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Nefrotik Düzey Proteinüri ile Başvurunun Çocukluk Çağı Iga Vasküliti Nefriti Seyrine Etkileri

Yıl 2023, Cilt: 45 Sayı: 4, 581 - 589, 20.07.2023
https://doi.org/10.20515/otd.1297048

Öz

İmmünglobulin A vasküliti (IgAV) palpabl purpura’ya ek olarak karın ağrısı, artrit, hematüri ve/veya proteinüri, IgA baskın depolanma gösteren doku biyopsisi kriterlerinden en az birisinin birlikteliği ile tanısı konulan bir küçük damar vaskülitidir. Bu hastalarda %30-50 oranlarında değişken prezentasyonlarla böbrek tutulumu görülebilmektedir. IgAV nefritinde (IgAVN) proteinüri renal prognoz hakkında fikir vericidir. Bu çalışmada çocukluk çağı IgAVN’de proteinüri miktarının klinikopatolojik özellikler ve renal sağkalım ile ilişkisini değerlendirmek amaçlanmıştır. Çalışmaya Ocak 2005-Aralık 2021 tarihleri arasında biyopsi ile IgAVN tanısı kesinleştirilmiş 48 çocuk hasta dahil edildi. Hastaların başvuru, 3.ay, 6.ay, 12. ay ve son başvuru dönemlerine ait klinik, laboratuvar ve patolojik bulgular, aldıkları tedaviler kaydedildi. Başvuru proteinüri miktarlarına göre hastalar nefrotik düzeyde olan ve olmayan olarak iki gruba ayrıldı. Renal sağkalım için Meadow sınıflaması kullanıldı. Hastaların ortanca tanı yaşı 8 (6-12), erkek/kız oranı 1.1 idi. Nefrotik düzey proteinürisi olan 34 hasta mevcuttu, bu hastalarda IgAV tanısından böbrek tutulumuna ve renal semptom başlangıcından biyopsi yapılmasına kadar geçen süre daha kısa (p=0.027), başvuru eGFR değerleri daha yüksekti (p=0.021). Nefrotik düzey proteinürisi olan hastaların biyopsilerinde kresent yüzdesi (p=0.036), klinikte steroide ek immunsupresif kullanımı daha fazla (p=0.011), remisyona girme süresi anlamlı olarak daha uzundu (p=0.016) ancak proteinürisi nefrotik düzeyde olan ve olmayanların renal sağkalım oranlarında anlamlı fark bulunmadı (p=0.469). Sonuç olarak, IgAVN’de proteinüri önemli bir bulgudur ve proteinürinin miktarı arttıkça böbrek hasarına katkısı artar. Daha ağır biyopsi bulguları, yoğun immunosupresif tedavi ihtiyacı ve uzamış remisyona girme süreleri göz önüne alındığında IgAV hastalarında düzenli aralıklarla idrarda protein taraması yapmak, erken tedavi başlanarak olası komplikasyonların önüne geçmek açısından önemlidir.

Kaynakça

  • Ozen S, Pistorio A, Iusan S, Bakkaloglu A, Herlin T, Brik R, et al. Paediatric Rheumatology International Trials organisation (PRINTo). EUlAR/PRINTo/PRES criteria for Henoch-Schönlein purpura, childhood pol yarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008.Part II: final classification criteria. Ann Rheum Dis. 2008;2010:798-806.
  • 2. Gardner-Medwin JM, Dolezalova P, Cummins C, Southwood TR. Incidence of Henoch-Schonlein purpura, Kawasaki disease, and rare vasculitides in children of different ethnic origins. The Lancet. 2002;360:1197-202.
  • 3. Narchi H. Risk of long term renal impairment and duration of follow up recommended for Henoch-Schönlein purpura with normal or minimal urinary findings: a systematic review. Archives of disease in childhood. 2005;90:916-20.
  • 4. Kurt-Şükür ED, Sekar T, Tullus K. Biopsy-proven Henoch-Schönlein purpura nephritis: a single center experience. Pediatric Nephrology. 2021;36:1207-15.
  • 5. Oni L, Gritzfeld JF, Jones C, Sinha MD, Wallace D, Stack M, et al. Comment on: European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis—the SHARE initiative. Rheumatology. 2021;60:e179-e80.
  • 6. Koskimies O, Mir S, Rapola J, Vilska J. Henoch-Schönlein nephritis: long-term prognosis of unselected patients. Archives of disease in childhood. 1981;56:482-4.
  • 7. Goldstein AR, White RH, Akuse R, Chantler C. Long-term follow-up of childhood Henoch-Schönlein nephritis. The Lancet. 1992;339:280-2.
  • 8. Bogdanović R. Henoch‐Schönlein purpura nephritis in children: risk factors, prevention and treatment. Acta Paediatrica. 2009;98:1882-9.
  • 9. Butani L, Morgenstern BZ. Long-term outcome in children after Henoch-Schönlein purpura nephritis. Clinical pediatrics. 2007;46:505-11.
  • 10. Jafar TH, Stark PC, Schmid CH, Landa M, Maschio G, Marcantoni C, de Jong PE, de Zeeuw D, Shahinfar S, Ruggenenti P, Remuzzi G, Levey AS; AIPRD Study Group. Angiotensin-Converting Enzymne Inhibition and Progression of Renal Disease. Proteinuria as a modifiable risk factor for the progression of non-diabetic renal disease. Kidney Int. 2001 Sep;60:1131-40.
  • 11. Schwartz G, Haycock G, Edelmann Jr C, Spitzer A. A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics. 1976;58:259-63.
  • 12. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. Journal of hypertension. 2016;34:1887-920.
  • 13. Vehaskari VM, Rapola J, Koskimies O, Savilahti E, Vilska J, Hallman N. Microscopic hematuria in schoolchildren: epidemiology and clinicopathologic evaluation. The Journal of pediatrics. 1979;95:676-84.
  • 14. Rodrigues JC, Haas M, HN R. IgA Nephropathy. Clinical journal of the American Society of Nephrology: CJASN. 2017;12:677-86.
  • 15. Meadow S, Glasgow E, White R, Moncrieff M, Cameron J, Ogg C. Schönlein—henoch nephritis. QJM: An International Journal of Medicine. 1972;41:241-60.
  • 16. Hastings MC, Rizk DV, Kiryluk K, Nelson R, Zahr RS, Novak J, et al. IgA vasculitis with nephritis: update of pathogenesis with clinical implications. Pediatric Nephrology. 2021:1-15.
  • 17. Topaloglu R, Sungur A, Baskin E, Besbas N, Saatci U, Bakkaloglu A. Vascular endothelial growth factor in Henoch-Schonlein purpura. The Journal of Rheumatology. 2001;28:2269-73.
  • 18. Ozaltin F, Besbas N, Uckan D, Tuncer M, Topaloglu R, Ozen S, et al. The role of apoptosis in childhood Henoch–Schonlein purpura. Clinical rheumatology. 2003;22:265-7.
  • 19. Feng D, Huang WY, Hao S, Niu XL, Wang P, Wu Y, Zhu GH. A single-center analysis of Henoch-Schonlein purpura nephritis with nephrotic proteinuria in children. Pediatr Rheumatol Online J. 2017; 4:15:15.
  • 20. Du Y, Hou L, Zhao C, Han M, Wu Y. Treatment of children with Henoch-Schönlein purpura nephritis with mycophenolate mofetil. Pediatr Nephrol. 2012;27:765-71.
  • 21. Mir S, Yavascan O, Mutlubas F, Yeniay B, Sonmez F. Clinical outcome in children with Henoch-Schönlein nephritis. Pediatric nephrology. 2007;22:64-70.
  • 22. Hennies I, Gimpel C, Gellermann J, Möller K, Mayer B, Dittrich K, et al. Presentation of pediatric Henoch–Schönlein purpura nephritis changes with age and renal histology depends on biopsy timing. Pediatric Nephrology. 2018;33:277-86.
  • 23. Delbet JD, Geslain G, Auger M, Hogan J, Salomon R, Peuchmaur M, Deschênes G, Buob D, Parmentier C, Ulinski T. Histological prognostic factors in children with Henoch-Schönlein purpura nephritis. Pediatr Nephrol. 2020 Feb;35:313-320.
  • 24. Nickavar A, Mehrazma M, Lahouti A. Clinicopathologic correlations in Henoch-Schonlein nephritis. Iran J Kidney Dis. 2012 Nov;6:437-40.
  • 25. Davin JC, Coppo R. Pitfalls in recommending evidence-based guidelines for a protean disease like Henoch-Schönlein purpura nephritis. Pediatr Nephrol. 2013 ;28:1897-903.
  • 26. Floege J, Feehally J. Treatment of IgA nephropathy and Henoch-Schönlein nephritis. Nat Rev Nephrol. 2013;9:320-7.
  • 27. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int Suppl. 2021;VOLUME 100( ISSUE 4S):126-27
  • 28. Coppo R, Mazzucco G, Cagnoli L, Lupo A, Schena FP. Long-term prognosis of Henoch-Schönlein nephritis in adults and children. Italian Group of Renal Immunopathology Collaborative Study on Henoch-Schönlein purpura. Nephrol Dial Transplant. 1997 ;12:2277-83.
  • 29. Ronkainen J, Ala-Houhala M, Huttunen NP, Jahnukainen T, Koskimies O, Ormälä T, Nuutinen M. Outcome of Henoch-Schoenlein nephritis with nephrotic-range proteinuria. Clin Nephrol. 2003 ;60:80-4.
  • 30. Gjerstad AC, Skrunes R, Tøndel C, Åsberg A, Leh S, Klingenberg C, et al. Kidney biopsy diagnosis in childhood in the Norwegian Kidney Biopsy Registry and the long-term risk of kidney replacement therapy: a 25-year follow-up. Pediatric Nephrology. 2022:1-8.
  • 31. Çakıcı EK, Gür G, Yazılıtaş F, Eroğlu FK, Güngör T, Arda N, et al. A retrospective analysis of children with Henoch–Schonlein purpura and re-evaluation of renal pathologies using Oxford classification. Clinical and Experimental Nephrology. 2019;23:939-47.
  • 32. Counahan R, Winterborn M, White R, Heaton J, Meadow S, Bluett N, et al. Prognosis of Henoch-Schönlein nephritis in children. Br Med J. 1977;2:11-4.

Effects of Presentation with Nephrotic Range Proteinuria on Childhood Iga Vasculitis Nephritis

Yıl 2023, Cilt: 45 Sayı: 4, 581 - 589, 20.07.2023
https://doi.org/10.20515/otd.1297048

Öz

Immunoglobulin A vasculitis (IgAV) is a small vessel vasculitis diagnosed by palpable purpura with at least one of following criteria; abdominal pain, arthritis, hematuria and/or proteinuria,IgA-predominant deposition in tissue samples. Renal involvement can be seen in 30-50% of the patients. Proteinuria in IgAV nephritis (IgAVN) is predictive of renal prognosis. In this study, we aimed to evaluate the relationship between the degree of proteinuria and clinicopathological features, renal survival in childhood IgAVN. Forty-eight patients with biopsy confirmed IgAVN between January 2005 and December 2021 were included in the study. Clinical, laboratory and pathological findings at admission, 3rd, 6th, 12th months and last visit, treatments they received were recorded. Based on degree of proteinuria at admission, patients were divided into two groups as nephrotic and non-nephrotic. Meadow classification was used for renal survival. The median age of the patients was 8 (6-12) years, and male/female ratio 1.1. There were 34 patients with nephrotic range proteinuria. In the nephrotic group, the time from IgAV to IgAVN and from IgAVN to biopsy was shorter (p=0.027), and eGFR values at admission were higher (p=0.021). In the these patients amount of crescents in biopsy (p=0.036), immunosuppressive use were more common (p=0.011) and time to remission was longer (p=0.016). No significant difference in renal survival was observed among both groups (p=0.469). In conclusion, proteinuria is an important finding in IgAVN. Considering aggressive biopsy findings, need for intensive immunosuppressive therapy, and delayed remission times, IgAV patients should be screened for proteinuria to prevent possible complications.

Kaynakça

  • Ozen S, Pistorio A, Iusan S, Bakkaloglu A, Herlin T, Brik R, et al. Paediatric Rheumatology International Trials organisation (PRINTo). EUlAR/PRINTo/PRES criteria for Henoch-Schönlein purpura, childhood pol yarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008.Part II: final classification criteria. Ann Rheum Dis. 2008;2010:798-806.
  • 2. Gardner-Medwin JM, Dolezalova P, Cummins C, Southwood TR. Incidence of Henoch-Schonlein purpura, Kawasaki disease, and rare vasculitides in children of different ethnic origins. The Lancet. 2002;360:1197-202.
  • 3. Narchi H. Risk of long term renal impairment and duration of follow up recommended for Henoch-Schönlein purpura with normal or minimal urinary findings: a systematic review. Archives of disease in childhood. 2005;90:916-20.
  • 4. Kurt-Şükür ED, Sekar T, Tullus K. Biopsy-proven Henoch-Schönlein purpura nephritis: a single center experience. Pediatric Nephrology. 2021;36:1207-15.
  • 5. Oni L, Gritzfeld JF, Jones C, Sinha MD, Wallace D, Stack M, et al. Comment on: European consensus-based recommendations for diagnosis and treatment of immunoglobulin A vasculitis—the SHARE initiative. Rheumatology. 2021;60:e179-e80.
  • 6. Koskimies O, Mir S, Rapola J, Vilska J. Henoch-Schönlein nephritis: long-term prognosis of unselected patients. Archives of disease in childhood. 1981;56:482-4.
  • 7. Goldstein AR, White RH, Akuse R, Chantler C. Long-term follow-up of childhood Henoch-Schönlein nephritis. The Lancet. 1992;339:280-2.
  • 8. Bogdanović R. Henoch‐Schönlein purpura nephritis in children: risk factors, prevention and treatment. Acta Paediatrica. 2009;98:1882-9.
  • 9. Butani L, Morgenstern BZ. Long-term outcome in children after Henoch-Schönlein purpura nephritis. Clinical pediatrics. 2007;46:505-11.
  • 10. Jafar TH, Stark PC, Schmid CH, Landa M, Maschio G, Marcantoni C, de Jong PE, de Zeeuw D, Shahinfar S, Ruggenenti P, Remuzzi G, Levey AS; AIPRD Study Group. Angiotensin-Converting Enzymne Inhibition and Progression of Renal Disease. Proteinuria as a modifiable risk factor for the progression of non-diabetic renal disease. Kidney Int. 2001 Sep;60:1131-40.
  • 11. Schwartz G, Haycock G, Edelmann Jr C, Spitzer A. A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics. 1976;58:259-63.
  • 12. Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. Journal of hypertension. 2016;34:1887-920.
  • 13. Vehaskari VM, Rapola J, Koskimies O, Savilahti E, Vilska J, Hallman N. Microscopic hematuria in schoolchildren: epidemiology and clinicopathologic evaluation. The Journal of pediatrics. 1979;95:676-84.
  • 14. Rodrigues JC, Haas M, HN R. IgA Nephropathy. Clinical journal of the American Society of Nephrology: CJASN. 2017;12:677-86.
  • 15. Meadow S, Glasgow E, White R, Moncrieff M, Cameron J, Ogg C. Schönlein—henoch nephritis. QJM: An International Journal of Medicine. 1972;41:241-60.
  • 16. Hastings MC, Rizk DV, Kiryluk K, Nelson R, Zahr RS, Novak J, et al. IgA vasculitis with nephritis: update of pathogenesis with clinical implications. Pediatric Nephrology. 2021:1-15.
  • 17. Topaloglu R, Sungur A, Baskin E, Besbas N, Saatci U, Bakkaloglu A. Vascular endothelial growth factor in Henoch-Schonlein purpura. The Journal of Rheumatology. 2001;28:2269-73.
  • 18. Ozaltin F, Besbas N, Uckan D, Tuncer M, Topaloglu R, Ozen S, et al. The role of apoptosis in childhood Henoch–Schonlein purpura. Clinical rheumatology. 2003;22:265-7.
  • 19. Feng D, Huang WY, Hao S, Niu XL, Wang P, Wu Y, Zhu GH. A single-center analysis of Henoch-Schonlein purpura nephritis with nephrotic proteinuria in children. Pediatr Rheumatol Online J. 2017; 4:15:15.
  • 20. Du Y, Hou L, Zhao C, Han M, Wu Y. Treatment of children with Henoch-Schönlein purpura nephritis with mycophenolate mofetil. Pediatr Nephrol. 2012;27:765-71.
  • 21. Mir S, Yavascan O, Mutlubas F, Yeniay B, Sonmez F. Clinical outcome in children with Henoch-Schönlein nephritis. Pediatric nephrology. 2007;22:64-70.
  • 22. Hennies I, Gimpel C, Gellermann J, Möller K, Mayer B, Dittrich K, et al. Presentation of pediatric Henoch–Schönlein purpura nephritis changes with age and renal histology depends on biopsy timing. Pediatric Nephrology. 2018;33:277-86.
  • 23. Delbet JD, Geslain G, Auger M, Hogan J, Salomon R, Peuchmaur M, Deschênes G, Buob D, Parmentier C, Ulinski T. Histological prognostic factors in children with Henoch-Schönlein purpura nephritis. Pediatr Nephrol. 2020 Feb;35:313-320.
  • 24. Nickavar A, Mehrazma M, Lahouti A. Clinicopathologic correlations in Henoch-Schonlein nephritis. Iran J Kidney Dis. 2012 Nov;6:437-40.
  • 25. Davin JC, Coppo R. Pitfalls in recommending evidence-based guidelines for a protean disease like Henoch-Schönlein purpura nephritis. Pediatr Nephrol. 2013 ;28:1897-903.
  • 26. Floege J, Feehally J. Treatment of IgA nephropathy and Henoch-Schönlein nephritis. Nat Rev Nephrol. 2013;9:320-7.
  • 27. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int Suppl. 2021;VOLUME 100( ISSUE 4S):126-27
  • 28. Coppo R, Mazzucco G, Cagnoli L, Lupo A, Schena FP. Long-term prognosis of Henoch-Schönlein nephritis in adults and children. Italian Group of Renal Immunopathology Collaborative Study on Henoch-Schönlein purpura. Nephrol Dial Transplant. 1997 ;12:2277-83.
  • 29. Ronkainen J, Ala-Houhala M, Huttunen NP, Jahnukainen T, Koskimies O, Ormälä T, Nuutinen M. Outcome of Henoch-Schoenlein nephritis with nephrotic-range proteinuria. Clin Nephrol. 2003 ;60:80-4.
  • 30. Gjerstad AC, Skrunes R, Tøndel C, Åsberg A, Leh S, Klingenberg C, et al. Kidney biopsy diagnosis in childhood in the Norwegian Kidney Biopsy Registry and the long-term risk of kidney replacement therapy: a 25-year follow-up. Pediatric Nephrology. 2022:1-8.
  • 31. Çakıcı EK, Gür G, Yazılıtaş F, Eroğlu FK, Güngör T, Arda N, et al. A retrospective analysis of children with Henoch–Schonlein purpura and re-evaluation of renal pathologies using Oxford classification. Clinical and Experimental Nephrology. 2019;23:939-47.
  • 32. Counahan R, Winterborn M, White R, Heaton J, Meadow S, Bluett N, et al. Prognosis of Henoch-Schönlein nephritis in children. Br Med J. 1977;2:11-4.
Toplam 32 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Konular Çocuk Nefrolojisi, Sağlık Kurumları Yönetimi
Bölüm ORİJİNAL MAKALELER / ORIGINAL ARTICLES
Yazarlar

Eda Didem Kurt Şükür 0000-0003-1451-4443

Osman Mete 0000-0001-7657-2572

Togay Yılmaz 0000-0002-5951-4394

Bora Gülhan 0000-0003-0236-5786

Diclehan Orhan 0000-0003-3637-5392

Fatih Özaltın 0000-0003-1194-0164

Ali Duzova 0000-0002-4365-2995

Rezan Topaloğlu 0000-0002-6423-0927

Yayımlanma Tarihi 20 Temmuz 2023
Yayımlandığı Sayı Yıl 2023 Cilt: 45 Sayı: 4

Kaynak Göster

Vancouver Kurt Şükür ED, Mete O, Yılmaz T, Gülhan B, Orhan D, Özaltın F, Duzova A, Topaloğlu R. Nefrotik Düzey Proteinüri ile Başvurunun Çocukluk Çağı Iga Vasküliti Nefriti Seyrine Etkileri. Osmangazi Tıp Dergisi. 2023;45(4):581-9.


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