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Haas M. IgA vasculitis nephritis: insights from kidney biopsies. Curr Opin Nephrol Hypertens 2024; 33:298-303. [PMID: 38411035 DOI: 10.1097/mnh.0000000000000972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW To present findings indicating the value of kidney biopsy in assessing prognosis and guiding clinical approach to patients with IgA vasculitis nephritis (IgAVN), including a recent international study examining the value of the Oxford (MEST-C) classification. RECENT FINDINGS Historically, kidney biopsies with IgAVN are scored using the International Society for Kidney Diseases in Children (ISKDC) classification. However, this classification has limited prognostic value, and most biopsies fall into just two of the six ISKDC grades. There are few studies examining the clinical value of the Oxford classification, which is well documented to be predictive of kidney outcomes in IgA nephropathy, in IgAVN. However, a recent study of 361 biopsied patients with IgAVN showed that endocapillary hypercellularity (Oxford E1) predicted a subclass of patients showing initial improvement in kidney function with immunosuppressive treatment, followed by a later decline. SUMMARY Kidney outcome in patients with biopsied IgAVN treated with immunosuppression is determined by clinical factors and endocapillary hypercellularity. The latter is not part of the ISKDC classification and supports including MEST-C scores in biopsy reports of IgAVN. Even patients showing a good initial response to immunosuppression require long-term follow-up due to risk of subsequent kidney function decline.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
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2
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Barbour SJ, Coppo R, Er L, Pillebout E, Russo ML, Alpers CE, Fogo AB, Ferrario F, Jennette JC, Roberts IS, Cook HT, Ding J, Su B, Zhong X, Fervenza FC, Zand L, Peruzzi L, Lucchetti L, Katafuchi R, Shima Y, Yoshikawa N, Ichikawa D, Suzuki Y, Murer L, Wyatt RJ, Park C, Nelson RD, Narus JH, Wenderfer S, Geetha D, Daugas E, Monteiro RC, Nakatani S, Mastrangelo A, Nuutinen M, Koskela M, Weber LT, Hackl A, Pohl M, Pecoraro C, Tsuboi N, Yokoo T, Takafumi I, Fujimoto S, Conti G, Santoro D, Materassi M, Zhang H, Shi S, Liu ZH, Tesar V, Maixnerova D, Avila-Casado C, Bajema I, Barreca A, Becker JU, Comstock JM, Cornea V, Eldin K, Hernandez LH, Hou J, Joh K, Lin M, Messias N, Muda AO, Pagni F, Diomedi-Camassei F, Tokola H, D'Armiento M, Seidl M, Rosenberg A, Sannier A, Soares MF, Wang S, Zeng C, Haas M. Histologic and Clinical Factors Associated with Kidney Outcomes in IgA Vasculitis Nephritis. Clin J Am Soc Nephrol 2024; 19:438-451. [PMID: 38261310 PMCID: PMC11020428 DOI: 10.2215/cjn.0000000000000398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/18/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Nephritis is a common manifestation of IgA vasculitis and is morphologically indistinguishable from IgA nephropathy. While MEST-C scores are predictive of kidney outcomes in IgA nephropathy, their value in IgA vasculitis nephritis has not been investigated in large multiethnic cohorts. METHODS Biopsies from 262 children and 99 adults with IgA vasculitis nephritis ( N =361) from 23 centers in North America, Europe, and Asia were independently scored by three pathologists. MEST-C scores were assessed for correlation with eGFR/proteinuria at biopsy. Because most patients ( N =309, 86%) received immunosuppression, risk factors for outcomes were evaluated in this group using latent class mixed models to identify classes of eGFR trajectories over a median follow-up of 2.7 years (interquartile range, 1.2-5.1). Clinical and histologic parameters associated with each class were determined using logistic regression. RESULTS M, E, T, and C scores were correlated with either eGFR or proteinuria at biopsy. Two classes were identified by latent class mixed model, one with initial improvement in eGFR followed by a late decline (class 1, N =91) and another with stable eGFR (class 2, N =218). Class 1 was associated with a higher risk of an established kidney outcome (time to ≥30% decline in eGFR or kidney failure; hazard ratio, 5.84; 95% confidence interval, 2.37 to 14.4). Among MEST-C scores, only E1 was associated with class 1 by multivariable analysis. Other factors associated with class 1 were age 18 years and younger, male sex, lower eGFR at biopsy, and extrarenal noncutaneous disease. Fibrous crescents without active changes were associated with class 2. CONCLUSIONS Kidney outcome in patients with biopsied IgA vasculitis nephritis treated with immunosuppression was determined by clinical risk factors and endocapillary hypercellularity (E1) and fibrous crescents, which are features that are not part of the International Study of Diseases of Children classification.
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Affiliation(s)
- Sean J. Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- BC Renal, Vancouver, British Columbia, Canada
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Lee Er
- BC Renal, Vancouver, British Columbia, Canada
| | | | - Maria Luisa Russo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | - Charles E. Alpers
- Department of Laboratory Medicine and Pathology, University of Washington Medical Center, Seattle, Washington
| | - Agnes B. Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Franco Ferrario
- Department of Medicine and Surgery, IRCCS San Gerardo, University Milan Bicocca, Monza, Italy
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ian S.D. Roberts
- Department of Cellular Pathology, Oxford University Hospitals NHS FT, Oxford, United Kingdom
| | | | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Baige Su
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Xuhui Zhong
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | | | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Licia Peruzzi
- Pediatric Nephrology Unit, Regina Margherita Children's Hospital, AOU Città della Salute della Scienza di Torino, Turin, Italy
| | - Laura Lucchetti
- Division of Nephrology, Bambino Gesù Children's Hospital–IRCCS, Rome, Italy
| | - Ritsuko Katafuchi
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, Wakayam Medical University, Takatsuki City, Japan
| | - Daisuke Ichikawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Luisa Murer
- Pediatric Nephrology Dialysis and Transplant Unit, Department of Women's and Child's Health, Azienda Ospedaliera-University of Padova, Padua, Italy
| | - Robert J. Wyatt
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Catherine Park
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Raoul D. Nelson
- Division of Pediatric Nephrology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - JoAnn H. Narus
- Pediatrics Clinical Trials Office, University of Utah, Salt Lake City, Utah
| | - Scott Wenderfer
- Division of Pediatric Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
- Texas Children's Hospital, Houston, Texas
| | - Duvuru Geetha
- Department of Medicine, Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Daugas
- Nephrology, Bichat Hospital, AP-HP, Paris, France
- INSERM U1149 and Université Paris Cité, Paris, France
| | - Renato C. Monteiro
- Centre for Research on Inflammation, Bichat Hospital, Inserm and Université Paris Cité, Paris, France
| | - Shinya Nakatani
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCC Ca’ Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Matti Nuutinen
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit, Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology, Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Mikael Koskela
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lutz T. Weber
- Pediatric Nephrology, Faculty of Medicine and University Hospital Cologne, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Agnes Hackl
- Pediatric Nephrology, Faculty of Medicine and University Hospital Cologne, Children's and Adolescents' Hospital, University of Cologne, Cologne, Germany
| | - Martin Pohl
- Medical Center, Department of General Pediatrics, Adolescent Medicine and Neonatology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carmine Pecoraro
- Comitato Tecnico Scientifico per la Ricerca e Innovaziione, A.O. Santobono-Pausilipon, Naples, Italy
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Department of Nephrology and Hypertension, Jikei University School of Medicine, Tokyo, Japan
| | - Ito Takafumi
- Kidney Center, Department of Internal Medicine, Nephrology, Teikyo University School of Medicine, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Shouichi Fujimoto
- Division of Dialysis, Department of Nephrology, University of Miyazaki Hospital, Miyazaki, Japan
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, AOU Policlinic G Martino, University of Messina, Messina, Italy
| | - Domenico Santoro
- Nephrology and Dialysis Unit AOU, G. Martino, University of Messina, Messina, Italy
| | - Marco Materassi
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Beijing, China
| | - Sufang Shi
- Kidney Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
| | - Zhi-Hong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Dita Maixnerova
- Department of Nephrology, 1st Faculty of Medicine, General University Hospital, Prague, Czech Republic
| | | | - Ingeborg Bajema
- Department of Pathology and Medical Biology, University of Groningen, Groningen, The Netherlands
| | - Antonella Barreca
- Pathology Unit, Città della Salute e della Scienza di Torino University Hospital, Turin, Italy
| | - Jan U. Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | | | - Virgilius Cornea
- Department of Pathology, University of Kentucky Medical Center, Lexington, Kentucky
| | - Karen Eldin
- Department of Pathology, Mass General Brigham, Salem Hospital, Salem, Massachusetts
| | | | - Jean Hou
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Mercury Lin
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nidia Messias
- Department of Pathology, Washington University in Saint Louis, St. Louis, Missouri
| | | | - Fabio Pagni
- Department of Medicine and Surgery, IRCCS San Gerardo, University Milan Bicocca, Monza, Italy
| | | | - Heikki Tokola
- Pathology, University Oulu and Oulu University Hospital, Oulu, Finland
| | - Maria D'Armiento
- Pathology Section, Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Maximilian Seidl
- Medical Center-University of Freiburg and Faculty of Medicine, Institute for Surgical Pathology, University of Freiburg, Freiburg, Germany
| | - Avi Rosenberg
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Aurélie Sannier
- Department of Pathology, AP-HP, Hôpital Bichat, Université Paris Cité, Paris, France
| | - Maria Fernanda Soares
- Department of Cellular Pathology, Oxford University Hospitals NHS FT, Oxford, United Kingdom
| | - Suxia Wang
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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Cao Y, Chen X, Peng Q, Huang TT, Fan XC. Clinical characteristics and risk factors of cardiac involvement in pediatric immunoglobulin A vasculitis: A 7-year retrospective study from a single tertiary medical center. Eur J Pediatr 2024; 183:1871-1880. [PMID: 38300364 DOI: 10.1007/s00431-024-05438-1] [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: 11/04/2023] [Revised: 12/30/2023] [Accepted: 01/14/2024] [Indexed: 02/02/2024]
Abstract
Immunoglobulin A vasculitis(IgAV) is the most common form of systemic vasculitis affecting children. To date, cardiac involvement in pediatric IgAV has not been fully investigated and its prevalence may be underestimated. This study aims to reveal the clinical and laboratory characteristics of cardiac involvement in pediatric IgAV and further determine its risk factors. A total of 1451 children with IgAV were recruited between January 2016 and December 2022. According to the severity of cardiac involvement, the patients were divided into the myocarditis/suspected myocarditis group, cardiac abnormalities group, and non-cardiac involvement group. Demographic, clinical, and laboratory characteristics were retrospectively extracted from the individual data collected in the medical records. Among the 1451 pediatric IgAV patients, 179 (12.3%) were identified with cardiac involvement, including 154 (10.6%) with cardiac abnormalities and 25 (1.7%) with myocarditis/suspected myocarditis. Cardiac involvement in pediatric IgAV mainly manifested as elevated cardiac biomarker levels (n = 162), electrocardiogram abnormalities (n = 46), and echocardiogram/chest X-ray abnormalities (n = 15); however, cardiac-related symptoms were only observed in 15.1% of patients with cardiac involvement. Multivariate analysis demonstrated that interval from disease onset to diagnosis > 7 days (OR, 2.157; 95% CI, 1.523-3.057; p < 0.001), IgAV with multi-organ involvement (OR, 1.806; 95% CI, 1.242-2.627; p = 0.002), and elevated D-dimer levels (OR, 1.939; 95% CI, 1.259-2.985; p < 0.001) were independent risk factors for cardiac involvement in pediatric IgAV. The length of hospital stay was significantly longer in the myocarditis/suspected myocarditis group compared with the other two groups (p < 0.05). Conclusion: This study suggests that cardiac involvements in pediatric IgAV is non-negligible, and cardiac involvement is associated with interval from disease onset to diagnosis > 7 days, IgAV with multi-organ involvement, and elevated D-dimer levels. Severe cardiac involvement may affect the prognosis of pediatric IgAV. What is Known: • Immunoglobulin A vasculitis (IgAV) is the most common form of systemic vasculitis affecting children and adolescents, which exhibits diverse clinical manifestations. Cases of severe IgAV complicated by cardiac involvement have been anecdotally reported. What is New: • The present study suggests that cardiac involvements in pediatric IgAV is non-negligible, and cardiac involvement is associated with interval from disease onset to diagnosis > 7 days, IgAV with multi-organ involvement, and elevated D-dimer levels. Severe cardiac involvement may affect the prognosis of pediatric IgAV.
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Affiliation(s)
- Yue Cao
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Xin Chen
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Qi Peng
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Tian Tuo Huang
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China
| | - Xiao Chen Fan
- Department of Pediatrics, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People's Republic of China.
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Nagai S, Horinouchi T, Ninchoji T, Ichikawa Y, Tanaka Y, Kitakado H, Ueda C, Kondo A, Aoto Y, Sakakibara N, Kaito H, Tanaka R, Shima Y, Fujimura J, Kamiyoshi N, Ishimori S, Nakanishi K, Yoshikawa N, Iijima K, Nozu K. Long-term outcome of combination therapy with corticosteroids, mizoribine and RAS inhibitors as initial therapy for severe childhood IgA vasculitis with nephritis. Pediatr Nephrol 2023; 38:4023-4031. [PMID: 37380934 DOI: 10.1007/s00467-023-06052-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Patients with severe IgA vasculitis with nephritis (IgAVN) typically receive aggressive therapy as an initial approach. We have consistently performed combination therapy including corticosteroids and immunosuppressants as initial therapy for severe IgAVN over a 20-year-plus period, with only minor changes to the treatment protocol. This study seeks to reveal the efficacy of combination therapy for severe IgAVN. METHODS We retrospectively studied 50 Japanese children diagnosed between 1996 and 2019 with clinicopathologically severe IgAVN who were defined as ISKDC classification grade IIIb-V and/or serum albumin < 2.5 g/dL. RESULTS The median age at the onset of IgAVN was 8.0 years (IQR: 6.0-10.0). At biopsy, 44% of patients had nephrotic syndrome and 14% had kidney dysfunction. All patients were treated with combination therapy after biopsy. Abnormal proteinuria resolved after initial therapy in all 50 patients. However, eight patients (16%) had recurrence of proteinuria. Abnormal proteinuria was again resolved in three of these patients with additional treatment. At the last follow-up (median 59.5 months; IQR, 26.2-84.2), the median urine protein-to-creatine ratio was 0.08 g/gCr (IQR, 0.05-0.15), and only one patient had kidney dysfunction. CONCLUSIONS Combination therapy provided good kidney outcomes for Japanese children with severe IgAVN. Even including recurrent cases, the degree of proteinuria was slight, and kidney function was good at the last follow-up. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sadayuki Nagai
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan.
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
- Department of Pediatrics, Harima-Himeji General Medical Center, 3-264 Kamiyacho, Himeji, Hyogo, 6705860, Japan
| | - Yuta Ichikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Yu Tanaka
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Hideaki Kitakado
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Chika Ueda
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Atsushi Kondo
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Yuya Aoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
- Department of Pediatrics, Harima-Himeji General Medical Center, 3-264 Kamiyacho, Himeji, Hyogo, 6705860, Japan
| | - Nana Sakakibara
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kakogawa Central City Hospital, 439 Honmachi, Kakogawa-cho, 675-8611, Kakogawa, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Japanese Red Cross Society Himeji Hospital, 1-12-1 Shimoteno, Himeji, 670-8540, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-cho, 569-1192, Takatsuki, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Nakagami-gun, 903-0125, Okinawa, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, 1-3-13 Kosobe-cho, 569-1192, Takatsuki, Japan
| | - Kazumoto Iijima
- Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, 1-6-7 Minatojima-Minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, 650-0017, Kobe, Japan
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Amatruda M, Carucci NS, Chimenz R, Conti G. Immunoglobulin A vasculitis nephritis: Current understanding of pathogenesis and treatment. World J Nephrol 2023; 12:82-92. [PMID: 37766840 PMCID: PMC10520755 DOI: 10.5527/wjn.v12.i4.82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/16/2023] [Accepted: 06/12/2023] [Indexed: 09/20/2023] Open
Abstract
The clinical spectrum of immunoglobulin A vasculitis nephritis (IgAVN) ranges from the relatively common transitory microscopic hematuria and/or low-grade proteinuria to nephritic or nephrotic syndrome, rapidly progressive glomerulonephritis, or even renal failure. Clinical and experimental studies have shown a multifactor pathogenesis: Infection triggers, impaired glycosylation of IgA1, complement activation, Toll-like-receptor activation and B cell proliferation. This knowledge can identify IgAVN patients at a greater risk for adverse outcome and increase the evidence for treatment recommendations.
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Affiliation(s)
- Michela Amatruda
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Nicolina Stefania Carucci
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Roberto Chimenz
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
| | - Giovanni Conti
- Pediatric Nephrology and Rheumatology Unit, AOU G Martino, University of Messina, Messina 98125, Italy
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YILDIRIM S, ERGÜVEN M. Reporting the clinical spectrum of children with IgAV in a retrospective 24-year cohort: Influences of age and sex on clinical presentation. Turk J Med Sci 2023; 53:1339-1347. [PMID: 38813037 PMCID: PMC10763743 DOI: 10.55730/1300-0144.5700] [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] [Received: 09/20/2022] [Revised: 10/26/2023] [Accepted: 08/11/2023] [Indexed: 05/31/2024] Open
Abstract
Background/aim Immunoglobulin A vasculitis (IgAV) is one of the most common types of vasculitis in children. The aims of this study were to investigate the clinical characteristics of the disease, and the effects of age and sex on the clinical course in children with IgAV. Materials and methods This was a retrospective study including pediatric patients diagnosed with IgAV who attended follow-ups at the pediatric rheumatology department of a tertiary healthcare institution between January 1997 and December 2020. The patients were grouped and compared according to sex and age at diagnosis (<7 years vs. ≥7 years). Results The study included 709 children with IgAV, 392 (55.3%) of whom were male. The mean age at diagnosis was 7.9 ± 3.2 years. The most common disease onset season was autumn (31.2%). Upper respiratory infections (27.8%) were the most common predisposing factors. Gastrointestinal system (GIS), joint, and renal involvement were observed in 52.8%, 47.5%, and 17.5% of patients, respectively. Renal involvement, GIS involvement, and disease relapse were significantly more common among those diagnosed after 7 years of age compared to those diagnosed before the age of 7 (p < 0.001, p = 0.033, and p < 0.001, respectively). Scrotal involvement and subcutaneous edema were more common among those diagnosed at younger than 7 years compared to those aged ≥7 years at diagnosis (p < 0.001 and p = 0.016, respectively). GIS involvement was more frequently seen in males compared to females (p = 0.046). Conclusion It was demonstrated that being ≥7 years of age at diagnosis or being a male were associated with higher likelihood of renal and GIS involvement in children with IgAV.
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Affiliation(s)
- Sema YILDIRIM
- Department of Pediatric, Göztepe Prof. Dr. Süleyman Yalçın City Hospital, İstanbul,
Turkiye
| | - Müferet ERGÜVEN
- Department of Pediatric Rheumatology, Faculty of Medicine, Düzce University, Düzce,
Turkiye
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7
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Xu JJ, Cai J, Hu B. Renal histopathological manifestations of IgA vasculitis nephritis in children and adults. Int Immunopharmacol 2023; 116:109760. [PMID: 36764272 DOI: 10.1016/j.intimp.2023.109760] [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: 11/29/2022] [Revised: 01/14/2023] [Accepted: 01/18/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND IgA vasculitis nephritis (IgAVN) is a common form of secondary glomerulonephritis and can occur in patients of any age. Our study was designed to reveal renal histopathological manifestations of children and adults with IgAVN and to explore the potential pathogenesis of IgAVN. METHODS Sixty-one pediatric and seventy adult patients with IgAVN were enrolled altogether, and all of them underwent kidney biopsies. General information, laboratory parameters, and renal histopathological manifestations of all patients were analyzed. RESULTS (1) Diabetes, hypertension, and various levels of proteinuria made no difference between children and adults. (2) Global sclerosis and tubular atrophy/interstitial fibrosis occurred more commonly in adults than in children (24.29 % vs 8.20 %, 65.71 % vs 9.84 %, respectively) (P < 0.05). (3) The immunofluorescence deposition of complement C3 was more apparent in adults (P < 0.05). (4) The deposition of IgA, IgG, IgM, and C3 in kidneys was unrelated to the pathological types. (5) The deposition of IgG or IgM was related to the deposition of IgA or C3 in children and adults (P < 0.05). CONCLUSIONS Chronic kidney injury occurred more commonly in adult IgAVN patients compared to pediatric IgAVN patients. Immunoglobulin and complement deposits in kidneys were independent of the types of renal pathological injury. Additionally, IgG and IgM were probably involved in IgAVN pathogenesis.
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Affiliation(s)
- Jin-Jin Xu
- Department of Pediatrics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China
| | - Jie Cai
- Department of Pediatrics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China
| | - Bo Hu
- Department of Pediatrics, the First Affiliated Hospital of Anhui Medical University, Hefei, Anhui 230022, China.
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8
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Zhang X, Che R, Xu H, Ding G, Zhao F, Huang S, Zhang A. Hemoperfusion and intravenous immunoglobulins for refractory gastrointestinal involvement in pediatric Henoch-Schönlein purpura: a single-center retrospective cohort study. BMC Pediatr 2022; 22:692. [PMID: 36460986 PMCID: PMC9716741 DOI: 10.1186/s12887-022-03709-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 10/25/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Henoch-Schönlein purpura (HSP) with refractory gastrointestinal (GI) symptoms is always difficult to handle because of its resistance to supportive therapies and glucocorticoid. This study aimed to evaluate the efficacy of hemoperfusion (HP) and intravenous immunoglobulins (IVIG) therapies in this population. METHODS Sixty-four HSP patients with refractory GI involvement (R-GI group) and 64 cases with mild GI symptoms (control group) were retrospectively analyzed in our center from March 2016 to October 2019. In R-GI group, 42 cases (subgroup A) were treated with IVIG and steroid, 13 cases (subgroup B) used HP and steroid, 9 cases (subgroup C) executed a combination of IVIG, HP and steroid. Demographic characteristics, clinical features, laboratory indexes and treatment outcomes were recorded. t-test, One-way ANOVA, Mann-Whitney U test, and multivariate logistic regression were used in comparing differences among subgroups and predicting independent risk factors. RESULTS Compared with the control group, R-GI cases experienced higher risk of renal involvement (P = 0.000), more steroid exposure (P = 0.000), six times expenses (P = 0.000) and 2.3 times length of hospitalization (P = 0.000). The independent risk factors of R-GI group were elevated neutrophils (OR 1.250 [95% CI 1.130-1.383]) and the percentage of B lymphocytes (OR 1.100 [95% CI 1.026-1.179]) as well as decreased IgG (OR 0.847 [95% CI 0.732-0.98]). In R-GI group, increased age (OR 1.039 [95% CI 1.016-1.062]) and IgM (OR 5.994 [95% CI 1.403-27.611]) were verified to be risk factors of HSP nephritis. All three subgroups could alleviate the symptoms effectively. Compared with those in subgroup A, patients in subgroup B were elder (P = 0.004), had less relapse (P = 0.002), steroid exposure (P = 0.033) and expenses (P = 0.031), more significant decrease of WBC (P = 0.026) after treatment. CONCLUSION The HSP with refractory GI involvement had much higher risk of medical burden and renal involvement. Both IVIG and HP therapies could ameliorate refractory GI symptoms efficiently. HP therapy tended to reduce the relapse, costs and steroid exposure in its audiences who were cooperated and with stable hemodynamics, while IVIG had better use in younger children.
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Affiliation(s)
- Xiaolu Zhang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Ruochen Che
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Haisheng Xu
- grid.452511.6Department of Emergency Medicine, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Guixia Ding
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Fei Zhao
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Songming Huang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China ,grid.452511.6Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Aihua Zhang
- grid.452511.6Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China ,grid.452511.6Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
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9
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Xu L, Li Y, Wu X. IgA vasculitis update: Epidemiology, pathogenesis, and biomarkers. Front Immunol 2022; 13:921864. [PMID: 36263029 PMCID: PMC9574357 DOI: 10.3389/fimmu.2022.921864] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/15/2022] [Indexed: 11/23/2022] Open
Abstract
Immunoglobulin A vasculitis (IgAV), formerly known as Henoch-Schönlein purpura, is the most common systemic vasculitis in children, characterized by diverse clinical manifestations with a wide spectrum ranging from isolated cutaneous vasculitis to systemic involvement. The incidence of IgAV is geographically and ethnically variable, with a prevalence in autumn and winter, suggesting a driving role that genetic and environmental factors play in the disease. Although IgAV has a certain degree of natural remission, it varies widely among individuals. Some patients can suffer from severe renal involvement and even progress to end-stage renal disease. Its pathogenesis is complex and has not been fully elucidated. The formation of galactose-deficient IgA1 (Gd-IgA1) and related immune complexes plays a vital role in promoting the occurrence and development of IgAV nephritis. In addition, neutrophil activation is stimulated through the binding of IgA to the Fc alpha receptor I expressed on its surface, resulting in systemic vascular inflammation and tissue damage. Starting from the epidemiological characteristics, this article will review the role of immunological factors such as Gd-IgA1, autoantibodies, circulating immune complexes, complement system, cellular immunization, and the contributions of environmental and genetic factors in the pathogenesis of IgAV, and conclude with the major biomarkers for IgAV.
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10
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Nagai S, Horinouchi T, Ninchoji T, Kondo A, Aoto Y, Ishiko S, Sakakibara N, Nagano C, Yamamura T, Kaito H, Tanaka R, Shima Y, Fujimura J, Kamiyoshi N, Ishimori S, Nakanishi K, Yoshikawa N, Iijima K, Nozu K. Use of renin-angiotensin system inhibitors as initial therapy in children with Henoch-Schönlein purpura nephritis of moderate severity. Pediatr Nephrol 2022; 37:1845-1853. [PMID: 35015121 DOI: 10.1007/s00467-021-05395-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cases of Henoch-Schönlein purpura nephritis (HSPN) with moderate severity were demonstrated to achieve good prognosis after treatment with renin-angiotensin system (RAS) inhibitors. However, some patients required additional treatment for recurrence after remission. This study aimed to clarify the effect of RAS inhibitors in HSPN cases with moderate severity, including the proportion of cases with recurrence and their response to additional treatment. METHODS Among 126 patients diagnosed with HSPN between 1996 and 2019, 71 patients with clinicopathologically diagnosed HSPN of moderate severity, defined as ISKDC grade II-IIIa and serum albumin ≥ 2.5 g/dL, were investigated. RESULTS Proteinuria became negative after RAS inhibitor treatment alone in all 71 cases. However, 16 (22.5%) had recurrence. Eleven recurrent cases achieved negative proteinuria again following additional treatment. At the last follow-up (median 46.5 months; IQR, 23.2-98.2), 5 patients had persistent mild proteinuria; no patients had estimated glomerular filtration rate < 90 mL/min/1.73 m2. The pathological findings in all recurrent cases were ISKDC grade IIIa. The 16 recurrent cases had significantly higher proportions of glomeruli with global/segmental sclerosis (25.0 vs. 0%, P < 0.001) and tubular atrophy/interstitial fibrosis (37.5 vs. 12.7%, P =0.0 24) than 55 cases without recurrence. CONCLUSIONS Japanese childhood HSPN cases with moderate severity had good outcomes without need for corticosteroids or immunosuppressants, when prescribed RAS inhibitor treatment. Even in recurrent cases, abnormal proteinuria was transient, and prognosis was excellent. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sadayuki Nagai
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan.
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Atsushi Kondo
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Yuya Aoto
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Shinya Ishiko
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Nana Sakakibara
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - China Nagano
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kakogawa Central City Hospital, 439 Honmachi, Kakogawa-cho, Kakogawa, 675-8611, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Japanese Red Cross Society Himeji Hospita, 1-12-1 Shimoteno, Himeji, 670-8540, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki, 569-1192, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara-cho, Nakagami-gun, Okinawa, 903-0125, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki, 569-1192, Japan
| | - Kazumoto Iijima
- Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, 1-6-7 Minatojima-minamimachi, Chuo-ku, Kobe, 650-0047, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017, Japan
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11
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Hastings MC, Rizk DV, Kiryluk K, Nelson R, Zahr RS, Novak J, Wyatt RJ. IgA vasculitis with nephritis: update of pathogenesis with clinical implications. Pediatr Nephrol 2022; 37:719-733. [PMID: 33818625 PMCID: PMC8490493 DOI: 10.1007/s00467-021-04950-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 12/17/2020] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
IgA vasculitis with nephritis (IgAVN) shares many pathogenetic features with IgA nephropathy (IgAN). The purpose of this review is to describe our current understanding of the pathogenesis of pediatric IgAVN, particularly as it relates to the four-hit hypothesis for IgAN. These individual steps, i.e., hits, in the pathogenesis of IgAN are (1) elevated production of IgA1 glycoforms with some O-glycans deficient in galactose (galactose-deficient IgA1; Gd-IgA1), (2) generation of circulating IgG autoantibodies specific for Gd-IgA1, (3) formation of pathogenic circulating Gd-IgA1-containing immune complexes, and (4) kidney deposition of the Gd-IgA1-IgG immune complexes from the circulation and induction of glomerular injury. Evidence supporting the four-hit hypothesis in the pathogenesis of pediatric IgAVN is detailed. The genetics, pediatric outcomes, and kidney histopathologic features and the impact of these findings on future treatment and potential biomarkers are discussed. In summary, the evidence points to the critical roles of Gd-IgA1-IgG immune complexes and complement activation in the pathogenesis of IgAVN. Future studies are needed to characterize the features of the immune and autoimmune responses that enable progression of IgA vasculitis to IgAVN.
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Affiliation(s)
- M Colleen Hastings
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
- Children's Foundation Research Institute at the Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Dana V Rizk
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Krzysztof Kiryluk
- Division of Nephrology, Department of Medicine, College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Raoul Nelson
- Division of Pediatric Nephrology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Rima S Zahr
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
- Children's Foundation Research Institute at the Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Jan Novak
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J Wyatt
- Division of Pediatric Nephrology and Hypertension, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.
- Children's Foundation Research Institute at the Le Bonheur Children's Hospital, Memphis, TN, USA.
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12
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Contrast-enhanced ultrasonography for assessing histopathology in pediatric immunoglobulin A nephropathy and Henoch-Schönlein purpura nephritis. Pediatr Radiol 2022; 52:2575-2583. [PMID: 35695915 PMCID: PMC9701653 DOI: 10.1007/s00247-022-05399-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/12/2022] [Accepted: 05/03/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Glomerular disease, including immunoglobulin A nephropathy (IgAN) and Henoch-Schönlein purpura nephritis, is one of the most common kidney diseases in children. The diagnosis of these diseases depends on pathological biopsy, although this procedure is seriously limited by its invasive and high-risk nature. OBJECTIVE To investigate the potential of contrast-enhanced ultrasonography (CEUS) for evaluating the histopathological severity of IgAN and Henoch-Schönlein purpura nephritis (HSPN). MATERIALS AND METHODS We investigated a total of 13 children with IgAN and 12 children with HSPN confirmed by renal histopathology. We reevaluated the pathological lesions of the children according to the Oxford classification and the Lee grading system and then all the children underwent CEUS. Using SonoLiver software, we constructed time-intensity curves of CEUS for regions of interest in the renal cortex. We analyzed CEUS quantitative parameters for IgAN and HSPN and used Spearman correlation analysis to examine the correlation between CEUS parameters and clinicopathological indexes in the study cohort. RESULTS The CEUS parameters rise time (RT) and time to peak (TTP) were significantly higher in children with Lee grade IV than in those with Lee grades II or III. Spearman correlation analysis revealed a positive correlation between rise time and time to peak with Lee grade in the overall cohort of children, and a positive correlation between rise time and time to peak and severity of crescents in the Oxford classification scoring system. CONCLUSION Contrast-enhanced US may be used as a noninvasive imaging technique to evaluate the severity of renal pathology and formation of crescents in children with IgAN and HSPN.
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13
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Fu R, Yang M, Li Z, Kang Z, Xun M, Wang Y, Wang M, Wang X. Risk assessment and prediction model of renal damage in childhood immunoglobulin A vasculitis. Front Pediatr 2022; 10:967249. [PMID: 36061380 PMCID: PMC9428464 DOI: 10.3389/fped.2022.967249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/01/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES To explore the risk factors for renal damage in childhood immunoglobulin A vasculitis (IgAV) within 6 months and construct a clinical model for individual risk prediction. METHODS We retrospectively analyzed the clinical data of 1,007 children in our hospital and 287 children in other hospitals who were diagnosed with IgAV. Approximately 70% of the cases in our hospital were randomly selected using statistical product service soltions (SPSS) software for modeling. The remaining 30% of the cases were selected for internal verification, and the other hospital's cases were reviewed for external verification. A clinical prediction model for renal damage in children with IgAV was constructed by analyzing the modeling data through single-factor and multiple-factor logistic regression analyses. Then, we assessed and verified the degree of discrimination, calibration and clinical usefulness of the model. Finally, the prediction model was rendered in the form of a nomogram. RESULTS Age, persistent cutaneous purpura, erythrocyte distribution width, complement C3, immunoglobulin G and triglycerides were independent influencing factors of renal damage in IgAV. Based on these factors, the area under the curve (AUC) for the prediction model was 0.772; the calibration curve did not significantly deviate from the ideal curve; and the clinical decision curve was higher than two extreme lines when the prediction probability was ~15-82%. When the internal and external verification datasets were applied to the prediction model, the AUC was 0.729 and 0.750, respectively, and the Z test was compared with the modeling AUC, P > 0.05. The calibration curves fluctuated around the ideal curve, and the clinical decision curve was higher than two extreme lines when the prediction probability was 25~84% and 14~73%, respectively. CONCLUSION The prediction model has a good degree of discrimination, calibration and clinical usefulness. Either the internal or external verification has better clinical efficacy, indicating that the model has repeatability and portability. CLINICAL TRIAL REGISTRATION www.chictr.org.cn, identifier ChiCTR2000033435.
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Affiliation(s)
- Ruqian Fu
- Academy of Pediatrics of University of South China, Changsha, China.,Department of Nephrology and Rheumatology of Hunan Children's Hospital, Changsha, China
| | - Manqiong Yang
- Department of Pediatrics, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Zhihui Li
- Academy of Pediatrics of University of South China, Changsha, China.,Department of Nephrology and Rheumatology of Hunan Children's Hospital, Changsha, China
| | - Zhijuan Kang
- Academy of Pediatrics of University of South China, Changsha, China.,Department of Nephrology and Rheumatology of Hunan Children's Hospital, Changsha, China
| | - Mai Xun
- Department of Nephrology and Rheumatology of Hunan Children's Hospital, Changsha, China
| | - Ying Wang
- Department of Pediatrics of Changsha Central Hospital, Changsha, China
| | - Manzhi Wang
- Department of Pediatrics of Changsha Central Hospital, Changsha, China
| | - Xiangyun Wang
- Department of Pediatrics of Changsha First People's Hospital, Changsha, China
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14
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Koskela M, Nihtilä J, Ylinen E, Kolho KL, Nuutinen M, Ritari J, Jahnukainen T. HLA-DQ and HLA-DRB1 alleles associated with Henoch-Schönlein purpura nephritis in Finnish pediatric population: a genome-wide association study. Pediatr Nephrol 2021; 36:2311-2318. [PMID: 33591409 PMCID: PMC8260528 DOI: 10.1007/s00467-021-04955-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 12/18/2020] [Accepted: 01/19/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The pathophysiology of Henoch-Schönlein purpura (HSP) is still unclear, but several findings suggest that genetic factors may influence disease susceptibility. We aimed to perform a genome-wide association study (GWAS) in pediatric HSP patients with an emphasis on severe HSP nephritis. METHODS The study included 46 HSP patients, 42 of whom had undergone kidney biopsy. Forty-nine pediatric patients with an inflammatory bowel disease (IBD) served as an autoimmune disease control group while Finnish bone marrow and blood donors represented the general reference population (n = 18,757). GWAS was performed for HSP and IBD samples in a case-control manner against the reference population. The analysis also included imputation of human leukocyte antigen (HLA) alleles. RESULTS GWAS analysis in HSP revealed several polymorphisms from the HLA region that surpassed the genome-wide significance level. Three HLA class II alleles were also significantly more frequent in HSP than in the reference population: DQA1*01:01, DQB1*05:01, and DRB1*01:01. Haplotype DQA1*01:01/DQB1*05:01/DRB1*01:01 occurred in 43.5% of HSP patients, whereas its frequency was 8.2% in IBD patients and 15.0% in the reference population. HSP patients with this haplotype showed similar baseline clinical findings and outcome as HSP patients negative for the haplotype. In IBD patients, no polymorphism or HLA allele appeared significant at the genome-wide level. CONCLUSIONS Our results suggest that haplotype DQA1*01:01/DQB1*05:01/DRB1*01:01 is associated with susceptibility to HSP, but not with the severity of the kidney involvement. These HLA associations did not occur in IBD patients, suggesting that they are specific to HSP and not related to susceptibility to autoimmune diseases in general.
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Affiliation(s)
- Mikael Koskela
- Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland. .,Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, PO Box 347, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland.
| | - Julia Nihtilä
- University of Helsinki, Helsinki, Finland.,Finnish Red Cross Blood Service, Helsinki, Finland
| | - Elisa Ylinen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, PO Box 347, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland
| | - Kaija-Leena Kolho
- Children's Hospital, Pediatric Research Center, University of Helsinki, Helsinki University Hospital, Helsinki, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Matti Nuutinen
- Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.,PEDEGO Research Unit, Research Unit for Pediatrics, Dermatology, Clinical Genetics, Obstetrics and Gynecology, Medical Research Center Oulu (MRC Oulu), Oulu, Finland
| | - Jarmo Ritari
- Finnish Red Cross Blood Service, Helsinki, Finland
| | - Timo Jahnukainen
- Department of Pediatric Nephrology and Transplantation, New Children's Hospital, University of Helsinki and Helsinki University Hospital, PO Box 347, Stenbäckinkatu 9, 00029 HUS, Helsinki, Finland
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15
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Luo X, Tan J, Wan D, Chen J, Hu Y. Predictability of the Oxford classification of IgA nephropathy in Henoch-Schonlein purpura nephritis. Int Urol Nephrol 2021; 54:99-109. [PMID: 33905044 DOI: 10.1007/s11255-021-02861-3] [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: 09/14/2020] [Accepted: 04/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Whether the Oxford classification of immunoglobulin A nephropathy can be utilized to predict the adverse renal outcome of Henoch-Schonlein purpura nephritis (HSPN) has been long-debated. We, therefore, performed a meta-analysis to evaluate the prognostic value of Oxford classification lesions in HSPN. METHODS We systematically searched Medline, EMBASE, Web of Science, and the Cochrane Library for articles published from January 1970 to August 2020. Cohort and case-control studies investigating the correlation between the Oxford classification and renal outcome were included, the quality of which was assessed by the Newcastle-Ottawa scale criteria. The pooled odds ratios (ORs) with their 95% confidence intervals (CIs) were calculated with a random-effects model or a fixed-effects model depending on the heterogeneity. RESULTS A total of 485 papers were reviewed and eventually 9 comparisons were included, providing data of 1688 patients with HSPN. ORs for adverse renal events were 2.83 (95% CI 1.84-4.35; P < 0.001), 1.96 (95% CI 1.28-2.98; P < 0.05), and 5.45 (95% CI, 3.15-9.45; P < 0.001) for patients with lesions of endocapillary hypercellularity (E), segmental sclerosis (S), and tubular atrophy /interstitial fibrosis (T), respectively, without significant heterogeneity (E: I2 = 0.0%; P = 0.498; S: I2 = 22.4%; P = 0.258; T: I2 = 33.6%; P = 0.171). Subgroup analysis adjusted for age also supported the results that E, S, and T lesions could serve as poor predictors (P < 0.05). Additionally, crescents (C) were strongly associated with renal outcome (OR 2.22; 95% CI 1.62-3.04; P < 0.001), with moderate heterogeneity (I2 = 49.3%; P = 0.066). However, it should be noted that it is not the presence but the proportions of crescent lesions that were related to the high risk of progression to adverse renal events, because the predictability of lower rates of crescent (C1, with crescents > 0 and ≤ 25%) was uncertain (OR 2.21; 95% CI 0.75-6.51; P > 0.05). Although the pooled OR revealed that lesions of mesangial hypercellularity (M) were correlated with poor renal prognosis (OR 2.41; 95% CI 1.07-5.43; P < 0.05), subgroup analysis separating children from adults indicated that there seemed to be no significant difference. CONCLUSIONS Oxford classification, especially for E, S, T, and C, might be recommended for patients with HSPN, regardless of children and adults.
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Affiliation(s)
- Xinyao Luo
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Jiaxing Tan
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Dingyuan Wan
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Junda Chen
- West China School of Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yahong Hu
- General Hospital of Western Theater Command of the Chinese People's Liberation Army, Chengdu, China.
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Wang M, Wang R, He X, Zhang P, Kuang Q, Yao J, Fang X, Shi Z, Wu H, Peng Y, Xia Z, Gao C. Using MEST-C Scores and the International Study of Kidney Disease in Children Classification to Predict Outcomes of Henoch-Schönlein Purpura Nephritis in Children. Front Pediatr 2021; 9:658845. [PMID: 33937154 PMCID: PMC8079736 DOI: 10.3389/fped.2021.658845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/11/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: Henoch-Schönlein purpura nephritis (HSPN) and IgA nephropathy (IgAN) bear similarities in some aspects. The histological classification of HSPN was built on the International Study of Kidney Disease in Children (ISKDC) criteria, while IgAN was established on the 2016 Oxford classification (MEST-C scores). The purpose of this paper was to discuss the predictive value of the ISKDC classification and MEST-C scores in children with HSPN. Methods: We performed a retrospective study of 877 children with HSPN in a single center between 2001 and 2019. The primary outcome was defined as chronic kidney disease-estimated glomerular filtration rate (eGFR) <90 ml/min/1.73 m2. Results: During the follow-up period of 23.3 (10.9-47.9) months, 51 (5.8%) patients reached the primary outcome. As revealed in a Kaplan-Meier plot, segmental glomerulosclerosis (S) (P < 0.001) and tubular atrophy/interstitial fibrosis (T) (P < 0.001) significantly predict poor renal outcome. Other Oxford lesions and the ISKDC classification, however, did not show a significant difference in a worse outcome. In a multivariate Cox model adjusted for pathological and clinical factors, eGFR [hazard ratio (HR) = 2.831, 95% confidence interval (95% CI) = 1.359-5.896], S lesion (HR = 3.936, 95% CI = 2.078-7.457), and T lesion (HR = 4.002, 95% CI = 1.733-9.242) were independent risk factors for the renal outcome. Conclusion: This series constitutes the largest series reported so far in the literature of such patients. According to our findings, S and T of the Oxford classification, which are ignored by the ISKDC classification, could be applied to predict the renal prognosis of children with HSPN.
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Affiliation(s)
- Meiqiu Wang
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Ren Wang
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Xu He
- Department of Pediatrics, Jinling Hospital, Nanjing, China
| | - Pei Zhang
- Department of Pediatrics, Jinling Hospital, Nanjing, China
| | - Qianhuining Kuang
- Department of Pediatrics, Jinling Hospital, Nanjing Medical University, Nanjing, China
| | - Jun Yao
- Department of Pediatrics, Jinling Hospital, Nanjing, China
| | - Xiang Fang
- Department of Pediatrics, Jinling Hospital, Nanjing, China
| | - Zhuo Shi
- Department of Pediatrics, Jinling Hospital, Nanjing, China
| | - Heyan Wu
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Yingchao Peng
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
| | - Zhengkun Xia
- Department of Pediatrics, Jinling Hospital, Nanjing, China
| | - Chunlin Gao
- Department of Pediatrics, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
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17
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Kurt-Şükür ED, Sekar T, Tullus K. Biopsy-proven Henoch-Schönlein purpura nephritis: a single center experience. Pediatr Nephrol 2021; 36:1207-1215. [PMID: 33089378 PMCID: PMC8009786 DOI: 10.1007/s00467-020-04809-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/23/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Knowledge on normal progress and treatment of Henoch-Schönlein purpura nephritis (HSPN) is limited. This study reviews outcome, clinical, pathological, and therapeutic factors affecting the prognosis of HSPN patients. METHODS Forty-nine children with biopsy-confirmed HSPN diagnosed between September 2008 and 2018 were included. Demographics, clinical and laboratory data, treatment, and outcome were recorded at the time of biopsy, 3, 6, 12, and 24 months and at last visit. Clinical outcome was graded according to Meadow's criteria. RESULTS The median age at time of biopsy was 10.1 years (IQR:5.7) and female/male ratio 24/25. At presentation, 40.8% of patients had nonnephrotic proteinuria, 18.4% nephrotic syndrome (NS), 4.1% nephritic syndrome (NephrS), and 36.7% NephrS+NS. There were 11 patients with an estimated glomerular filtration rate below 90 ml/min/1.73 m2. Biopsy specimens were classified according to International Study of Kidney Diseases in Children (ISKDC) and Oxford Classification MEST-C scoring systems. Forty-one patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, 37 patients steroids, and 35 patients other immunosuppressive medications. At last visit, 24 patients had stage 1 chronic kidney disease (CKD), three stage 2 CKD, and two had stage 5 CKD. Neither clinical parameters nor ISKDC biopsy grade or treatment modalities effected the final outcome. The Oxford classification showed significantly increased segmental glomerulosclerosis in patients with unfavorable outcome. Favorable outcome was associated with shorter time from kidney involvement to biopsy and start of treatment. CONCLUSION A large proportion of patients continued to show signs of CKD at last follow-up while only a small proportion developed stage 5 CKD.
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Affiliation(s)
- Eda Didem Kurt-Şükür
- Department of Pediatric Nephrology, Dr. Sami Ulus Children’s Hospital, Ankara, Turkey
| | - Thivya Sekar
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kjell Tullus
- Department of Pediatric Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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18
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Tan J, Xu Y, Jiang Z, Pei G, Tang Y, Tan L, Zhong Z, Tarun P, Qin W. Global Glomerulosclerosis and Segmental Glomerulosclerosis Could Serve as Effective Markers for Prognosis and Treatment of IgA Vasculitis With Nephritis. Front Med (Lausanne) 2020; 7:588031. [PMID: 33195349 PMCID: PMC7646400 DOI: 10.3389/fmed.2020.588031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/22/2020] [Indexed: 02/05/2023] Open
Abstract
Background: This study was aimed at investigating the clinical significance and curative effect of global glomerulosclerosis (GS) and segmental glomerulosclerosis (S) in adult-onset IgA vasculitis with nephritis (IgAV-N) patients since there was no consensus pathological grading method for adult IgAV-N. Methods: A total of 188 biopsy-proven IgAV-N patients were prospectively identified. Patients were separately assigned to GS0/GS1/GS2 group and S0/S1/S2 based on the scores of global glomerulosclerosis and segmental glomerulosclerosis (0% /0-15% />15%, respectively). Results: GS0, GS1, and GS2 occurred in 56.4, 29.2, and 14.4% of the adult-onset IgAV-N, respectively. Patients in GS2 group tended to have the most serious renal deterioration and the highest levels of blood pressure. IgAV-N patients were also divided into S0 group (64.4%), S1 group (20.7%), and S2 group (14.9%), where no obvious differences in baseline data were noted. K-M curves indicated that GS2 group had the worst renal outcome (P = 0.05) while there seemed to be no significant differences between GS0 group and GS1 group. In addition, no remarkable differences in primary outcome were found among S0 group, S1 group, and S2 group though the prognosis of S2 group tended to be the worst. However, the prognosis of S0/S1 group was markedly better than that of S2 (P = 0.04). The discrimination of poor prognosis could be improved by adding the pathological indicators of global glomerulosclerosis and segmental glomerulosclerosis. Most importantly, immunosuppressive treatment might be a superior alternative in IgAV-N patients without sclerosis scores or with lower level of sclerosis scores. But addition of immunosuppression was not recommended in patients with higher sclerosis scores. Conclusions: Global glomerulosclerosis and segmental sclerosis might be used for management and treatment of adult-onset IgAV-N.
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Affiliation(s)
- Jiaxing Tan
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Yicong Xu
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Zheng Jiang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Gaiqin Pei
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Yi Tang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Li Tan
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Zhengxia Zhong
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China.,West China School of Medicine, Sichuan University, Chengdu, China
| | - Padamata Tarun
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Wei Qin
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China
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19
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Yu B, Shi S, Hou W, Liu L, Lv J, Wang S, Zhang H. Evaluation of the Oxford classification in immunoglobulin A vasculitis with nephritis: a cohort study and meta-analysis. Clin Kidney J 2020; 14:516-525. [PMID: 33623674 PMCID: PMC7886544 DOI: 10.1093/ckj/sfaa129] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Indexed: 12/21/2022] Open
Abstract
Background Similarities in clinicopathological presentations in immunoglobulin A (IgA) nephropathy and IgA vasculitis with nephritis (IgAVN) raise the question of the utility of the Oxford classification in the latter. The aim of this study was to evaluate the Oxford classification in IgAVN. Methods We conducted a retrospective cohort study and meta-analysis following systematic searching of the MEDLINE and Excerpta Medica Database (EMBASE) databases between January 2009 and September 2019. We modeled the association of 30 and 50% decline in estimated glomerular filtration rate or end-stage renal disease with pathologic lesions of the Oxford classification including mesangial hypercellularity (M), endocapillary hypercellularity (E), segmental glomerulosclerosis (S), interstitial fibrosis/tubular atrophy (T) and crescents (C). Results were pooled using random-effects meta-analysis. Results The cohort study included 132 patients, and only T lesion was an independently risk factor in IgAVN. The meta-analysis yielded six retrospective studies with 721 patients and 139 endpoints. In multivariate model, T lesion was significantly associated with renal outcome (hazard ratio = 2.45, P = 0.007). M and C lesions could not predict renal outcome without evidence of heterogeneity. E and S lesions could not predict renal outcome with evidence of heterogeneity (I 2 = 66.6%; P = 0.01, and I 2 = 65.8%; P = 0.03, respectively). Subgroup analysis showed that the possible reasons to the heterogeneity were from usage of immunosuppressant, sample size and follow-up time. Conclusions The study suggests that the Oxford classification could not be fully validated in IgAVN. Higher portion of immunosuppressant especially before renal biopsy might be the main confounder for the predictive value of Oxford classification in IgAVN.
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Affiliation(s)
- Bingxin Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Sufang Shi
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Wanyin Hou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Lijun Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Suxia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Electron Microscopy Laboratory, Peking University First Hospital, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
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20
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Karadağ ŞG, Sönmez HE, Demir F, Çakan M, Öztürk K, Tanatar A, Çakmak F, Sözeri B, Aktay Ayaz N. Rheumatic diseases in Syrian refugee children: a retrospective multicentric study in Turkey. Rheumatol Int 2020; 40:583-589. [PMID: 32088751 DOI: 10.1007/s00296-020-04534-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 02/08/2020] [Indexed: 11/27/2022]
Abstract
Since the Syrian civil war in 2011, an estimated number of 3.6 million Syrian refugees crossed into Turkey, and almost half of them were children. The distribution of rheumatic diseases in Syrian refugee children is not known. The aim of this study was to describe the profile of rheumatic diseases in Syrian refugee children living in Turkey. The demographic data, clinical and laboratory findings, medications, complications and outcome results of Syrian refugee children who had visited Pediatric Rheumatology Departments of University of Health Science Kanuni Sultan Süleyman Research and Training Hospital, Ümraniye Research and Training Hospital, Şanlıurfa Research and Training Hospital, and Cengiz Gökçek Maternity and Gynecology Hospital between April 1, 2011, and September 1, 2019, were evaluated retrospectively. A total of 151 patients were included in the study. Among them, 51 patients had juvenile idiopathic arthritis (JIA), 49 had familial Mediterranean fever (FMF), 43 had vasculitis, and 8 had connective tissue diseases. Homozygous M694V mutation was the most common mutation among FMF patients. Oligoarticular JIA (41.2%) was the most frequent type of JIA, and enthesitis-related arthritis (ERA) (27.5%) was the second one. The frequency of systemic JIA was 11.8%. One patient with SLE died due to complicated meningitis. This is the first study evaluating the distribution of rheumatic diseases in Syrian refugee children. Clinical follow-up of rheumatologic diseases is difficult in Syrian refugees due to language barriers, social and cultural differences. Health care systems should be well organized to provide appropriate care to asylum seekers.
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Affiliation(s)
- Şerife Gül Karadağ
- Department of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Hafize Emine Sönmez
- Department of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Ferhat Demir
- Department of Pediatric Rheumatology, Ümraniye Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Mustafa Çakan
- Department of Pediatric Rheumatology, Şanlıurfa Research and Training Hospital, Şanlıurfa, Turkey
| | - Kübra Öztürk
- Department of Pediatric Rheumatology, Cengiz Gökçek Maternity and Gynecology Hospital, Gaziantep, Turkey
| | - Ayşe Tanatar
- Department of Pediatric Rheumatology, Faculty of Medicine, Istanbul University, 34093, Çapa-Fatih, Istanbul, Turkey
| | - Figen Çakmak
- Department of Pediatric Rheumatology, Kanuni Sultan Süleyman Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, Ümraniye Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, Faculty of Medicine, Istanbul University, 34093, Çapa-Fatih, Istanbul, Turkey.
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21
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Yu Y, Chen J, Yin H, Deng Z, Xie Y, Yuan Q, Xu H, Liu S, Tao L, Peng Z. Efficacy of steroid and immunosuppressant combined therapy in Chinese patients with Henoch-Schönlein purpura nephritis: A retrospective study. Int Immunopharmacol 2020; 81:106229. [PMID: 32014710 DOI: 10.1016/j.intimp.2020.106229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 01/15/2023]
Abstract
/y) and proteinuria were measured. The primary outcome progression was analyzed using Kaplan-Meier survival curves. The effect of the combined therapy on renal outcome was analyzed by multivariable Cox regression. Propensity score matching and sensitivity analysis were used to explore whether pathological features impacted prognosis. Patients who received combined steroid and immunosuppressant therapy were more likely to recover from HSPN and had proteinuria <3 g/24 h (P = 0.02) or 1 g/24 h (P = 0.03). Multiple Cox regression analysis confirmed that this decrease was independent of renin-angiotensin system blockers. Further sensitivity analysis showed that combined therapy was effective in patients with crescents (P = 0.02). However, combined steroid and immunosuppressant therapy was not more effective in patients with endocapillary hypercellularity (E), tubular atrophy/interstitial fibrosis (T), or segmental sclerosis (S). Combined steroid and immunosuppressant therapy was significantly associated with HSPN remission, and more effectively decreased proteinuria during the initial disease phase.
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Affiliation(s)
- Yue Yu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Jingjing Chen
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Hongling Yin
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Zhenghao Deng
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Yanyun Xie
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Qiongjing Yuan
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Hui Xu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Shao Liu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Lijian Tao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
| | - Zhangzhe Peng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China.
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22
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Yun D, Kim DK, Oh KH, Joo KW, Moon KC, Kim YS, Lee K, Han SS. MEST-C pathological score and long-term outcomes of child and adult patients with Henoch-Schönlein purpura nephritis. BMC Nephrol 2020; 21:33. [PMID: 32000703 PMCID: PMC6993338 DOI: 10.1186/s12882-020-1691-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/14/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Henoch-Schönlein purpura nephritis (HSPN), a small-vessel vasculitis, shares renal pathological features with immunoglobulin A nephropathy. Oxford classification of immunoglobulin A nephropathy pathology has been updated to the MEST-C score, but its application in HSPN remains unresolved. METHODS Two hundred and thirteen patients with biopsy-proven HSPN were retrieved from the Seoul National University Hospital between 2000 and 2017. Renal outcome risks (i.e., end-stage renal disease or doubling of serum creatinine) were evaluated according to MEST-C scores after stratification by age: 113 children aged < 18 years (9.2 ± 3.6 years) and 100 adults aged ≥18 years (38.6 ± 18.3 years). We pooled our data with four previous cohort studies in which MEST or MEST-C scores were described in detail. RESULTS Twenty-one child (19%) and 16 adult (16%) patients reached the renal outcome during the median follow-up periods of 12 years and 13 years, respectively (maximum 19 years). In children, M1 and T1/T2 scores revealed worse renal outcomes than did M0 and T0 scores, respectively, whereas the T score was the only factor related to worse outcomes in adult patients after adjusting for multiple clinical and laboratory variables. The pooled data showed that M1, S1, and T1/T2 in children and E1 and T1/T2 in adults were correlated with poorer renal outcomes than those of their counterpart scores. CONCLUSIONS The Oxford classification MEST-C scores can predict long-term renal outcomes in patients with HSPN.
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Affiliation(s)
- Donghwan Yun
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea.,Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, South Korea
| | - Kyoungbun Lee
- Department of Pathology, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea.
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, South Korea.
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Prediction of renal outcome in Henoch-Schönlein nephritis based on biopsy findings. Pediatr Nephrol 2020; 35:659-668. [PMID: 31797094 PMCID: PMC7056733 DOI: 10.1007/s00467-019-04415-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/05/2019] [Accepted: 11/01/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND In Henoch-Schönlein nephritis (HSN), a risk factor for unfavorable outcome is prolonged proteinuria, but the value of renal biopsies in prognosis assessment is debatable. METHODS We evaluated serial renal biopsies from 26 HSN patients. Follow-up biopsy occurred at median 2.1 years after diagnostic biopsy. Patients formed two groups at the follow-up biopsy: patients without proteinuria (group I; n = 11) and with proteinuria (group II; n = 15). Biopsies underwent evaluation according to three classifications: International Study of Kidney Disease in Children (ISKDC), Oxford (MEST-C), and semiquantitative classification (SQC) including an activity and chronicity score. Analysis also included expression of pro-fibrotic (alpha-smooth muscle actin and vimentin) and inflammatory (P-selectin glycoprotein ligand-1) molecules in the diagnostic biopsy specimens. Definition of unfavorable outcome was active renal disease or reduced renal function at last follow-up. RESULTS Between the biopsies, SQC chronicity score increased in 22 (85%) patients, whereas activity score and ISKDC grade decreased in 21 (81%) and 17 (65%), respectively. Of the MEST-C parameters, endocapillary proliferation (from 83 to 13%; p < 0.001) and crescents (from 63 to 25%; p = 0.022) showed significant reduction, and segmental glomerulosclerosis (from 38 to 79%; p = 0.006) significant increment. These changes occurred similarly in groups I and II. Expression of the pro-fibrotic and inflammatory molecules showed no clinically significant differences between groups I and II. None in group I and five (33%) patients in group II had unfavorable outcome (p = 0.053). CONCLUSIONS Our results suggest that follow-up biopsies provide limited additional information to clinical symptoms in HSN outcome prediction.
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Li X, Tang M, Yao X, Zhang N, Fan J, Zhou N, Sun Q, Chen Z, Meng Q, Lei L, Zhang H, Ling C, Hua L, Chen X, Liu X. A clinicopathological comparison between IgA nephropathy and Henoch–Schönlein purpura nephritis in children: use of the Oxford classification. Clin Exp Nephrol 2019; 23:1382-1390. [DOI: 10.1007/s10157-019-01777-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
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