Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Gathering expert consensus to inform a proposed trial in chronic nonbacterial osteomyelitis (CNO)

Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disease that primarily affects children and adolescents. CNO is associated with pain, bone swelling, deformity, and fractures. Its pathophysiology is characterized by increased inflammasome assembly and imbalanced expression of cytokines. Treatment is currently based on personal experience, case series and resulting expert recommendations. Randomized controlled trials (RCTs) have not been initiated because of the rarity of CNO, expired patent protection of some medications, and the absence of agreed outcome measures. An international group of fourteen CNO experts and two patient/parent representatives was assembled to generate consensus to inform and conduct future RCTs. The exercise delivered consensus inclusion and exclusion criteria, patent protected (excludes TNF inhibitors) treatments of immediate interest (biological DMARDs targeting IL-1 and IL-17), primary (improvement of pain; physician global assessment) and secondary endpoints (improved MRI; improved PedCNO score which includes physician and patient global scores) for future RCTs in CNO.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

POS1257 READING THE WAVES: IDENTIFYING DISTINCT PHENOTYPES OF MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN IN A SINGLE CANADIAN CENTER DURING THE 2020-2021 COVID-19 PANDEMIC

Background

The COVID-19-associated multisystem inflammatory syndrome in children (MIS-C) is characterized by Kawasaki disease (KD)-like features and circulatory shock [1]. The genesis of SARS-CoV-2 variants triggered successive waves of mass infections followed by MIS-C outbreaks.

Objectives

To compare MIS-C phenotypes across the waves of the COVID-19 pandemic. To identify predictors of pediatric intensive care unit (PICU) admission and treatment with biologic agents.

Methods

Youth aged 0-18 years, fulfilling the WHO case definition of MIS-C, and admitted to the Alberta Children’s Hospital during the COVID-19 pandemic (May 2020-December 2021) were included. Clinical, laboratory, imaging, and treatment data were captured (KD-like manifestations, signs of shock and/or hypotension, peak C-reactive protein (CRP) and ferritin, platelet count nadir, peak NT-proBNP and troponin, liver enzyme abnormalities, sodium and albumin nadir, echocardiogram findings, biologic agents).

Results

57 consecutive MIS-C patients (median age 6 years, IQR 4-6; 72% males) were included. 31 patients (54%) required PICU admission. All received immunoglobulins, 44 (77%) received corticosteroids, 8 patients (14%) were treated with biologic agents. Patients presenting during the third (mainly driven by Alpha variant) or fourth wave (mainly driven by Delta variant) presented with higher ferritin and NT-proBNP levels, and more liver enzyme abnormalities, hypoalbuminemia and thrombocytopenia compared to those presenting during the first or second wave (Table 1, Figure 1). PICU admission was associated with the presence of shock/hypotension, higher CRP, ferritin, and NT-proBNP levels, lower albumin levels, and the presence of ventricular dysfunction on echocardiogram (Table 1). A logistic regression model combining peak NT-proBNP, troponin and ferritin levels explained 70% (Nagelkerke R2) of the variance in PICU admission and correctly classified 91% of the cases. NT-proBNP was the sole significant contributor (p=0.017). Treatment with biologic agents was associated with higher CRP (mean 148.8 mg/l versus 251.7 mg/l; p=0.024) and ferritin (797 μg/l versus 1280 μg/l; p=0.049) levels.

Table 1.

Upper panel: Differences in MIS-C features of patients presenting during the first phase of the COVID-19 pandemic (first + second wave) compared to those presenting during the second phase (third + fourth wave) (*one missing value). Lower panel: Differences regarding MIS-C features between patients admitted to PICU compared to those managed on the general ward.

Phase 1(n = 31)Phase 2(n = 26)P-valuePeak ferritin, μg/l (mean, SD)548 (529)1129 (724)<0.001Liver enzyme abnormalities (n, %)10 (32)18 (69)0.008Peak NT-proBNP, ng/l (mean, SD)5250 (4721)13366 (11211)0.012Hypoalbuminemia (n, %)24 (80)*25 (100)*0.027Thrombocytopenia (n, %)11 (35)18 (69)0.017PICUNo(n = 26)Yes(n = 31)P-valueShock/hypotension (n, %)19 (73)31 (100)0.002Peak CRP, mg/l (mean, SD)140.7 (92)203.8 (84)0.008Peak ferritin, μg/l (mean, SD)612 (676)1183 (627)0.002Peak NT-proBNP, ng/l (mean, SD)3772 (5074)15584 (9662)<0.001Albumin nadir, g/l (mean, SD)24 (4)19 (3)0.014Ventricular dysfunction (n, %)2 (8)18 (58)<0.001Figure 1.

Violin plots depicting differences in key laboratory MIS-C features between the waves (A) and both phases (phase 1 = wave 1 + 2, phase 2 = wave 3 + 4; B) of the COVID-19 pandemic.

Conclusion

A shift in MIS-C phenotype was identified across the successive COVID-19 waves, including the predominance of features associated with macrophage activation syndrome in later stages. These findings may reflect the impact of distinct SARS-CoV-2 variants. NT-proBNP emerged as the most important MIS-C feature predicting PICU admission, underscoring the importance of monitoring.

References

[1]Riphagen S, Gomez X, Gonzalez-Martinez C, et al. Hyperinflammatory shock in children during COVID-19 pandemic. Lancet 2020;395(10237):1607–8

Disclosure of Interests

None declared

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

Surveillance of Periodic Fever Syndromes in Canada

BACKGROUND: Periodic fever syndromes (PFS) represent a group of rare, inflammatory disorders, which have their onset in childhood, and are associated with significant lifelong morbidity, and at times, increased mortality. The majority of affected children have recurrent, self-limited inflammatory episodes with unprovoked fever. The severe inflammatory state during an attack causes signs and symptoms in one or more organ systems. The Canadian Pediatric Surveillance Program (CPSP) studies relevant conditions of public health importance that are of such low incidence or prevalence that national ascertainment of cases are needed. Conditions that are studied share a high disability, morbidity and economic costs to society, despite the low frequency. More than 2400 pediatricians including relevant subspecialists, have been enrolled as CPSP participants. This program provides an ideal mechanism for surveillance of PFS in Canada.

OBJECTIVES: To estimate the incidence of periodic fever syndromes in the Canadian paediatric population, to describe the patterns of presentation, and to raise awareness in the medical community.

DESIGN/METHODS: This study was initiated through the Canadian Paediatric Surveillance Program (CPSP), and was carried out over a three year period ending in September 2014. The case definition included patients less than 18 years of age presenting with a newly diagnosed periodic fever syndrome (PFS). Conditions under surveillance included Familial Mediterranean fever (FMF), Tumor necrosis factor receptor-associated periodic syndrome (TRAPS), Hyperimmunoglobulin D syndrome (HIDS), cryopyrin-associated periodic syndromes (CAPS), Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), and Undefined periodic fever syndromes. The study protocol outlined established clinical and/or genetic criteria for diagnosis. Participating pediatricians and pediat-ric subspecialists across the country were sent monthly reporting forms. Detailed questionnaires were completed by physicians who report a recent diagnosis. Submissions were screened for accuracy and confirmed cases then entered into a database.

RESULTS: Between September 2011 and August 2014 a total of 221 cases of PFS were reported. Detailed questionnaires were completed on 194 (88%), from which 13 were excluded. Of the 181 confirmed cases, 85 (47%) were PFAPA, 72 (40%) were undefined PFS, 17 (10%) were FMF, and the remaining 6 cases were CAPS, TRAPS, and HIDS. The mean age at diagnosis was 5.5 years (range 12 months – 16 years). On average symptom onset occurred 2.5 years before diagnosis (range 1-4 years). The majority of reporting physicians were rheumatologists (58%), and paediatricians (36%). Cases were identified in all provinces across Canada with the majority (103, 57%) from Ontario. For the 72 undefined PFS cases the reporting physicians described 36% as PFAPA-like, 10% FMF-like, 5% HIDS-like, 3% CAPS-like, and 1% TRAPS-like. Such cases had features of the specified PFS but either did not meet the full criteria, or confirmatory tests were not available at the time of reporting. Among all cases reported in the study, 58% had genetic testing completed as part of their diagnosis. The majority of cases without any genetic testing had been diagnosed as PFAPA.

CONCLUSION: Periodic fever syndromes represent rare forms of autoin-flammatory disease, which affect many Canadian children. This CPSP study identified that the most common PFS diagnosed was PFAPA followed by undefined PFS and FMF. CAPS, HIDS, and TRAPS were rarely diagnosed. Children with PFS were seen by multiple physicians over an average of two to three years before a diagnosis was made. It is hoped that increased awareness of these rare conditions will facilitate earlier diagnosis and the initiation of effective treatments for these children.