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De Mutiis C, Wenderfer SE, Basu B, Bagga A, Orjuela A, Sar T, Aggarwal A, Jain A, Boyer O, Yap HK, Ito S, Ohnishi A, Iwata N, Kasapcopur O, Laurent A, Chan EYH, Mastrangelo A, Ogura M, Shima Y, Rianthavorn P, Silva CA, Trindade V, Tullus K. Development of clinical and laboratory biomarkers in an international cohort of 428 children with lupus nephritis. Pediatr Nephrol 2024:10.1007/s00467-024-06405-6. [PMID: 38802607 DOI: 10.1007/s00467-024-06405-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Lupus nephritis (LN) is a very severe manifestation of lupus. There is no consensus on which treatment goals should be achieved to protect kidney function in children with LN. METHODS We retrospectively analyzed trends of commonly used laboratory biomarkers of 428 patients (≤ 18 years old) with biopsy-proven LN class ≥ III. We compared data of patients who developed stable kidney remission from 6 to 24 months with those who did not. RESULTS Twenty-five percent of patients maintained kidney stable remission while 75% did not. More patients with stable kidney remission showed normal hemoglobin and erythrocyte sedimentation rate from 6 to 24 months compared to the group without stable kidney remission. eGFR ≥ 90 ml/min/1.73m2 at onset predicted the development of stable kidney remission (93.8%) compared to 64.7% in those without stable remission (P < 0.00001). At diagnosis, 5.9% and 20.2% of the patients showed no proteinuria in the group with and without stable kidney remission, respectively (P = 0.0001). dsDNA antibodies decreased from onset of treatment mainly during the first 3 months in all groups, but more than 50% of all patients in both groups never normalized after 6 months. Complement C3 and C4 increased mainly in the first 3 months in all patients without any significant difference. CONCLUSIONS Normal eGFR and the absence of proteinuria at onset were predictors of stable kidney remission. Significantly more children showed normal levels of Hb and erythrocyte sedimentation rate (ESR) from 6 to 24 months in the group with stable kidney remission.
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Affiliation(s)
- Chiara De Mutiis
- Paediatric Unit, Maggiore Hospital, Azienda USL, Bologna, Italy.
| | - Scott E Wenderfer
- Pediatric Nephrology, The University of British Columbia, BC Children's Hospital, Vancouver, BC, Canada
| | - Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Alvaro Orjuela
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Tanmoy Sar
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar Medical College and Hospital, Kolkata, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Avinash Jain
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
- Department of Clinical Immunology and Rheumatology, Sawai Mansingh Medical College, Jaipur, India
| | - Olivia Boyer
- Pediatric Nephrology, Necker Enfants Malades Hospital, Université Paris Cité, Paris, France
- Néphrologie Pédiatrique, Hôpital Necker, Paris, France
| | - Hui-Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, Japan
| | - Ai Ohnishi
- Department of Pediatrics, Yokohama City University, Fukuura, Kanazawa-Ku, Yokohama, Kanagawa, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Istanbul, Turkey
| | - Audrey Laurent
- Department of Pediatric Nephrology, Rheumatology and Dermatology, Hospices Civils de Lyon, Lyon, France
| | - Eugene Yu-Hin Chan
- Paediatric Nephrology Centre, Hong Kong Children's Hospital, Kowloon, Hong Kong SAR
- Department of Paediatrics, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Masao Ogura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Pornpimol Rianthavorn
- Division of Nephrology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Clovis A Silva
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Vitor Trindade
- Pediatric Rheumatology Unit, Children's Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Kjell Tullus
- Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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2
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Smith EMD, Egbivwie N, Jorgensen AL, Ciurtin C, Al-Abadi E, Armon K, Bailey K, Brennan M, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, Malik G, McLaren Z, Pilkington C, Ramanan AV, Rangaraj S, Ratcliffe A, Riley P, Sen E, Sridhar A, Wilkinson N, Wood F, Beresford MW, Hedrich CM. Real world treatment of juvenile-onset systemic lupus erythematosus: Data from the UK JSLE cohort study. Clin Immunol 2022; 239:109028. [PMID: 35513304 DOI: 10.1016/j.clim.2022.109028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/28/2022] [Accepted: 04/28/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the absence of clinical trials evidence, Juvenile-onset Systemic Lupus Erythematosus (JSLE) treatment plans vary. AIM To explore 'real world' treatment utilising longitudinal UK JSLE Cohort Study data. METHODS Data collected between 07/2009-05/2020 was used to explore the choice/sequence of immunomodulating drugs from diagnosis. Multivariate logistic regression determined how organ-domain involvement (pBILAG-2004) impacted treatment choice. RESULT 349 patients met inclusion criteria, median follow-up 4-years (IQR:2,6). Mycophenolate mofetil (MMF) was most commonly used for the majority of organ-domains, and significantly associated with renal involvement (OR:1.99, 95% CI:1.65-2.41, pc < 0.01). Analyses assessing the sequence of immunomodulators focused on 197/349 patients (meeting relevant inclusion/exclusion criteria). 10/197 (5%) solely recieved hydroxychloroquine/prednisolone, 62/197 (31%) received a single-immunomodulator, 69/197 (36%) received two, and 36/197 patients (28%) received ≥three immunomodulators. The most common first and second line immunomodulator was MMF. Rituximab was the most common third-line immunomodulator. CONCLUSIONS Most UK JSLE patients required ≥two immunomodulators, with MMF used most commonly.
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Affiliation(s)
- Eve M D Smith
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK.
| | - Naomi Egbivwie
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK; Liverpool University Hospitals NHS Foundation Trusts, Liverpool, UK
| | | | - Coziana Ciurtin
- Centre for Adolescent Rheumatology, University College London, London, UK
| | - Eslam Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - Kate Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - Kathryn Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Brennan
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - Kirsty Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - Daniel P Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - Alice Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - Valentina Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - Gulshan Malik
- Paediatric Rheumatology, Royal Aberdeen Children's Hospital, Aberdeen, UK
| | - Zoe McLaren
- Liverpool University Hospitals NHS Foundation Trusts, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Athimalaipet V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - Satyapal Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals, Nottingham, UK
| | - Annie Ratcliffe
- Department of Paediatrics, Taunton & Somerset NHS Foundation Trust - Musgrove Park Hospital, Taunton, UK
| | - Phil Riley
- Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - Ethan Sen
- Paediatric Rheumatology, Great North Children's Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Arani Sridhar
- Leicester Children's Hospital, University Hospitals of Leicester NHS trust, Leicester, UK
| | - Nick Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - Fiona Wood
- Department of Paediatrics, University Hospitals of Morecambe Bay NHS Foundation Trust, Royal Lancaster Infirmary, Lancaster, UK
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
| | - Christian M Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
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3
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Ward LM, Ma J, Robinson ME, Scharke M, Ho J, Houghton K, Huber A, Scuccimarri R, Barsalou J, Roth J, Shenouda N, Matzinger MA, Lentle B, Jaremko JL, Koujok K, Watanabe Duffy K, Stein R, Sbrocchi AM, Rodd C, Miettunen PM, LeBlanc CMA, Larche M, Jurencak R, Cummings EA, Couch R, Cabral DA, Atkinson S, Alos N, Sykes E, Konji VN, Rauch F, Siminoski K, Lang B. Osteoporotic Fractures and Vertebral Body Reshaping in Children With Glucocorticoid-treated Rheumatic Disorders. J Clin Endocrinol Metab 2021; 106:e5195-e5207. [PMID: 34232311 DOI: 10.1210/clinem/dgab494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Osteoporotic fractures are an important cause of morbidity in children with glucocorticoid-treated rheumatic disorders. OBJECTIVE This work aims to evaluate the incidence and predictors of osteoporotic fractures and potential for recovery over six years following glucocorticoid (GC) initiation in children with rheumatic disorders. METHODS Children with GC-treated rheumatic disorders were evaluated through a prospective inception cohort study led by the Canadian STeroid-induced Osteoporosis in the Pediatric Population (STOPP) Consortium. Clinical outcomes included lumbar spine bone mineral density (LS BMD), vertebral fractures (VF), non-VF, and vertebral body reshaping. RESULTS A total of 136 children with GC-treated rheumatic disorders were enrolled (mean age 9.9 years, SD 4.4). The 6-year cumulative fracture incidence was 16.3% for VF, and 10.1% for non-VF. GC exposure was highest in the first 6 months, and 24 of 38 VF (63%) occurred in the first 2 years. Following VF, 16 of 19 children (84%) had complete vertebral body reshaping. Increases in disease activity and body mass index z scores in the first year and declines in LS BMD z scores in the first 6 months predicted incident VF over the 6 years, while higher average daily GC doses predicted both incident VF and non-VF. LS BMD z scores were lowest at 6 months (mean -0.9, SD 1.2) and remained low by 6 years even when adjusted for height z scores (-0.6, SD 0.9). CONCLUSION VF occurred early and were more common than non-VF in children with GC-treated rheumatic disorders. Eighty-four percent of children with VF underwent complete vertebral body reshaping, whereas vertebral deformity persisted in the remainder of children. On average, LS BMD z scores remained low at 6 years, consistent with incomplete recovery.
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Affiliation(s)
- Leanne M Ward
- University of Ottawa, Ottawa, Ontario K1H 8L1, Canada
| | - Jinhui Ma
- McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | | | - Maya Scharke
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Josephine Ho
- University of Calgary, Calgary T3B 6A8, Alberta, Canada
| | - Kristin Houghton
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | - Adam Huber
- Dalhousie University, Halifax B3K 6R8, Nova Scotia, Canada
| | | | - Julie Barsalou
- Université de Montréal, Montréal H3T 1C5, Quebec, Canada
| | - Johannes Roth
- University of Ottawa, Ottawa, Ontario K1H 8L1, Canada
| | | | | | - Brian Lentle
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | | | | | | | - Robert Stein
- University of Western Ontario, London N6A 5A5, Ontario, Canada
| | | | - Celia Rodd
- University of Manitoba, Winnipeg R3E 0Z3, Manitoba, Canada
| | | | | | - Maggie Larche
- McMaster University, Hamilton, Ontario L8S 4L8, Canada
| | | | | | - Robert Couch
- University of Alberta, Edmonton, Alberta T6G 2R3, Canada
| | - David A Cabral
- University of British Columbia, Vancouver V6T 1Z4, British Columbia, Canada
| | | | - Nathalie Alos
- Université de Montréal, Montréal H3T 1C5, Quebec, Canada
| | - Elizabeth Sykes
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Victor N Konji
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario K1H 8L1, Canada
| | - Frank Rauch
- McGill University, Montréal H4A 3J1, Quebec, Canada
| | | | - Bianca Lang
- Dalhousie University, Halifax B3K 6R8, Nova Scotia, Canada
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4
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Grosso G, Sandholm K, Antovic A, Gunnarsson I, Zickert A, Vikerfors A, Truedsson L, Bruzelius M, Nilsson B, Nilsson-Ekdahl K, Svenungsson E. The Complex Relationship between C4b-Binding Protein, Warfarin, and Antiphospholipid Antibodies. Thromb Haemost 2021; 121:1299-1309. [PMID: 33412597 DOI: 10.1055/a-1347-5655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Low levels of total C4b-binding protein (C4BPt), a circulating inhibitor of the classical/lectin complement pathways, were observed in patients with antiphospholipid antibodies (aPLs) and during warfarin treatment. OBJECTIVES To investigate the associations between aPL and C4BPt in patients with persistently positive (++) aPL, with/without clinical manifestations and systemic lupus erythematosus (SLE), and in controls. Furthermore, we explored the impact of anticoagulation on C4BPt and in relation to complement activation. METHODS In a cross-sectional design we investigated defined subgroups: primary (p) antiphospholipid syndrome (APS, N = 67), aPL++ individuals without clinical manifestations (aPL carriers, N = 15), SLE-aPL++ (N = 118, among them, secondary [s] APS, N = 56), aPL negative (-) SLE (SLE-aPL-, N = 291), and 322 controls. Clinical characteristics, including treatment, were tabulated. C4BPt was determined with a magnetic bead method. Complement proteins (C1q, C2, C3, C4, C3a, C3dg, sC5b-9, factor I [FI]) were measured. A mediation analysis was performed to decompose the total effect of aPL++ on C4BPt into the direct and indirect effects of aPL++ through warfarin. RESULTS Overall, C4BPt is 20% decreased in aPL++ patients, regardless of SLE, APS, clinical manifestations, and aPL profile. C4BPt levels associate positively with complement proteins C1q, C2, C3, and C4, and negatively with complement activation product C3dg. In the SLE group, warfarin treatment contributes to approximately half of the C4BPt reduction (9%) CONCLUSION: Both aPLs and warfarin are associated with C4BPt reduction. Complement activation in aPL++ patients may partly be explained by impaired inhibition through depressed C4BPt levels. Further studies are needed to understand the clinical implications.
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Affiliation(s)
- Giorgia Grosso
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Kerstin Sandholm
- Linnaeus Center for Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
| | - Aleksandra Antovic
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Iva Gunnarsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Agneta Zickert
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Lennart Truedsson
- Department of Microbiology, Immunology and Glycobiology, Lund University Hospital, Lund, Sweden
| | - Maria Bruzelius
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Bo Nilsson
- Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Kristina Nilsson-Ekdahl
- Linnaeus Center for Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden.,Department of Immunology, Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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5
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Rosina S, Tibaldi J, Mazzoni M, Bava C, Natoli V, Ravelli A. Update on Outcome Measures for Pediatric Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2020; 72 Suppl 10:163-170. [PMID: 33091272 DOI: 10.1002/acr.24212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/07/2020] [Indexed: 11/11/2022]
Affiliation(s)
| | - Jessica Tibaldi
- IRCCS Istituto Giannina Gaslini and Università degli Studi di Genova, Genoa, Italy
| | | | | | | | - Angelo Ravelli
- Sechenov First Moscow State Medical University, Moscow, Russia
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6
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Tesser A, de Carvalho LM, Sandrin-Garcia P, Pin A, Pastore S, Taddio A, Roberti LR, de Paula Queiroz RG, Ferriani VPL, Crovella S, Tommasini A. Higher interferon score and normal complement levels may identify a distinct clinical subset in children with systemic lupus erythematosus. Arthritis Res Ther 2020; 22:91. [PMID: 32334613 PMCID: PMC7183668 DOI: 10.1186/s13075-020-02161-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 03/25/2020] [Indexed: 12/21/2022] Open
Abstract
Background Systemic lupus erythematosus (SLE) is a complex multi-system disease, characterized by both autoimmune and autoinflammatory clinical and laboratory features. The role of type I interferon (IFN) in SLE has been demonstrated from the 2000s, by gene expression analyses showing significant over-expression of genes related to type I IFN signalling pathway (IFN signature). However, several studies questioned the role of measuring the intensity of IFN signature (IFN score) to chase SLE activity. We would assess if the IFN signature can help the clinical and therapeutic stratification of patients with pediatric SLE. Methods We measured the IFN score in peripheral whole blood from a series of subjects with childhood-onset SLE and correlated the results with clinical and laboratory parameters. Results Thirty-one subjects were included in the study, among which the 87% displayed a positive IFN score. The only significant relation was found for high IFN score in subjects with normocomplementemia. No correlation was observed between IFN score and SLEDAI-2K, BILAG-2004 and SLICC. Patients with high IFN score and normal complement levels also presented lower anti-dsDNA antibodies. Conclusions The integration between IFN signature analysis and complement levels may easily distinguish two groups of subjects, in which the autoimmune or autoinflammatory component of the disease seems to be prevalent.
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Affiliation(s)
- Alessandra Tesser
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | | | | | - Alessia Pin
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Serena Pastore
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Andrea Taddio
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy.,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | | | | | | | - Sergio Crovella
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy.,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Alberto Tommasini
- Department of Pediatrics, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy. .,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy.
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7
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Massias JS, Smith EMD, Al-Abadi E, Armon K, Bailey K, Ciurtin C, Davidson J, Gardner-Medwin J, Haslam K, Hawley DP, Leahy A, Leone V, McErlane F, Mewar D, Modgil G, Moots R, Pilkington C, Ramanan AV, Rangaraj S, Riley P, Sridhar A, Wilkinson N, Beresford MW, Hedrich CM. Clinical and laboratory characteristics in juvenile-onset systemic lupus erythematosus across age groups. Lupus 2020; 29:474-481. [PMID: 32233733 PMCID: PMC7528537 DOI: 10.1177/0961203320909156] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Systemic lupus erythematous (SLE) is a systemic autoimmune/inflammatory condition. Approximately 15–20% of patients develop symptoms before their 18th birthday and are diagnosed with juvenile-onset SLE (JSLE). Gender distribution, clinical presentation, disease courses and outcomes vary significantly between JSLE patients and individuals with adult-onset SLE. This study aimed to identify age-specific clinical and/or serological patterns in JSLE patients enrolled to the UK JSLE Cohort Study. Methods Patient records were accessed and grouped based on age at disease-onset: pre-pubertal (≤7 years), peri-pubertal (8–13 years) and adolescent (14–18 years). The presence of American College of Rheumatology (ACR) classification criteria, laboratory results, disease activity [British Isles Lupus Assessment Group (BILAG) and Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) scores] and damage [Systemic Lupus International Collaborating Clinics (SLICC) damage index] were evaluated at diagnosis and last follow up. Results A total of 418 JSLE patients were included in this study: 43 (10.3%) with pre-pubertal disease onset; 240 (57.4%) with peri-pubertal onset and 135 (32.3%) were diagnosed during adolescence. At diagnosis, adolescent JSLE patients presented with a higher number of ACR criteria when compared with pre-pubertal and peri-pubertal patients [pBILAG2004 scores: 9(4–20] vs. 7(3–13] vs. 7(3–14], respectively, p = 0.015] with increased activity in the following BILAG domains: mucocutaneous (p = 0.025), musculoskeletal (p = 0.029), renal (p = 0.027) and cardiorespiratory (p = 0.001). Furthermore, adolescent JSLE patients were more frequently ANA-positive (p = 0.034) and exhibited higher anti-dsDNA titres (p = 0.001). Pre-pubertal individuals less frequently presented with leukopenia (p = 0.002), thrombocytopenia (p = 0.004) or low complement (p = 0.002) when compared with other age groups. No differences were identified in disease activity (pBILAG2004 score), damage (SLICC damage index) and the number of ACR criteria fulfilled at last follow up. Conclusions Disease presentations and laboratory findings vary significantly between age groups within a national cohort of JSLE patients. Patients diagnosed during adolescence exhibit greater disease activity and “classic” autoantibody, immune cell and complement patterns when compared with younger patients. This supports the hypothesis that pathomechanisms may vary between patient age groups.
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Affiliation(s)
- J S Massias
- School of Medicine, University of Liverpool, UK
| | - E M D Smith
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
| | - E Al-Abadi
- Department of Rheumatology, Birmingham Children's Hospital, Birmingham, UK
| | - K Armon
- Department of Paediatric Rheumatology, Cambridge University Hospitals, Cambridge, UK
| | - K Bailey
- Department of Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - C Ciurtin
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - J Davidson
- Department of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | | | - K Haslam
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, UK
| | - D P Hawley
- Department of Paediatric Rheumatology, Sheffield Children's Hospital, Sheffield, UK
| | - A Leahy
- Department of Paediatric Rheumatology, Southampton General Hospital, Southampton, UK
| | - V Leone
- Department of Paediatric Rheumatology, Leeds Children Hospital, Leeds, UK
| | - F McErlane
- Paediatric Rheumatology, Great North Children's Hospital, Royal Victoria Infirmary, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - D Mewar
- Department of Rheumatology, Royal Liverpool University Hospital, Liverpool, UK
| | - G Modgil
- Department of Paediatrics, Musgrove Park Hospital, Taunton, UK
| | - R Moots
- Department of Rheumatology, University Hospital Aintree, Liverpool, UK
| | - C Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - A V Ramanan
- University Hospitals Bristol NHS Foundation Trust & Bristol Medical School, University of Bristol, Bristol, UK
| | - S Rangaraj
- Department of Paediatric Rheumatology, Nottingham University Hospitals Nottingham, UK
| | - P Riley
- Department of Paediatric Rheumatology, Royal Manchester Children's Hospital, Manchester, UK
| | - A Sridhar
- Department of Paediatrics, Leicester Royal Infirmary, Leicester, UK
| | - N Wilkinson
- Guy's & St Thomas's NHS Foundation Trust, Evelina Children's Hospital, London, UK
| | - M W Beresford
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
| | - C M Hedrich
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, UK
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8
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Donohue SJ, Midgley A, Davies JC, Wright RD, Bruce I, Beresford MW, Hedrich CM. Differential analysis of serum and urine S100 proteins in juvenile-onset systemic lupus erythematosus (jSLE). Clin Immunol 2020; 214:108375. [PMID: 32135275 DOI: 10.1016/j.clim.2020.108375] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/28/2020] [Accepted: 02/28/2020] [Indexed: 12/21/2022]
Abstract
Up to 80% of juvenile-onset systemic lupus erythematosus (jSLE) patients develop lupus nephritis (LN) that affects treatment and prognosis. Easily accessible biomarkers do not exist to reliably diagnose LN, leaving kidney biopsies as the gold-standard. Calcium-binding S100 proteins are expressed by innate immune cells and epithelia and may act as biomarkers in systemic inflammatory conditions. We quantified S100 proteins in the serum and urine of jSLE patients, matched healthy and inflammatory (IgA vasculitis) controls. Serum S100A8/A9, and serum and urine S100A12 are increased in jSLE patients when compared to controls. Furthermore, serum S100A8/A9, and serum and urine S100A12 are increased in jSLE patients with active as compared to patients with inactive/no LN. No differences in S100A4 levels were seen between groups. This study demonstrates potential promise for S100A8/A9 and S100A12 as biomarkers for jSLE and active LN. Findings require to be confirmed and tested prospectively in independent and larger multi-ethnic cohorts.
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Affiliation(s)
- S J Donohue
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - A Midgley
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - J C Davies
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - R D Wright
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - I Bruce
- Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, The University of Manchester, Manchester, UK.
| | - M W Beresford
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK; National Institute for Health Research (NIHR) Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust Hospital, UK
| | - C M Hedrich
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK; National Institute for Health Research (NIHR) Alder Hey Clinical Research Facility, Alder Hey Children's NHS Foundation Trust Hospital, UK.
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9
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Peterknecht E, Keasey MP, Beresford MW. The effectiveness and safety of biological therapeutics in juvenile-onset systemic lupus erythematosus (JSLE): a systematic review. Lupus 2018; 27:2135-2145. [PMID: 30336753 DOI: 10.1177/0961203318804879] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To systematically review and summarize the available literature regarding the effectiveness and safety of biologics in the treatment of juvenile-onset systemic lupus erythematosus. METHODS PubMed was systematically searched for relevant literature (2012-2017 inclusive) using the following criteria: (1) patients diagnosed with juvenile-onset systemic lupus erythematosus (≤18 years at diagnosis); (2) treatment with any biological agent; and (3) outcome measures assessing effectiveness and safety. Systematic literature reviews, meta-analyses, randomized controlled trials, cohort studies, case control studies, cross sectional surveys and case-series with ≥3 patients were included. Independent extraction of articles by two authors using predefined criteria was performed. The quality of each study was assessed using CASP tools and Oxford CEBM Levels of Evidence. RESULTS Nine articles met inclusion criteria: six cohort studies, two case series and one pilot study, totalling 230 patients. All but one article reported the effects of rituximab, the other those of belimumab. Overall, patients had active disease refractory to standard of care regimens using corticosteroids and immunosuppressants. Available evidence for rituximab demonstrated improvements in disease activity, complement levels and anti-dsDNA titres accompanying a steroid-sparing effect. CONCLUSION Rituximab can be considered an effective treatment in juvenile-onset systemic lupus erythematosus patients with severe disease manifestations and/or refractory disease. Based on current evidence, use of belimumab in juvenile-onset systemic lupus erythematosus patients cannot be recommended. The long-term safety of these biological agents remains uncertain. Further prospective studies, ideally robust randomized controlled trials, are urgently needed to obtain more accurate data on the effectiveness and long-term safety of rituximab, belimumab and other biologics in juvenile-onset systemic lupus erythematosus.
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Affiliation(s)
- E Peterknecht
- 1 University of Liverpool Medical School, University of Liverpool, Liverpool, UK
| | - M P Keasey
- 2 Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, USA
| | - M W Beresford
- 3 Clinical Academic Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- 4 Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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10
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Groot N, de Graeff N, Avcin T, Bader-Meunier B, Brogan P, Dolezalova P, Feldman B, Kone-Paut I, Lahdenne P, Marks SD, McCann L, Ozen S, Pilkington C, Ravelli A, Royen-Kerkhof AV, Uziel Y, Vastert B, Wulffraat N, Kamphuis S, Beresford MW. European evidence-based recommendations for diagnosis and treatment of childhood-onset systemic lupus erythematosus: the SHARE initiative. Ann Rheum Dis 2017. [PMID: 28630236 DOI: 10.1136/annrheumdis-2016-210960] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) is a rare, multisystem and potentially life-threatening autoimmune disorder with significant associated morbidity. Evidence-based guidelines are sparse and management is often based on clinical expertise. SHARE (Single Hub and Access point for paediatric Rheumatology in Europe) was launched to optimise and disseminate management regimens for children and young adults with rheumatic diseases like cSLE. Here, we provide evidence-based recommendations for diagnosis and treatment of cSLE. In view of extent and complexity of cSLE and its various manifestations, recommendations for lupus nephritis and antiphospholipid syndrome will be published separately. Recommendations were generated using the EULAR (European League Against Rheumatism) standard operating procedure. An expert committee consisting of paediatric rheumatologists and representation of paediatric nephrology from across Europe discussed evidence-based recommendations during two consensus meetings. Recommendations were accepted if >80% agreement was reached. A total of 25 recommendations regarding key approaches to diagnosis and treatment of cSLE were made. The recommendations include 11 on diagnosis, 9 on disease monitoring and 5 on general treatment. Topics included: appropriate use of SLE classification criteria, disease activity and damage indices; adequate assessment of autoantibody profiles; secondary macrophage activation syndrome; use of hydroxychloroquine and corticosteroid-sparing regimens; and the importance of addressing poor adherence. Ten recommendations were accepted regarding general diagnostic strategies and treatment indications of neuropsychiatric cSLE. The SHARE recommendations for cSLE and neuropsychiatric manifestations of cSLE have been formulated by an evidence-based consensus process to support uniform, high-quality standards of care for children with cSLE.
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Affiliation(s)
- Noortje Groot
- Wilhelmina Children's Hospital, Utrecht, Netherlands.,Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | - Tadej Avcin
- University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | | | - Paul Brogan
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Pavla Dolezalova
- General University Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Brian Feldman
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Pekka Lahdenne
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Stephen D Marks
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Liza McCann
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Seza Ozen
- Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | | | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Genoa, Italy
| | | | - Yosef Uziel
- Meir Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Bas Vastert
- Wilhelmina Children's Hospital, Utrecht, Netherlands
| | | | - Sylvia Kamphuis
- Sophia Children's Hospital, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Michael W Beresford
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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11
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Zhao Q, Chen X, Li J, Jiang J, Li M, Zhong W, Li Z, Leung SO, Zhang F, Hu P. Pharmacokinetics, Pharmacodynamics and Preliminary Observations for Clinical Activity and Safety of Multiple Doses of Human Mouse Chimeric Anti-CD22 Monoclonal Antibody (SM03) in Chinese Patients with Systemic Lupus Erythematosus. Clin Drug Investig 2017; 36:889-902. [PMID: 27424629 DOI: 10.1007/s40261-016-0426-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES SM03 is a novel recombinant, human/mouse chimeric immunoglobulin G1 monoclonal antibody directed against the CD22 antigen on human B lymphocytes. This was the first study to investigate the pharmacokinetics, pharmacodynamics, immunogenicity, safety and clinical activity of SM03 in patients with systemic lupus erythematosus (SLE). METHODS This study was an open, multiple-centre, parallel-group, multiple-ascending-dose, phase I study in 29 SLE patients. Pharmacokinetic assessment was conducted in 22 of these patients. Eligible patients received multiple intravenous infusions of SM03 for 4 weeks (240 mg/m2, 600 or 900 mg, once weekly) and were monitored over an 84-day observation period for pharmacokinetics, pharmacodynamics, immunogenicity, safety and clinical response. RESULTS After multiple-dose SM03, the maximal serum concentration of SM03 was reached within 3-7 h. The mean elimination half-life was 15 days. The average accumulation ratios of the area under the time-concentration curve and the maximum concentration after the fourth administration of SM03 were 2.0 and 1.5. CD19+ B-lymphocyte counts were decreased. Infections were the most common adverse events. No drug-related serious adverse events were reported. The therapeutic benefit of SM03 was observed mainly in patients with moderate-to-severe disease activity. CONCLUSION Pharmacokinetic exposure increased in a lower-than-dose-proportional manner up to 900 mg. SM03 was well tolerated at doses ranging from 240 mg/m2 to 900 mg, with no new safety signals identified. SM03 has potential efficacy in Chinese patients with SLE.
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Affiliation(s)
- Qian Zhao
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China
| | - Xia Chen
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China
| | - Jing Li
- Department of Rheumatology, Peking Union Medical College Hospital, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ji Jiang
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Wen Zhong
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China
| | - Zhengdong Li
- SinoMab BioScience, Ltd, BioIncubator No. 1-301, Science and Technology Park, Nanshan District, Shenzhen, 518057, Guangdong, China
| | - Shui-On Leung
- SinoMab BioScience, Ltd, BioIncubator No. 1-301, Science and Technology Park, Nanshan District, Shenzhen, 518057, Guangdong, China.
| | - Fengchun Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, 1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Pei Hu
- Clinical Pharmacology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 41 Damucang, Xicheng District, Beijing, 100032, China.
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12
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Smith EMD, Jorgensen AL, Midgley A, Oni L, Goilav B, Putterman C, Wahezi D, Rubinstein T, Ekdawy D, Corkhill R, Jones CA, Marks SD, Newland P, Pilkington C, Tullus K, Beresford MW. International validation of a urinary biomarker panel for identification of active lupus nephritis in children. Pediatr Nephrol 2017; 32:283-295. [PMID: 27590021 PMCID: PMC5203828 DOI: 10.1007/s00467-016-3485-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/26/2016] [Accepted: 07/14/2016] [Indexed: 01/20/2023]
Abstract
BACKGROUND Conventional markers of juvenile-onset systemic lupus erythematosus (JSLE) disease activity fail to adequately identify lupus nephritis (LN). While individual novel urine biomarkers are good at detecting LN flares, biomarker panels may improve diagnostic accuracy. The aim of this study was to assess the performance of a biomarker panel to identify active LN in two international JSLE cohorts. METHODS Novel urinary biomarkers, namely vascular cell adhesion molecule-1 (VCAM-1), monocyte chemoattractant protein 1 (MCP-1), lipocalin-like prostaglandin D synthase (LPGDS), transferrin (TF), ceruloplasmin, alpha-1-acid glycoprotein (AGP) and neutrophil gelatinase-associated lipocalin (NGAL), were quantified in a cross-sectional study that included participants of the UK JSLE Cohort Study (Cohort 1) and validated within the Einstein Lupus Cohort (Cohort 2). Binary logistic regression modelling and receiver operating characteristic curve analysis [area under the curve (AUC)] were used to identify and assess combinations of biomarkers for diagnostic accuracy. RESULTS A total of 91 JSLE patients were recruited across both cohorts, of whom 31 (34 %) had active LN and 60 (66 %) had no LN. Urinary AGP, ceruloplasmin, VCAM-1, MCP-1 and LPGDS levels were significantly higher in those patients with active LN than in non-LN patients [all corrected p values (p c) < 0.05] across both cohorts. Urinary TF also differed between patient groups in Cohort 2 (p c = 0.001). Within Cohort 1, the optimal biomarker panel included AGP, ceruloplasmin, LPGDS and TF (AUC 0.920 for active LN identification). These results were validated in Cohort 2, with the same markers resulting in the optimal urine biomarker panel (AUC 0.991). CONCLUSION In two international JSLE cohorts, urinary AGP, ceruloplasmin, LPGDS and TF demonstrate an 'excellent' ability for accurately identifying active LN in children.
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Affiliation(s)
- Eve Mary Dorothy Smith
- Department of Women's and Children's Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children's Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP, UK.
| | - Andrea Lyn Jorgensen
- Department of Biostatistics, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Angela Midgley
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK
| | - Louise Oni
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK
| | - Beatrice Goilav
- Division of Nephrology, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY USA
| | - Chaim Putterman
- Division of Rheumatology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY USA
| | - Dawn Wahezi
- Division of Pediatric Rheumatology, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY USA
| | - Tamar Rubinstein
- Division of Pediatric Rheumatology, Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY USA
| | - Diana Ekdawy
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK
| | - Rachel Corkhill
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK
| | - Caroline Ann Jones
- Department of Paediatric Nephrology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Stephen David Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital, London, UK
| | - Paul Newland
- Biochemistry Department, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Clarissa Pilkington
- Department of Paediatric Rheumatology, Great Ormond Street Hospital, London, UK
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital, London, UK
| | - Michael William Beresford
- Department of Women’s and Children’s Health, Institute of Translational Medicine, Institute of Child Health in the Park, Alder Hey Children’s Hospital and University of Liverpool, Eaton Road, Liverpool, L12 2AP UK ,Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
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13
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Abstract
Juvenile systemic lupus erythematosus (JSLE) represents 15—20% of all SLE cases. The leading presenting symptoms of JSLE are constitutional and not specific such as fatigue, headache, weight loss or mood swings. They are also encountered in healthy adolescents, which explains frequent diagnosis delay. The frequency of irreversible damage is high in JSLE and involves especially the renal, musculoskeletal and neuropsychiatric systems. Although the overall prognosis has markedly improved, thanks to earlier diagnosis and new therapeutic approaches, cardiovascular, hematological events and chronic renal failure remain severe, and constitute the main disease-related causes of death. Treatment is based on hydroxycloroquine and corticosteroids. Immunosuppressive agents must be discussed to decrease the duration of corticosteroids use. New drugs and monoclonal antibodies targeting B-cells and B-cell related cytokines are being evaluated with encouraging results. Management of JSLE has to challenge three objectives: controlling disease progression, obtaining patient's adherence to treatment, and preventing consequences of medication side effects on growth, puberty, development and fertility. Patients' quality of life and psychosocial development have also to be taken into account, as well as the organization of a successful transition from paediatric to adult care. Lupus (2007) 16, 606—612.
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Affiliation(s)
- I Kone-Paut
- Department of Pediatrics and Pediatric Rheumatology, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France.
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14
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Patel M, Oni L, Midgley A, Smith E, Tullus K, Marks SD, Jones CA, Pilkington C, Beresford MW. Increased concentration of plasma TNFR1 and TNFR2 in paediatric lupus nephritis. Lupus 2016; 25:1040-4. [PMID: 26854079 DOI: 10.1177/0961203316631634] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 01/13/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Juvenile-onset systemic lupus erythematous (JSLE) is a debilitating condition that frequently involves the kidneys (lupus nephritis; LN). Tumour necrosis factor alpha (TNF-α), an important pro-inflammatory cytokine, is expressed locally in the kidney and correlates with LN disease activity. The aim of this study was to ascertain whether soluble receptors for TNF-α (sTNFR1/sTNFR2) are significantly increased in children with LN. METHODS Plasma samples were collected from JSLE patients at routine review. Concentrations of sTNFR1 and sTNFR2 were measured (median; interquartile range, IQR) using enzyme-linked immunosorbent assay (ELISA) in 25 JSLE patients (seven LN) and 20 healthy controls (HCs). RESULTS sTNFR2 concentration was significantly increased in JSLE (5149 pg/dl, 3413-8561) compared to HCs (3858 pg/dl, 2254-5165; p = 0.049). sTNFR1 concentration was significantly increased in active LN (n = 7, 1765 pg/dl, IQR 1133-4167) compared to inactive LN (n = 18, 1104 pg/dl, 886-1272; p = 0.018). There was a non-significant increase in sTNFR2 concentration in active LN (9829 pg/dl, 3298-21271) compared to inactive LN (4595 pg/dl, 3345-6993; p = 0.146). sTNFR1 concentration correlated moderately with sTNFR2 (r = 0.66, p < 0.001). sTNFR2 demonstrated strong positive correlations with ESR (r = 0.941, p < 0.01) and anti-dsDNA antibodies (r = 0.998, p = 0.041). Both receptors also positively correlated with creatinine (TNFR1 r = 0.81, p < 0.001; TNFR2 r = 0.50, p = 0.015) and urinary albumin creatinine ratio (TNFR1 r = 0.64, p < 0.01; TNFR2 r = 0.63, p < 0.01). CONCLUSIONS These data indicate that sTNFR1 and sTNFR2 concentrations are elevated in LN and may reflect renal activity. These results provide basis for further investigation into the pathological pathways underlying LN.
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Affiliation(s)
- M Patel
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK
| | - L Oni
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - A Midgley
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK
| | - E Smith
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - K Tullus
- Department of Paediatric Nephrology, Great Ormond Street Children's NHS Hospital, London, UK
| | - S D Marks
- Department of Paediatric Nephrology, Great Ormond Street Children's NHS Hospital, London, UK
| | - C A Jones
- Department of Paediatric Nephrology, Great Ormond Street Children's NHS Hospital, London, UK
| | - C Pilkington
- Department of Rheumatology, Great Ormond Street Children's NHS Hospital, London, UK
| | - M W Beresford
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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15
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Murphy CL, Yee CS, Gordon C, Isenberg D. From BILAG to BILAG-based combined lupus assessment—30 years on. Rheumatology (Oxford) 2015; 55:1357-63. [DOI: 10.1093/rheumatology/kev387] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Indexed: 11/13/2022] Open
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16
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LeBlanc CMA, Ma J, Taljaard M, Roth J, Scuccimarri R, Miettunen P, Lang B, Huber AM, Houghton K, Jaremko JL, Ho J, Shenouda N, Matzinger MA, Lentle B, Stein R, Sbrocchi AM, Oen K, Rodd C, Jurencak R, Cummings EA, Couch R, Cabral DA, Atkinson S, Alos N, Rauch F, Siminoski K, Ward LM. Incident Vertebral Fractures and Risk Factors in the First Three Years Following Glucocorticoid Initiation Among Pediatric Patients With Rheumatic Disorders. J Bone Miner Res 2015; 30:1667-75. [PMID: 25801315 PMCID: PMC4556451 DOI: 10.1002/jbmr.2511] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/10/2015] [Accepted: 03/13/2015] [Indexed: 12/21/2022]
Abstract
Vertebral fractures are an important yet underrecognized manifestation of osteoporosis in children with chronic, glucocorticoid-treated illnesses. Our goal was to determine the incidence and clinical predictors of vertebral fractures in the 3 years following glucocorticoid initiation among pediatric patients with rheumatic disorders. Incident vertebral fractures were evaluated according to the Genant semiquantitative method on lateral radiographs at baseline and then annually in the 3 years following glucocorticoid initiation. Extended Cox models were used to assess the association between vertebral fractures and clinical risk predictors. A total of 134 children with rheumatic disorders were enrolled in the study (mean ± standard deviation (SD) age 9.9 ± 4.4 years; 65% girls). The unadjusted vertebral fracture incidence rate was 4.4 per 100 person-years, with a 3-year incidence proportion of 12.4%. The highest annual incidence occurred in the first year (6.0%; 95% confidence interval (CI) 2.9% to 11.7%). Almost one-half of the patients with fractures were asymptomatic. Every 0.5 mg/kg increase in average daily glucocorticoid (prednisone equivalents) dose was associated with a twofold increased fracture risk (hazard ratio (HR) 2.0; 95% CI 1.1 to 3.5). Other predictors of increased vertebral fracture risk included: (1) increases in disease severity scores between baseline and 12 months; (2) increases in body mass index Z-scores in the first 6 months of each 12-month period preceding the annual fracture assessment; and (3) decreases in lumbar spine bone mineral density Z-scores in the first 6 months of glucocorticoid therapy. As such, we observed that a clinically significant number of children with rheumatic disorders developed incident vertebral fractures in the 3 years following glucocorticoid initiation. Almost one-half of the children were asymptomatic and thereby would have been undiagnosed in the absence of radiographic monitoring. In addition, discrete clinical predictors of incident vertebral fractures were evident early in the course of glucocorticoid therapy.
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Affiliation(s)
| | - Jinhui Ma
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Monica Taljaard
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Johannes Roth
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | | | - Paivi Miettunen
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Bianca Lang
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Adam M Huber
- Department of Pediatrics, Dalhousie University, Halifax, NS, Canada
| | - Kristin Houghton
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Jacob L Jaremko
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Josephine Ho
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Nazih Shenouda
- Department of Medical Imaging, University of Ottawa, Ottawa, ON, Canada
| | | | - Brian Lentle
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Robert Stein
- Department of Pediatrics, University of Western Ontario, London, ON, Canada
| | | | - Kiem Oen
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Celia Rodd
- Department of Pediatrics, University of Manitoba, Winnipeg, MB, Canada
| | - Roman Jurencak
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | | | - Robert Couch
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - David A Cabral
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | | | - Nathalie Alos
- Department of Pediatrics, Université de Montréal, Montréal, QC, Canada
| | - Frank Rauch
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Kerry Siminoski
- Department of Radiology and Diagnostic Imaging, and Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Leanne M Ward
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
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17
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Quinlan C, Kari J, Pilkington C, Deanfield J, Shroff R, Marks SD, Tullus K. The vascular phenotype of children with systemic lupus erythematosus. Pediatr Nephrol 2015; 30:1307-16. [PMID: 26001699 DOI: 10.1007/s00467-015-3059-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 01/09/2015] [Accepted: 01/23/2015] [Indexed: 01/06/2023]
Abstract
BACKGROUND The increased risk of cardiovascular disease (CVD) in adults with systemic lupus erythematosus (SLE) has been known since the 1970s, but studies in juvenile-onset SLE (JSLE) have reported conflicting results and more data are needed. The aim of this cross-sectional study was to establish the baseline risk of CVD in a cohort of UK patients with JSLE. METHODS Data were collected to establish disease duration, disease activity, medication use and activity levels, as well as demographic data, including family history of CVD. Vascular phenotype was established using well-validated measures of carotid intima media thickness (cIMT) and pulse wave velocity (PWV). RESULTS In total, 45 children (39 female; mean age 13.5 ± 2.9 years) with JSLE were recruited to the study. Of these, 24 had a history of biopsy-proven lupus nephritis and five had an estimated glomerular filtration rate of <90 ml/min/1.73 m(2). Comparison of these JSLE patients with healthy controls previously scanned at our hospital revealed that the cIMT value was significantly higher in the former (0.45 vs. 0.37 mm, respectively; p < 0.0001). This difference was associated with the use of antihypertensives (p = 0.04) and higher or lower doses of prednisolone (p < 0.0001). PWV was not significantly different in the patient and control group (5.27 vs. 5.34 m/s, respectively; p = 0.77). In the patient group, the mean body mass index percentile was 65.63 ± 28.8, and the median physical activity score was 1,773 (676-2,854) metabolic equivalents of task (METs). None of the patients admitted to cigarette smoking, and ten had a positive family history of cardiovascular disease (CVD). CONCLUSION This study shows that our patients with JSLE had increased cIMT without an increase in PWV, suggesting possible early adaptive changes in JSLE. Follow-up data are needed to determine whether these changes result in clinically significant CVD.
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Affiliation(s)
- Catherine Quinlan
- Department of Nephrology, The Royal Children's Hospital, Parkville, Victoria, 3052, Australia,
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18
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Ballantine L, Midgley A, Harris D, Richards E, Burgess S, Beresford MW. Increased soluble phagocytic receptors sMer, sTyro3 and sAxl and reduced phagocytosis in juvenile-onset systemic lupus erythematosus. Pediatr Rheumatol Online J 2015; 13:10. [PMID: 25878564 PMCID: PMC4397859 DOI: 10.1186/s12969-015-0007-y] [Citation(s) in RCA: 30] [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: 12/15/2014] [Accepted: 03/20/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The TAM-receptor tyrosine kinase family, Tyro3, Axl and Mer are key to apoptotic cell clearance. Reduced phagocytic clearance in systemic lupus erythematosus (SLE) leads to prolonged exposure of nuclear autoantigen to the immune system. Here we measure the levels of TAM receptors and the phagocytic capacity of monocytes and macrophages in juvenile-onset SLE (JSLE). METHOD Mer protein was measured on monocytes from JSLE, healthy control and JIA patients. JSLE, healthy control and JIA patients' plasma were analysed for soluble Mer (sMer), soluble Tyro3 (sTyro) and soluble Axl (sAxl). A phagocytosis assay measured the effect of JSLE serum on phagocytic potential of JSLE and control monocytes to engulf E. Coli bacteria and healthy macrophages to engulf apoptotic neutrophils. RESULTS Mer receptor expression was significantly decreased on JSLE monocytes compared to healthy controls. Plasma sMer, sTyro and sAxl were significantly increased in JSLE patients compared to controls (p < 0.05). Adult healthy control macrophages had significantly decreased phagocytosis of E. Coli and apoptotic neutrophils in the presence of 10% JSLE serum compared to control serum (p < 0.05). CONCLUSION JSLE patients have a decreased phagocytosis due to both serum and cell-derived factors. Significantly increased levels of sMer, sTyro3 and sAxl may be important factors contributing to the deficit in phagocytosis ability.
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Affiliation(s)
- Lucy Ballantine
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP UK
| | - Angela Midgley
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP UK
| | - David Harris
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP UK
| | - Ella Richards
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP UK
| | - Sarah Burgess
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP UK
| | - Michael W Beresford
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital, Eaton Road, Liverpool, L12 2AP UK
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19
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Basophil count, a marker for disease activity in systemic lupus erythematosus. Clin Rheumatol 2014; 34:891-6. [PMID: 25403252 DOI: 10.1007/s10067-014-2822-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 11/04/2014] [Accepted: 11/04/2014] [Indexed: 01/02/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic multisystem autoimmune disease, with frequent flares amid remissions. Basophils contribute to the immunopathogenesis of SLE. This retrospective clinical study evaluated blood basophil count as a potential marker of SLE activity. This study included 213 patients with SLE, 70 with non-SLE chronic kidney disease (CKD), and 100 healthy volunteers. SLE disease activity was scored using the SLE Disease Activity Index (SLEDAI). Baseline and post-immunosuppressant bioparameters were compared in patients with active SLE, with second samples taken at total SLEDAI ≤4. Blood basophil counts and other conventional biomarkers were compared among the groups. Among the 213 SLE patients (192 women, 21 men; mean age 33.0 ± 12.0 years), 149 had active disease. Basophil counts were significantly lower in patients with SLE than in patients with non-SLE CKD and healthy controls (0.009 ± 0.010 vs. 0.025 ± 0.015 vs. 0.022 ± 0.010 × 10(9)/L, p <0.001), and lower in patients with active than inactive SLE (0.008 ± 0.009 vs. 0.014 ± 0.012 × 10(9)/L, p <0.001). Basophil counts in SLE patients were significantly higher after than before immunosuppressive treatment (0.021 ± 0.017 vs. 0.008 ± 0.008 × 10(9)/L, p <0.001) and correlated with total SLEDAI score (r = -0.30, p <0.001). Receiver operator curve analysis showed that basophil counts were similar to conventional markers (leukocytes, platelets, and double-stranded (ds) DNA IgG) in differentiating active from inactive SLE. These findings indicate that blood basophil counts may be a useful biomarker in evaluating SLE activity.
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20
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Chiewchengchol D, Murphy R, Morgan T, Edwards SW, Leone V, Friswell M, Pilkington C, Tullus K, Rangaraj S, McDonagh JE, Gardner-Medwin J, Wilkinson N, Riley P, Tizard J, Armon K, Sinha MD, Ioannou Y, Mann R, Bailey K, Davidson J, Baildam EM, Pain CE, Cleary G, McCann LJ, Beresford MW. Mucocutaneous manifestations in a UK national cohort of juvenile-onset systemic lupus erythematosus patients. Rheumatology (Oxford) 2014; 53:1504-12. [PMID: 24692572 DOI: 10.1093/rheumatology/keu137] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To determine whether mucocutaneous manifestations are associated with major organ involvement in a UK national cohort of juvenile-onset SLE (JSLE) patients. METHODS JSLE patients (n = 241) from 15 different centres whose diagnosis fulfilled four or more of the ACR criteria were divided into two groups: those with at least one ACR mucocutaneous criterion (ACR skin feature positive) and those without (ACR skin feature negative) at diagnosis. The relative frequency of skin involvement was described by the paediatric adaptation of the 2004 British Isles Lupus Assessment Group (pBILAG-2004) index. RESULTS One hundred and seventy-nine patients (74%) had ACR-defined skin involvement with no significant demographic differences compared with those without. ACR skin feature negative patients showed greater haematological (84% vs 67%), renal (43% vs 26%) (P < 0.05) and neurological (16% vs 4%) involvement (P = 0.001). Forty-two per cent of ACR skin feature negative patients had skin involvement using pBILAG-2004, which included maculopapular rash (17%), non-scaring alopecia (15%), cutaneous vasculitis (12%) and RP (12%). ACR skin feature negative patients with moderate to severe skin involvement by pBILAG-2004 showed greater renal and haematological involvement at diagnosis and over the follow-up period (P < 0.05). Higher immunosuppressive drug use in the skin feature negative group was demonstrated. CONCLUSION Patients who fulfil the ACR criteria but without any of the mucocutaneous criteria at diagnosis have an increased risk of major organ involvement. The pBILAG-2004 index has shown that other skin lesions may go undetected using the ACR criteria alone, and these lesions show a strong correlation with disease severity and major organ involvement.
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Affiliation(s)
- Direkrit Chiewchengchol
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Ruth Murphy
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Thomas Morgan
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Steven W Edwards
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Valentina Leone
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Mark Friswell
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Clarissa Pilkington
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kjell Tullus
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Satyapal Rangaraj
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Janet E McDonagh
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Janet Gardner-Medwin
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Nick Wilkinson
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Phil Riley
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Jane Tizard
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kate Armon
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Manish D Sinha
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Yiannis Ioannou
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Rebecca Mann
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Kathryn Bailey
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK. Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, Universi
| | - Joyce Davidson
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Eileen M Baildam
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Clare E Pain
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Gavin Cleary
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Liza J McCann
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Michael W Beresford
- Institute of Translational Medicine, Alder Hey Children's NHS Foundation Trust Hospital and Institute of Integrative Biology, University of Liverpool, Liverpool, Department of Dermatology, Queens Medical Centre, Nottingham University Teaching Hospitals, Nottingham, Institute of Integrative Biology, University of Liverpool, Liverpool, Leeds General Infirmary, Leeds Teaching Hospital Trust, Leeds, Great North Children's Hospital Foundation Trust, Newcastle-upon-Tyne, Great Ormond Street Hospital for Children NHS Trust, London, Nottingham Children's Hospital and Nottingham University Hospital NHS Trust, Nottingham, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, School of Medicine, Glasgow University, Glasgow, Children's Hospital, Oxford Radcliffe Hospital NHS Trust, Oxford, Royal Manchester Children's NHS Trust Hospital, Manchester, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, Jenny Lind Children's Hospital, Norfolk and Norwich University Hospital NHS Foundation Trust, Norfolk, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, University College London Hospitals NHS Foundation Trust and Arthritis Research UK Centre for Adolescent Rheumatology, University College London, London, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, University Hospital Coventry and Warwickshire NHS Trust, Coventry, George Eliot Hospital NHS Trust, Nuneaton, Royal Hospital for Sick Children NHS Lothian University Trust, Edinburgh and Royal Hospital for Sick Children NHS Greater Glasgow and Clyde, Glasgow and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.
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Watson L, Tullus K, Pilkington C, Chesters C, Marks SD, Newland P, Jones CA, Beresford MW. Urine biomarkers for monitoring juvenile lupus nephritis: a prospective longitudinal study. Pediatr Nephrol 2014; 29:397-405. [PMID: 24241909 DOI: 10.1007/s00467-013-2668-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 10/12/2013] [Accepted: 10/15/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND In juvenile-onset systemic lupus erythematosus (JSLE), renal involvement (lupus nephritis) is frequently seen and can result in long-term morbidity. This prospective longitudinal study aimed to identify the utility of standard and/or novel biomarkers for monitoring and predicting lupus nephritis in a real world setting. METHODS Using an unselected JSLE cohort, urine samples were collected during routine clinical review. Protein concentrations of urinary monocyte chemo-attractant protein 1 (uMCP1) and neutrophil gelatinase-associated lipocalin (uNGAL) were analysed along with standard disease activity markers, and were compared with current and subsequent disease activity. RESULTS JSLE patients (n = 64; median age 14.1 years) were seen at 3 (interquartile range: 2-5) clinical reviews over 364 (182-532) days. Multivariate analysis demonstrated uMCP1 and serum C3 as independent variables (p < 0.001) for active renal disease at the time of the current review. uMCP1 was an excellent predictor of improved renal disease over time (AUC: 0.81; p = 0.013). uNGAL was a good predictor of worsened renal disease activity (AUC 0.76; p = 0.04) over time. CONCLUSION Biomarkers (uMCP1, serum C3) can indicate current renal involvement in JSLE, whilst uMCP1 and uNGAL are able to predict subsequent renal disease activity changes. Moving towards biomarker-led monitoring may improve the renal outcome for our patients.
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Affiliation(s)
- Louise Watson
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK,
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22
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Abstract
Paediatric-onset systemic lupus erythematosus (SLE) is usually more severe than its adult counterpart. In particular, there is a higher incidence of renal and central nervous system involvement. Specific measures to assess disease activity and damage have been implemented. The disease is very rare before the fifth birthday and therefore the onset of an SLE picture in the first years of life should lead to the suspicion of the presence of one of the rare monogenic diseases that causes SLE or of one of those congenital diseases that has been showed to be closely associated with the SLE.
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Affiliation(s)
- Clara Malattia
- Department of Pediatrics, University of Genoa and Pediatria e Reumatologia, G. Gaslini Institute, Genoa, Italy.
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23
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Ballantine LE, Ong J, Midgley A, Watson L, Flanagan BF, Beresford MW. The pro-inflammatory potential of T cells in juvenile-onset systemic lupus erythematosus. Pediatr Rheumatol Online J 2014; 12:4. [PMID: 24433387 PMCID: PMC3898918 DOI: 10.1186/1546-0096-12-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 12/24/2013] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND T cells are important to systemic lupus erythematosus (SLE) disease progression. This study determined the pro-inflammatory potential of T cells within the rare condition juvenile-onset SLE (JSLE). METHOD IL-17A and Th1/Th2-related cytokine concentrations were measured in plasma/serum from JSLE patients (n = 19, n = 11) and HC (n = 18, n = 7). IL17A, RORC, IL23 and IL23R mRNA were measured in peripheral blood mononuclear cells (PBMCs) from JSLE and healthy controls (HC) (n = 12). Th17-associated cytokine expression was analysed in the supernatant of CD3/CD28 activated JSLE (n = 7) and HC (n = 6) PBMCs. RESULTS JSLE plasma IL-17A level (21.5 ± 5.2 pg/ml) was higher compared to HC (7.2 ± 2.5 pg/ml, p = 0.028). No differences were found in Th1/Th2 cytokines levels. IL = 17A (p = 0.022), IL-6 (p = 0.028) and IL-21 (p = 0.003) concentrations were increased in supernatants from activated JSLE PBMCs. IL-17 F (p = 0.50) and IL-22 (p = 0.43) were also increased but were not statistically significant. IL17A and IL23 mRNA was significantly higher in JSLE PBMCs (p = 0.018 and p = 0.01). CONCLUSION JSLE T cells have an increased ability to secrete Th17 associated cytokines once activated, which could contribute to the pro-inflammatory disease phenotype seen in these patients.
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Affiliation(s)
- Lucy E Ballantine
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children's NHS Foundation Trust Hospital Eaton Road, Liverpool L12 2AP, UK.
| | - Joanne Ong
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital Eaton Road, Liverpool L12 2AP, UK
| | - Angela Midgley
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital Eaton Road, Liverpool L12 2AP, UK
| | - Louise Watson
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital Eaton Road, Liverpool L12 2AP, UK
| | - Brian F Flanagan
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital Eaton Road, Liverpool L12 2AP, UK
| | - Michael W Beresford
- Department of Women’s and Children’s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children’s NHS Foundation Trust Hospital Eaton Road, Liverpool L12 2AP, UK,Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust Hospital Eaton Road, Liverpool L12 2AP, UK
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24
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Nuttall A, Isenberg DA. Assessment of disease activity, damage and quality of life in systemic lupus erythematosus: new aspects. Best Pract Res Clin Rheumatol 2013; 27:309-18. [PMID: 24238688 DOI: 10.1016/j.berh.2013.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multisystem auto-immune disorder that results from a combination of genetic, environmental and hormonal factors. The heterogeneity of disease presentation and course in different individuals and the variability in the disease progression/fluctuations within the same patient have made finding a unifying assessment tool difficult. It is currently accepted that assessment of patients with SLE cannot be accomplished with a single index. Formal evaluation of three aspects of the disease, disease activity, disease damage and patient-related quality of life (QoL), is required. In the recent decade, the pathogenesis of SLE at the cellular and molecular levels has been the subject of much research. Robust assessment tools are needed to correlate the presence of various serological markers with disease activity. In addition, multiple clinical trials of new therapies have necessitated validated measures that can give a sensitive response index. This review focusses on the SLE assessment tools currently in use and their translational application in clinical research and trials.
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Watson L, Leone V, Pilkington C, Tullus K, Rangaraj S, McDonagh JE, Gardner-Medwin J, Wilkinson N, Riley P, Tizard J, Armon K, Sinha MD, Ioannou Y, Archer N, Bailey K, Davidson J, Baildam EM, Cleary G, McCann LJ, Beresford MW. Disease activity, severity, and damage in the UK Juvenile-Onset Systemic Lupus Erythematosus Cohort. ACTA ACUST UNITED AC 2012; 64:2356-65. [PMID: 22294381 DOI: 10.1002/art.34410] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The UK Juvenile-Onset Systemic Lupus Erythematosus (JSLE) Cohort Study is a multicenter collaborative network established with the aim of improving the understanding of juvenile SLE. The present study was undertaken to describe the clinical manifestations and disease course in patients with juvenile SLE from this large, national inception cohort. METHODS Detailed data on clinical phenotype were collected at baseline and at regular clinic reviews and annual followup assessments in 232 patients from 14 centers across the UK over 4.5 years. Patients with SLE were identified according to the American College of Rheumatology (ACR) SLE classification criteria. The present cohort comprised children with juvenile SLE (n=198) whose diagnosis fulfilled ≥4 of the ACR criteria for SLE. RESULTS Among patients with juvenile SLE, the female:male sex distribution was 5.6:1 and the median age at diagnosis was 12.6 years (interquartile range 10.4-14.5 years). Male patients were younger than female patients (P<0.01). Standardized ethnicity data demonstrated a greater risk of juvenile SLE in non-Caucasian UK patients (P<0.05). Scores on the pediatric adaptation of the 2004 British Isles Lupus Assessment Group disease activity index demonstrated significantly increased frequencies of musculoskeletal (82%), renal (80%), hematologic (91%), immunologic (54%), and neurologic (26%) involvement among the patients over time. A large proportion of the patients (93%) were taking steroids and 24% of the patients required treatment with cyclophosphamide. Disease damage was common, with 28% of the patients having a Systemic Lupus International Collaborating Clinics/ACR damage score of ≥1. CONCLUSION The data on these patients from the UK JSLE Cohort Study, comprising one of the largest national inception cohorts of patients with juvenile SLE to date, indicate that severe organ involvement and significant disease activity are primary characteristics in children with juvenile SLE. In addition, accumulation of disease-associated damage could be seen.
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Affiliation(s)
- Louise Watson
- University of Liverpool and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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Rodd C, Lang B, Ramsay T, Alos N, Huber AM, Cabral DA, Scuccimarri R, Miettunen PM, Roth J, Atkinson SA, Couch R, Cummings EA, Dent PB, Ellsworth J, Hay J, Houghton K, Jurencak R, Larché M, LeBlanc C, Oen K, Saint-Cyr C, Stein R, Stephure D, Taback S, Lentle B, Matzinger M, Shenouda N, Moher D, Rauch F, Siminoski K, Ward LM. Incident vertebral fractures among children with rheumatic disorders 12 months after glucocorticoid initiation: a national observational study. Arthritis Care Res (Hoboken) 2012; 64:122-31. [PMID: 22213727 DOI: 10.1002/acr.20589] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the frequency of incident vertebral fractures (IVF) 12 months after glucocorticoid (GC) initiation in children with rheumatic diseases and to identify children at higher risk. METHODS Children with rheumatic diseases initiating GC were enrolled in a prospective observational study. Annual spine radiographs were evaluated using the Genant semiquantitative method. Spine areal bone mineral density (aBMD) was measured every 6 months. Clinical features, including cumulative GC dose, back pain, disease and physical activity, calcium and vitamin D intake, and spine aBMD Z scores, were analyzed for association with IVF. RESULTS Seven (6%) of 118 children (95% confidence interval 2.9-11.7%) had IVF. Their diagnoses were: juvenile dermatomyositis (n = 2), systemic lupus erythematosus (n = 3), systemic vasculitis (n = 1), and mixed connective tissue disease (n = 1). One child was omitted from the analyses after 4 months because of osteoporosis treatment for symptomatic IVF. Children with IVF received on average 50% more GC than those without (P = 0.030), had a greater increase in body mass index (BMI) at 6 months (P = 0.010), and had greater decrements in spine aBMD Z scores in the first 6 months (P = 0.048). Four (67%) of 6 children with IVF and data to 12 months had spine aBMD Z scores less than -2.0 at 12 months compared to 16% of children without IVF (P = 0.011). CONCLUSION The incidence of VF 12 months following GC initiation was 6%; most children were asymptomatic. Children with IVF received more GC, had greater increases in BMI, and had greater declines in spine aBMD Z scores in the first 6 months.
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Affiliation(s)
- Celia Rodd
- McGill University, Montreal, Quebec, Canada
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Watson L, Midgley A, Pilkington C, Tullus K, Marks S, Holt R, Jones C, Beresford M. Urinary monocyte chemoattractant protein 1 and alpha 1 acid glycoprotein as biomarkers of renal disease activity in juvenile-onset systemic lupus erythematosus. Lupus 2011; 21:496-501. [PMID: 22147846 DOI: 10.1177/0961203311431249] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A higher proportion of patients with juvenile-onset systemic lupus erythematosus (JSLE) will have renal involvement compared with adult-onset disease, some progressing to renal failure in adulthood. Histological examination is the gold standard for diagnosing lupus nephritis (LN), but its invasive nature limits routine use. Using cross-sectional cohort analysis, we aimed to determine whether urinary concentrations of monocyte chemoattractant protein-1 (MCP1), alpha-1-acid glycoprotein (AGP) and interferon-inducible protein 10 (IP10) are biomarkers of active LN. Sixty JSLE patients recruited to the UK JSLE Cohort Study were categorized according to the British Isles Lupus Assessment Group (BILAG) activity index. Patients with active renal JSLE (n = 8; renal BILAG score A, B) had significantly higher urinary MCP1 concentrations than patients with inactive renal disease (n = 52; renal BILAG score C, D, E; 582 pg/mg creatinine [Cr], 207 pg/mg Cr; p = 0.018) or healthy controls (n = 23; 117 pg/mg Cr; p = 0.005). Urinary AGP concentration was significantly elevated in patients with active renal disease compared with inactive renal disease (1517 ng/mg Cr, 485 ng/mg Cr; p = 0.027) or healthy controls (313 ng/mg Cr; p = 0.013). Urinary IP10 concentration was not significantly different between groups, but did strongly correlate with uMCP and uAGP levels (rho = 0.38, p = 0.009; rho = 0.33, p = 0.021). Urinary MCP1 and AGP are biomarkers of LN, providing insight into its pathophysiology. Longitudinal studies are warranted.
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Affiliation(s)
- L Watson
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK.
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Lattanzi B, Consolaro A, Solari N, Ruperto N, Martini A, Ravelli A. Measures of disease activity and damage in pediatric systemic lupus erythematosus: British Isles Lupus Assessment Group (BILAG), European Consensus Lupus Activity Measurement (ECLAM), Systemic Lupus Activity Measure (SLAM), Systemic Lupus Erythematosus Di. Arthritis Care Res (Hoboken) 2011; 63 Suppl 11:S112-7. [DOI: 10.1002/acr.20623] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Hung WT, Chen YM, Lan JL, Chen HH, Chen YH, Chen DY, Hsieh CW, Wen MC. Antinucleosome antibodies as a potential biomarker for the evaluation of renal pathological activity in patients with proliferative lupus nephritis. Lupus 2011; 20:1404-1410. [DOI: 10.1177/0961203311417033] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The objective of this study is to evaluate the correlation between antinucleosome antibodies and renal pathological activity in patients with proliferative lupus nephritis (LN). We evaluated 36 patients with proliferative LN, 14 non-renal lupus patients and 10 healthy volunteers. Lupus activity was assessed using the British Isles Lupus Assessment Group 2004 (BILAG 2004) index, serum anti-double stranded DNA (anti-dsDNA) levels, serum complement levels and daily urinary protein levels. All 36 lupus nephritis patients received renal biopsy. Antinucleosome antibodies were detected by enzyme-linked immunosorbent assay (ELISA). Our results showed that levels of serum antinucleosome antibodies were significantly higher in LN patients (median 90.35 units/ml, interquartile range [IQR] 37.38–135.23) than in non-renal SLE patients (median 5.45 units/ml, IQR 2.6–28.93, p <0.05) and in healthy volunteers (median 3.35 units/ml, IQR 2.95–5.23, p <0.001). Serum levels of antinucleosome antibodies were positively correlated with BILAG index (Spearman’s r = 0.645, p <0.001) and serum anti-dsDNA antibody levels ( rs = 0.644, p <0.01), while serum levels of antinucleosome antibodies were negatively correlated with serum levels of C3 ( rs = -0.400, p <0.01) and C4 ( rs = -0.300, p <0.05). Serum levels of antinucleosome antibodies were positively correlated with the histological activity index of LN ( rs = 0.368, p <0.05). However, there was no significant correlation between serum levels of antinucleosome antibodies and the histological chronicity index. In conclusion, the serum level of antinucleosome antibodies is a potential biomarker for early recognition of renal involvement and evaluation of disease activity in SLE. Our preliminary results suggested that serum levels of antinucleosome antibodies might be a potential biomarker in evaluating pathological activity of LN.
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Affiliation(s)
- WT Hung
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taiwan
| | - YM Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taiwan
| | - JL Lan
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taiwan
- Institute of Biomedical Science, National Chung-Hsing University, Taiwan
| | - HH Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taiwan
| | - YH Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taiwan
| | - DY Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taiwan
- Institute of Biomedical Science, National Chung-Hsing University, Taiwan
- School of Medicine, Chung-Shan Medical University, Taiwan
| | - CW Hsieh
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taiwan
- School of Medicine, Chung-Shan Medical University, Taiwan
| | - MC Wen
- Department of Pathology, Taichung Veterans General Hospital, Taiwan
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Abstract
UNLABELLED There is still a significant morbidity and mortality associated with childhood-onset systemic lupus erythematosus (SLE), despite an increasing armamentarium of immunosuppressive agents. The ideal therapeutic strategy for children and adolescents with SLE should provide the right amount of treatment to allow normal growth, development and fertility while reducing the disease activity and damage that can be accrued over the years. Each patient should have individualized treatments tailored to their organ involvement, disease severity and history of flares together with recent clinical, haematological and immunological parameters to avoid further flares of disease activity and side-effects of treatment, especially severe infections and future malignancies. The most commonly cited side-effects of medications include Cushingoid features of corticosteroids, infective complications of cyclophosphamide and gastrointestinal side-effects of mycophenolate mofetil. There is increasing evidence to support the use of oral mycophenolate mofetil as opposed to cyclophosphamide for both induction and maintenance therapies in many children with SLE with or without lupus nephritis (LN). Recently, case series utilizing B-lymphocyte depletion therapies with rituximab look promising for patients with severe or refractory disease activity. In this article, we explore current evidence to effectively treat children and adolescents with SLE with or without LN. CONCLUSION Modern therapeutic strategies include reduced doses and use of corticosteroids and intravenous cyclophosphamide respectively, with increased use of azathioprine, MMF and rituximab.
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Affiliation(s)
- Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Trust, London, UK.
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Huber AM, Gaboury I, Cabral DA, Lang B, Ni A, Stephure D, Taback S, Dent P, Ellsworth J, LeBlanc C, Saint-Cyr C, Scuccimarri R, Hay J, Lentle B, Matzinger M, Shenouda N, Moher D, Rauch F, Siminoski K, Ward LM. Prevalent vertebral fractures among children initiating glucocorticoid therapy for the treatment of rheumatic disorders. Arthritis Care Res (Hoboken) 2010; 62:516-26. [PMID: 20391507 DOI: 10.1002/acr.20171] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Vertebral fractures are an under-recognized problem in children with inflammatory disorders. We studied spine health among 134 children (87 girls) with rheumatic conditions (median age 10 years) within 30 days of initiating glucocorticoid therapy. METHODS Children were categorized as follows: juvenile dermatomyositis (n = 30), juvenile idiopathic arthritis (n = 28), systemic lupus erythematosus and related conditions (n = 26), systemic arthritis (n = 22), systemic vasculitis (n = 16), and other conditions (n = 12). Thoracolumbar spine radiograph and dual x-ray absorptiometry for lumbar spine (L-spine) areal bone mineral density (BMD) were performed within 30 days of glucocorticoid initiation. Genant semiquantitative grading was used for vertebral morphometry. Second metacarpal morphometry was carried out on a hand radiograph. Clinical factors including disease and physical activity, calcium and vitamin D intake, cumulative glucocorticoid dose, underlying diagnosis, L-spine BMD Z score, and back pain were analyzed for association with vertebral fracture. RESULTS Thirteen vertebral fractures were noted in 9 children (7%). Of these, 6 patients had a single vertebral fracture and 3 had 2-3 fractures. Fractures were clustered in the mid-thoracic region (69%). Three vertebral fractures (23%) were moderate (grade 2); the others were mild (grade 1). For the entire cohort, mean +/- SD L-spine BMD Z score was significantly different from zero (-0.55 +/- 1.2, P < 0.001) despite a mean height Z score that was similar to the healthy average (0.02 +/- 1.0, P = 0.825). Back pain was highly associated with increased odds for fracture (odds ratio 10.6 [95% confidence interval 2.1-53.8], P = 0.004). CONCLUSION In pediatric rheumatic conditions, vertebral fractures can be present prior to prolonged glucocorticoid exposure.
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Affiliation(s)
- A M Huber
- Dalhousie University, Halifax, Nova Scotia, Canada
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Wittmann L, Sensky T, Meder L, Michel B, Stoll T, Büchi S. Suffering and Posttraumatic Growth in Women With Systemic Lupus Erythematosus (SLE): A Qualitative/Quantitative Case Study. PSYCHOSOMATICS 2009; 50:362-74. [DOI: 10.1176/appi.psy.50.4.362] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Marks SD, Tullus K, Sebire NJ. Current issues in pediatric lupus nephritis: role of revised histopathological classification. Fetal Pediatr Pathol 2006; 25:297-309. [PMID: 17696041 DOI: 10.1080/15513810701209512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Childhood-onset systemic lupus erythematosus (SLE) has an unpredictable natural history with variable clinical manifestations. The prognosis of SLE is linked closely to renal involvement with lupus nephritis (LN), which is more severe in patients with childhood-onset compared with adult-onset disease. The histopathological classification of LN facilitates treatment decisions, protocols, and clinical research. After the World Health Organization and modified WHO classifications of LN from 1974 to 1995, the International Society of Nephrology and Renal Pathology Society Working Group revised the histopathological classification of LN. The reclassification was published in 2004 after their consensus conference held at Columbia University in New York in May 2002. The aims of the reclassification were to standardize definitions, emphasize clinically relevant lesions, and encourage uniform and reproducible reporting among centers. Although the revised classification is time-consuming, it is important for future international collaboration on multicenter trials of disease-modifying agents. The prognosis of SLE and LN is linked to the histopathology of the renal lesion, but the clinical manifestations of LN, including nephrotic syndrome and hypertension, cannot predict the degree of renal involvement. However, we are many years away from completely understanding the etiopathogenesis of LN and the predictive role of the revised histological classification for direction of patient management.
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Abstract
Adolescence is a time of profound biological and psychosocial change. The management of a complex chronic condition such as systemic lupus erythematosus (SLE) during this period is a challenging but rewarding task for the clinician. Early diagnosis and optimal disease control is essential in order to facilitate normal adolescent development and minimize long-term disease sequelae. Current treatment regimens are associated with significant toxicity in young people, and there is a need for new, less toxic regimens. There are currently no controlled therapeutic studies in adolescents with SLE. Those involved in the care of these young people must ensure that they have appropriate access to specialist medical services while ensuring that their specific needs as adolescents in the health-care system are addressed.
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Affiliation(s)
- Michael W Beresford
- Department of Rheumatology, Royal Liverpool Children's Hospital, Liverpool L1 2 2AP, UK
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Marks SD, Patey S, Brogan PA, Hasson N, Pilkington C, Woo P, Tullus K. B lymphocyte depletion therapy in children with refractory systemic lupus erythematosus. ACTA ACUST UNITED AC 2005; 52:3168-74. [PMID: 16200620 DOI: 10.1002/art.21351] [Citation(s) in RCA: 122] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the safety and efficacy of B lymphocyte depletion therapy in patients with refractory childhood-onset systemic lupus erythematosus (SLE). METHODS Seven patients (4 of whom were female), ages 7.7-16.1 years (median 14.8 years) with active SLE that was resistant to standard immunosuppressive agents were treated with B cell depletion. During a 2-week period, patients received two 750-mg/m2 intravenous infusions of rituximab, with intravenous cyclophosphamide (if they had not previously received this treatment) and high-dose oral corticosteroids. RESULTS Patients were followed up for a median of 1.0 years, and no serious adverse effects were noted. In all patients, the clinical symptoms and signs for which rituximab therapy was initiated were improved. There was significant improvement in the British Isles Lupus Assessment Group global scores, from a median score of 22 (range 14-37) at baseline to a median score of 6 (range 4-11) at followup (P = 0.002). In 2 patients with severe multisystem and life-threatening disease unresponsive to standard therapy (including plasma exchange), renal replacement therapy was successfully withdrawn following B cell depletion therapy. These 2 patients have subsequently shown further significant improvement in renal function and proteinuria. CONCLUSION This open-label study demonstrates that targeted B cell depletion therapy can be a safe and efficacious addition to therapy with standard immunosuppressive agents in patients with refractory childhood SLE. The drugs used for treatment of childhood SLE need to be the most effective, least toxic agents, allowing normal growth and development.
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Affiliation(s)
- Stephen D Marks
- Department of Paediatric Nephrology, Institute of Child Health and Great Ormond Street Hospital for Children NHS Trust, London, UK.
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