PEDIATRICS Vol. 121 No. 4 April 2008, pp. 870-871 (doi:10.1542/peds.2008-0138)
LETTER TO THE EDITOR |
Corticosteroid Therapy for Henoch Schönlein Purpura
Keisha L. Gibson, MDM. Ahinee Amamoo, MS
William A. Primack, MD
UNC Kidney Center
University of North Carolina School of Medicine
CB #7155
Chapel Hill, NC 27599
To the Editor.—
Weiss et al's1 meta-analysis concludes that several weeks of corticosteroid use decreases the risk of long-term renal disease in children presenting with Henoch Schonlein purpura (HSP). They base this conclusion on a combined odds ratio ([OR]: 0.43; 95% confidence interval (CI): [0.19–0.96]) of 3 placebo-controlled or prospective trials. We disagree with their conclusion on the basis of selection bias in the studies reported, differences in duration of follow-up, as well as new data from a prospective study presented by Dudley et al2 at the 2007 American Society of Nephrology meeting that reported no differences in development of renal disease between those receiving prednisolone and placebo (OR: 1.32; 95% CI: [0.59–2.94]).
Extrapolating the results of the analyzed trials to the practice of the primary care pediatrician may not be wise, because the children reported were either hospitalized for HSP or presented to a tertiary care level emergency department. It is reasonable to assume that they, on average, were sicker and may have had more severe involvement than the child with HSP presenting to a primary care practice.
Methodologic issues that raise concern about the validity of Weiss et al's1 meta-analysis include differences in treatment regimens and follow-up duration. Follow-up periods for each study were quite different with Ronkainen et al3 who reported 6 months of follow-up compared with 1 year for the Mollica et al4 and Huber et al5 trials. Also, the Mollica et al4 study, which was designed as an incidence trial compared with the prevalence design of the other 3 studies, included 2 patients who developed renal disease >1 year after their HSP diagnosis but are not taken into account by Weiss et al1 in their metanalysis. If we exclude Mollica et al4 from the meta-analysis and add the Dudley et al2 study, we measure a new combined OR: 0.89; 95% CI (0.52–1.54). However, if the Dudley et al and Mollica et al2,4 studies are included, we measure a combined OR: 0.77; 95% CI (0.44–1.39) (Fig 1). Both of the combined OR reported indicate a trend toward supporting steroids in patients with HSP, but neither are statistically significant because the CIs cross the null.
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Weiss et al1 in their sensitivity analysis for future studies estimate that 5%–20% of untreated patients with HSP will develop persistent renal involvement. This is a large overestimate because long-term studies of unselected patients with HSP show less than a 2% prevalence of persistent renal involvement.6
The relatively small subgroup of HSP patients who may benefit from corticosteroids includes those who present with renal involvement and probably those with severe abdominal symptoms requiring medical attention.4,6,7 In summary, we feel the data does not currently exist, however, to recommend the routine use of corticosteroids to prevent renal disease in children with uncomplicated HSP, and that if steroids are to be used for these children, it should be only in the context of a controlled trial.
REFERENCES
1. Weiss PF, Feinstein JA, Luan X, Burnham JM, Feudtner C. Effects of corticosteroid on Henoch-Schonlein purpura: a systematic review.
Pediatrics. 2007;120
(5):1079
–1087
2. Dudley J, Smith G, Llewellyn-Edwards A, Tizard J. Randomised placebo controlled trial to assess the role of early prednisolone on the development and progression of Henoch-Schonlein purpura nephritis. J Am Soc Nephrol . 2007;18 :47A
3. Ronkainen J, Koskimies O, Ala-Houhala M, et al. Early prednisone therapy in Henoch Schonlein purpura: a randomized, double-blind, placebo-controlled trial. J Pediatr. 2006;149 (2):241 –247[CrossRef][Web of Science][Medline]
4. Mollica F, Li Volti S, Garozzo R, Russo G. Effectiveness of early prednisone treatment in preventing the development of nephropathy in anaphylactoid purpura. Eur J Pediatr. 1992;151 (2):140 –144[CrossRef][Web of Science][Medline]
5. Huber AM, King J, McLaine P, Klassen T, Pothos M. A randomized, placebo-controlled trial of prednisone in early Henoch Schonlein purpura [ISRCTN85109383]. BMC Medicine. 2004;2 :7[CrossRef][Medline]
6. Saulsbury FT. Henoch Schonlein purpura in children: report of 100 patients and review of the literature. Medicine (Baltimore). 1999;78 (6):395 –409[CrossRef][Medline]
7. Narchi H. Risk of long term renal impairment and duration of follow up recommended for Henoch-Schonlein purpura with normal or minimal urinary findings: a systematic review.
Arch Dis Child. 2005;90
(9):916
–920
PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics
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