初发过敏性紫癜患儿发病早期肾脏受累危险因素分析
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摘要
目的探讨初发过敏性紫癜(HSP)患儿发病早期肾脏受累的危险因素,为合并肾脏受累危险因素的HSP患儿的临床早期干预提供参考。方法选择2011年1月至2015年12月,于四川大学华西第二医院儿科接受住院治疗的1 402例初发HSP患儿为研究对象。根据HSP患儿发病早期是否合并肾脏受累,将其分为肾脏受累组(n=423)与对照组(n=979,肾脏未受累)。采用回顾性分析方法,收集所有患儿的临床病例资料。2组患儿性别、发病年龄、居住地区、发病季节、发病至确诊时间的构成比,发病早期皮疹、胃肠道症状、关节肿痛、肾脏受累、血管神经性水肿、神经系统受累发生率等比较,采用χ~2检验。采用多因素非条件logistic回归分析,评估HSP患儿发病早期肾脏受累的独立危险因素。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求,并与所有受试儿监护人签署临床研究知情同意书。结果①本研究1 402例患儿中,发病早期合并肾脏受累为423例(30.17%),合并胃肠道症状为937例(66.84%),合并关节肿痛症状为609例(43.33%),合并血管神经性水肿为352例(25.11%),合并神经系统受累为31例(2.21%),所有患儿合并皮疹。②发病早期肾脏受累影响因素的单因素分析结果显示,2组HSP患儿的发病年龄、发病季节、发病至确诊时间的构成比比较,差异均有统计学意义(χ~2=53.682,P<0.001;χ~2=11.990,P=0.007;χ~2=14.635,P<0.001)。肾脏受累组患儿居住于农村、无关节肿痛症状、合并血管神经性水肿所占比例,均显著高于对照组,并且差异均有统计学意义(χ~2=10.032,P=0.002;χ~2=6.514,P=0.011;χ~2=6.362,P=0.012)。③多因素非条件logistic回归分析结果显示,HSP患儿的发病年龄为≥5～7岁(OR=2.23,95%CI:1.42～3.51,P<0.001),≥7～9岁(OR=2.38,95%CI:1.51～3.76,P<0.001),≥9岁(OR=4.11,95%CI:2.65～6.36,P<0.001),以及于秋季发病(OR=1.61,95%CI:1.09～2.37,P=0.014)与冬季发病(OR=1.79,95%CI:1.09～2.37,P=0.001),发病至确诊时间≥8 d(OR=1.59,95%CI:1.17～2.17,P=0.004),居住于农村(OR=1.37,95%CI:1.07～1.76,P=0.012)及合并血管神经性水肿(OR=1.74,95%CI:1.32～2.31,P<0.001),均为HSP患儿发病早期肾脏受累的独立危险因素;而合并关节肿痛(OR=0.77,95%CI:0.60～0.99,P=0.038),则为HSP患儿发病早期肾脏受累的独立保护因素。结论本研究第一次提出合并血管神经性水肿,是初发HSP患儿发病早期肾脏受累的独立危险因素。HSP患儿发病年龄≥5岁、于秋季或者冬季发病、发病至确诊时间≥8 d、居住于农村等,亦均为该病患儿发病早期肾脏受累的独立危险因素。
Objective To explore the risk factors of renal involvement in children with primary Henoch-Sch■nlein purpura(HSP)in the early stage,and provide clinical references for early intervention of HSP these children with risk factors of renal involvement.Methods A total of 1 402 children with primary HSP who hospitalized in Department of Pediatrics,West China Second University Hospital,Sichuan University from January 2011 to December 2015 were included in this study.According to whether combined with renal involvement or not in the early stage of HSP,these children were divided into the renal involvement group(n=423)and control group(n=979,without renal involvement).Their demographic data and clinical manifestation were collected by retrospective method.Constituent ratios of gender,age of onset,residential area,season of onset and duration from symptoms onset to diagnosis,and incidences of skin rash,gastrointestinal symptoms,joint swelling and pain,renal involvement,angioneurotic edema,and nervous system involvement in the early stage were compared between two groups by chi-square test.Multivariate unconditional logistic regression analysis was used to assess the risk factors of renal involvement in children with HSP in the early stage.This study was in line with the World Medical Association Declaration of Helsinki revised in 2013.The guardians of all children signed the clinical research informed consents.Results(1)Among the 1 402 children with HSP,423 cases(30.17%)occurred renal involvement in the early stage of onset,937cases(66.84%)with gastrointestinal symptoms,609 cases(43.33%)with joint swelling and pain,352 cases(25.11%)with angioneurotic edema,31cases(2.21%)with nervous system involvement,and all cases(100%)with skin rash.(2)Univariate analysis of the influencing factors of renal involvement in the early stage of HSP showed that there were statistically significant differences between two groups in constituent ratios of age of onset,season of onset,and duration from symptoms onset to diagnosis(χ~2=53.682,P<0.001;χ~2=11.990,P=0.007;χ~2=14.635,P<0.001).And the proportions of children lived in rural areas,without joint swelling or pain and with angioneurotic edema in renal involvement group all were statistically higher than those in control group,and all the differences were statistically significant(χ~2=10.032,P=0.002;χ~2=6.514,P=0.011;χ~2=6.362,P=0.012).(3)Multivariate unconditional logistic regression analysis results showed that the onset age of HSP≥5years old(≥5-7years old,OR=2.23,95%CI:1.42-3.51,P<0.001;≥7-9years old,OR=2.38,95%CI:1.51-3.76,P<0.001;≥9years old,OR=4.11,95%CI:2.65-6.36,P<0.001),onset in the autumn(OR=1.61,95%CI:1.09-2.37,P=0.014)and winter(OR=1.79,95%CI:1.09-2.37,P=0.001),the duration from symptoms onset to diagnosis≥8d(OR=1.59,95%CI:1.17-2.17,P=0.004),living in rural areas(OR=1.37,95%CI:1.07-1.76,P=0.012)and combined with angioneurotic edema(OR=1.74,95%CI:1.32-2.31,P<0.001)were independent risk factors for renal involvement in children with HSP in the early stage.While combined with joint swelling and pain(OR=0.77,95%CI:0.60-0.99,P=0.038)was independent protective factors for renal involvement in children with HSP in the early stage.Conclusions Results in this study first show that HSP children combined with angioneurotic edema have high risk of renal involvement in the early stage of HSP and reconfirm that onset age of HSP≥5years old,onset in autumn or winter,duration from symptoms onset to diagnosis≥8d,and residence in rural areas all are the independent risk factors for renal involvements in children with primary HSP in the early stage.
Objective To explore the risk factors of renal involvement in children with primary Henoch-Sch■nlein purpura(HSP)in the early stage,and provide clinical references for early intervention of HSP these children with risk factors of renal involvement.Methods A total of 1 402 children with primary HSP who hospitalized in Department of Pediatrics,West China Second University Hospital,Sichuan University from January 2011 to December 2015 were included in this study.According to whether combined with renal involvement or not in the early stage of HSP,these children were divided into the renal involvement group(n=423)and control group(n=979,without renal involvement).Their demographic data and clinical manifestation were collected by retrospective method.Constituent ratios of gender,age of onset,residential area,season of onset and duration from symptoms onset to diagnosis,and incidences of skin rash,gastrointestinal symptoms,joint swelling and pain,renal involvement,angioneurotic edema,and nervous system involvement in the early stage were compared between two groups by chi-square test.Multivariate unconditional logistic regression analysis was used to assess the risk factors of renal involvement in children with HSP in the early stage.This study was in line with the World Medical Association Declaration of Helsinki revised in 2013.The guardians of all children signed the clinical research informed consents.Results(1)Among the 1 402 children with HSP,423 cases(30.17%)occurred renal involvement in the early stage of onset,937cases(66.84%)with gastrointestinal symptoms,609 cases(43.33%)with joint swelling and pain,352 cases(25.11%)with angioneurotic edema,31cases(2.21%)with nervous system involvement,and all cases(100%)with skin rash.(2)Univariate analysis of the influencing factors of renal involvement in the early stage of HSP showed that there were statistically significant differences between two groups in constituent ratios of age of onset,season of onset,and duration from symptoms onset to diagnosis(χ~2=53.682,P<0.001;χ~2=11.990,P=0.007;χ~2=14.635,P<0.001).And the proportions of children lived in rural areas,without joint swelling or pain and with angioneurotic edema in renal involvement group all were statistically higher than those in control group,and all the differences were statistically significant(χ~2=10.032,P=0.002;χ~2=6.514,P=0.011;χ~2=6.362,P=0.012).(3)Multivariate unconditional logistic regression analysis results showed that the onset age of HSP≥5years old(≥5-7years old,OR=2.23,95%CI:1.42-3.51,P<0.001;≥7-9years old,OR=2.38,95%CI:1.51-3.76,P<0.001;≥9years old,OR=4.11,95%CI:2.65-6.36,P<0.001),onset in the autumn(OR=1.61,95%CI:1.09-2.37,P=0.014)and winter(OR=1.79,95%CI:1.09-2.37,P=0.001),the duration from symptoms onset to diagnosis≥8d(OR=1.59,95%CI:1.17-2.17,P=0.004),living in rural areas(OR=1.37,95%CI:1.07-1.76,P=0.012)and combined with angioneurotic edema(OR=1.74,95%CI:1.32-2.31,P<0.001)were independent risk factors for renal involvement in children with HSP in the early stage.While combined with joint swelling and pain(OR=0.77,95%CI:0.60-0.99,P=0.038)was independent protective factors for renal involvement in children with HSP in the early stage.Conclusions Results in this study first show that HSP children combined with angioneurotic edema have high risk of renal involvement in the early stage of HSP and reconfirm that onset age of HSP≥5years old,onset in autumn or winter,duration from symptoms onset to diagnosis≥8d,and residence in rural areas all are the independent risk factors for renal involvements in children with primary HSP in the early stage.
引文
[1]Gardner-Medwin JM,Dolezalova P,Cummins C,et al.Incidence of Henoch-Sch9nlein purpura,Kawasaki disease,and rare vasculitides in children of different ethnic origins[J].Lancet,2002,360(9341):1197-1202.
[2]Yang YH,Hung CF,Hsu CR,et al.A nationwide survey on epidemiological characteristics of childhood Henoch-Sch9nlein purpura in Taiwan[J].Rheumatology,2005,44(5):618-622.
[3]李克莉,刘大卫,武文娣,等.中国六个市2007~2009年过敏性紫癜住院病例发病情况分析[J].中国疫苗和免疫,2011,17(2):128-132.
[4]Davin JC,Coppo R.Henoch-Sch9nlein purpura nephritis in children[J].Nat Rrev Nephrol,2014,10(10):563-573.
[5]吴小川.儿童过敏性紫癜循证诊治建议解读[J].中华儿科杂志,2013,51(7):508-511.
[6]Jauhola O,Ronkainen J,Koskimies O,et al.Renal manifestations of Henoch-Schonlein purpura in a 6-month prospective study of 223children[J].Arch Dis Child,2010,95(11):877-882.
[7]Chan H,Tang YL,Lv XH,et al.Risk Factors associated with renal involvement in childhood Henoch-Sch9nlein purpura:a Meta-analysis[J].PLoS One,2016,11(11):e0167346.
[8]Sano H,Izumida M,Shimizu H,et al.Risk factors of renal involvement and significant proteinuria in Henoch-Sch9nlein purpura[J].Eur J Pediatr,2002,161(4):196-201.
[9]Ronkainen J,Nuutinen M,Koskimies O.The adult kidney24 years after childhood Henoch-Sch9nlein purpura:a retrospective cohort study[J].Lancet,2002,360(9334):666-670.
[10]Bogdanovic′R.Henoch-Sch9nlein purpura nephritis in children:risk factors,prevention and treatment[J].Acta Paediatr,2009,98(12):1882-1889.
[11]Ozen S,Pistorio A,Iusan SM,et al.EULAR/PRINTO/PRES criteria for Henoch-Sch9nlein purpura,childhood polyarteritis nodosa,childhood Wegener granulomatosis and childhood Takayasu arteritis:Ankara 2008.PartⅡ:Final classification criteria[J].Ann Rheum Dis,2010,69(5):798-806.
[12]Chen JY,Mao JH.Henoch-Sch9nlein purpura nephritis in children:incidence,pathogenesis and management[J].World J Pediatr,2015,11(1):29-34.
[13]Rostoker G.Sch9nlein-henoch purpura in children and adults:diagnosis,pathophysiology and management[J].BioDrugs,2001,15(2):99-138.
[14]Rigante D,Candelli M,Federico G,et al.Predictive factors of renal involvement or relapsing disease in children with Henoch-Sch9nlein purpura[J].Rheumatol Int,2005,25(1):45-48.
[15]孙小妹,戴亮,孙飞扬,等.成都地区与川西高原地区过敏性紫癜患儿临床特征比较[J].现代预防医学,2018,45(12):2274-2276,2287.
[16]Zhao YL,Liu ZJ,Bai XM,et al.Obesity increases the risk of renal involvement in children with Henoch-Schonlein purpura[J].Eur J Pediatr,2015,174(10):1357-1363.
[17]Shin JI,Park JM,Shin YH,et al.Predictive factors for nephritis,relapse,and significant proteinuria in childhood Henoch-Sch9nlein purpura[J].Scand J Rheumatol,2006,35(1):56-60.
[18]de Almeida JL,Campos LM,Paim LB,et al.Renal involvement in Henoch-Sch9nlein purpura:a multivariate analysis of initial prognostic factors[J].J Pediatr(Rio J),2007,83(3):259-266.
[19]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[J].Arch Dis Child,2005,90(9):916-920.
[20]Gupta V,Aggarwal A,Gupta R,et al.Differences between adult and pediatric onset Henoch-Schonlein purpura from North India[J].Int J Rheum Dis,2018,21(1):292-298.
[21]Algoet C,Proesmans W.Renal biopsy 2-9years after Henoch Sch9nlein purpura[J].Pediatr Nephrol,2003,18(5):471-473.
[22]Yang YH,Hung CF,Hsu CR,et al.A nationwide survey on epidemiological characteristics of childhood Henoch-Sch9nlein purpura in Taiwan[J].Rheumatology(Oxford),2005,44(5):618-622.
[23]Wang XH,Zhu YM,Gao LQ,et al.Henoch-Sch9nlein purpura with joint swelling and involvement:analysis of 71cases[J].Pediatr Rheumatol Online J,2016,14(1):20.
[24]Wang K,Sun X,Cao Y,et al.Risk factors for renal involvement and severe kidney disease in 2 731 Chinese children with Henoch-Sch9nlein purpura:a retrospective study[J].Medicine(Baltimore),2018,97(38):e12520.
[25]Lee YH,Kim YB,Koo JW,et al.Henoch-Schonlein purpura in children hospitalized at a tertiary hospital during 2004-2015in Korea:epidemiology and clinical management[J].Pediatr Gastroenterol Hepatol Nutr,2016,19(3):175-185.
[26]Mao YY,Yin L,Huang H,et al.Henoch-Sch9nlein purpura in 535Chinese children:clinical features and risk factors for renal involvement[J].J Int Med Res,2014,42(4):1043-1049.
[27]刘雄彪,汪晓红,刘璐苑,等.过敏性紫癜伴发血管神经性水肿7例[J].中国皮肤性病学杂志,2017,31(8):927.
[28]Duman MA,Duru NS,■al■kan B,et al.Lumbar swelling as the unusual presentation of Henoch-Schonlein purpura in a child[J].Balkan Med J,2016,33(3):360-362.
[29]王佳佩,吴菱,王天波,等.伴血管神经性水肿的过敏性紫癜患儿预后及治疗[J].临床荟萃,2017,32(1):68-70.
[2]Yang YH,Hung CF,Hsu CR,et al.A nationwide survey on epidemiological characteristics of childhood Henoch-Sch9nlein purpura in Taiwan[J].Rheumatology,2005,44(5):618-622.
[3]李克莉,刘大卫,武文娣,等.中国六个市2007~2009年过敏性紫癜住院病例发病情况分析[J].中国疫苗和免疫,2011,17(2):128-132.
[4]Davin JC,Coppo R.Henoch-Sch9nlein purpura nephritis in children[J].Nat Rrev Nephrol,2014,10(10):563-573.
[5]吴小川.儿童过敏性紫癜循证诊治建议解读[J].中华儿科杂志,2013,51(7):508-511.
[6]Jauhola O,Ronkainen J,Koskimies O,et al.Renal manifestations of Henoch-Schonlein purpura in a 6-month prospective study of 223children[J].Arch Dis Child,2010,95(11):877-882.
[7]Chan H,Tang YL,Lv XH,et al.Risk Factors associated with renal involvement in childhood Henoch-Sch9nlein purpura:a Meta-analysis[J].PLoS One,2016,11(11):e0167346.
[8]Sano H,Izumida M,Shimizu H,et al.Risk factors of renal involvement and significant proteinuria in Henoch-Sch9nlein purpura[J].Eur J Pediatr,2002,161(4):196-201.
[9]Ronkainen J,Nuutinen M,Koskimies O.The adult kidney24 years after childhood Henoch-Sch9nlein purpura:a retrospective cohort study[J].Lancet,2002,360(9334):666-670.
[10]Bogdanovic′R.Henoch-Sch9nlein purpura nephritis in children:risk factors,prevention and treatment[J].Acta Paediatr,2009,98(12):1882-1889.
[11]Ozen S,Pistorio A,Iusan SM,et al.EULAR/PRINTO/PRES criteria for Henoch-Sch9nlein purpura,childhood polyarteritis nodosa,childhood Wegener granulomatosis and childhood Takayasu arteritis:Ankara 2008.PartⅡ:Final classification criteria[J].Ann Rheum Dis,2010,69(5):798-806.
[12]Chen JY,Mao JH.Henoch-Sch9nlein purpura nephritis in children:incidence,pathogenesis and management[J].World J Pediatr,2015,11(1):29-34.
[13]Rostoker G.Sch9nlein-henoch purpura in children and adults:diagnosis,pathophysiology and management[J].BioDrugs,2001,15(2):99-138.
[14]Rigante D,Candelli M,Federico G,et al.Predictive factors of renal involvement or relapsing disease in children with Henoch-Sch9nlein purpura[J].Rheumatol Int,2005,25(1):45-48.
[15]孙小妹,戴亮,孙飞扬,等.成都地区与川西高原地区过敏性紫癜患儿临床特征比较[J].现代预防医学,2018,45(12):2274-2276,2287.
[16]Zhao YL,Liu ZJ,Bai XM,et al.Obesity increases the risk of renal involvement in children with Henoch-Schonlein purpura[J].Eur J Pediatr,2015,174(10):1357-1363.
[17]Shin JI,Park JM,Shin YH,et al.Predictive factors for nephritis,relapse,and significant proteinuria in childhood Henoch-Sch9nlein purpura[J].Scand J Rheumatol,2006,35(1):56-60.
[18]de Almeida JL,Campos LM,Paim LB,et al.Renal involvement in Henoch-Sch9nlein purpura:a multivariate analysis of initial prognostic factors[J].J Pediatr(Rio J),2007,83(3):259-266.
[19]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[J].Arch Dis Child,2005,90(9):916-920.
[20]Gupta V,Aggarwal A,Gupta R,et al.Differences between adult and pediatric onset Henoch-Schonlein purpura from North India[J].Int J Rheum Dis,2018,21(1):292-298.
[21]Algoet C,Proesmans W.Renal biopsy 2-9years after Henoch Sch9nlein purpura[J].Pediatr Nephrol,2003,18(5):471-473.
[22]Yang YH,Hung CF,Hsu CR,et al.A nationwide survey on epidemiological characteristics of childhood Henoch-Sch9nlein purpura in Taiwan[J].Rheumatology(Oxford),2005,44(5):618-622.
[23]Wang XH,Zhu YM,Gao LQ,et al.Henoch-Sch9nlein purpura with joint swelling and involvement:analysis of 71cases[J].Pediatr Rheumatol Online J,2016,14(1):20.
[24]Wang K,Sun X,Cao Y,et al.Risk factors for renal involvement and severe kidney disease in 2 731 Chinese children with Henoch-Sch9nlein purpura:a retrospective study[J].Medicine(Baltimore),2018,97(38):e12520.
[25]Lee YH,Kim YB,Koo JW,et al.Henoch-Schonlein purpura in children hospitalized at a tertiary hospital during 2004-2015in Korea:epidemiology and clinical management[J].Pediatr Gastroenterol Hepatol Nutr,2016,19(3):175-185.
[26]Mao YY,Yin L,Huang H,et al.Henoch-Sch9nlein purpura in 535Chinese children:clinical features and risk factors for renal involvement[J].J Int Med Res,2014,42(4):1043-1049.
[27]刘雄彪,汪晓红,刘璐苑,等.过敏性紫癜伴发血管神经性水肿7例[J].中国皮肤性病学杂志,2017,31(8):927.
[28]Duman MA,Duru NS,■al■kan B,et al.Lumbar swelling as the unusual presentation of Henoch-Schonlein purpura in a child[J].Balkan Med J,2016,33(3):360-362.
[29]王佳佩,吴菱,王天波,等.伴血管神经性水肿的过敏性紫癜患儿预后及治疗[J].临床荟萃,2017,32(1):68-70.