Published online April 1, 2008
PEDIATRICS Vol. 121 No. 4 April 2008, pp. 871-872 (doi:10.1542/peds.2008-0321)

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LETTER TO THE EDITOR

Corticosteroid Therapy for Henoch Schönlein Purpura: In Reply

Pamela Weiss, MD
Jon Burnham, MD, MSCE
Division of Rheumatology
Department of Pediatrics
Children's Hospital of Philadelphia
Philadelphia, PA 19104

James Feinstein, MD
Chris Feudtner, MD, MPH, PhD
Division of General Pediatrics
Department of Pediatrics
Children's Hospital of Philadelphia
Philadelphia, PA 19104

For patients with HSP, the clinical outcome of "persistent renal disease" requires definition. If it is defined as end-stage renal disease, then Gibson et al are correct that only 2% of children with HSP develop "persistent renal disease."¹ From a patient-oriented perspective, however, there are other renal outcomes that should be assessed. Up to 50% of children with HSP may develop persistent urinary abnormalities.¹ Although neither persistent hematuria nor proteinuria accurately predict the onset of significant kidney pathology, patients nonetheless experience continual medical surveillance that may involve repeated primary physician or subspecialist visitations, urine analyses, laboratory investigations, blood pressure monitoring, and renal biopsies; if all of this could be avoided without deleterious consequences, all the better.

In regards to our meta-analysis, 2 additional points warrant clarification. First, Gibson et al are correct in that we conservatively excluded 2 patients from the Mollica et al² study who developed delayed nephritis; however, both were controls and, if included, would have augmented the beneficial effects of corticosteroids. Including the results of Dudley et al³ should be done, mindful of the fact that they defined "persistent renal disease" as prolonged proteinuria only, whereas the studies included in our review also included hematuria. Indeed, persistent hematuria, in the setting of normal protein excretion, can be associated with significant renal pathology (ISKDC classifications Iia–IIIb), and should be recognized.⁴

Finally, we ask the larger question: What outcomes matter for children with HSP? Certainly renal disease is to be feared, but other outcomes that should be assessed regarding the impact of corticosteroids include (1) quicker resolution of pain: given the wholesale cost of prednisone at 2 mg/kg for a 20 kg child is $1.15 per day (www.drugstore.com), as long as this dose is not associated with harm, treatment to reduce symptoms may be warranted; (2) avoidance of surgical intervention: if during the acute phase of HSP a therapy could reduce the rates of abdominal surgery for exploration or actual intestinal injury, such a treatment would be valuable; (3) avoidance of problems seemingly unrelated to HSP: recent reports have linked a history of HSP with several late-onset medical conditions, including hypertension,^5,6 preeclampsia,^5–7 and persistent nailfold capillary changes, suggesting a chronic vasculitis.⁸ Verification of these associations, and the role of any HSP-directed therapy to prevent these developments, remains to be seen. Certainly, additional studies regarding the impact of corticosteroids and other interventions on the short-term and long-term manifestations of HSP are warranted. Still, the current published literature supports the notion that early use of corticosteroids is associated with better HSP outcomes and no harm.

REFERENCES

1. 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]
2. 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]
3. 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
4. Zhang GZ, Wu XC, Yi H, et al. Relationship between clinical manifestations and renal pathology in children with Henoch-Schonlein purpura nephritis[in Chinese]. Zhongguo Dang Dai Er Ke Za Zhi. 2007;9 (2):129 –132[Medline]
5. Butani L, Morgenstern BZ. Long-term outcome in children after Henoch-Schonlein purpura nephritis. Clin Pediatr (Phila). 2007;46 (6):505 –511[Abstract/Free Full Text]
6. Ronkainen J, Nuutinen M, Koskimies O. The adult kidney 24 years after childhood Henoch-Schonlein purpura: a retrospective cohort study. Lancet. 2002;360 (9334):666 –670[CrossRef][Web of Science][Medline]
7. Goldstein AR, White RH, Akuse R, Chantler C. Long-term follow-up of childhood Henoch-Schonlein nephritis. Lancet. 1992;339 (8788):280 –282[CrossRef][Web of Science][Medline]
8. Martino F, Agolini D, Tsalikova E, et al. Nailfold capillaroscopy in Henoch-Schonlein purpura: a follow-up study of 31 cases. J Pediatr. 2002;141 (1):145[CrossRef][Web of Science][Medline]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Weiss, P. Articles by Feudtner, C. Search for Related Content PubMed Articles by Weiss, P. Articles by Feudtner, C. Related Collections Heart & Blood Vessels Social Bookmarking                         What's this?