outcomes and the possible predicting factors related to outcome among a large cohort of pediatric HSP patients.Methods: We conducted a medical record review study between July 2016 and January 2019 and evaluated the clinical manifestations and potential risk factors for severe gastrointestinal (GI) involvement, biopsy-proven nephritis and relapses.Results: The study included 420 HSP patients, of which the mean age at diagnosis was 7.68 ± 3.15 years. Clinical manifestations were arthralgia and/or arthritis (n = 244, 58.1%), abdominal pain (n = 235, 56%), subcutaneous edema (n = 163, 38.8%), and renal involvement (n = 125, 29.8%). Disease recurred for at least once, in 69 (16.4%) patients and colchicine treatment yielded a favorable response in 11 of 12 relapsing patients, who did not respond to ibuprofen or steroids. Frequencies of renal involvement and biopsy-proven nephritis were higher in patients with severe GI involvement. Besides, patients with biopsy-proven nephritis had higher rates of abdominal pain, intussusception, severe GI involvement, and systemic steroid administration.Conclusion: We speculate that renal involvement, biopsy-proven nephritis and severe GI involvement can be related to each other. Colchicine may be effective in patients with relapsing disease.

Early recognition and treatment of Henoch-Schönlein purpura in children

Henoch-Schönlein purpura (HSP) is characterised by a non-blanching rash, which commonly affects the lower limbs of children aged 3-15 years. It is the most common vasculitis in children. HSP often develops after an upper respiratory tract infection and is more likely to present in autumn, winter and spring. The majority of cases resolve with symptomatic treatment although some cases may progress to serious complications, including renal involvement. A case study is presented and differential diagnoses are explored. The pathophysiology of HSP is discussed. Nurses are often the first to assess patients so they are in an ideal position to recognise and treat HSP early on. Admission of a child into hospital is a stressful event for the parents and child; the nurse can help by ensuring prompt admission to hospital and offering support and reassurance to the family.

Autoantibodies Specific for Galactose-Deficient IgA1 in IgA Vasculitis With Nephritis

Introduction

Patients with IgA nephropathy (IgAN) have elevated serum levels of galactose-deficient IgA1 (Gd-IgA1) that are bound by Gd-IgA1–specific autoantibodies in pathogenic immune complexes. Renal biopsy histopathologic features of IgA vasculitis (IgAV) with nephritis (IgAV-N) are similar to those of IgAN. Mucosal infections often are associated with clinical onset and exacerbation in both diseases. We investigated whether patients with IgAV-N share pathogenic characteristics of IgAN.

Methods

We generated IgA1- and IgG-secreting cell lines from Epstein-Barr virus (EBV)–immortalized cells of patients with IgAV without nephritis (IgAV-woN), IgAV-N, and IgAN and from healthy individuals. Sera and cell-culture supernatants were used for analysis of Gd-IgA1 and Gd-IgA1–specific IgG autoantibodies.

Results

IgA1-producing cells from patients with IgAV-N, like cells from patients with IgAN, secreted more Gd-IgA1 than did cells from patients with IgAV-woN or healthy control subjects, in agreement with elevated serum Gd-IgA1 levels in patients with IgAV-N and IgAN. IgA1-producing cells from patients with IgAV-N had altered expression of genes involved in O-glycan biosynthesis: decreased for core 1 synthase (glycoprotein-N-acetylgalactosamine 3-β-galactosyltransferase 1; C1GALT1) and C1GALT1 Specific Chaperone 1 (C1GALTC1; COSMC) and elevated for N-acetylgalactosaminide α-2,6-sialyltransferase 2 (ST6GALNAC2). Levels of Gd-IgA1–specific IgG in sera and supernatants of IgG-producing cells were similar for patients with IgAV-N and IgAN and higher than those for IgAV-woN patients or healthy control subjects. Moreover, patients with IgAV-N who had active disease, manifested by hematuria and substantial proteinuria, had higher serum levels of Gd-IgA1–specific IgG autoantibodies than did patients with IgAV-N who had inactive disease.

Conclusion

Serum levels and cellular production of Gd-IgA1 and Gd-IgA1–specific IgG autoantibodies were elevated in patients with IgAV-N, supporting the hypothesis that IgAV-N and IgAN share pathogenic features.

IgA1 isolated from Henoch-Schönlein purpura children promotes proliferation of human mesangial cells in vitro

Previous studies show that the proliferation of human mesangial cells (HMCs) played a significant part in the pathogenesis of Henoch-Schönlein purpura nephritis (HSPN). The aim of this study was to explore the proliferation of HMCs induced by IgA1 isolated from the sera of HSP patients. HMCs were cultured in three different types of media, including IgA1 from patients with HSP (HSP IgA1 group), healthy children (healthy IgA1 group) and medium (control group). The proliferation of HMCs incubated with IgA1 was determined by cell counting kit-8 assay and bromodeoxyuridine incorporation. The expression of ERK1/2 and phosphatidylinositol 3 kinase/protein kinase B/mammalian targets of the rapamycin (PI3K/AKt/mTOR) signals and transferrin receptor (TfR/CD71) was detected with the methods of immunoblotting. The results indicated that the proliferation of HMCs significantly increased in the HSP IgA1 group compared with that in the control group or the healthy IgA1 group (P < 0.001). Moreover, we found that IgA1 isolated from HSP patients activated ERK and PI3K/AKt/mTOR signals, and markedly increased TfR/CD71 expression in HMCs. These effects induced by IgA1 isolated from patients with HSP were inhibited by human TfR polyclonal antibody (hTfR pAb) and soluble human transferrin receptor (sTfR), indicating that IgA1-induced HMC proliferation and ERK1/2 and PI3K/AKt/mTOR activation were dependent on TfR/CD71 engagement. Altogether, these data suggested that TfR/CD71 overexpression and ERK1/2 and PI3K/AKt/mTOR activation were engaged in HMC proliferation induced by IgA1 from HSP patients, which might be related to the mesangial injury of HSPN.

Association between anti-α-1,4-D-polygalacturonic acid antibodies and Henoch-Schönlein purpura in children

Objective

To investigate the relationship between anti-α-1,4-D-polygalacturonic acid (PGA) antibodies, particularly immunoglobulin (Ig)A, and Henoch-Schönlein purpura (HSP) in children.

Methods

This observational case–control study investigated PGA-IgA, PGA-IgG, and PGA/PGA-IgA circulating immune complex (PGA/PGA-IgA CIC) in paediatric patients with HSP versus controls. Children with HSP were also evaluated for food specific IgG and food intolerance. Between-group differences in anti-PGA antibodies were analysed.

Results

Serum PGA-IgA and PGA-IgG levels were significantly increased in patients with acute HSP (n = 251) versus those with urticaria (n = 48), acute respiratory infections (n = 95), surgical controls (n = 53) and neonates (n = 92). PGA/PGA-IgA CIC levels were also significantly higher in the acute HSP group versus surgical control and neonate groups. Levels of PGA/PGA-IgA CIC and PGA-IgA were significantly correlated (r = 0.997), and PGA-IgA showed high diagnostic specificity for HSP. No statistically significant differences were observed in PGA-IgA and PGA-IgG between various degrees of food intolerance in children with HSP.

Conclusion

Increased anti-PGA antibodies, particularly PGA-IgA and PGA/PGA-IgA CIC, were significantly associated with acute HSP in children. Food intolerance was not found to be associated with increased anti-PGA antibodies in children with HSP.

Do practical laboratory indices predict the outcomes of children with Henoch-Schönlein purpura?

Objectives: Henoch Schönlein Purpura (HSP) is the most common systemic vasculitis of childhood and often has a self-limiting course. We aimed to study whether practical laboratory parameters at the diagnosis predict disease course including recurrence and nephritis in addition to severe gastrointestinal involvement in children with HSP. Methods: This retrospective cohort study included 214 HSP patients, 43.5% (n = 93) female and 56.5% (n =121) male, who were diagnosed in our department. Laboratory parameters before treatment, including neutrophil, lymphocyte and platelet counts, mean platelet volume (MPV), neutrophil-to-lymphocyte (NLR), and platelet-to-lymphocyte ratios (PLR) were obtained retrospectively. Age at diagnosis, duration of follow-up, gender, preceding infections, medications, arthritis and arthralgia, abdominal pain, severe GI involvement, invagination, renal involvement and presence of nephritis, outcomes, and presence of recurrences were retrospectively recorded from medical files. Severe GI involvement was determined as severe colicky abdominal pain, bowel edema in ultrasonography or overt GI bleeding. A relapse was defined as a new flare of cutaneous lesions or other manifestations in a patient at least four asymptomatic weeks after the initial HSP episode. Results: Mean age at diagnosis was 7.6 ± 3.1 years. Biopsy-proven nephritis was found in 16 (7.5%) patients. Severe GI involvement was present in 77 (36%) patients, whereas only 12 (5.6%) patients were diagnosed with intussusception and in 29 (13.5%) patients, HSP recurred. Neutrophil count and NLR were found higher in HSP patients with severe gastrointestinal involvement and biopsy-proven nephritis. Additionally, only platelet count was lower and MPV was higher in patients with recurrent HSP. Conclusion: Elevated neutrophil count and NLR may be relevant markers for severe GI involvement and nephritis, whereas platelet count and MPV were the only laboratory parameters associated with disease recurrence.

Acute renal insufficiency and pancreatitis in a child with atypical Henoch-Schönlein purpura: efficacy of a single dose of cyclophosphamide

A 9-year-old boy with petechiae on the legs and abdominal pain was unsuccessfully treated with steroids. He was admitted to our hospital for the onset of fever, ecchymosis, and arthralgia. Skin lesions suggested vasculitis, but they were not typical of Henoch–Schönlein purpura. He showed ecchymosis of the scrotal bursa, diffusion of petechiae to the trunk and arms, vomiting, severe abdominal pain, oliguria with hyponatremia, hypoalbuminemia, low C3 levels, high levels of creatinine, blood urea nitrogen, and tubular enzymes, proteinuria, and glycosuria. The urinary sediment showed macrohaematuria, and hyaline and cellular casts. Ultrasound showed polyserositis. He was treated with intravenous furosemide, albumin, and methylprednisolone. He underwent colonoscopy and gastroscopy because of development of acute pancreatitis and severe anaemia. Typical lesions of Henoch–Schönlein purpura were observed in the small intestine and colon mucosa. He received three high doses of methylprednisolone, followed by intravenous cyclophosphamide. A dramatic and persistent response was observed after these doses. A single high dose of cyclophosphamide is appropriate in Henoch–Schönlein purpura with acute renal failure and severe pancreatitis that are non-responsive to high-dose steroids.

[Comparison of age-based clinical and abnormal immune parameters in patients with Henoch-Schönlein purpura]

Objective: To explore age-based clinical and immune parameters in Henoch-Schönlein purpura (HSP) to determine clinically useful markers reflecting disease characteristic. Methods: A cohort of 502 patients with HSP were enrolled into this retrospective study to evaluate their clinical and immune data. Results: Majority HSP cases occurred at age ≤14 years and showed significant immune imbalances of ESR, CD3(+) cells, CD4(+) cells, CD3(-)CD16(+)CD56(+) cells, CD4(+)/CD8(+) cells, IgG, IgA, IgM, IgE, complements C3/C4 and ASO in the acute phase. Compared to patients aged >14 years, symptoms of joint were more frequent at disease onset in patients aged ≤14 years (20.8% vs 7.6%, χ(2)=13.547, P<0.001) , and involvement of digestive tract and joint were also more frequent (57.4% vs 33.8%, χ(2)=24.106, P<0.001; 55.9% vs 32.5%, χ(2)=23.768, P<0.001, respectively) , but not for involvement of kidney (21.4% vs 51.3%, χ(2)=42.440, P<0.001) . The patients aged ≤14 years had distinct immune state, reductions of CD3(+) cells, CD4(+) cells and IgG were more frequent than patients aged >14 years, also increase of ASO (33.1% vs 20.0%, χ(2)=6.656, P=0.010) , but not increase of IgA (2.6% vs 39.4%, χ(2)=15.582, P<0.001) . In addition, reduction of IgG and increase of IgE were positively associated with digestive tract involvement (P<0.001, P=0.001, respectively) , reduction of CD3(+)CD4(+) cells and normal IgM were positively associated with joint involvement (P=0.004, P=0.003, respectively) , increase of CD3(+)CD8(+) cells and normal CD3(+) cells were positively associated with kidney involvement (P=0.032, P=0.014, respectively) . Conclusion: HSP showed significant immune imbalance in the acute phase, patients between aged ≤14 and >14 years had distinct clinical and immune characteristic, and abnormal immune parameters were significantly associated with organ involvements.

Correlation between Traditional Chinese Medicine Symptom Patterns and the Renal Function, Immunologic Function Index, and Blood Coagulation Index in Patients with Henoch-Schönlein Purpura Nephritis

Objective

We investigate the correlation between the patterns of traditional Chinese medicine (TCM) syndromes and the damage of renal function, immunologic function index, and blood coagulation index in patients with Henoch-Schönlein purpura nephritis (HSPN) and thus provide the therapeutic effects of Chinese herbs decoction on HSPN.

Methods

We studied 262 hospitalized patients diagnosed with HSPN between 1 February 2016 and 1 January 2017. Indexes like renal function, immunologic function, and blood coagulation were measured. The patients were classified into four different patterns of TCM symptoms.

Results

In a total of 262 patients with HSPN, dampness-heat accumulation accounted for 59.5%, which is the highest proportion of TCM symptom patterns, liver-kidney yin deficiency accounted for 17.6%, qi and yin deficiency ratio reached 12.6%, and blood-heat bleeding accounted for 9.9%. 24-hour proteinuria was heavier in the dampness-heat accumulation patients who had immune disorders and were in hypercoagulative state and hyperfibrinolysis conditions.

Conclusion

We analyzed and summarized the clinical characteristics of patients with HSPN and found that dampness-heat accumulation was dominant in patients and was always accompanied by immune disorders and coagulation disorders. These results provided the largest therapeutic effects of Chinese herbs decoction for clinical treatment.

Childhood systemic vasculitis

Vasculitides are characterized by inflammation of the vessel wall. Most of the vasculitides tend to occur in vessels of a specific size and certain target organs. In this review, we discuss each specific childhood vasculitis according to the latest Chapel Hill Consensus Conference 2012 nomenclature system and the Ankara 2008 classification criteria. We have also reviewed the clinical and laboratory characteristics and the recent treatment recommendations for the vasculitides we encounter in children.

The incidence and severity of IgA vasculitis with nephritis over a 10-year period in our hospital

BACKGROUND

To evaluate the recent frequency of onset and severity of IgA vasculitis with nephritis (IgAVN) in Fukushima Prefecture, we examined the epidemiology and clinico-pathological manifestations of IgAVN in our hospital over a 10-year period.

METHODS

We enrolled 18 patients with IgAVN treated between 2004 and 2013 in the Department of Pediatrics, Fukushima Medical University School of Medicine. These patients were divided into two groups; Group 1 consisted of 12 patients with IgAVN hospitalized between 2004 and 2008 and Group 2 consisted of 6 patients with IgAVN hospitalized between 2009 and 2013. The epidemiology, clinical features, laboratory data, pathological findings, and outcome were retrospectively compared between the two groups.

RESULTS

The numbers of patients with IgAVN per year in Group 2 were lower than that in Group 1. The frequency of patients with higher than grade IIIb disease in Group 2 (50%) was lower than that in Group 1 (94%); furthermore, the frequency of patients with higher than grade IV disease in Group 2 (0%) was lower than that in Group 1 (50%).

CONCLUSIONS

Our findings suggest that the incidence of onset and severity of IgAVN in patients diagnosed between 2009 and 2013 were lower than those in patients diagnosed between 2004 and 2008.

Anaphylactoid Purpura Associated with Streptococcal Cellulitis: A Case Report and Literature Review

A 54-year-old Japanese man noticed painful swelling and redness of his left leg. He was admitted for treatment of cellulitis, which was accompanied with increased anti-streptolysin O and anti-streptokinase titers in his clinical course. After Piperacillin/Tazobactam administration, the skin lesion resolved. However, the patient then developed arthritis, palpable purpura, and intermittent abdominal pain, later found to be secondary to a severe duodenal ulcer. He was diagnosed with cellulitis-associated anaphylactoid purpura and was given prednisolone, which dramatically improved his symptoms. The anaphylactoid purpura was likely caused by Streptococcus-induced cellulitis, which was successfully treated with prednisolone. Association between these diseases is rare.

Application value of laboratory indexes in the differential diagnosis of Henoch-Schoenlein purpura

OBJECTIVE

The aim of this study was to explore the value of laboratory indexes in the differential diagnosis of Henoch-Schoenlein purpura (HSP).

METHODS

Patients with HSP hospitalized at the Children's Hospital of Zhejiang University School of Medicine between January 2010 and December 2014 were enrolled in this prospective study. In addition, septic patients with rash and patients with urticaria, simple hematuria, and acute appendicitis hospitalized during the same period were selected at random as differential diagnosis subjects, and healthy children were selected as normal controls. The levels of IgA, D‑dimer, fibrinogen (FIB), and platelet (PLT) and the platelet distribution width (PDW) of these individuals were tested and analyzed, and the ROC curve was used to determine the applicability of these indexes to differentiate between patients with HSP and other diseases easily confused with HSP, as well as to determine the efficacy of combined diagnosis.

RESULTS

There were remarkable differences in the levels of FIB, D‑dimer, IgA, PLT, and PDW among patients with HSP, sepsis patients with rash, patients with urticaria, simple hematuria, or acute appendicitis and healthy children (P < 0.01).

CONCLUSION

The levels of IgA, D‑dimer, and PLT can be applied separately for the differential diagnosis of HSP, and these indexes and FIB can be combined appropriately to improve the diagnostic efficacy.

Staphylococcus Infection-Associated GN - Spectrum of IgA Staining and Prevalence of ANCA in a Single-Center Cohort

BACKGROUND AND OBJECTIVES

Staphylococcus infection-associated GN (SAGN) is a well recognized disease entity, particularly because of the frequent IgA-dominant glomerular immunoglobulin staining on kidney biopsy. Biopsy features can resemble two other disease entities - primary IgA nephropathy and Henoch-Schönlein purpura nephritis - posing a diagnostic pitfall. This is clinically relevant because of the crucial difference in the therapeutic approach. The diagnosis of SAGN is further complicated by the variability in the degree of glomerular IgA (and C3) staining, the extent of electron dense immune-type deposits, and positive ANCA serology in some patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a thorough histopathologic review of our single-center cohort of 78 culture-proven SAGN biopsies to assess the spectrum of IgA staining, prevalence of ANCA serology, prevalence of subepithelial "humps," and other histologic features to distinguish from primary IgA nephropathy.

RESULTS

Among the 78 SAGN biopsies, IgA staining was trace in 25%, mild in 19%, moderate in 44%, and strong in 12% of the cases. C3 was frequently moderate-to-strong but was trace in 14% of the biopsies. Concomitantly trace IgA, IgG, and C3 (pauci-immune pattern) was seen in 13%. Crescents were present in 35% of the SAGN biopsies. Out of 41 patients tested for ANCA, nine (22%) were positive, including patients with endocarditis and other infections. Subepithelial humps were identified in only 31% of the SAGN biopsies.

CONCLUSIONS

SAGN biopsies show marked variability in IgA immunofluorescence staining and low frequency of subepithelial humps compared with poststreptococcal GN. Occasional ANCA positivity is present in cases of SAGN, even in infections other than endocarditis. Therefore, biopsy diagnosis can be difficult particularly when clinical symptoms of infection are subtle. Both the pathologist and the nephrologist should be aware of these diagnostic pitfalls.

Urinary myeloid IgA Fc alpha receptor (CD89) and transglutaminase-2 as new biomarkers for active IgA nephropathy and henoch-Schönlein purpura nephritis

BACKGROUND

IgA nephropathy (IgAN) and Henoch-Schönlein purpura nephritis (HSPN) are glomerular diseases that share a common and central pathogenic mechanism. The formation of immune complexes containing IgA1, myeloid IgA Fc alpha receptor (FcαRI/CD89) and transglutaminase-2 (TG2) is observed in both conditions. Therefore, urinary CD89 and TG2 could be potential biomarkers to identify active IgAN/HSPN.

METHODS

In this multicenter study, 160 patients with IgAN or HSPN were enrolled. Urinary concentrations of CD89 and TG2, as well as some other biochemical parameters, were measured.

RESULTS

Urinary CD89 and TG2 were lower in patients with active IgAN/HSPN compared to IgAN/HSPN patients in complete remission (P < 0.001). The CD89xTG2 formula had a high ability to discriminate active from inactive IgAN/HSPN in both situations: CD89xTG2/proteinuria ratio (AUC: 0.84, P < 0.001, sensitivity: 76%, specificity: 74%) and CD89xTG2/urinary creatinine ratio (AUC: 0.82, P < 0.001, sensitivity: 75%, specificity: 74%). Significant correlations between urinary CD89 and TG2 (r = 0.711, P < 0.001), proteinuria and urinary CD89 (r = - 0.585, P < 0.001), and proteinuria and urinary TG2 (r = - 0.620, P < 0.001) were observed.

CONCLUSIONS

Determination of CD89 and TG2 in urine samples can be useful to identify patients with active IgAN/HSPN.

Beneficial effects of creatine phosphate sodium for the treatment of Henoch-Schönlein purpura in patients with early renal damage detected using urinary kidney injury molecule-1 levels

Henoch-Schönlein purpura (HSP) is a small-vessel disease in children that is often accompanied by kidney damage. Despite many efforts to improve the early assessment of renal injury in HSP patients, effective markers are still lacking. In recent years, the relationship between kidney injury molecule-1 (KIM-1) and tubulointerstitial injury has drawn much attention, especially regarding the diagnostic potential of serum and urinary KIM-1 levels. However, the diagnostic value of KIM-1 for detecting urinary kidney injury in HSP patients is still elusive. Furthermore, the treatment of Henoch-Schönlein purpura nephritis (HSPN) relies on the clinician's experience without performing renal biopsy, so it is important to find an effective biomarker and therapy. In the present study, we investigated the diagnostic value of urinary KIM-1 for early renal injury in HSP patients enrolled in a prospective, single-center study. Urinary KIM-1 levels were measured in 27 patients with HSP, 32 patients with HSPN (21 HSPN patients had undergone renal biopsy), and 16 healthy donors, as normal controls. The HSPN patients were randomly divided to receive either routine therapy (n = 13) or routine treatment combined with creatine phosphate sodium (CP) (n = 19). Urinary KIM-1 levels were significantly greater in the HSP and HSPN groups than those in the healthy control group (P < 0.01), and were significantly greater in the HSPN group than in the HSP group (P < 0.01). The urinary KIM-1 levels decreased significantly after 10-14 days of treatment with CP compared with conventional therapy (P < 0.05).

CONCLUSION

Our results demonstrate the diagnostic value of KIM-1 and the therapeutic potential of CP for early renal damage in HSP patients.

WHAT IS KNOWN

Urine kidney injury molecule-1 (KIM-1) is a sensitive biomarker for tubulointerstitial injury. Henoch-Schonlein purpura (HSP) usually presents with renal damage.

WHAT IS NEW

Our results suggest that the urinary KIM-1 level is a sensitive and specific biomarker for the detection of early renal damage in HSP and may predict the severity of HSP and HSPN. The administration of creatine phosphate sodium (CP) may reduce urinary KIM-1 levels and thus correct the hypoxic condition of the kidney. Preconditioning with CP may also be a useful adjunct for preventing early renal damage in HSPN patients.

Clinical manifestations of Henoch-Schönlein purpura nephritis and IgA nephropathy: comparative analysis of data from the Japan Renal Biopsy Registry (J-RBR)

Background

The clinical presentation of Henoch–Schönlein purpura nephritis (HSPN) has not been thoroughly investigated among patients of different ages. We therefore compared the features of HSPN and IgA nephropathy (IgAN) based on data from the Japan Renal Biopsy Registry (J-RBR).

Methods

This cross-sectional study analyzed data from patients who were registered in the J-RBR between 2007 and 2012. Clinico-pathological findings at diagnosis were compared among children (aged ≤18 years), adult (aged 19–64 years) and elderly (aged ≥65 years) patients with HSPN (n = 513) and IgAN (n = 5679).

Results

The age at diagnosis considerably differed between HSPN and IgAN; HSPN peaked at 1–19 and at 60–69 years, whereas IgAN peaked at 30–39 years. The clinical features were significantly more severe for HSPN than IgAN, especially proteinuria (children, 1.28 vs. 0.57; adult, 1.95 vs. 1.05; elderly patients, 2.71 vs. 1.64 g/day), and low albumin levels (children, 3.72 vs. 4.13; adults, 3.62 vs. 3.99; elderly patients, 3.07 vs. 3.57 g/dL). The rate (%) of histologically classified endocapillary proliferative or crescentic glomerulonephritis was higher in patients with HSPN than with IgAN. Multiple regression analysis revealed that low albumin level and high BP were independent factors associated with decreased estimated glomerular filtration rates in adult and elderly patients with HSPN.

Conclusions

Age at HSPN diagnosis was bimodally distributed, and the clinical features of HSPN were more severe than those of IgAN across all age groups.

Macrophage migration inhibitory factor urinary excretion revisited – MIF a potent predictor of the immunosuppressive treatment outcomes in patients with proliferative primary glomerulonephritis

Background

Macrophage migration inhibitory factor (MIF) is a cytokine that shares many activities with other pro-inflammatory cytokines in primary glomerulonephritis (GN). This study assesses the influence of immunosuppressive treatment on serum and urine MIF in patients with proliferative (PGN) and non-proliferative (NPGN) glomerulonephritis, and evaluates the potential of MIF in predicting outcomes.

Methods

Eighty-four patients (45 males and 39 females) with primary GN were included. Urinary excretion of MIF (ng/mg of urinary creatinine) was measured both pre- and post-treatment with combined steroids and cyclophosphamide. After a 12-month follow-up, the patients were retrospectively divided into four subgroups: responders of proliferative GN (R-PGN), non-responders of proliferative GN (NR-PGN), responders of non-proliferative GN (R-NPGN) and non-responders of non-proliferative GN (NR-NPGN).

Results

The median pre-treatment urinary MIF values were higher in PGN than in NPGN (3.6 versus 2.2; ANOVA P = 0.039). The highest pre-treatment urinary excretion of MIF was observed in NR-PGN (median 6.1), which was significantly higher than other subgroups (ANOVA P < 0.05). The treatment significantly reduced MIF urinary excretion only in R-PGN (P < 0.01). In NR-PGN, pre- (5.9 ± 2.9 pg/mgCr) and post-treatment mean MIF excretion (4.9 ± 2.3 pg/mgCr) exceeded the calculated cut off value (3.3 pg/mgCr).

Conclusion

MIF urinary excretion appears to be a prognostic marker of therapy outcomes only in proliferative glomerulonephritis, in which lower urinary MIF may be linked with good prognosis, whereas a higher MIF urinary excretion value was a marker of unfavorable therapy outcomes. In Non-Responders, urinary MIF measurements may help to reconsider the choice of the immunosuppressive regimen at early stages of the treatment and act as an impulse to search for new therapeutic strategies.

IgA Cutaneous Purpura Post-Renal Transplantation in a Patient With Long-Standing IgA Nephropathy: Case Report and Literature Review

BACKGROUND

IgA vasculitis is a small-vessel vasculitis caused by deposition of IgA antibodies in tissues. IgA nephropathy and IgAV have long been considered related conditions.

OBJECTIVE

To assess the prevalence and implications of new-onset Henoch-Schönlein purpura (HSP) after renal transplant in patients with underlying IgA nephropathy.

METHODS

The PubMed database was searched for keywords such as IgAV, IgA vasculitis, Henoch-Schönlein purpura, HSP, IgA nephropathy, and renal transplant.

RESULTS

Two cases of new-onset IgA vasculitis post-renal transplant after stopping the prednisone or receiving seasonal influenza vaccine have been reported. We report the case of new-onset IgA cutaneous vasculitis in a renal transplant patient with IgA nephropathy after reduction in his prednisone dosage.

CONCLUSION

The new development of cutaneous IgA vasculitis is unusual in renal transplant patients with IgA nephropathy. Despite these patients' being immunosuppressed, the presence of IgA vasculitis could signal the recurrence of IgA nephropathy.

An analysis of the levels of the soluble form of the endothelial protein C receptor in children with Henoch-Schönlein Purpura

The pathogenesis of Henoch-Schönlein Purpura (HSP) has not been clearly defined. Inflammatory cytokines have been associated with HSP but there are only a few reports that have focused on coagulation. The endothelial protein C receptor (EPCR), which has anticoagulant and antiinflammatory activity, is the key component of the protein C pathway. Recent studies have implicated the soluble form of EPCR (sEPCR) in Wegener's granulomatosis, Behçet's disease, and systemic lupus erythematosus. The aim of this study was to evaluate the levels of sEPCR in HSP children. Twenty-two children with HSP and 17 healthy children were included. We found no significant differences (P > .05) between patient and control groups in the levels of von Willebrand factor and thrombomodulin. The median sEPCR values in the HSP group were lower than the control group (79 vs. 102 ng/mL, respectively) (P > .05). The mean sEPCR value in HSP patients with severe abdominal pain was lower than without (88.8 ± 54.9 vs. 108.2 ± 66.3 ng/mL, respectively) (P > .05). In addition, the mean IL-6 serum levels were significantly elevated in HSP patients during the acute stage of HSP (2.1 ± 1.7 vs. 1.5 ± 1.2 pg/mL, P = .038). We also observed a slight negative correlation between the levels of sEPCR and IL-6 (R = -.135, P > .05). To our knowledge, this was the first study to analyze sEPCR levels in HSP. Our results did not conclusively identify a direct role of sEPCR in HSP, but our findings warrant further investigations, especially in severe HSP cases characterized by gastrointestinal bleeding or renal involvement.

Relationship between immune parameters and organ involvement in children with Henoch-Schonlein purpura

Henoch-Schonlein purpura (HSP) is the most common type of connective tissue diseases which increasingly occurs in children in recent years and its pathogenesis remains unclear. In order to explore the immune parameters and underlying pathogenesis mechanism of children with HSP, the study involved 1232 patients with HSP having different clinical symptoms and their laboratory indicators were evaluated. Th1/Th2 imbalance and overactivity of Th2 cells can cause increase in the synthesis and release of immunoglobulins in children with HSP. The number of red blood cells and white blood cells in urine was directly proportional to the level of IgA and inversely proportional to the level of serum complements (C3 and C4). Activation of these complements caused by immunoglobulin in patients with HSP plays an important role in renal injury. The urinary protein content in children with HSP along with proteinuria was positively correlated with IgE level, and IgE mediated type 1 hypersensitivity can cause increase in capillary permeability and weakened the charge barrier; hence, it could be considered as one of the causes of proteinuria in HSP. Additionally, the NK cells percentage was reduced and impaired immune function of NK cells were related to the immune injury of the digestive tract and kidney.

Effects of Chinese herbs in children with Henoch-Schonlein purpura nephritis: a randomized controlled trial

OBJECTIVE

To research the curative effect of Chinese herbs for clearing away heat, promoting diuresis, nourishing the kidney, and consolidating essence in children with Henoch-Schonlein purpura nephritis (HSPN) with internal accumulation of damp-toxin using randomized controlled observations on large samples. To seek the mechanism of the therapy and its scope of indications.

METHODS

Overall, 186 children with HSPN were randomly divided into two groups: treatment group (n = 126) treated with Chinese herbs for clearing heat and promoting diuresis and a control group (n = 60) treated with Western Medicine. The treatment was carried out for three courses of 4 weeks each. We recorded changes in patient urine routines, 24 h urinary protein, blood-coagulating series, immunoglobulin and T-cell subgroups, and improvements in main symptoms. We evaluated the alleviation of clinical symptoms and the improvement of proteinuria, hematuria, and other laboratory test results. Finally, we analyzed the patient population suitable for this therapy according to the relationship between the grouping of patient body weight and curative effect.

RESULTS

Damp-heat syndrome improved in the treatment group, with a significant difference in total effective rate after a 4-week treatment (chi2 = 13.5220, P = 0.0002) and in curative rate after a 12-week treatment (chi2 = 6.3410, P = 0.0118), compared to those in the control group. The curative effect in the treatment group was greater than that in the control group but there was no statistical difference between the two groups. The curative effect after a 4-week treatment of patients in the treatment group weighing 30 kg or less based on Traditional Chinese Medicine (TCM) signs and urinary protein was significantly greater than that in the control group. However, there was no statistical difference in the curative effect on urinary red cells and various indexes after a 12-week treatment between the two groups.

CONCLUSION

Therapy for clearing away heat, promoting diuresis, nourishing the kidney, and consolidating essence using TCM is effective in children with HSPN from internal accumulation of damp-toxin. The therapy is especially suitable for patients weighing 30 kg or less. The curative effect may be related to the improvement of immune function and blood-coagulation.

Urinary MCP-1/creatinine in Henoch-Schönlein purpura and its relationship with nephritis

BACKGROUND

Monocyte chemotactic protein-1 (MCP-1) plays a direct role in the infiltration of macrophages and monocytes during the early stages of Henoch-Schönlein purpura (HSP) nephritis. The aim of this study was to compare the urinary MCP-1/creatinine levels in children with and without HSP nephritis and determine if they are associated with the severity of renal lesions.

METHODS

We included 77 patients with HSP and 25 healthy control children. Levels of serum creatinine, urinalysis, and 12-h proteinuria assessments were performed. Urinary MCP-1 levels were determined by ELISA.

RESULTS

Fifty-seven patients had nephritis (74 %). Urinary MCP-1/creatinine levels were significantly higher in patients with HSP nephritis (median, 653 pg/mg) compared to those with HSP without nephritis (median, 269 pg/mg) or healthy children (191 pg/mg). In addition, higher MCP-1/creatinine levels were observed in HSP patients who had renal biopsy (median, 1,412 pg/mg) in comparison to HSP patients without renal biopsy (median, 302 pg/mg). The urinary MCP-1 cut-off value of 530 pg/mg could be used to distinguish patients who undergo renal biopsy with a sensitivity of 81 % and specificity of 77 %.

CONCLUSIONS

Urinary MCP-1/creatinine levels are elevated in the early stages of severe HSP nephritis and can be used as a biomarker for HSP nephritis.

Efficacy of triptolide for children with moderately severe Henoch-Schönlein purpura nephritis presenting with nephrotic range proteinuria: a prospective and controlled study in China

Objective. To observe the clinical efficacy of the Chinese herb, Triptolide, in children with moderately severe Henoch-Schönlein purpura nephritis (HSPN). Methods. From January 2007 to December 2011, 56 HSPN children manifested by nephrotic range proteinuria with normal kidney function and <50% crescents or sclerosing lesions on biopsy were hospitalized in the Children's Hospital of Zhejiang University School of Medicine. They were divided into two groups: the treatment group (n = 42; Triptolide at a dosage of 1 mg/kg·d, combined with prednisone at a dosage of 2 mg/kg·d, within a course of medium-to-long-term therapy of 6 to 9 months) and the control group (n = 14; prednisone alone, with the same procedure). Results. Short-term remission was observed in 95% of patients from treatment group and in 72% of patients from control group, respectively. There was a significant difference between both groups (χ² = 6.222, P = 0.029) for short-term effects. Meanwhile, no significant difference, as proteinuria, hematuria, hypertension, and decreased eGFR, was observed between the two groups in long-term followup (χ² = 3.111, P = 0.097). The Kaplan-Meier plot analysis also revealed no significant difference (χ² = 2.633, P = 0.105). Conclusion. Triptolide is effective in relieving short-term symptoms for moderately severe HSPN children, though its long-term effects need to be observed further.

B-cell-targeted therapy in adult glomerulonephritis

INTRODUCTION

There are many mechanisms through which B lymphocytes have been implicated in the pathogenesis of glomerulonephritis. There are a number of trials and clinical studies in glomerulonephritis involving depletion of CD20(+) B lymphocytes using rituximab. Newer anti-CD20 agents are currently under evaluation, as are drugs targeting alternative B-cell targets such as B lymphocyte stimulator. Such selective, targeted B-cell therapies, if shown to be effective, may be of value in minimising toxicity from more conventional agents.

AREAS COVERED

This article reviews the role of B cells as a target for therapy in adult renal disease resulting from primary glomerulonephritis and that occurring secondary to systemic disease. It will not address intracellular signalling or co-stimulatory pathways as therapeutic targets.

EXPERT OPINION

There are indications for B-cell targeted therapies in a number of adult glomerulonephritides, with varying degrees of evidence. Further understanding of the mechanisms of B-cell depletion and repletion, and interplay with B-cell survival factors, is necessary in order to identify patients who will respond favourably.

S-Fas urinary excretion helps to predict the immunosuppressive treatment outcomes in patients with proliferative primary glomerulonephritis

Deregulation of soluble apoptosis stimulating fragment (sFas) plays an important role in glomerulonephritis (GN). The study assed the influence of immunosuppressive treatment on serum and urine sFas in patients with proliferative (PGN) and non-proliferative (NPGN) GN, and evaluated the potential of sFas measurements in predicting outcomes. Eighty-four patients with GN (45 males and 39 females) were included. Serum concentration (ng/mL) and urinary excretion (ng/mg of urinary creatinine) of sFas were measured before and after the treatment. After 12 months of therapy with steroids and cyclophosphamide, patients were divided into two subgroups according to the treatment results: Responders (R) and Non-Responders (NR). The sFas urinary excretion was reduced after treatment in both PGN and NPGN (from 17.12 ± 15 to 5.3 ± 4.2, P = 0.008 and from 10.11 ± 6.1 to 3.4 ± 3.0, P = 0.039; respectively) whereas the sFas serum concentration remained unchanged. In PGN, pre-treatment urinary sFas concentration was significantly lower in the Responders than in Non-Responders (2.3 ± 3.1 vs 19.4 ± 14.1, P = 0.003), and was lower still than in both R (P = 0.044) and NR (P = 0.042) subgroups with NPGN. The immunosuppressive treatment reduced sFas urinary excretion in proliferative and non-proliferative GN and results suggest that the lower urinary sFas may be linked with favorable therapy outcomes in patients with PGN.

Epidemiology of immunoglobulin A vasculitis (Henoch-Schönlein): current state of knowledge

PURPOSE OF REVIEW

To review the current knowledge of epidemiological features of immunoglobulin (Ig) A vasculitis (Henoch-Schönlein) and disease etiology.

RECENT FINDINGS

The annual incidence of IgA vasculitis in the population is an estimated 3-26.7/100 000 for children and infants and 0.8-1.8/100 000 for adults. These may be conservative approximations of the true frequency because of skewed case-finding strategies. In children, the marked autumn-winter peak in incidence rates, the frequent occurrence after an upper respiratory tract infection and the short interval between disease onset in index cases and in other family members collectively point to a transmissible infectious process. A subset of adult IgA vasculitis could be related to preceding or concurrent malignancies. Despite several lines of evidence supporting the critical role of an exogenous factor in IgA vasculitis, recent progress has been made in understanding the genetic susceptibility to IgA vasculitis. Recent findings also lessened the suggestion that IgA vasculitis might be triggered by vaccination.

SUMMARY

IgA vasculitis is two to 33 times more common in children than adults and appears to have a strong environmental component, with possibly different risk factors in childhood and adulthood. Support is strengthening for a role of genetics in IgA vasculitis.

Classification of vascular disorders in the skin and selected data on new evaluation and treatment

Cutaneous vascular disorders are common. They include arteries, veins, and lymphatic vessels, or a mixture of them. In this review, we discuss classification, new developments in understanding and treatment of vascular diseases. We focus on infantile hemangiomas and drug therapy, vasculitides with new vasculitic syndromes, yellow nail syndrome and localized lymphatic malformations. Benign cutaneous vascular lesions may be a sign of severe internal diseases. In many cases multidisciplinary treatment is important. The dermatologist can often act as a pilot for these patients.

Soluble transferrin receptor in urine, a new biomarker for IgA nephropathy and Henoch-Schönlein purpura nephritis

OBJECTIVES

IgA nephropathy (IgAN) and Henoch-Schönlein purpura nephritis (HSPN) might represent different ends of a continuous spectrum of glomerular disease. In both conditions, upregulated soluble transferrin receptor (sTfR) might be excreted in urine, which could be a potential biomarker to monitor disease activity and therapeutic response.

METHODS

In this pilot study, 132 Caucasian patients consulting the Nephrology Department at the Ghent University Hospital because of a glomerulopathy and 50 normal controls were included. Urinary sTfR concentrations were determined in concentrated urine using a newly developed latex-enhanced immunonephelometric assay.

RESULTS

Median urinary sTfR concentration was higher in patients with a primary glomerulopathy than in healthy subjects (p<0.0001). More importantly, absolute median levels of urinary sTfR were markedly higher in patients with active IgAN or HSPN [10μg/L, 95% confidence interval (CI): 6-18μg/L] in comparison with those with other morphological types of glomerulopathy (2μg/L, 95%CI: 1-4μg/L) (p<0.0001). A statistically significant difference in urinary sTfR concentration was observed between patients with active IgAN or HSPN and patients who had achieved partial or complete remission (p<0.0001). Multiple regression analysis with urinary sTfR as dependent variable revealed that proteinuria was the main predictor of urinary sTfR concentration (r(2)=0.52, p<0.001).

CONCLUSION

Determination of sTfR in urine is a new and sensitive method for a potential biomarker of IgAN and HSPN.

Association of matrix metalloproteinase-9 level with the risk of renal involvement for Henoch-Schönlein purpura in children

Matrix metalloproteinase-9 (MMP-9) is an enzyme that implicates in the pathogenesis of renal diseases. Henoch-Schönlein purpura nephritis (HSPN) is the most serious long-term complication of Henoch-Schönlein purpura, and it is one of the most common renal diseases in children. There was no any meta-analysis to explore the association of MMP-9 level with the risk of HSPN, and this meta-analysis was performed to evaluate the association between MMP-9 level and HSPN risk in children. A predefined literature search and selection of eligible relevant studies were performed to collect data from electronic databases. Eight articles were identified for the analysis of association between MMP-9 level and HSPN risk in children. In this meta-analysis, urinary MMP-9 level was associated with the risk of HSPN [odds ratio (OR) = 77.21, 95% confidence interval (CI): 54.56-99.86, p < 0.00001]. Furthermore, there was a notably difference for the association of the serum MMP-9 level with HSPN risk (OR = 135.91, 95% CI: 82.54-189.27, p < 0.00001). In conclusion, urinary/serum MMP-9 level is associated with the risk of HSPN. However, the data used for the meta-analysis in this article were from some low-level studies with small samples, and more studies should be performed in the future.

Aberrant histone modifications in peripheral blood mononuclear cells from patients with Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP), the most common type of leukocytoclastic vasculitis, is caused by T cell-mediated autoimmune reactions. In this study, we analyze histone modification patterns in peripheral blood mononuclear cells (PBMCs) of HSP patients, and investigate the expression levels of inflammatory cytokines (IFN-γ, IL-2, IL-4, IL-6 and IL-13), transcription factors (T-bet, GATA-3 and TIM-1) and chemokines (CXCL4 and CXCL10) in HSP patients. Our results show that histone H3 acetylation and methylation are significantly enhanced in PBMCs from HSP patients. We also demonstrate specifically that marked increases in histone H3 acetylation and H3 lysine 4 trimethylation occur at the IL-4 loci in these patients. In addition, the expression levels of IL-4, IL-6, IL-13, GATA-3, TIM-1 and CXCL4 are also increased. These findings suggest that abnormal histone modifications are present in the PBMCs of patients with HSP, possibly contributing to the activation of pathological immune responses associated with HSP.

Recent understanding on diagnosis and management of central nervous system vasculitis in children

Central nervous system vasculitides in children may develop as a primary condition or secondary to an underlying systemic disease. Many vasculitides affect both adults and children, while some others occur almost exclusively in childhood. Patients usually present with systemic symptoms with single or multiorgan dysfunction. The involvement of central nervous system in childhood is not frequent and it occurs more often as a feature of subtypes like childhood polyarteritis nodosa, Kawasaki disease, Henoch Schönlein purpura, and Bechet disease. Primary angiitis of the central nervous system of childhood is a reversible cause of severe neurological impairment, including acute ischemic stroke, intractable seizures, and cognitive decline. The first line therapy of CNS vasculitides is mainly based on corticosteroids and immunosuppressor drugs. Other strategies include plasmapheresis, immunoglobulins, and biologic drugs. This paper discusses on current understanding of most frequent primary and secondary central nervous system vasculitides in children including a tailored-diagnostic approach and new evidence regarding treatment.