HSP nephritis: when should you refer to a Nephrologist?

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1 HSP nephritis: when should you refer to a Nephrologist? Dr. Louise Oni (nee Watson) NIHR Academic Clinical Lecturer Paediatric Nephrology, Alder Hey Children s Hospital, University of Liverpool

2 Outline Background Renal monitoring What investigations to perform When to refer to nephrology When would we do a renal biopsy Management

3 New name Henoch Schonlein Purpura Immunoglobulin A vasculitis

Blood leak small vessels Inflammatory cells IgA C3

4 Pathophysiology Systemic small vessel vasculitis Elevated IgA Abnormal glycosylated IgA Vasodilation Blood leak small vessels Inflammatory cells IgA C3 Leukocytoclastic vasculitis Endothelial cell necrosis

Most common childhood vasculitis Micropolyangitis Wegener PAN Cutaneous Takayasu Unclassified Average DGH; n=1,347 European children HSP Henoch Schonlein purpura Child: 3-27 cases/ 100,000 Onset in

5 Most common childhood vasculitis Micropolyangitis Wegener PAN Cutaneous Takayasu Unclassified Average DGH; n=1,347 European children HSP Henoch Schonlein purpura Child: 3-27 cases/ 100,000 Onset in Autumn- Winter Preceding viral illness (URTI) Catchment population of 60,000 children 6-12 cases of HSP/year Rare for GP population 1 case for approx. every 36 GP s Ruperto et al, Ann Rheum Dis, 2010;69:790-7, Watts et al, Semin Arthrit Rheum, 1995;25(1):28-34

6 Typical patient Males>Females 1.5>1 Gardner-Medwin et al, Lancet 2002;360:

7 Typically presents with rash Non-erosive arthritis, arthralgia Abdominal pain, bleeding, intussusception Scrotal involvement Renal involvement Rarely neurological, lung

8 Rash characteristics

9 EULAR/PReSClassification of childhood HSP Ozen et al, Ann Rheum Dis, 2006; 65(7): , Ozen et al, Ann Rheum Dis, 2010; 69(5):

10 Prognosis Acute illness < 1 month, resolution < 3 months 30 days: 70% complete recovery 2 years: 94% complete recovery 5 years: 1% HSP ESRFnephritis (HSPN) Only 1/3 recurrent long term episode consequence, asymptomatic Requires active monitoring Long term outcome HSPN <10% persistent haematuria/proteinuria (1 year) 1.7% UK ESRF ESRF: Up to 20% if nephritic or nephrotic Mir et al 2007, Shenoy et al, 2007, Butani et al, UK Renal Registry 2005

11 Standardising management of HSPN HSP diagnosis? Monitoring for nephritis Diagnosis; EULAR criteria No renal involvement Renal involvement Resolved renal involvement? HSPN Diagnosis; Renal biopsy ISKDC classification Persistent/resolv e? ESRF

Monitoring varies Renal monitoring 6 months follow up paediatrician, GP Urine testing by nurses or parents Henoch Schonlein Purpura A 5-Year Review and Proposed Pathway Louise Wa

12 Monitoring varies Renal monitoring 6 months follow up paediatrician, GP Urine testing by nurses or parents Henoch Schonlein Purpura A 5-Year Review and Proposed Pathway Louise Watson 1 *, Amanda R. W. Richard son 2, Richard C. L. Holt 2, Caroline A. Jones 2, Michael W. Beresford 1 1 Department of Women s and Children s Health, Institute of Translational Medicine, University of Liverpool, Alder Hey Children s NHS Foundation Trust Hospital, Liverpool, United Kingdom, 2 Department of Paediatric Nephrology, Alder Hey Children s NHSFoundation Trust Hospital, Liverpool, United Kingdom Abst ract Henoch Schonlein Purpura (HSP) is the commonest systemic vasculitis of childhood typically presenting with a palpable purpuric rash and frequently involving the renal system. We are the first group to clinically assess, critically analyse and

13 Older children more likely to develop HSP nephritis P<0.01 Normal outcome Renal outcome Watson et al, PlosONE, 2012

14 Day 7 Urinalysis: Predicting outcome Proteinuria: Poor predictor Confidence Interval Positive predictive ratio 32% (15 to 55%) Sensitivity 78% (45 to 94%) Absence of proteinuria: Good predictor of normal outcome Negative predictive ratio 97% (90 to 99%) Specificity 84% (75 to 90%)

15 Variations in biopsy indications HSP Steering group meeting, Dec 2012 Can the UK produce a consensus guideline on the indications for undertaking a renal biopsy in childhood HSP?

16 Consensus technique UK HSPN Steering Group Formation of HSPNWG UK Paediatric Nephrologists Facilitators JAN-APRIL 2015 Plan methodology Establish UK support Delphi survey 1 Experts BAPN presentation Dec 2014 Pilot survey to trainees (n=5) Delphi survey 2 Construct and dissemination of clinical care guideline; 1. The indications for undertaking a renal biopsy in childhood HSP Agreed consensus: >1 response per specialist centre, 80% agreement

17 Survey response Questions asked: Features of HSPN Proteinuria Haematuria Hypertension Impaired renal function Duration of abnormalities Measuring proteinuria Medications for future trial

18 Consensus indications for renal biopsy 1. Proteinuria o UPCR >250mg/mmol o>4 weeks after diagnosis o Spot early morning urine protein:creatinine ratio 2. Nephroticsyndrome o Low albumin, oedema, heavy proteinuria 3. Nephritic syndrome o Hypertension, haematuria, renal impairment 4. Any of; hypertension, macroscopic haematuriaonly if with proteinuria

19 SHARE guidelines

20 If concerns during renal monitoring Clinical review by paediatrician Routine examination (rash, joints, abdo) Oedema BP, weight May need repeat reviews if <4 weeks from diagnosis Avoid NSAIDs

21 Discuss with nephrologist If meets indications for biopsy Proteinuria UPCR >250 mg/mmol at 4 weeks Nephrotic or nephritic syndrome Other features with proteinuria Persistent hypertension >95 th centile on 3 separate occasions Rheumatology: Joints or recurrent Gastroenterology: GI symptoms Surgeons: Intussusception, testes

22 Management Henoch Schonlein Purpura Arthritis/Arthralgia Abdominal involvement Renal involvement Renal monitoring Rest, analgesia, NSAIDs GI bleeding, severe abdominal pain Corticosteroids 1mg/kg, max 60mg 2/52, wean 2/52 Ronkainen J, et al. J Pediatr 2006;149:241 7.Weiss et al, Pediat 2007;120(5): Chartapisak et al, Cochrane, 2010 Discharge if urine/bp normal after 6 months Renal biopsy (i) active features on biopsy- Immunosuppression (ii) persistent proteinuria -ACEi (iii) Persisent haematuria Gen Paed FU

23 Evidence-based treatment of HSPN Systematic review of RCTs: no difference Early corticosteroids V s placebo, total n=379 1 Cyclophosphamide V s supportive, n=56 Cyclosporin V s methylprednisolone RCT, n=24 2 Other studies Cyclophosphamide + methylprednisolone, n=12 3 Azathioprine + steroids, n=21 4 Cochrane: Few RCTs 5 no proven benefit Challenges: self resolving, high risk groups, no standardised care Consensus survey: future trials MMF, AZA, CYC +/- steroids; ACEi/placebo 1. Tizardet al, unpublished, personal communication; Dudley 2007, Huber 2004, Mollica 2004, Ronkainen Jauholaet al, Flynn et al, Bergstein et al, ChartapisakW et al. 2009

24 Patient information

25 Summary HSP common childhood vasculitis General paediatric condition Rare for GP Monitoring for HSPN important If abnormal monitoring review &primary investigations Discuss with nephrology if meets biopsy criteria & undertake secondary investigations Routine referral if persistent findings at 6 months Reliable patient information available

26 Acknowledgements Patients and families Original HSP pathway committee: Dr. Gavin Cleary Dr. Briar Stewart Dr. Dave Casson Elvina White Pauline Stone UK PaediatricNephrologists & trainees for contributing to the Delphi survey UK HSPN Steering group Dr. Jane Tizard Dr. Paul Brogan Prof. Michael Beresford Dr. Caroline Jones Dr. Richard Holt Dr. Amanda Richardson Prof. Matthew Peak Dr. Theo Anbu Dr. Kjell Tullus Dr. Rajeev Shukla Dr. Milos Ognjanovic Dr. Mohan Shenoy

LRI Children s Hospital

LRI Children s Hospital Management of Henoch Schönlein Purpura (HSP) in children Staff relevant to: Clinical staff working within the UHL Children s Hospital. Team approval date: July 2017 Version: V 3