Acute renal failure as the initial manifestation of systemic lupus erythematosus in children

Clinicopathology of childhood-onset renal systemic lupus erythematosus

AIMS

To determine the clinicolaboratory renal manifestations; glomerular, extra-glomerular histopathologic lesions; renal tubular dysfunction (RTD) frequency and outcome of a short-term renal follow up in Nigerian children with systemic lupus erythematosus (SLE).

METHODS

A non-randomized prospective study of consecutive cases of childhood-onset SLE with nephropathy was conducted. Baseline/follow-up clinicolaboratory data were collected. Each patient was followed up for 12 months.

RESULTS

Seven of the 11 children studied were girls. The median age at diagnosis was 11.0 years. Median diagnosis time interval (1.9 years) and median time of renal disease onset (1.0 year) were similar. Hypertension, nephrotic syndrome and acute renal failure (ARF) occurred in 45.5%, 54.5% and 63.7% of the patients, respectively. The glomerular lesions were non-proliferative lupus nephritis (LN) in 9.0% (class II LN); focal (class III LN) and diffuse (class IV LN) proliferative LN (PLN) in 27.0% and 64.0%, respectively. Tubulointerstitial nephritis (TIN, 91.0%) and RTD (64.0%) were common. ARF (P = 0.033) and RTD (P = 0.015) were significantly associated with severe TIN. Complete renal remission rate at end-point was 71.4%. Relapse and renal survival rates were 14.3% and 86.0%, respectively. RTD was persistent in 43.0%.

CONCLUSION

Renal function disorders, diffuse PLN and extra-glomerular lesions were frequent. Significant association of ARF and RTD with severe TIN in this series suggests the need for early renal tubular function (RTF) assessment in our SLE patients. Deranged RTF may be marker of severe TIN in SLE warranting early confirmatory renal biopsy and aggressive interventional treatment.

Lupus nephropathy and cardiopulmonary and hepatic dysfunctions in a child

Systemic lupus erythematosus (SLE) is a potentially fatal autoimmune multi-systemic rheumatologic disorder. An unusual case is reported of an 11.9-year-old Nigerian girl who was diagnosed after 2.8 years of non-specific symptoms and six episodes of recurrent haemolysis and pancytopaenia warranting blood transfusions. At diagnosis, she had hepatitis, polyarthritis, nephropathy, and cardiopulmonary and bone-marrow dysfunctions. Lymphopaenia, thrombocytopaenia, and direct antiglobulin-test positive haemolytic anaemia were present. Rapid resolution of disease activity followed exchange blood transfusion after an initial poor response to corticosteroid and cyclophosphamide therapy. Any child with recurrent haemolysis and pancytopaenia of unknown aetiology should be investigated for SLE.

Systemic lupus erythematosus

Systemic Lupus Erythematosus (SLE) of childhood is a complex and challenging disease which can occur at any age. Identification of disease early in it's course and aggressive, appropriate management leads to improved outcome for an individual child. The history of SLE indicates how much progress has been made in the last quarter century. A discussion of the etiopathogenesis of SLE demonstrates the complexity of the syndrome. This is followed by a description of clinical manifestations, including diagnostic criteria, differential diagnosis and suggested methods for eliciting important symptoms to make the diagnosis. Evaluation of specific organs is next reviewed highlighting critical organ manifestations that are significant for future prognosis. Treatment of SLE includes a variety of medications, including non-steroidal anti-inflammatory medications, steroids and immuno-suppressive drugs. Attention to physical activity, stress and nutrition is equally important. Signs and symptoms that indicate disease flare or infection are described. Lastly, related syndromes are reviewed.

A practical guide to systemic lupus erythematosus

Systemic lupus erythematosus is a challenging disease with varied manifestations resulting from widespread immune complex deposition. It may present in the general pediatric office as an acute illness with fever, rash, and hematuria, or as chronic fatigue and malaise that might be mistaken for "school phobia". Although SLE remains an infrequent disease in general pediatric practice, mild cases are more frequent than was previously recognized. These children benefit from therapy if the physician is alert to their occurrence and makes the appropriate diagnosis. The understanding of the role of genetics and environmental agents in the pathogenesis of SLE has improved over the past 10 years. In addition, the past 10 years have seen refinements in the use of immunosuppressive regimens, such as cyclophosphamide, that have led to both improved quality of life and improved survival for children with active SLE unresponsive to corticosteroids. Although long-term concerns regarding the safety and efficacy of immunosuppressive drug regimens persist, the future is increasingly bright for children with SLE who receive appropriate care in a timely fashion.

Lupus nephritis in childhood and adolescence

Lupus nephritis in childhood usually presents after the age of 10 years, and presentation under 5 years is very rare. More males (F:M ratio 4.5:1) are affected than in adult-onset cases, but the ratio is the same in prepubertal and pubertal children. The incidence of clinically evident renal disease is greater at onset than in adults (82%), the usual presentation being with proteinuria, 50% having a nephrotic syndrome. Half the children show World Health Organisation class IV nephritis in renal biopsies. Neuropsychiatric lupus is present at onset in 30%, may complicate 50% at some point and remains a major problem. Prognosis has improved greatly over the past 30 years, at least in part the result of immunosuppressive treatment. Treatment of the initial phase may be guided by the severity of the renal biopsy appearances, more aggressive treatment including cytotoxic agents, i.v. methylprednisolone and perhaps plasma exchange, although the value of exchange is not established. Controversy persists as to the most effective cytotoxic treatment in the acute phase, both oral and i.v. cyclophosphamide and azathioprine being used in different units. In the chronic maintenance phase it seems established both clinically and histologically that addition of a cytotoxic agent improves outcome, but again the drug and route of administration are contentious. Azathioprine has the advantage of being safe for pregnancy and not gonadotoxic, whilst i.v. cyclophosphamide has been demonstrated to improve results over prednisolone alone in controlled trials and has advantages in non-compliant patients. No trial comparing the two regimes has been carried out, and one is needed. Today children much less commonly go into renal failure, and the main causes of actual death (15% of patients over 10 years) are now infections and extra-renal manifestations of lupus, principally neurological. Morbidity of the disease and the treatment remain a major problem, especially when treatment exacerbates complications of the disease itself, such as infections, osteonecrosis, thrombosis, vascular disease and possibly neoplasia.

Distal renal tubular acidosis as the initial manifestation of systemic lupus erythematosus in an adolescent

Distal renal tubular acidosis (dRTA) as the initial manifestation of systemic lupus erythematosus (SLE) has not been described previously. We report a 14-year-old female adolescent, first presenting with findings consistent with dRTA, whose renal biopsy demonstrated immune mesangial deposits consistent with lupus nephritis. Seven months later, she developed classic extrarenal manifestations of SLE. We recommend that adolescents with dRTA be evaluated and followed closely for the possibility of SLE.

Clinical aspects of systemic lupus erythematosus in childhood

Systemic lupus erythematosus (SLE) is an uncommon childhood illness that is characterized by the formation of autoantibodies and immune complexes, which mediate inflammatory responses in multiple organ systems. Children who develop SLE are frequently very ill at the time of presentation and need careful evaluation to determine which organ systems are involved and how severely, meticulous control of medications to suppress active disease, and close monitoring to avoid complications from both the disease and its treatment.