Does steroid treatment of abdominal pain prevent renal involvement in Henoch-Schönlein purpura?

Abstract

To the Editor: The treatment of gastrointestinal (GI) manifestations of Henoch-Schönlein purpura (HSP) with steroids is still under debate (1,2). Current recommendations are based on only a few retrospective studies (1,2). GI manifestations represent a significant risk factor for renal involvement (3), and renal involvement determines the prognosis of HSP (1). We demonstrate the immediate responses of GI symptoms to steroids and a reduction of renal involvement with early steroid treatment in the follow-up of 101 children with HSP and GI involvement. We analyzed retrospectively the case histories of all 101 children (age 10 months to 16 years, mean 6 years) with HSP and GI involvement treated between Jan. 1, 1987, and Dec. 31, 1997, at our institution. All children had palpable purpura and abdominal pain and fulfilled the diagnostic criteria for HSP (4). Of the 101 children, 23 also had GI bleeding. Follow-up for at least 1.5 years was carried out in all patients except one. Renal involvement was defined as significant proteinuria (>30 mg/dl protein in morning urine) or hematuria (>10 red blood cells/μl). Severe abdominal pain (n = 34) or GI bleeding with abdominal pain (n = 23) was treated with prednisone, 2 mg/kg. The dosage of prednisone was increased up to 3 to 5 mg/kg if symptoms persisted for more than 24 hours. In 26 children, steroid treatment was started in the first 3 weeks of disease and was given for at least 1 week. Statistical analyses were performed with Fisher's exact test. Forty-four (77%) of the 57 children (age 2–16, mean 6 years) treated with steroids recovered within 24 hours after initiation of steroid treatment. The GI symptoms of the other 13 patients disappeared within 24 hours after increasing prednisone dosage. Children who did not receive steroids (age 1–13, mean 6 years) had abdominal pain for a median of 5 days (range 1–28). No side effects caused by steroids were observed. Two children with intussusception at day 8 and day 21 of disease were not treated with steroids. One child treated with prednisone for 12 hours had intussusception on the second day of disease. Renal involvement was significantly rarer (P < 0.01) after at least 1 week of steroid treatment for GI manifestations in the first 3 weeks of disease (Table 1). Of the 41 children with renal involvement, 13 had isolated hematuria, 11 had isolated proteinuria, 9 had hematuria combined with proteinuria, and 8 had nephritis (hematuria and at least one of the following: elevated creatine, decreased creatinine clearance, or blood pressure above the 95th percentile [5]). No child had nephrotic or progressive nephritis.TABLE 1: Frequency of renal involvement related to early one-week steroid treatment in patients with gastrointestinal manifestations of Henoch-Schönlein purpuraThe treatment of GI symptoms and the prevention of renal involvement in HSP with steroids are controversial (1,2). Abdominal pain is sometimes self-limiting in HSP (2). Children in our group who did not receive steroids had an average of 5 days of abdominal pain, whereas all patients with abdominal pain or GI bleeding recovered within 24 to 48 hours after steroid treatment was initiated. Prospective, randomized studies of steroid treatment for GI manifestations are lacking, but clinical experience demonstrates the effectiveness of steroids (1,2). An additional important reason for early treatment of abdominal pain is the prevention of renal involvement in HSP. Abdominal pain is a significant risk factor for renal involvement (3), and renal involvement determines the prognosis in HSP (1). Early 1-week prednisone treatment within the first 3 weeks of disease reduced the rate of renal involvement in our study. Several retrospective studies have shown that renal disease can be prevented with steroids, but others showed no benefit of steroids (1,2). One prospective, randomized, controlled study reported a significant decrease in renal involvement in children treated with steroids (6). In our experience, in children with HSP, early treatment with steroids for at least 1 week is an effective therapy for abdominal pain and seems to reduce the risk of renal involvement with GI manifestations. Further prospective, randomized, controlled studies are required to study the effectiveness of steroids in preventing renal involvement. Thomas Reinehr Guido Bürk Werner Andler