ACR Meeting Abstracts

ACR Meeting Abstracts

Abstract Number: 2174

Urinalysis Monitoring In Children With Henoch-Schönlein Purpura: Is It Time To Revise?

Hao Wang1, Manasita Tanya2, Justin Hung Tiong Tan2, Sook Fun Hoh3, Lena Das4 and Thaschawee Arkachaisri5, 1Paediatrics, Duke-NUS Graduate Medical School, Singapore, Singapore, 2Rheumatology and Immunology, KK Women's and Children's Hospital, Singapore, Singapore, 3Nursing, KK Women's and Children's Hospital, Singapore, Singapore, 4Pediatric Rheumatology, KK Women's and Children's Hospital, Singapore, Singapore, 5Rheumatology & Immunology, KK Women's and Children's Hospital and Duke-NUS Graduate Medical School, Singapore, Singapore

Meeting: ACR/ARHP Annual Meeting 2013

Keywords: , ,

Session Information

Title: Pediatric Rheumatology-Clinical and Therapeutic Aspects III: Juvenile Idiopathic Arthritis and Other Pediatric Rheumatic Diseases

Session Type: Abstract Submissions (ACR)

Background/Purpose: Major complication of Henoch-Schönlein Purpura (HSP) is renal impairment. Recommended urinalysis (UA) monitoring over a period of 2 years has been a common practice in many pediatric rheumatology centers. Cost-effectiveness following this guideline is questionable. We explore the natural history of UA outcomes in our inception HSP cohort.   Methods: Patients with HSP with at least 6 mo follow-up and seen between 3/2009 and 6/2013, at our institute were recruited. A 2-year UA monitoring protocol was adopted (monthly for 6 mo, if normal then every 3 months for 18 mo). Minimal renal involvement was defined as isolated hematuria (urine RBC > 5/hpf) and/or proteinuria (urine protein > 1+), and renal impairment as presentation of nephritic, nephrotic symptoms, or renal failure. Recurrent HSP were excluded. Kaplan-Meier estimate and log-rank test were used to analyze the differences between groups for time to event. Logistic regression was used to assess relationships of cofactors.   Results: 56 patients (43% F) were analyzed. The ethnicity of our cohort reflected Singapore racial distribution. Majority of referrals (80%) were admitted. The median duration of follow up was 17.2 (10.6-24.2) mo. Over 1/2 of patients had subcutaneous edema and elevated serum IgA. 29 patients presented with abnormal UA at diagnosis (n=16, 55.2%, 5/16 developed renal impairment within 2 mo) or during follow up (n=13, 44.8%). Only one patient (7.7%) developed abnormal UA after 6 mo. UA was normalized in 24 patients during follow up, within a median time of 9.1 (95% CI: 3.5-14.6) mo. No association between demographic or clinical features and different renal outcomes was unveiled. Among patients with no renal impairment, an earlier subsidence of renal involvement (p = 0.009) was noted in patients with normal UA at diagnosis (n=13, median time: 2.9 mo, 95% CI: 1.5-4.4; 11 cases (84.6%) resolved by 12 mo), compared to children with abnormal UA at diagnosis (n=7, median time: 15.7 mo, 95% CI: 6.7-24.7). Non-renal indication of prednisolone use did not affect time to UA subsidence (p = 0.32).

Table 1.   Patient characteristics, treatments and outcomes

 

DEMOGRAPHIC
Age of Onset (years) (Median, IQR) 4.8 (3.8-6.5)
Race Chinese 43 (76.8%), Malay 8 (14.3%), Indian 1 (1.8%), Others 4 (7.1%)
CLINICAL MANIFESTATIONS
Previous infection 32 (57.1%)
Rash 56 (100%)
Subcutaneous edema 35 (62.5%)
Abdominal pain 24 (42.9%)
Arthritis 5 (8.9%)
High IgAa 27 (64.1%)
ESR (Median, IQR)b (Reference: 0-10 mm/50 min) 20.0 (10.0-32.0)
CRP (Median, IQR)c (Reference: 0-9.9 mg/L) 8.6 (5.3-30.4)
WBC (Median, IQR)d (Reference: 5.5-15.5×109/L) 11.9 (9.6-13.9)
Platelets (Median, IQR) d (Reference: 150-450×109/L) 363.0 (303.8-459.8)
TREATMENT
Prednisolone Renal impairment N 5
Duration (weeks) (median, IQR) 33.6 (23.5-51.8)
Other indications N 29
Duration (weeks) (median, IQR) 8.0 (4.0-9.9)
Immunosuppressant 3 (5.4%)
RENAL OUTCOME
Normal UA at diagnosis 40 (71.4%) Normal UA during follow up 27 (67.5%)
Minimal renal involvement during follow up 13 (32.5%) Abnormal UA 29 (51.8%)
Minimal renal involvement at diagnosis 16 (28.6%) Renal involvement resolved during follow up 7 (43.8%)
Renal involvement persisted 4 (25.0%)
Renal impairment during follow up 5 (31.3%)

a: Out of 41 patients with IgA tested, as per normal range for age.

b: Erythrocyte sedimentation rate, out of 39 patients with ESR tested.

c: C-reative protein, out of 35 patients with CRP tested.

d: White blood cells and platelets, out of 50 patients with CBC tested.

  Conclusion: Several observations were demonstrated in our cohort: 1. One-third of normal UA at diagnosis developed abnormal UA and majority (92.3%) did so within the first 6 months. 2. Resolution of abnormal UA at diagnosis was slower than that of abnormal UA later. 3. As expected, the use of corticosteroids had no effect on time to UA resolution. With these findings, we propose a shorter duration of UA monitoring to 6 months in HSP patients with normal UA at diagnosis and follow up. A shorter duration of 12 months from onset of abnormal UA may be adequate for HSP patients with normal UA at diagnosis. Patients with abnormal UA at diagnosis may be followed up for a minimum of 24 months. This proposal is being evaluated and validated in our longitudinal cohort study with collaboration with other centers in the region.

 

Disclosure:

H. Wang,
None;

M. Tanya,
None;

J. H. T. Tan,
None;

S. F. Hoh,
None;

L. Das,
None;

T. Arkachaisri,
None.

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