(HSP). - Nottingham University Hospitals NHS Trust

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Nottingham University Hospitals
NHS Trust
Henoch-Schönlein Purpura (HSP)
Title of Guideline (must include the word “Guideline” (not
protocol, policy, procedure etc)
Contact Name and Job Title (author)
Directorate & Speciality
Date of submission
Date on which guideline must be reviewed (this should be
one to three years)
Explicit definition of patient group to which it applies (e.g.
inclusion and exclusion criteria, diagnosis)
Abstract
Key Words
Statement of the evidence base of the guideline – has the
guideline been peer reviewed by colleagues?
Evidence base: (1-5)
1a
meta analysis of randomised controlled trials
1b
at least one randomised controlled trial
2a
at least one well-designed controlled study without
randomisation
2b
at least one other type of well-designed quasiexperimental study
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
Target audience
Guideline for Management of
Henoch-Schönlein Purpura and
Henoch-Schönlein Purpura
Nephritis
Dr. Tom Forbes
Paediatric Nephrology Registrar
Dr. Andrew Lunn
Consultant Paediatric Nephrologist
Dr Corinne Langstaff
Consultant Paediatric Nephrologist
Family Health,
Renal
July 2016
July 2019
All children with a diagnosis of
Henoch-Schönlein Purpura (HSP)
This guideline describes the diagnosis
and management of HSP in the
paediatric population, including a
pathway for screening for renal
involvement.
Paediatrics, Children, HenochSchönlein, purpura, HSP, vasculitis,
renal, nephritis, abdominal pain,
arthritis
Use of corticosteroids not indicated to
prevent renal involvement in HSP – 1a
Use of corticosteroids in severe HSP
abdominal pain or arthritis – 1b
Screening Pathway for HSP Nephritis
–3
Paediatric Nephrology Consultants
General Paediatric Consultants
Paediatric Clinical Guidelines Group
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
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Document History
Version Number
Date Produced
Author
V1
Jan 2005
V2
Dec 2009
Dr F Hussain
V3
June 2013
v4
June 2016
Dr T Forbes, Dr A Lunn
Dr C Langstaff
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
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Nottingham University Hospitals
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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
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Nottingham University Hospitals
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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
AND
Normotensive
NO







Any Haematuria or Proteinuria on dipstick
AND / OR
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
 Severe abdo pain
 GI haemorrhage
 Neurological symptoms
 Other acute complications eg.orchitis
Confirm diagnosis with registrar or
consultant.
Organise general paediatric review within
1 week
Counsel re: indications for further medical
review
Provide urine containers for early morning
urine specimen (EMU)
Provide infoKID.org.uk web address for
information on HSP
YES
Admit under general paediatrics
Are any of the following present?
 Hypertension
 Urine Protein:creatinine ratio (uPCR)
>100 mg/mmol creatinine
 Macroscopic haematuria
 Albumin < 30 g/dl
 eGFR < 90ml/min/1.73m2
YES
Refer to Paediatric Nephrology
Dr Andrew Lunn

See blood pressure centile charts in Appendices
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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
YES
 Normal urinalysis
and send urgently to GP (a
AND
template is available on NOTIS)
 Normotensive
Ensure patient/parents have
infoKID.org.uk website address
or print out infoKID HUS leaflet
NO
if parents have no computer
access
Macroscopic haematuria
Urine protein ≥1+ → send urine prot:creat ratio (uPCR)
BP >95th centile on three occasions
Oedema
YES
YES
YES
YES
NO
NO
NO
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
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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
diagnosis (date):
Macroscopic or microscopic haematuria
YES
Urine protein ≥1+
YES
th
BP >95 centile on three occasions
YES
Oedema
YES
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
diagnosis (date): Urine protein ≥1+
YES
th
BP >95 centile on three occasions
YES
Oedema
YES
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
diagnosis (date): Urine protein ≥1+
YES
th
BP >95 centile on three occasions
YES
Oedema
YES
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
diagnosis (date): Urine protein≥1+
YES
BP >95th centile on three occasions
YES
Oedema
YES
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
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
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
diagnosis
(date):
Macroscopic haematuria
YES NO
Urine protein ≥1+ → send urine prot:creat ratio (uPCR)
YES NO
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
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Nottingham University Hospitals
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6 months
post
diagnosis
(date):
Macroscopic haematuria
YES NO
Urine protein ≥ 1+ → send urine prot:creat ratio (uPCR) YES NO
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 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
but history of proteinuria ≥1+
Dr Andrew Lunn
Discharge - arrange lifelong annual GP
•
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.
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Pathway for patients referred back during GP
assessment period:
Macroscopic haematuria
Urine protein ≥1+ → send urine prot:creat ratio
uPCR >200 mg/mmol or >100 mg/mmol and increasing
BP >95th centile on three occasions
Oedema
YES NO
YES NO
YES NO
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
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Nottingham University Hospitals
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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
 Rash
 Abdominal pain ± nausea and
vomiting
 Arthritis/arthralgia
 Nephritis
Uncommon Features
 Intussusception
 Haematemesis and malaena
 Scrotal/testicular swelling
 Pancreatitis/gall bladder involvement
 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
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

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
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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
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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
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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
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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
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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
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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