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Abstract
Immunoglobulin A vasculitis (IgA vasculitis) is a small-vessel vasculitis usually triggered by bacterial or viral infections, antibiotics, and vaccinations. Although it is a disease of the pediatric population, it can occur in adults as well. We present a case of IgA vasculitis that was triggered by underlying infective endocarditis (IE). IE is a rare and fatal cause of the vasculitis that requires timely diagnosis and management to prevent catastrophic outcomes. Our patient was treated with antibiotics for IE, which led to the resolution of vasculitis.
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2
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Abstract
BACKGROUND AND OBJECTIVES Although Henoch-Schönlein purpura (HSP) is the most common form of renal vasculitis in childhood, progression to ESRD is rare, and there are few data on outcomes of renal transplantation in patients with HSP. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This is a matched retrospective cohort study of renal allografts using the United Network of Organ Sharing database (1987 to 2005). Of the 189,211 primary renal allografts, there were 339 with a diagnosis of HSP. The primary end point was allograft survival. RESULTS Compared with the remainder of the database, the HSP population was younger (25 years versus 46 years), and had a higher proportion of women (47% versus 40%), live donors (50% versus 35%), and Caucasians (77% versus 60%). Controlling for age, gender, donor source, ethnicity, and year of transplantation, death-censored graft survival for patients with HSP was 80.0% at 5 years and 58.8% at 10 years compared with 79.0% at 5 years and 55.4% at 10 years in the non-HSP population. Among patients with reported causes of graft loss, failure from recurrent disease occurred in 13.6% of patients with HSP, compared with 6.6% in the non-HSP population. When analyzing allograft survival in recipients with HSP compared with those with IgA nephropathy, there was no difference in 10-year allograft survival (58.4% and 59.3%, respectively). CONCLUSIONS These data indicate that although there is an increased risk of graft failure attributable to recurrent disease in patients with HSP, a diagnosis of HSP has little effect on overall renal allograft survival.
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Affiliation(s)
- Joyce P Samuel
- Department of Pediatrics, Division of Pediatric Nephrology and Hypertension, University of Texas Health Science Center at Houston, 6431 Fannin (MSB 3.121), Houston, TX 77030, USA
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Han SS, Sun HK, Lee JP, Ha JW, Kim SJ, Kim YS. Outcome of renal allograft in patients with Henoch-Schönlein nephritis: single-center experience and systematic review. Transplantation 2010; 89:721-6. [PMID: 20010329 DOI: 10.1097/tp.0b013e3181c9cc4a] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Henoch-Schönlein nephritis (HSN) is a rare condition resulting in end-stage renal disease. Therefore, graft outcomes and recurrence rates after transplantation are not well studied. Also, the effect of donor type on graft outcome has not been evaluated thoroughly. METHODS The graft outcome and recurrence rate in 20 kidney recipients with HSN were compared with age-, sex-, and donor source-matched controls (control A, primary immunoglobulin A nephropathy; control B, other causes; 40 recipients per group). To assess the effect of donor type, we pooled our data with two previous cohort studies where donor type had been described in detail. RESULTS Overall graft survival rates were 87.7% at 10 years. The overall recurrence rate of HSN was 15.4% over 10 years. Graft survival and recurrence rates in the HSN group were similar to those of control A and control B. The pooled data showed a 29.4% incidence rate for recurrent HSN. Living related donor transplantation showed a trend of higher recurrence compared with recipients with nonrelated grafts, although it was marginally significant (P=0.059). However, the graft survival rate in related-donor recipients was not inferior to that in the unrelated-donor recipients. CONCLUSIONS Long-term graft survival and recurrence rates in kidney recipients with HSN were comparable to those of recipients with primary immunoglobulin A nephropathy. The type of donor did not significantly affect long-term graft survival.
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Affiliation(s)
- Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Moroni G, Gallelli B, Diana A, Carminati A, Banfi G, Poli F, Montagnino G, Tarantino A, Messa P. Renal transplantation in adults with Henoch-Schonlein purpura: long-term outcome. Nephrol Dial Transplant 2008; 23:3010-6. [DOI: 10.1093/ndt/gfn209] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lee J, Clayton F, Shihab F, Goldfarb-Rumyantzev A. Successful treatment of recurrent Henoch-Schönlein purpura in a renal allograft with plasmapheresis. Am J Transplant 2008; 8:228-31. [PMID: 17973963 DOI: 10.1111/j.1600-6143.2007.02022.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Acute and severe cases of Henoch-Schönlein purpura (HSP) nephritis have been treated with plasmapheresis (PA) in both adults and children. It has been used either alone or with steroids, antiplatelets or cytoxic drugs. Generally, renal function has been shown to improve when PA is utilized. The role of PA in recurrent HSP after renal transplantation is unclear and has not been well described in the literature. We report a 29-year-old female with HSP who developed end-stage renal disease and subsequently underwent a renal transplantation with eventual loss of the allograft 5 years later due to recurrent HSP nephritis. Retransplantion was performed and the patient developed active HSP nephritis in her second allograft within a week after transplantation. In an effort to preserve her allograft, four cycles of PA were performed. Her proteinuria resolved and renal biopsies afterwards demonstrated marked reduction in mesangial IgA deposition. We conclude that PA may be useful in recurrent HSP nephritis, especially when used early. The risk of additional immunosuppression caused by PA needs to be considered. More studies need to be done to evaluate the efficacy of PA in this setting as well as to define the optimal treatment regimen.
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Affiliation(s)
- J Lee
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Soler MJ, Mir M, Rodriguez E, Orfila A, Munne A, Vázquez S, Lloveras J, Puig JM. Recurrence of IgA Nephropathy and Henoch-Schönlein Purpura After Kidney Transplantation: Risk Factors and Graft Survival. Transplant Proc 2005; 37:3705-9. [PMID: 16386512 DOI: 10.1016/j.transproceed.2005.09.172] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND IgA nephropathy (IgA) is one of the most common glomerulonephritis. Renal transplantation is the treatment of choice for patients with ESRD due to any kind of glomerulopathy, including IgA and Henoch-Schönlein purpura nephritis (H-SP), but original disease recurrence is now the third most frequent cause of allograft loss. METHODS Eighty-seven cases of glomerulonephritis as the original disease were divided in two groups: group A--37 affected with 31 IgA and 6 H-SP; and group B--50 with other glomerulopathies. We compared patient and graft survivals at 5 years. To assess the presence of IgA or H-SP recurrence in group A patients, we performed an allograft biopsy in the presence of microhematuria, proteinuria, or an increased plasma creatinine. Known risk factors influencing recurrence rate were also analyzed. RESULTS Five-year patient (97% vs 95%) and graft survivals (81% vs 78%) were not significantly different between groups A and B. Patients with crescentic glomerulonephritis (CGN) at the moment of diagnosis of IgA or H-SP showed a 5-year graft survival of 71% in contrast with 100% graft survival among those with mesangial or focal and segmental glomerulosclerosis pattern (P = .03). Histological recurrence was diagnosed in eight patients: six IgA and two H-SP. Women (P = .013) and a good HLA match (P = .029) were significantly associated with the risk of recurrence. CONCLUSIONS When compared with other glomerulonephritis patients, with IgA or S-HP showed similar 5-year graft and patient survivals. Nevertheless, graft survival was shorter among patients with crescentic glomerulonephritis at the moment of diagnosis. Thus, the disease prognosis after grafting may be linked to the initial histological aggressiveness. Women and those patients transplanted with a good HLA match were prone to develop disease recurrence with a tendency toward a lower 5-year graft survival.
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Affiliation(s)
- M J Soler
- Nephrology Department, Hospital del Mar, Universtat Autonoma de Barcelona, Spain
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Ogura Y, Suzuki S, Shirakawa T, Masuda M, Nakamura H, Iijima K, Yoshikawa N. Haemophilus parainfluenzae antigen and antibody in children with IgA nephropathy and Henoch-Schönlein nephritis. Am J Kidney Dis 2000; 36:47-52. [PMID: 10873871 DOI: 10.1053/ajkd.2000.8264] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although the pathogenesis of immunoglobulin A (IgA) nephropathy and Henoch-Schönlein nephritis (HSN) remains uncertain, there is substantial evidence that they are immune complex-mediated diseases. Recently, Haemophilus parainfluenzae antigens were shown in the glomerular mesangium of adult patients with IgA nephropathy, and greater levels of IgA antibody against H parainfluenzae were also shown in the sera of adult patients with IgA nephropathy. The present study was performed to detect H parainfluenzae antigens and antibody against H parainfluenzae in children with IgA nephropathy and HSN. H parainfluenzae antigens in the mesangium were examined by indirect immunofluorescence, and antibody against H parainfluenzae was examined by enzyme-linked immunosorbent assay. Diffuse global staining of the mesangium with rabbit antisera against H parainfluenzae was shown in 10 of the 32 patients (31%) with IgA nephropathy and 12 of the 34 patients (35%) with HSN. Conversely, only 2 of the 47 patients (4%) with other renal diseases showed staining of glomeruli with rabbit antisera against H parainfluenzae (IgA nephropathy versus other renal diseases, P = 0.003; HSN versus other renal diseases, P = 0.0006). Patients with IgA nephropathy and those with HSN showed significantly greater levels of plasma IgA1 antibody against H parainfluenzae than patients with other renal diseases (IgA nephropathy versus other renal diseases, P = 0.008; HSN versus other renal diseases, P = 0.025). These findings suggest that H parainfluenzae has a role in the cause of these two conditions in a subset of patients.
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Affiliation(s)
- Y Ogura
- Faculty of Health Science and Department of Pediatrics, Kobe University School of Medicine, Kobe, Japan
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Clarkson AR, Elias TJ, Faull RJ, Bannister KM. Immunoglobulin a nephropathy and renal transplantation. Transplant Rev (Orlando) 1999; 13:174-82. [DOI: 10.1016/s0955-470x(99)80081-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Haubitz M, Kliem V, Koch KM, Nashan B, Schlitt HJ, Pichlmayr R, Brunkhorst R. Renal transplantation for patients with autoimmune diseases: single-center experience with 42 patients. Transplantation 1997; 63:1251-7. [PMID: 9158017 DOI: 10.1097/00007890-199705150-00010] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND In patients with autoimmune diseases such as vasculitis or systemic lupus erythematosus (SLE), end-stage renal disease develops in a high percentage of patients, and kidney transplantation has become a therapeutic option. However, only limited data about the prognosis and outcome after kidney transplantation are available. METHODS Long-term graft survival and graft function of renal transplant recipients with SLE, Wegener's granulomatosis, microscopic polyangiitis, Goodpasture's syndrome, and Henoch-Schonlein purpura were evaluated in a single center. In addition, the incidence of renal and extrarenal relapses and the impact of the immunosuppressive therapy on the course of the autoimmune disease were studied. RESULTS Renal transplant recipients with autoimmune diseases such as vasculitis and SLE had a patient survival rate (94% after 5 years) and a graft survival rate (65% after 5 years) comparable to those of patients with other causes of end-stage renal disease (patient survival 88% and graft survival 71% after 5 years). Graft losses due to the underlying disease were rare. Extrarenal relapses occurred in three patients with Wegener's granulomatosis, one patient with microscopic polyangiitis, and three patients with SLE, but were less frequent compared with the period with chronic dialysis therapy. Autoantibody levels in patients with SLE, Wegener's granulomatosis, or microscopic polyangiitis did not seem to influence the outcome. CONCLUSIONS Renal transplantation should be offered to patients with autoimmune diseases. Follow-up should include the short-term control of renal and extrarenal disease activity.
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Affiliation(s)
- M Haubitz
- Department of Nephrology, Medical School Hannover, Germany
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Abstract
Virtually all diseases affecting the native kidney recur in the kidney transplant with the exception of Alport syndrome, polycystic kidney disease, hypertension, chronic pyelonephritis, and chronic interstitial nephritis. Fortunately, in the majority of patients, recurrence of the original disease has minimal clinical impact, with only approximately 5% of all graft loss occurring as a result of recurrent disease. The primary renal diseases that commonly recur include membranoproliferative glomerulonephritis type II, IgA nephropathy, and focal and segmental glomerular sclerosis. The most common systemic disease that recurs is diabetic nephropathy. Living-related transplantation should be used with caution in patients with the hemolytic uremic syndrome, recurrent focal and segmental glomerular sclerosis, and membraneous glomerulonephritis. Fabry disease and primary hyperoxaluria type I are no longer absolute contraindications to kidney transplantation.
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Affiliation(s)
- E L Ramos
- Department of Medicine, University of Florida, Gainesville 32610-0224
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Abstract
After a long period during which few new data on the vasculitides emerged, the past decade has seen a real explosion of data on the subject. This began with basic clinical descriptions and the delineation of long term outcome as survival improved to a major extent under the influence of improved treatment regimes. In parallel, better understanding of the immunopathology has emerged. Of particular interest have been descriptions of autoantibody systems in vasculitis which seem to be specific to vasculitis and therefore diagnostically useful: the antineutrophil cytoplasmic antibodies (ANCA). Whether or not these are pathogenetically significant as well as useful remains a matter for debate. In parallel, anti endothelial cell antibodies have been described, but their role (if any), in pathogenesis remains equally obscure. There are some suggestions that vasculitis is becoming more common, but increased awareness and the availability of ANCA have undoubtedly increased awareness of the subject.
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Affiliation(s)
- J S Cameron
- United Medical School, Guy's Hospital, London, UK
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12
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Abstract
Recurrent or de novo diseases account for only 5% of graft failure in children, but have much to teach us about mechanisms. In children, almost the only metabolic disease with recurrence is type I hyperoxaluria, in which the poor long-term results of isolated renal transplantation make combined liver and renal transplantation, or even prophylactic liver transplantation before renal failure the preferable alternatives. While many forms of nephritis may show histological recurrence in allografts, it is notable that in many patients this is accompanied by no clinical manifestations or only mild disease: this is particularly so in mesangiocapillary glomerulonephritis (MCGN) type II. IgA-associated nephropathy and Henoch-Schönlein purpura. However focal segmental glomerulosclerosis and MCGN type I recur with sufficient frequency and severity to deter the use of living donors unless there is no alternative. The same is true of haemolytic-uraemic syndromes. As many as 10% of paediatric grafts may show de novo membranous nephropathy, but in the majority this is mild or not clinically evident. In contrast, the rare anti-glomerular basement membrane nephritis affecting some patients with Alport's syndrome usually results in graft failure, but occurs in only a minority of recipients with the syndrome. For all types of disease in allografts, risk factors for recurrence are poorly worked out, and attempts at treatment generally ineffective.
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Affiliation(s)
- J S Cameron
- Clinical Science Laboratories, Guy's Hospital, London, UK
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14
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Abstract
Renal insufficiency occurs in at least 1.5% of children with anaphylactoid purpura (AP). We reviewed the records of 16 children who developed end-stage renal disease (ESRD group) secondary to AP and matched them for age, era of onset, renal histology, and clinical severity at onset with 16 children who had AP but whose creatine clearance returned to and remained normal (recovery group). We reviewed creatinine clearances at 1, 3, 5, and 10 years after onset. A creatinine clearance greater than 70 ml/min per 1.73 m2 was present in 50% of the patients in the ESRD group at 3 years and in 25% at 5 years after onset. In contrast, all patients in the recovery group had a creatinine clearance greater than 70 ml/min per 1.73 m2 by 3 years (7 of 16 had a creatinine clearance greater than 125 ml/min per 1.73 m2) and all were normal 95-125 ml/min per 1.73 m2) by 5 years. Thus, the presence of an increased creatinine clearance (greater than 125 ml/min per 1.73 m2) at 3 years predicted recovery, while failure to reach a creatinine clearance of greater than 70 ml/min per 1.73 m2 at 3 years predicted progression to ESRD. There was no evidence of recurrent systemic AP or nephritis in the 14 patients who underwent renal allograft transplantation. We conclude that long-term evaluation of patients over many years is required to identify those who will progress to ESRD from AP and that recurrence of AP in the renal transplant is uncommon.
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Affiliation(s)
- T E Bunchman
- Department of Pediatrics, University of Minnesota, Minneapolis 55455
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Abstract
The diagnosis of recurrent renal disease after transplantation is dependent on an accurate and complete diagnosis of the initial cause of renal failure and a similar determination of the cause of graft failure. To be classified as recurrent, the disease in the renal graft must be identical to that seen in the native kidneys. Recurrence of disease accounts for less than 2% of all graft failures, but the overall incidence of recurrent disease is probably 5 to 10 times more common. The most frequent cause of recurrent disease is glomerulonephritis, which was first recognized to recur soon after renal transplantation was introduced. It was then recognized that a variety of metabolic disorders would recur, but it has taken 25 years of experience for a clear picture to emerge of recurrence in most conditions. No initial cause of renal failure poses a contraindication to at least one attempt at transplantation, although with Fabry's disease and oxalosis, a special assessment of the risks for the individual recipient is warranted. In some patients, experience has shown the need for a delay in the commitment to transplantation (eg, in those with anti-glomerular basement membrane [GBM] antibody glomerulonephritis or Henoch Schonlein purpura), the need for the choice of a particular immunosuppressive regimen (eg, in hemolytic uremic syndrome [HUS]), the need for avoidance of primary nonfunction (eg, in oxalosis), and the desirability of avoiding live kidney donation (eg, in heterozygote donors in Fabry's disease, high-risk recipients with focal glomerulosclerosis, and in recipients with HUS). Probably all types of glomerulonephritis recur, but with great variation in frequency and severity. In some forms of glomerulonephritis, recurrence may be frequent and definite on histopathological criteria but may only have a minor clinical expression (eg, dense deposit disease, anti-GBM antibody glomerulonephritis, IgA nephropathy), but in others, recurrence is less predictable yet it is clearly associated with premature graft failure (eg, focal glomerulosclerosis, membranous nephropathy). A common theme emerging is that where the initial glomerulonephritis is aggressive and causes kidney failure over a short time, recurrence is more likely, and when present, it will lead to graft failure with an increased frequency. Clinical manifestations, the frequency of recurrence, and the prognosis of the graft are now identified for most conditions. Unexpected observations have included the rarity of recurrent systemic lupus erythematosus (SLE), the immediate return of heavy proteinuria in focal glomerulosclerosis, and the predictable return of dense deposit disease.(ABSTRACT TRUNCATED AT 400 WORDS)
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Affiliation(s)
- T H Mathew
- Renal Unit, Queen Elizabeth Hospital, Woodville South, South Australia
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