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Nottingham University Hospitals


NHS Trust

Henoch-Schönlein Purpura (HSP)


Title of Guideline (must include the word “Guideline” (not Guideline for Management of
protocol, policy, procedure etc)
Henoch-Schönlein Purpura and
Henoch-Schönlein Purpura
Nephritis
Contact Name and Job Title (author) Dr. Tom Forbes
Paediatric Nephrology Registrar
Dr. Andrew Lunn
Consultant Paediatric Nephrologist
Dr Corinne Langstaff
Consultant Paediatric Nephrologist
Directorate & Speciality Family Health,
Renal
Date of submission July 2016
Date on which guideline must be reviewed (this should be July 2019
one to three years)
Explicit definition of patient group to which it applies (e.g. All children with a diagnosis of
inclusion and exclusion criteria, diagnosis)
Henoch-Schönlein Purpura (HSP)
Abstract This guideline describes the diagnosis
and management of HSP in the
paediatric population, including a
pathway for screening for renal
involvement.
Key Words Paediatrics, Children, Henoch-
Schönlein, purpura, HSP, vasculitis,
renal, nephritis, abdominal pain,
arthritis
Statement of the evidence base of the guideline – has the Use of corticosteroids not indicated to
guideline been peer reviewed by colleagues?
prevent renal involvement in HSP – 1a
Evidence base: (1-5)
1a meta analysis of randomised controlled trials Use of corticosteroids in severe HSP
1b at least one randomised controlled trial abdominal pain or arthritis – 1b
2a at least one well-designed controlled study without
randomisation
2b at least one other type of well-designed quasi-
Screening Pathway for HSP Nephritis
experimental study –3
3 well –designed non-experimental descriptive studies
(ie comparative / correlation and case studies)
4 expert committee reports or opinions and / or clinical
experiences of respected authorities
5 recommended best practise based on the clinical
experience of the guideline developer
Consultation Process Paediatric Nephrology Consultants
General Paediatric Consultants
Paediatric Clinical Guidelines Group
Target audience Nottingham Children’s Hospital Staff

This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or
expert. Caution is advised when using guidelines after the review date.

Dr Andrew Lunn Page 1 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

Document History
Version Number Date Produced Author
V1 Jan 2005
V2 Dec 2009 Dr F Hussain
V3 June 2013 Dr T Forbes, Dr A Lunn
Dr C Langstaff
v4 June 2016 Dr A Lunn

Minor amendments from previous guideline:


1. Clarification of proteinuria criteria for referral to paediatric nephrology – Page 5
and page 9

2. Updated new eGFR reporting – page 12

3. Updated numbering and contents table

Dr Andrew Lunn Page 2 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

Contents of the Guideline

Contents
1. Patient Pathways ................................................................................................................ 4

Initial Management of Newly Diagnosed HSP ................................................................... 4

General Paediatric Review at 1 Week Following Diagnosis .............................................. 5

HSP Letter for GP if urinalysis/blood pressure normal at 1 week review .......................... 5

General Paediatric Pathway ............................................................................................... 7

Pathway for patients referred back during GP assessment period: ................................... 9

2. Background ...................................................................................................................... 10

3. Clinical Features ............................................................................................................... 10

4. Diagnosis .......................................................................................................................... 11

5. Investigation ..................................................................................................................... 12

6. Indications for Admission ................................................................................................. 12

7. Management..................................................................................................................... 13

7.1. Supportive ................................................................................................................. 13

7.2. Steroids ..................................................................................................................... 13

7.3. Nephrology referral.................................................................................................... 13

7.4. Other Specialist referral............................................................................................. 13

8. Follow Up.......................................................................................................................... 13

9. Outcome ........................................................................................................................... 14

10. References ....................................................................................................................... 15

11. Audit Points ...................................................................................................................... 15

Appendix 1: Blood pressure centiles for boys by age and height percentile ........................... 16

Appendix 2: Blood pressure centiles for girls by age and height percentile ............................ 17

Dr Andrew Lunn Page 3 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

1. Patient Pathways
Initial Management of Newly Diagnosed HSP
Diagnosis of HSP
 Purpura, predominatly lower limbs and buttocks
 Abdominal pain (75% cases)
 Arthritis / arthralgia (66% cases)
 Haematuria / proteinuria
 Hypertension
Exclude of other causes of purpuric rash
(eg. Meningococcal septicaemia, DIC, ALL, TTP, NAI, other vasculitidies)

 Normal urinalysis  Any Haematuria or Proteinuria on dipstick


AND AND / OR
 Normotensive  Hypertension (bp > 95th centile on 3 separate
readings)*

 FBC, Urea, electrolytes, creatinine, albumin


 Urine protein:creatinine ratio (uPCR)

Any indication for admission?


 Hypertension
 Oedema
 Abnormal blood or urine test results
 Severe joint pain
NO  Severe abdo pain YES
 GI haemorrhage
 Neurological symptoms
 Other acute complications eg.orchitis

 Confirm diagnosis with registrar or Admit under general paediatrics


consultant.
 Organise general paediatric review within Are any of the following present?
1 week  Hypertension
 Counsel re: indications for further medical  Urine Protein:creatinine ratio (uPCR)
review >100 mg/mmol creatinine
 Provide urine containers for early morning  Macroscopic haematuria
urine specimen (EMU)  Albumin < 30 g/dl
 Provide infoKID.org.uk web address for  eGFR < 90ml/min/1.73m2
information on HSP
YES

Refer to Paediatric Nephrology

Dr Andrew Lunn Page 4 of 17 June 2016

 See blood pressure centile charts in Appendices


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Nottingham University Hospitals
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General Paediatric Review at 1 Week Following


Diagnosis

 History and examination


 Urine dipstick
 Blood pressure measurement

 Complete GP follow up letter


and send urgently to GP (a YES  Normal urinalysis
template is available on NOTIS) AND
 Ensure patient/parents have  Normotensive
infoKID.org.uk website address
or print out infoKID HUS leaflet NO
if parents have no computer
access
Macroscopic haematuria YES NO
Urine protein ≥1+ → send urine prot:creat ratio (uPCR) YES NO
BP >95th centile on three occasions YES NO
Oedema YES NO

If NO to ALL of above

 General Paediatric follow up in one week.


 Print out GENERAL PAEDIATRIC PATHWAY and file in notes
 Ensure patient/parents have infoKID.org.uk website address or print out infoKID
HUS leaflet if parents have no computer access

If YES to ANY of above

 FBC, PRP, Clotting, ASOT, ANA, dsDNA, ANCA, C3, C4


 Renal USS
 Early morning urine for urine protein: creat ratio (uPCR)
 Ensure patient/parents have infoKID.org.uk website address or print out
infoKID HUS leaflet if parents have no computer access
 Refer to paediatric nephrology on call consultant – for review within 1 week
if above investigations abnormal or uPCR > 200 mg/mmol or uPCR > 100
mg/mmol and rising.
 General Paediatric follow-up pathway if investigations normal and uPCR
does not show significant proteinuria.

Dr Andrew Lunn Page 5 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

HSP Letter for GP if urinalysis/blood pressure normal at 1


week review

Date:_____/_____/_____ Date of Diagnosis:_____/_____/_____

Dear Dr ___________________,

RE:

____________________________ has been diagnosed with Henoch-Schönlein


Pupura (HSP). The urinalysis was normal and the blood pressure was:
______/______ using a small adult / adult cuff.
95% centile blood pressure for height centile is _____/_____.

All children with HSP require follow up screening for the development of HSP
nephritis which will develop in up to 50% of patients, usually within the first 6 weeks,
but sometimes up to 6 months after the initial episode.

We would be grateful if you could perform ongoing clinical review according to the
proforma below and refer to the general paediatrician on call (07713097061) if any
signs of nephritis develop.

Yours sincerely,

2 weeks post Macroscopic or microscopic haematuria YES NO


diagnosis (date): Urine protein ≥1+ YES NO
th
BP >95 centile on three occasions YES NO
Oedema YES NO
If YES to ANY of above refer to general paediatrician on call 07713097061
If No to all of above, review 1 month following diagnosis.
1 month post Macroscopic or microscopic haematuria YES NO
diagnosis (date): Urine protein ≥1+ YES NO
th
BP >95 centile on three occasions YES NO
Oedema YES NO
If YES to ANY of above refer to general paediatrician on call 07713097061
If NO to all of above, arrange review for 3 months following diagnosis.
3 months post Macroscopic or microscopic haematuria YES NO
diagnosis (date): Urine protein ≥1+ YES NO
th
BP >95 centile on three occasions YES NO
Oedema YES NO
If YES to ANY of above refer to general paediatrician on call 07713097061
If NO to all of above, arrange review for 6 months following diagnosis.
6 months post Macroscopic or microscopic haematuria YES NO
diagnosis (date): Urine protein≥1+ YES NO
BP >95th centile on three occasions YES NO
Oedema YES NO
If YES to ANY of above refer to general paediatrician on call 07713097061
If NO to all of above, no further follow up required
Dr Andrew Lunn Page 6 of 17 June 2016
Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

General Paediatric Pathway


for children with HSP nephritis
ie. All patients with microscopic haematuria
with no proteinuria at one week post diagnosis
Date of diagnosis: 95th centile for bp:
2 weeks post Macroscopic haematuria YES NO
diagnosis Urine protein ≥1+ → send urine prot:creat ratio (uPCR) YES NO
(date): uPCR >200 mg/mmol or >100 mg/mmol and increasing
BP >95th centile on three occasions YES NO
Oedema YES NO
If YES to any of above:
1) FBC, PRP, Clotting, ASOT, ANA, dsDNA, ANCA, C3, C4
2) Renal USS
3) Refer to paediatric nephrology – for review within 1 week
If NO to all of above, arrange paediatric review for 1 month following diagnosis
1 month post Macroscopic haematuria YES NO
diagnosis Urine protein ≥1+ → send urine prot:creat ratio (uPCR) YES NO
(date): uPCR >200 mg/mmol or >100 mg/mmol and increasing
BP >95th centile on three occasions YES NO
Oedema YES NO
If YES to any of above:
1) FBC, PRP, Clotting, ASOT, ANA, dsDNA, ANCA, C3, C4
2) Renal USS
3) Refer to paediatric nephrology – for review within 2 weeks
If NO to all of above, arrange paediatric review for 2 months following diagnosis
2 months Macroscopic haematuria YES NO
post Urine protein ≥1+ → send urine prot:creat ratio (uPCR) YES NO
diagnosis uPCR >200 mg/mmol or >100 mg/mmol and increasing
(date): BP >95th centile on three occasions YES NO
Oedema YES NO
If YES to any of above:
1) FBC, PRP, Clotting, ASOT, ANA, dsDNA, ANCA, C3, C4
2) Renal USS
3) Refer to paediatric nephrology – for review within 2 weeks
If NO to all of above, arrange paediatric review for 3 months following diagnosis
3 months Macroscopic haematuria YES NO
post Urine protein≥1+→ send urine prot:creat ratio (uPCR) YES NO
diagnosis uPCR >200 mg/mmol or >100 mg/mmol and increasing
(date): BP >95th centile on three occasions YES NO
Oedema YES NO
If YES to any of above:
1) FBC, PRP, Clotting, ASOT, ANA, dsDNA, ANCA, C3, C4
2) Renal USS
3) Refer to paediatric nephrology – for review within 1 month
If NO to all of above, arrange paediatric review for 6 months following diagnosis
Dr Andrew Lunn Page 7 of 17 June 2016
Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

6 months Macroscopic haematuria YES NO


post Urine protein ≥ 1+ → send urine prot:creat ratio (uPCR) YES NO
diagnosis uPCR >200 mg/mmol or >100 mg/mmol and increasing
(date): BP >95th centile on three occasions YES NO
Oedema YES NO
If YES to any of above:
1) FBC, PRP, Clotting, ASOT, ANA, dsDNA, ANCA, C3, C4
2) Renal USS
3) Refer to paediatric nephrology – for review within 1 month
If NO to all of above, arrange paediatric review for 12 months following diagnosis
12 months Macroscopic OR MICROSCOPIC haematuria YES NO
post Urine protein ≥1+ → send urine prot:creat ratio (uPCR) YES NO
diagnosis uPCR >50 mg/mmol
(date): BP >95th centile on three occasions YES NO
Oedema YES NO
If YES to any of above:
Continue to 1) FBC, PRP, Clotting, ASOT, ANA, dsDNA, ANCA, C3, C4
review 6 2) Renal USS
monthly 3) Refer to paediatric nephrology – for routine review

If NO to all of above for 2 consecutive clinic visits 6 months apart and


If urinalysis negative for ≥6 months and Discharge – no further follow up
never had a history of proteinuria ≥1+

If urinalysis negative for ≥6 months Discharge - arrange lifelong annual GP


but history of proteinuria ≥1+ • review of BP
• urine dipstick for proteinuria
• All female patients should be
counselled about the need to tell their GP
and obstetrician about their history of
HSP if they become pregnant.

Dr Andrew Lunn Page 8 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

Pathway for patients referred back during GP


assessment period:

Macroscopic haematuria YES NO


Urine protein ≥1+ → send urine prot:creat ratio YES NO
uPCR >200 mg/mmol or >100 mg/mmol and increasing
BP >95th centile on three occasions YES NO
Oedema YES NO

If NO to ALL of above (ie. Only microscopic haematuria without


significant proteinuria)

 General Paediatric follow up


o within one week if less than 2 months following diagnosis
o within two weeks if more than 2 months following diagnosis.
 Print out general paediatric pathway (p6 and 7) and file in notes

If YES to ANY of above

 Refer to paediatric nephrology on call consultant


 Request Renal USS

Dr Andrew Lunn Page 9 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

2. Background
 HSP is the most common vasculitis of childhood
 Incidence1
 estimated 20.4 per 100,000 children in the UK
 more common in Asian (24.0 per 100,000) and caucasian (17.8 per 100,000)
children
 less common in Afrocarribean children (6.2 per 100,000)
 Can affect any age but rare in infants and adults
 Peak incidence between 4-7 years (70.3 per 100,000)
 Male to female ratio 1.2-1.8:1.0
 More common in winter, autumn and spring than summer2

3. Clinical Features
HSP is a small vessel vasculitis that can affect many different organs:

Dominant Features Uncommon Features


 Rash  Intussusception
 Abdominal pain ± nausea and  Haematemesis and malaena
vomiting  Scrotal/testicular swelling
 Arthritis/arthralgia  Pancreatitis/gall bladder involvement
 Nephritis  Case reports of vasculitis involving
lung, brain and heart

3.1. Skin
 Almost 100% children will develop a non-blanching rash, however it may develop
late in some children presenting initially with other features.
 Petechiae, purpura, ecchymoses
 Often starts as erythematous maculopapular or urticarial appearance
 Extensor surfaces
 Often symmetrical
 Classically lower limbs and buttocks
 Rash on face, trunk, arms in non-ambulant children
 Sensitivity 90% if localised to lower limbs and buttocks3
 Sensitivity drops to 20% if more widespread (see other causes below)

3.2. Joints
 Arthritis or arthralgias, oligo-articular
 First symptom in 15% of patients
 Knee (38%) and ankle (85%) most common4
 Usually within 1-4 weeks of diagnosis
 Transient or migratory – often improves within 2-3 days

3.3. Gastrointestinal
 50-75% of patients
 Precedes rash in 10% of cases4
 Common
 Nausea and vomiting
 Colicky abdominal pain – often improves within 2-3 days
 Gastrointestinal bleeding (8%)
 Paralytic ileus
Dr Andrew Lunn Page 10 of 17 June 2016
Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

 Uncommon
 Intussusception
 Pancreatitis
 Protein losing enteropathy – hypoalbuminaemia and oedema without
proteinuria
 Rare
 Ischaemia and necrosis without intussusception
 Gall bladder involvement
 Intestinal perforation

3.4. Renal
 20-54% of patients (reports vary based on definition of microscopic haematuria)
 Isolated hypertension
 Spectrum of presentation5:
 Isolated haematuria (micro or macroscopic) ± proteinuria
 Nephritic or nephrotic syndrome
 A minority of patients will progress to end-stage renal failure (see below)

3.5. Other
 Orchitis (must consider testicular torsion as differential diagnosis)
 Intracranial (headaches, seizures, encephalopathy)
 Lung (case reports)
 Heart (case reports)

4. Diagnosis
The diagnosis of HSP is made on clinical grounds. There is no objective
laboratory test that will confirm a diagnosis.

HSP should remain in the differential diagnosis of any patient presenting with
abdominal pain with or without a skin rash. This is one of the reasons why urinalysis
in children presenting with non-specific abdominal pain is so important.

It is important to consider other causes of non-blanching rash:


 Disseminated intravascular coagulation
 Meningococcal sepsis
 Other sepsis
 Other vasculitides
 Cutaneous small vessel vasculitis
 Granulomatosis with polyangitis (formerly Wegener’s)
 Systemic lupus erythematous (SLE)
 Microscopic polyarteritis
 Polyarteritis nodosa
 Causes of thrombocytopaenia
 Reduced production: leukaemic, aplastic anaemia
 Increased destruction: Idiopathic thrombocytopaenic purpura, haemolytic
uraemic syndrome
 Hypersplenism

Dr Andrew Lunn Page 11 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

5. Investigation
The role of investigation is to exclude other diagnoses suspected on clinical grounds
and to identify patients with renal involvement.

All patients should have:


 Blood pressure
 Dipstick urinalysis

If the presentation is classical, the child does not have features requiring admission
and the blood pressure and urinalysis are normal, blood tests are not necessary.

In patients where there is uncertainty about the diagnosis the following tests
should be considered:
 Full blood count to exclude thrombocytopenia and autoimmune cytopenias.
 Electrolytes, urea and creatinine if:
 the urinalysis demonstrates ++ proteinuria or more
 hypertension
 oliguria
 or concerns about dehydration or fluid overload
 Coagulation Studies if there are features aside from the rash consistent with
sepsis or a bleeding disorder.
 Autoantibodies should be discussed with paediatric registrar or consultant on
call.
 Blood culture if there is concern about sepsis (remember antibiotics should
be given within one hour).
 Renal tract ultrasound.
 Early morning urine protein:creatinine ratio (P:Cr) can be performed to
exclude orthostatic proteinuria and quantify pathological proteinuria in a child with
a dipstick positive for protein.

6. Indications for Admission


 Any indication of renal involvement
 Hypertension
 Estimated GFR (eGFR) ,90 ml/min/1.73 m2 as reported with automated
reporting system.
 If automated reporting not available calculate eGFRwith Schwartz Formula:

eGFR = (height (cm) x K) / serum creatinine (µmol/l)

K differs according to the method used to measure creatinine.


In Nottingham: K = 36 for males 13 years of age or older
K = 30 for all others

 Cases with glomerulonephritis, nephrotic syndrome or abnormal eGFR


should be discussed with the nephrology registrar or consultant on call.
 Severe joint pain
 Severe abdominal pain
 Gastrointestinal haemorrhage
 Any neurological symptom
 Other atypical features should be discussed with the paediatric registrar or
consultant on call.

Dr Andrew Lunn Page 12 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

7. Management
7.1. Supportive
 Hydration
 Simple analgesia
 Paracetamol
 NSAIDs – if hypertension or evidence of renal involvement discuss
with nephrologist
 There is no evidence to suggest that use of NSAIDs for short periods
increases the risk of GI bleeding in otherwise well children.

7.2. Steroids
 There is no strong evidence supporting the routine use of prednisolone to
reduce the long-term renal outcome in children with HSP (Evidence Level
1a).6, 10
 In children with severe abdominal or joint pain not responding to simple
analgesia, a course of prednisolone 1mg/kg daily for 1-2 weeks may be
considered after discussion with treating consultant (Evidence Level 1b).7,8
 Surgical review must be considered prior to the use of steroids in HSP
abdominal pain.

7.3. Nephrology referral


 Nephritic syndrome (haematuria, hypertension, oliguria, abnormal GFR)
 Nephrotic syndrome (proteinuria >200 mg/mmol creatinine,
hypoalbuminaemia <25 g/L, oedema)
 Abnormal GFR
 Any other renal concern eg. Isolated hypertension or lower grade proteinuria
 The aim is to detect those with severe renal involvement in order to
commence immunosuppressive therapy early to reduce the risk of renal
damage.

7.4. Other Specialist referral


 Consider urgent surgical referral if possible intussusception, perforation or
testicular torsion.
 Dermatology advice may be helpful if skin involvement is severe
 Consider gastroenterology referral if severe gut involvement

8. Follow Up
 All patients fit for discharge should be reviewed at 1 week following first
symptoms. Depending on results of urinalysis and blood pressure measurement
they should be followed up for at least 6 months by
o GP (if urinalysis negative) – according to HSP letter for GP (p5)
o General Paediatrician (microscopic haematuria, proteinuria
<200mg/mmol) – according to general paediatric pathway (p6,7)
o Paediatric Nephrologist (macroscopic haematuria, proteinuria >200
mg/mmol, hypertension, oedema)

 Provide all parents with information about the condition (www.infoKID.org.uk).

 Parents should not be given urine dipsticks for home testing, but should be
given urine containers so an early morning urine can be brought to each clinic
appointment.

Dr Andrew Lunn Page 13 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

9. Outcome
HSP without renal involvement:
 The majority of children make a full recovery.
 HSP relapse rates have been reported up to 35% of patients2 – these can be
managed as described above for a primary episode.
 A small proportion will develop late renal involvement during follow-up. Of those
children who will develop renal involvement:
 84% will be identified within 4 weeks,
 90% will be identified within 6 weeks,
 97% will be identified within 6 months.
Risk of long term renal impairment5:
 If isolated haematuria or proteinuria – 1.6%
 If nephritis or nephrotic syndrome – 19.5% (2.5 times greater in females)

Dr Andrew Lunn Page 14 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

10. References

1. Gardner-Medwin JMM, Dolezalova P, Cummins C, Southwood TR. Incidence of


Henoch-Schönlein purpura, Kawasaki disease, and rare vasculitides in children of
different ethnic origins. Lancet. 2002; 360: 1197–202.

2. Trapani S, Micheli A, Francesca G, Resti M, Chiappini E, Falcini F et al. Henoch


Schönlein purpura in childhood: epidemiological and clinical analysis of 150 cases
over a 5-year period and review of literature. Semin Arthritis Rheum. 2005; 35: 143–
53.

3. Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin, Brik R et al.


EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis
nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis:
Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis. 2010; 69: 798–806.

4. Jauhola O, Ronkainen J, Koskimies O, Ala-Houhala M, Arikoski P, Hölttä T et al.


Clinical course of extrarenal symptoms in Henoch-Schönlein purpura: a 6-month
prospective study. Arch Dis Child. 2010; 95: 871–876.

5. Narchi H. Risk of long term renal impairment and duration of follow up


recommended for Henoch-Schönlein purpura with normal or minimal urinary findings:
a systematic review. Arch Dis Child. 2005; 90: 916–920.

6. Chartapisak W, Opastirakul S, Hodson EM, Willis NS, Craig JC. Interventions for
preventing and treating kidney disease in Henoch-Schönlein Purpura (HSP).
Cochrane Database of Systematic Reviews. 2009, Issue 3. Art. No.: CD005128.

7. Ronkainen J, Koskimies O, Ala-Houhala M, Antikainen M, Merenmies J, Rajantie J


et al. Early prednisolone therapy in Henoch-Schönlein purpura: a randomized,
double-blind, placebo-controlled trial. J Pediatr. 2006; 149(2): 241-247

8. Weiss PF, Feinstein JA, Luan X, Burnham JM, Feudtner C. Corticosteroids May
Improve Clinical Outcomes During Hospitalisation for Henoch-Schönlein Purpura.
Pediatrics. 2010; 126(4): 674-681

9. Watson L, Richardson AR, Holt RC, Jones CA, Beresford MW. Henoch Schönlein
Purpura – A 5–Year Review and Proposed Pathway. PLoS ONE. 2012; 7(1): e29512

10. Dudley J, Smith G, Llewelyn-Edwards A et al. Rabndomised, double blind,


placebo-controlled trial to determine whether steroids reduce the incidence and
severity of nephropathy in Henoch-Schonlein Purpura (HSP). Arch Dis Child 2013;
98: 756-763

11. Audit Points


1. Adherence to flow charts
2. Long term outcome of patients with renal involvement

Dr Andrew Lunn Page 15 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

Appendix 1: Blood pressure centiles for boys by age


and height percentile

Dr Andrew Lunn Page 16 of 17 June 2016


Not t ingham Children’s Hospit al
Nottingham University Hospitals
NHS Trust

Appendix 2: Blood pressure centiles for girls by age


and height percentile

Dr Andrew Lunn Page 17 of 17 June 2016