Low-dose corticosteroid with mizoribine might be an effective therapy for elderly-onset ISKDC grade VI IgA vasculitis

Both the diagnosis of elderly-onset IgA vasculitis (IgAV) and its prognosis can be difficult because of its rarity and the likely presence of comorbidities. Furthermore, the treatment of elderly-onset IgAV remains controversial: the ideal dosages of corticosteroid and/or immunosuppressants have not been determined. In the elderly, corticosteroid adverse effects can lead to severe outcomes, and a consensus regarding its benefit and risk balance has not been reached. We report a case of IgAV in an 89-year-old patient who was admitted to our hospital to investigate a 30-day history of palpable purpura and pitting edema on her leg. A renal biopsy showed membranoproliferative glomerulonephritis with IgA deposits (The International Study of Kidney Disease in Children (ISKDC) grade VI), which is a predictor of a poor prognosis; these findings led to early intervention with low-dose corticosteroid (15 mg/day) and mizoribine. As a result, a complete remission without obvious adverse effects was obtained. Early intervention with low-dose corticosteroid and mizoribine based on renal histopathology results might be an effective treatment for elderly-onset ISKDC grade VI IgAV.

Henoch-Schönlein Purpura Nephritis in Children: Prognosis and Treatment Experiences

Henoch-Schönlein purpura is a type of systemic small vessel vasculitis. The dominant manifestation is the cutaneous component, the illness is self-limiting in nature, and the prognosis and outcome depend mostly on renal manifestations. We analysed the associations among clinical and laboratory parameters with the prognosis and outcome of HSP in children hospitalised at the Paediatrics clinic, Clinical Centre, Kragujevac between January 2011 and January 2012. Children who developed nephritis were older on average and all manifested with arthritis, abdominal complaints, microhaematuria, elevated D-dimer levels in the serum, and significant proteinuria and microalbuminuria (≥ 300 mg/L), and two children had pre-existing allergic conditions. All three children with repeatedly positive proteins in the morning sample urine test had significant proteinuria (≥0,5 g/24 h) and microalbuminuria (≥ 300 mg/L). These children had more bursts of rash and more severe and lasting abdominal pain and arthritis compared to children with normal urine tests. They were therefore treated with glucocorticoids and an angiotensin-converting enzyme inhibitor. The glomerular filtration rate measured by determining creatinine clearance was normal in all patients. These patients were diagnosed with Henoch-Schönlein purpura nephritis, and their condition was regularly monitored. Analysis of this group of patients demonstrated that the average age of 8 years and abdominal complaints were indicative of nephritis development.. Because both of these parameters are easily noted at disease onset, we suggest careful monitoring of disease course in these children.

Evolution of IgA nephropathy into anaphylactoid purpura in six cases--further evidence that IgA nephropathy and Henoch-Schonlein purpura nephritis share common pathogenesis

BACKGROUND

As the morphological and immunohistochemical manifestations of immunoglobulin A (IgA) nephropathy and Henoch-Schonlein purpura nephritis (HSPN) are very similar, they are considered to share a common pathogenesis. Although HSPN usually develops after the appearance of anaphylactoid purpura, we have encountered patients whose renal symptoms preceded purpura.

METHODS

We reviewed the clinical courses of patients who were first diagnosed with IgA nephropathy, but developed purpura later, at the National Center for Child Health and Development in Tokyo, Japan.

RESULTS

Of the 53 patients who were diagnosed with primary IgA nephropathy at our institute during the study period (March 2002 to July 2015), six (11 %) developed anaphylactoid purpura after the diagnosis of primary IgA nephropathy and therefore met the inclusion criteria. Duration between the onset of nephritis and subsequent appearance of purpura ranged from 5 months to 14 years. One patient reached end-stage renal failure due to IgA nephropathy and developed purpura after renal transplantation. All renal biopsies performed before the appearance of purpura showed mesangial proliferation with predominant IgA deposits. Urinary findings deteriorated in three patients after the appearance of purpura, including one patient who developed rapidly progressive glomerulonephritis. Renal biopsy findings worsened in two patients. At the last observation, two patients showed mild renal insufficiency.

CONCLUSIONS

Our clinical experience and previous reports support the argument that IgA nephropathy and HSPN are different manifestations of a single disease. Hence, it is acceptable to consider that they are variants of a single disease.

Pulmonary hemorrhage associated with Henoch-Schöenlein purpura in an adult patient primary diagnosed of IgA nephropathy

We describe a case of IgA nephropathy (IgAN) followed by pulmonary hemorrhage associated with Henoch-Schöenlein purpura (HSP) in an adult female. The patient had a history of renal insufficiency and persistent hematuria and proteinuria, without any extra-renal involvement. She was diagnosed with IgAN 7 years before the onset of HSP and had received immunosuppressive therapy for 6 years. One year after discontinuing oral prednisolone and mizoribine, she suffered a pulmonary hemorrhage. She presented with exacerbated urinary findings, and palpable purpura, resulting in the diagnosis of HSP. Intravenous pulse methylprednisolone followed by oral prednisolone (1 mg/kg/day) and a monthly intravenous cyclophosphamide pulse resolved the pulmonary hemorrhage. In a review of 36 HSP patients complicated with pulmonary hemorrhage, 27.8 % of the patients perished [Rajagopala et al., Semin Arthritis Rheum 42:391-400, 1]. While the most efficient therapeutic strategies for these patients have yet to be determined, we speculate that an aggressive therapy of pulse methylprednisolone combined with immunosuppression agents is likely to bring about the best outcome in cases with pathological conditions similar to our patient's. On the other hand, discontinuance of immunosuppressive therapy might have resulted in the aggravation of the disease, hence we should examine patients carefully not to miss the cue.

IgA Cutaneous Purpura Post-Renal Transplantation in a Patient With Long-Standing IgA Nephropathy: Case Report and Literature Review

BACKGROUND

IgA vasculitis is a small-vessel vasculitis caused by deposition of IgA antibodies in tissues. IgA nephropathy and IgAV have long been considered related conditions.

OBJECTIVE

To assess the prevalence and implications of new-onset Henoch-Schönlein purpura (HSP) after renal transplant in patients with underlying IgA nephropathy.

METHODS

The PubMed database was searched for keywords such as IgAV, IgA vasculitis, Henoch-Schönlein purpura, HSP, IgA nephropathy, and renal transplant.

RESULTS

Two cases of new-onset IgA vasculitis post-renal transplant after stopping the prednisone or receiving seasonal influenza vaccine have been reported. We report the case of new-onset IgA cutaneous vasculitis in a renal transplant patient with IgA nephropathy after reduction in his prednisone dosage.

CONCLUSION

The new development of cutaneous IgA vasculitis is unusual in renal transplant patients with IgA nephropathy. Despite these patients' being immunosuppressed, the presence of IgA vasculitis could signal the recurrence of IgA nephropathy.