Management of IgA Vasculitis with Nephritis

The Recurrence of Systemic Diseases in Kidney Transplantation

Kidney transplantation is the most effective replacement therapy for kidney failure, providing the best outcomes in terms of patient survival and offering a better quality of life. However, despite the progressive improvement in kidney survival, the recurrence of original disease remains one of the most important causes of graft loss and a major challenge that requires clinical vigilance throughout the transplant's duration. Additionally, the type and severity of recurrence affect both treatment options and graft survival. This is especially true for the recurrence of systemic diseases. In this narrative review, we will discuss the timing, frequency, severity, and treatment of post-transplant recurrence in three systemic diseases: lupus nephritis (LN), Antineutrophil Cytoplasmic Antibodies (ANCA)-associated glomerulonephritis (ANCA-GN), and Henoch-Schönlein purpura (HSP). The recurrence of lupus nephritis is less common than that of primary focal segmental glomerulosclerosis or C3 glomerulopathy. Its severity can range from mild mesangial to diffuse proliferative forms, with varying prognoses and treatment options, much like the original disease. In some patients with LN, as well as in those with ANCA-GN or HSP, the reactivation of the primary disease can affect other organs besides the kidneys, potentially leading to life-threatening conditions. These cases may require a multidisciplinary approach, making these transplants clinically more challenging. Extrarenal flare-ups often necessitate an increase in immunosuppression, which in turn raises the risk of infections. In these autoimmune diseases, the role of immunological tests in determining the timing of kidney transplants remains a topic of ongoing debate. However, elevated levels of certain immunological markers, such as anti-dsDNA antibodies, ANCA titers, or serum immunoglobulin A may indicate a reactivation of the disease, suggesting the need for more intensive patient monitoring.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Immunoglobulin A vasculitis nephritis: Current understanding of pathogenesis and treatment

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.

Interventions for preventing and treating kidney disease in IgA vasculitis

BACKGROUND

IgA vasculitis (IgAV), previously known as Henoch-Schönlein purpura, is the most common vasculitis of childhood but may also occur in adults. This small vessel vasculitis is characterised by palpable purpura, abdominal pain, arthritis or arthralgia and kidney involvement. This is an update of a review first published in 2009 and updated in 2015.

OBJECTIVES

To evaluate the benefits and harms of different agents (used singularly or in combination) compared with placebo, no treatment or any other agent for (1) the prevention of severe kidney disease in people with IgAV with or without kidney involvement at onset, (2) the treatment of established severe kidney disease (macroscopic haematuria, proteinuria, nephritic syndrome, nephrotic syndrome with or without acute kidney failure) in IgAV, and (3) the prevention of recurrent episodes of IgAV-associated kidney disease.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 2 February 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing interventions used to prevent or treat kidney disease in IgAV compared with placebo, no treatment or other agents were included.

DATA COLLECTION AND ANALYSIS

Two authors independently determined study eligibility, assessed the risk of bias and extracted data from each study. Statistical analyses were performed using the random-effects model, and the results were expressed as risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Twenty studies (1963 enrolled participants) were identified; one three-arm study has been assessed as two studies. Nine studies were at low risk of bias for sequence generation (selection bias), and nine studies were at low risk of bias for allocation concealment (selection bias). Blinding of participants and personnel (performance bias) and outcome assessment (detection bias) was at low risk of bias in four and seven studies, respectively. Nine studies reported complete outcome data (attrition bias), while 10 studies reported expected outcomes, so were at low risk of reporting bias. Five studies were at low risk of other bias. Eleven studies evaluated therapy to prevent persistent kidney disease in IgAV with or without kidney involvement at presentation. There was probably no difference in the risk of persistent kidney disease any time after treatment (5 studies, 746 children: RR 0.74, 95% CI 0.42 to 1.32) or at one, three, six and 12 months in children given prednisone for 14 to 28 days at presentation of IgAV compared with placebo or supportive treatment (moderate certainty evidence). There may be no differences in the risk of any persistent kidney disease with antiplatelet therapy (three studies) or heparin (two studies) in children with or without any kidney disease at study entry, although heparin may reduce the risk of proteinuria by three months compared with placebo or no specific treatment (2 studies, 317 children: RR 0.47, 95% CI 0.31 to 0.73). One study comparing montelukast with placebo found no differences in outcomes as assessed by severity scale scores. Nine studies examined the treatment of severe IgAV-associated kidney disease. In two studies (one involving 56 children and the other involving 54 adults), there may be no differences in efficacy outcomes or adverse effects with cyclophosphamide compared with placebo or supportive treatment. In two studies, there may be no differences in the numbers achieving remission of proteinuria with intravenous (IV) cyclophosphamide compared with mycophenolate mofetil (MMF) (65 children evaluated) or tacrolimus (142 children evaluated). In three small studies comparing cyclosporin with methylprednisolone (15 children), MMF with azathioprine (26 children), or MMF with leflunomide (19 children), it is unclear whether the treatment had any effect on the numbers in remission or the degree of proteinuria between treatment groups because of small numbers of included participants. In one study comparing plasmapheresis, cyclophosphamide and methylprednisolone with cyclophosphamide and methylprednisolone, there may be no difference in the numbers achieving remission. One study compared fosinopril with no specific therapy and reported fosinopril reduced the number of participants with proteinuria. No studies were identified that evaluated the efficacy of therapy on kidney disease in participants with recurrent episodes of IgAV.

AUTHORS' CONCLUSIONS

There are no substantial changes in conclusions from this update compared with the initial review or the previous update despite the addition of five studies. From generally low to moderate certainty evidence, we found that there may be little or no benefit in the use of corticosteroids or antiplatelet agents to prevent persistent kidney disease in children with IgAV in participants with no or minimal kidney involvement at presentation. We did not find any studies which evaluated corticosteroids in children presenting with IgAV and nephritic and/or nephrotic syndrome, although corticosteroids are recommended in such children in guidelines. Though heparin may be effective in reducing proteinuria, this potentially dangerous therapy is not justified to prevent serious kidney disease when few children with IgAV develop severe kidney disease. There may be no benefit of cyclophosphamide compared with no specific treatment or corticosteroids. While there may be no benefit in the efficacy of MMF or tacrolimus compared with IV cyclophosphamide in children or adults with IgAV and severe kidney disease, adverse effects, particularly infections, may be lower in MMF or tacrolimus-treated children. Because of small patient numbers and events leading to imprecision in results, it remains unclear whether cyclosporin, MMF or leflunomide have any role in the treatment of children with IgAV and severe kidney disease. We did not identify any studies which evaluated corticosteroids.

Neutrophil-to-lymphocyte ratio as an independent inflammatory indicator for poor renal prognosis in adult IgA vasculitis with nephritis

BACKGROUND

Skin-limited IgAV patients usually present self-limiting disease and good prognosis, while adult IgA vasculitis with nephritis (IgAV-N) present severe phenotype and poor prognosis. Previous studies showed that neutrophil-to-lymphocyte ratio (NLR) was an inflammatory indicator for predicting systemic involvement in children IgAV patients. In this study, we focused on adult IgAV-N patients to explore the relationship of NLR with disease phenotype and long-term renal prognosis.

METHODS

In this study, 245 IgAV-N patients, 1151 IgAN patients and 251 healthy controls were recruited. Composite endpoint was defined as 30% eGFR declined or end stage kidney disease.

RESULTS

IgAV-N patients presented increased white blood cells (WBC), neutrophils (NE), platelet-to-lymphocyte ratio (PLR), and NLR levels, while decreased lymphocyte (LY) than healthy controls. When compared to clinical and pathological features matched IgAN patients, IgAV-N patients still showed higher WBC, NE, and NLR levels. NLR showed the best performance for the diagnosis of IgAV-N with the highest area under the ROC curves (0.738). IgAV-N patients in high NLR group (>2.41) presented with sever baseline manifestations and more acute pathological lesions than low NLR group (≤2.41). 77 patients with regular follow-up were used for survival analysis. After adjusting some well-known risk factors, NLR levels remained as an independent risk factor for poor renal outcome in adult patients with IgAV-N (HR, 1.913; 95% CI, 1.314 to 2.787, P = 0.001).

CONCLUSIONS

NLR levels were associated with the clinical and pathological phenotypes, and NLR may serve as an independent risk factor for poor renal outcome in adult IgAV-N patients.

Epidemiological and clinical aspects of immunoglobulin A vasculitis in childhood: a retrospective cohort study

Background

A retrospective study was conducted in order to investigate and describe the characteristics of Immunoglobulin A vasculitis (IgAV), previously known as Henoch-Schӧnlein purpura, in the paediatric population of a community-based healthcare delivery system in the Italian region of Abruzzo.

Methods

This is a population-based retrospective chart review of the diagnosis of IgAV in children ages 0 to 18, admitted to the Department of Paediatrics of Chieti and Pescara between 1 January 2000 and 31 December 2016. All children enrolled presented with clinical symptoms and laboratory findings and met the EULAR/PRINTO/PRES 2008 criteria.

Results

Two-hundred-eight children met the criteria for IgAV, with the highest incidence reported among children below 7-years of age. A correlation with recent infections was found in 64% of the cohort; the onset was more frequently during the winter and fall. Purpura had a diffuse distribution in the majority of patients; joint impairment was the second most frequent symptom (43%), whereas the gastrointestinal tract was involved in 28% of patients.

Conclusions

Hereby, we confirm the relative benignity of IgAV in a cohort of Italian children; with regards to renal involvement, we report a better outcome compared to other studies. However, despite the low rate of renal disease, we observed a wide use of corticosteroids, especially for the treatment of persistent purpura.