Clinical characteristics and outcomes of children with hypertensive encephalopathy

Abstract

Background

Hypertensive encephalopathy (HE) is characterized by a severe increase in blood pressure, leading to neurological symptoms such as severe headache, seizure, and mental status change. Prompt medical treatment is crucial, often leading to full recovery without long-term neurological deficits. However, untreated cases can result in serious complications. This study aimed to describe the clinical characteristics and outcomes of children who developed HE.

Materials and methods

A retrospective review of medical records in patients aged < 18 years diagnosed with HE in Ramathibodi Hospital was conducted. Data were collected, including demographics, underlying conditions, clinical presentations, blood pressure levels during HE, medications used, diagnostic investigations, and outcomes. Patients with pre-existing neurological symptoms or incomplete data were excluded. Data between the groups with kidney diseases and non-kidney diseases were compared.

Results

Fifty-three patients (26 males) were included with a mean age of 8.9 ± 4 years and a median follow-up time of 47.8 months. Kidney disease (51%) was the most common cause of hypertension. Patients with kidney disease were older (10.3 vs. 7.5 years, p = 0.01), had a shorter duration between the diagnosis of underlying conditions and development of HE (70 vs. 457 days, p = 0.04), and a larger proportion of females (66.7% vs. 34.6%, p = 0.02). Neither clinical manifestations, such as generalized tonic-clonic seizures, headaches, and mental status changes, nor survival were different between the kidney and non-kidney groups. Five patients who developed recurrent episodes of HE had the underlying diseases involving endothelial injuries, such as small vessel vasculitis, and were on calcineurin inhibitors after hematopoietic stem cell transplantation (HSCT).

Conclusions

Patients with kidney diseases were older and developed HE earlier, but there was no difference in survival between the kidney and non-kidney groups. Recurrent episodes of HE were detected in patients with small vessel vasculitis or taking calcineurin inhibitors after HSCT, prompting the pediatricians to be vigilant for blood pressure control in these patients.

Introduction

Hypertensive encephalopathy (HE) is defined by a severe blood pressure elevation resulting in neurological symptoms like severe headache, nausea, vomiting, alteration of consciousness, and seizures [1]. In normal circumstances, the brain maintains constant blood flow despite changes in blood pressure, which is called cerebral autoregulation [2]. However, severe hypertension disrupts the cerebral endothelium and blood-brain barrier, narrowing the vascular lumen by fibrinoid material deposition and inducing vasodilation, leading to cerebral edema and micro-hemorrhages. In this condition, cerebral imaging can vary from normal findings to typical lesions of posterior reversible encephalopathy syndrome (PRES), which is a reversible clinic-radiological syndrome often linked with acute severe hypertension and conditions like eclampsia, sepsis, autoimmune disease, and transplantation [3–5].

Common presentation of HE ranges from headache and mental status change to seizure, with acute post-streptococcal glomerulonephritis and hemato-oncologic diseases being two of the most common causes, followed by those who received hematopoietic stem cell transplantation [6, 7]. Another study from Korea [8] compared children with kidney and non-kidney diseases and revealed a higher systolic blood pressure (SBP) at presentation (172.5 mmHg vs. 137.1 mmHg), and a greater incidence of PRES in the kidney group (66.6% vs. 12.5%). A recent study in Thailand [7] also noted a higher baseline blood pressure in children with kidney diseases who were diagnosed with PRES. MRI was shown abnormal findings in the parietal and occipital lobes in the majority of patients (42 out of 47 patients) [9]. Mortality was reported to be about 20% in hemato-oncologic patients with PRES [10], but a lower rate of mortality was reported in those who had kidney conditions [7].

While these studies provide valuable insights into HE and PRES, there are still limited data on the characteristics and outcomes of HE in pediatric patients. Therefore, this study aimed to compare the clinical characteristics and outcomes of pediatric HE patients with and without kidney disease and to identify the risk factors associated with recurrent HE episodes.

Materials and methods

Study design

This study was conducted retrospectively by reviewing medical records of patients admitted or referred during the years 2015–2023 due to HE to Ramathibodi Hospital, Bangkok, Thailand. It was approved by the Ethics Committee for Human Research from the Faculty of Medicine Ramathibodi Hospital Mahidol University (MURA 2023/373). HE was defined by patients with severe hypertension who developed any neurological symptoms such as headache, alteration of consciousness, or seizure. Patients under 18 years old who had experienced at least one HE episode were included, but those with incomplete data or pre-existing neurological conditions such as epilepsy were excluded.

Data collection

Data, including four main categories, were collected: demographic data, pre-HE data, data during the development of HE, and outcomes. Demographic data included gender, age, and underlying diseases. Pre-HE data included underlying disease, the timing of its diagnosis, and the medications being taken. Data during HE development included clinical presentation, blood pressure measured by oscillometric devices, body weight, and height. For comparisons of parameters between different age groups, body mass index was calculated for z-score for age and gender using the WHO Anthroplus software, and blood pressure was calculated for index by dividing blood pressure with the age-gender specific cut-off for hypertension in each patient [11] (index > 1, meaning that the patient’s blood pressure is above the cut-off for hypertension). Results from various investigations were also obtained, including creatinine (Cr) and estimated glomerular filtration rate (eGFR) by the Schwartz formula [12]. Furthermore, imaging studies, including computerized tomography (CT), magnetic resonance imaging (MRI), and electroencephalography (EEG) results, were also collected to provide a comprehensive understanding of neurological involvement during this phase.

Posterior reversible encephalopathy syndrome (PRES) from cerebral imaging is defined as the presence of vasogenic edema that appears as a hyperintense signal on T2 MRI with the fluid-attenuated inversion recovery (FLAIR) sequences, or hypodensity on CT, typically seen in parieto-occipital regions. Finally, outcome data included the number of HE episodes, the duration of anti-seizure medication (ASM) use, and the survival rate.

Statistical analysis

Data were analyzed using IBM SPSS version 29. The Kolgomorov-Smirnov test was used to test for normality. The T-test or Mann-Whitney test was used to compare continuous data, and the Fisher exact or Chi-square test was used to compare categorical data. Statistical significance was identified when the p-value was less than 0.05.

Results

Study population

A total of fifty-three (26 males) patients with a mean age of 8.96 years were included in the present study, after excluding four cases with incomplete data. The patients were divided into two groups based on the causes of hypertension: the kidney group (N = 27) and the non-kidney group (N = 26). In the kidney group, 9 patients had lupus nephritis, while the remaining 18 had other kidney-related conditions. The non-kidney group included 18 patients with hemato-oncologic diseases, including 8 patients who received hematopoietic stem cell transplantation (HSCT). Five patients had gastrointestinal diseases. Two patients with rheumatologic diseases were diagnosed with juvenile idiopathic arthritis and systemic lupus erythematosus without nephritis. There was one healthy child admitted due to respiratory syncytial virus (RSV) bronchitis and received steroid treatment, as shown in Table 1.

Table 1.

Underlying diseases of the patients in the present study

Underlying diseases	Number of patients
Kidney diseases (N = 27)
• Lupus nephritis	9
• Takayasu arteritis with renal artery stenosis	4
• Nephrotic syndrome	6
• Acute post-streptococcal glomerulonephritis	1
• Henoch-SchÖnlein purpura	3
• End-stage kidney disease from unknown cause	1
• Microscopic polyangiitis	1
• Vesicoureteral reflux	1
Hematologic/oncologic diseases (N = 18)
• Post-HSCT (N = 8)
- Transfusion-dependent thalassemia	4
- Hematologic malignancy	1
- Evans syndrome	1
- Hyper-IgM syndrome	1
- Dyskeratosis congenita	1
• Non-HSCT (N = 10)
- Hematologic malignancy	7
- Solid tumor	1
- Transfusion-dependent thalassemia	1
- Aplastic anemia	1
Gastrointestinal diseases (N = 5)
• Biliary atresia s/p liver transplantation	4
• Crohn disease	1
Rheumatologic diseases (no kidney involvement)	2
A previously healthy child with respiratory syncytial virus bronchitis	1

HSCT hematopoietic stem cell transplantation

Clinical data between the kidney and non-kidney groups

Table 2 shows a comparison of parameters between the kidney and non-kidney groups. The patients in the kidney group had a significantly older age (10.33 vs. 7.54 ears, p = 0.01) and more females (66.7 vs. 34.6%, p = 0.02) than the non-kidney group. The median duration from the onset of the underlying disease to the development of HE was significantly shorter in the kidney group compared to the non-kidney group (70 vs. 457 days, p = 0.04). The number of patients who developed hypertension prior to HE was similar between the two groups (44.4% vs. 69.2%, p = 0.132), while anti-hypertensive medications used before developing HE were significantly higher in the kidney group than in the non-kidney group. At the time of HE, the SBP index in the kidney group showed a trend toward higher (1.40 vs. 1.29, p = 0.069) compared to the non-kidney group, though this difference did not reach statistical significance. The steroid dosage used before developing HE was comparable between the two groups (5.71 vs. 4.9 mg/kg/day of hydrocortisone equivalence, p = 0.889). Generalized tonic-clonic seizure was the most common presentation, with a higher proportion in the kidney group compared with the non-kidney group (74.1 vs. 42.3%, p = 0.019). Meanwhile, the other symptoms, including headache, visual impairment, nausea, vomiting, and alteration of consciousness, were not statistically significantly different.

Table 2.

Clinical parameters between the kidney and non-kidney groups

Parameters	All (N = 53)	Kidney (N = 27)	Non-Kidney (N = 26)	p-value
Age (years); mean (SD)	8.96 (4.03)	10.33 (3.77)	7.54 (3.85)	0.01
Gender (male); N (%)	26 (49.1%)	9 (33.3%)	17 (65.4%)	0.02
Duration from diagnosis of underlying condition before HE, days; median (IQR)	130 (18.5-712.5)	70 (14–196)	457 (19.8–1563)	0.04
BMI z-score; mean (SD)	0.1 (1.89)	−0.14 (1.76)	0.36 (2.02)	0.33
SBP index; mean (SD)	1.35 (0.22)	1.40 (0.23)	1.29 (0.19)	0.069
DBP index; median (IQR)	1.3 (1.2–1.5)	1.3 (1.2–1.5)	1.2 (1.1–1.5)	0.215
Number of patients developed hypertension prior to HE; N (%)	37 (56.6%)	22 (44.4%)	15 (69.2%)	0.059
Number of patients treated for hypertension prior to HE; N (%)	32 (56.6%)	20/22 (91%)	12/15 (80%)	0.34
Number of anti-hypertensive medications used prior to HE; median (IQR)	2.5 (1–3)	3 (2-3.5)	1 (1–2)	0.01
Anti-hypertensive medications used before HE
- Enalapril	10 (18.9%)	7 (25.9%)	3 (11.5%)	0.293
- Losartan	2 (3.8%)	2 (7.4%)	0 (0%)	0.491
- Amlodipine	30 (56.6%)	18 (66.7%)	12 (46.2%)	0.132
- Atenolol	11 (20.8%)	7 (25.9%)	4 (15.4%)	0.344
- Doxazosin	5 (9.4%)	5 (18.5%)	0 (0%)	0.051
- Hydralazine	10 (18.9%)	10 (37%)	0 (0%)	< 0.001
Clinical manifestations
- Generalized tonic-clonic seizure	31 (58.5%)	20 (74.1%)	11 (42.3%)	0.019
- Focal seizure	19 (35.8%)	4 (14.8%)	15 (57.7%)	0.001
- Headache	21 (39.6%)	10 (37%)	11 (42.3%)	0.695
- Visual impairment	5 (9.4%)	1 (3.7%)	4 (15.4%)	0.192
- Nausea	4 (7.5%)	3 (11.1%)	1 (3.8%)	0.61
- Vomiting	7 (13.2%)	5 (18.5%)	2 (7.7%)	0.42
- Alteration of consciousness	14 (26.4%)	6 (22.2%)	8 (30.8%)	0.48
eGFR, ml/min/1.73m2; mean (SD)	119.09 (76.43)	81.98 (61.54)	157.64 (71.96)	< 0.001
CT performed, N (%)	44 (83.02%)	19 (70.37%)	25 (96.15%)	0.024
CT results (N = 44)
- Normal	15 (34.1%)	5 (26.3%)	10 (40%)	0.343
- PRES	27 (61.4%)	14 (73.7%)	13 (52%)	0.143
- Hypodensity at occipital lobe	22 (50%)	12 (63.2%)	10 (40%)	0.128
- Hypodensity at parietal lobe	25 (56.8%)	13 (68.4%)	12 (48%)	0.176
- Hemorrhage	4 (9.1%)	1 (5.3%)	3 (12%)	0.622
- Thrombosis	2 (4.5%)	0 (0%)	2 (8%)	0.498
MRI performed, N (%)	30 (56.6%)	13 (48.15%)	17 (65.38%)	0.206
MRI results (N = 30)
- Normal, N (%)	7 (23.33%)	2 (15.38%)	5 (29.41%)	0.427
- PRES, N (%)	23 (76.67%)	11 (84.6%)	12 (70.6%)	0.427
- Hemorrhage, N (%)	1 (3.3%)	1 (7.7%)	0 (0%)	0.433
- Thrombosis, N (%)	2 (6.7%)	1 (7.7%)	1 (5.9%)	1.0
EEG performed, N (%)	28 (52.83%)	17 (62.96%)	11 (42.31%)	0.132
EEG results (N = 28)
- Normal, N (%)	12 (42.86%)	7 (41.18%)	5 (45.45%)	1.0
- Continuous slow activity, N (%)	16 (57.14%)	10 (58.82%)	6 (54.55%)	1.0
- Epileptiform discharge, N (%)	4 (14.29%)	3 (17.65%)	1 (9.09%)	1.0
The last anti-seizure medication (ASM) to control seizures
- No ASM	10 (18.87%)	5 (18.52%)	5 (19.23%)	0.054
- Levetiracetam	23 (43.40%)	8 (29.63%)	15 (57.69%)
- Phenytoin	13 (24.53%)	10 (37.04%)	3 (11.54%)
- Sodium valproate	3 (5.66%)	3 (11.11%)	0 (0%)
- Phenobarbital	2 (3.77%)	1 (3.70%)	1 (3.85%)
- Topiramate	2 (3.77%)	0 (0%)	2 (7.69%)
Duration of anti-seizure medication, days; median (IQR)	75 (12–373)	113 (7-373)	63.5 (18-393.75)	0.569
Number of recurrent episodes; median (IQR)	1 (1–1)	1 (1–1)	1 (1–1)	0.965
Duration of follow-up (months); mean (SD)	49.77 (44.49)	56.78 (46.99)	42.50 (41.38)	0.247
Survival at last follow-up; N (%)	44 (83%)	24 (88.9%)	20 (76.9%)	0.293

SD standard deviation, IQR inter-quartile range, BMI body mass index, SBP systolic blood pressure, DBP diastolic blood pressure, eGFR estimated glomerular filtration rate, CT computerized tomography, MRI magnetic resonance imaging, PRES posterior reversible encephalopathy syndrome, CNS central nervous system; EEG, electroencephalography

Imaging and electroencephalography

Imaging and EEG findings were also assessed. Among 44 patients who had a CT scan, normal findings were slightly more common in the non-kidney group (40%) compared to the kidney group (26.3%), though there was no statistically significant (p = 0.343). Hypodensities in various parts of the brain were observed in both groups, with the parietal lobe being the most involved. Typical PRES lesion was identified more frequently in the kidney group than in the non-kidney group, but it was no significant difference (73.7% vs. 52%, p = 0.143).

Among 30 patients who underwent MRI, PRES remained the most common finding seen in both groups. Hemorrhage and thrombosis were rare in both CT and MRI findings. EEG was assessed in 28 patients (52.8%). Normal EEG findings were observed in 41.2% and 45.5% of the kidney and non-kidney groups, respectively. Continuous slow activity was seen similarly between the two groups, while epileptiform discharges were identified in only a small number of patients, with involvement observed in the temporal lobe (2 cases), frontal lobe (1 case), and a combined parietal–occipital distribution in one case.

Outcomes

Only 10 patients with HE (18.87%) did not need anti-seizure medication (ASM), while the rest were on ASM, with 43.4% receiving levetiracetam as the most common ASM for seizure control. Phenytoin, sodium valproate, phenobarbital, and topiramate were used in smaller proportions between the two groups. The median duration of ASM used was not significantly different between the two groups (113 vs. 63 days, p = 0.569). Follow-up imaging was conducted only in 16 patients, with 8 from each group. From the kidney group, half of the patients had normal imaging (either CT or MRI) while 25% showed complete resolution of PRES, and the rest 25% showed only partial resolution of PRES, with no progression of imaging in this group. In the non-kidney group, 1 patient had a progression of PRES, and another patient showed permanent damage from PRES. A follow-up EEG was also performed in 11 patients, with 5 from the kidney group and 6 from the non-kidney group. Most of the patients showed normal EEG, except for 1 patient from the non-kidney group who remained abnormal.

The overall survival rate was high (83%), with no significant differences between the two groups. Among the nine patients who expired during follow-up, three were from the kidney group, and six were from the non-kidney group. The causes of death were sepsis, except for one patient in the kidney group, who experienced fatal cerebral hemorrhage and brain herniation following the fourth episode of HE, and one patient in the non-kidney group, who expired after receiving palliative care.

Recurrent episode of HE

Table 3 describes the characteristics of 5 patients with recurrent episodes of HE. Comparing the recurrent and non-recurrent HE groups (Table 4), there was no significant difference in age, duration of ASM, and survival between the two groups. Nonetheless, imaging findings indicated that the recurrent HE group exhibited a higher number of CT lesions in the first HE episode (2.5 vs. 1, p = 0.115) compared to the non-recurrent group, though it was still not significantly different. For blood pressure indices, while not significantly different between the two groups, there was a trend toward lower SBP and DBP indices in the recurrent group. Interestingly, the proportion of patients with small vessel vasculitis (lupus nephritis and microscopic polyangiitis) and being on calcineurin inhibitors after HSCT was significantly more common in the recurrent than the non-recurrent groups.

Table 3.

Characteristics of 5 patients with recurrent hypertensive encephalopathy

Gender	Underlying diseases	Post-HSCT	Small vessel vasculitis	Age (years)	Imaging	Episodes
Female	Beta thalassemia major	✓		14	PRES	3
Female	End-stage kidney disease from microscopic polyangiitis		✓	11	PRES	4
Female	SLE with LN		✓	9	PRES	2
Male	SLE with LN		✓	14	PRES	2
Male	Dyskeratosis congenita	✓		11	Atypical PRES	2

HSCT hematopoietic stem cell transplantation, SLE systemic lupus erythematosus, LN lupus nephritis, PRES posterior reversible encephalopathy syndrome

Table 4.

Clinical parameters at the first episode of HE compared between the recurrent and non-recurrent HE groups

Parameters	Non-recurrence (N = 48)	Recurrence (N = 5)	p-value
Age (years), mean (SD)	9.19 (4.13)	11.8 (2.17)	0.157
Small vessel vasculitis or CNI used in post-HSCT; N (%)	17 (35.42%)	5 (100%)	0.009
Kidney diseases; N (%)	24 (50%)	3 (60%)	0.670
SBP index, mean (SD)	1.36 (0.22)	1.22 (0.15)	0.152
DBP index, mean (SD)	1.40 (0.33)	1.18 (0.14)	0.120
Numbers of CT lesions, median (IQR)	1 (0–2)	2.5 (2-3.75)	0.115
Duration of ASM, median (IQR)	63.5 (13–293)	372 (187–293)	0.889
Duration of follow-up (months); mean (SD)	51.04 (43.81)	37.6 (54.52)	0.525
Survival at last follow-up; N (%)	41 (85.4%)	3 (60%)	0.196

SD standard deviation, IQR inter-quartile range, HSCT hematopoietic stem cell transplantation, SBP systolic blood pressure, DBP diastolic blood pressure, CT computerized tomography, ASM anti-seizure medications

Discussion

The present study highlights insights into the clinical characteristics and outcomes of pediatric HE. The kidney group experienced HE at an older age, was predominantly female, developed an episode of HE earlier, and required a higher number of anti-hypertensive medications than the non-kidney group. Almost 10% of patients developed recurrent episodes of HE, and this was seen as more common in patients with small vessel vasculitis or post-HSCT.

There are limited data on the clinical outcomes of children with HE. Most of the previous studies were retrospectively conducted in a single center. In the present study, most patients in the kidney group were older females with lupus nephritis compared to the non-kidney group, which is consistent with the previous study in Thailand [7]. However, another study in Korea [8] revealed that the kidney group had a younger age. This discrepancy may be attributed to differences in the causes of hypertension between the studies. In the latter study, the common cause of hypertension in the kidney group was renal artery stenosis, with a lesser proportion being lupus nephritis. In addition, the present study revealed that the kidney group developed HE earlier after diagnosis of the underlying diseases and required a higher number of anti-hypertensive medications than those in the non-kidney group, as these patients developed HT during the course of acute glomerulopathy. On the other hand, the non-kidney patients were mainly diagnosed with hematologic or oncologic diseases during pre-adolescence and later developed HE after hematopoietic stem cell transplantation (HSCT), about 1–2 years after diagnosis. At the first HE episode, the kidney group showed a trend toward higher systolic blood pressure than the non-kidney group. These findings were also observed in the previous studies [7, 13]. Altogether, these findings emphasize the importance of monitoring and early intervention in pediatric patients, especially those with kidney diseases, to prevent HE.

Seizure was the most common presentation in the present study, with generalized tonic-clonic being the most common semiology occurring in 75% of patients. The previous studies also reported that 65–93% of patients presented with generalized tonic-clonic seizures [8, 13–15]. The median duration of ASM use in the present study was 75 days, with 10 patients not requiring any ASM. This duration of ASM use was consistent with the previous studies [16, 17]. Brain imaging was performed in nearly all patients, but only half had an EEG study. Abnormalities detected from the neuroimaging or EEG were not significantly different between the kidney and non-kidney groups, which was consistent with the previous study [7]. Another study by Ahn et al. reported that all 9 patients in the kidney group had abnormal MRI findings and 6 had typical PRES lesions, but only 5 out of 8 non-kidney patients had abnormal MRI [8].

The present study revealed that nearly 10% of patients had recurrent HE episodes, but the proportion of patients with kidney diseases was comparable between the recurrent and non-recurrent groups. Another study [7] reported that 25% (4 out of 16) of patients had recurrent HE episodes, and all 4 patients had kidney diseases. The present study observed that about 23% (5 out of 22) of patients with small vessel vasculitis or those who received HSCT had recurrent HE episodes. As the pathogenesis of HE is related to the disruption of endothelial cells commonly found in patients with small vessel vasculitis or post-HSCT taking calcineurin inhibitors, we postulated that this may explain why these two conditions share a common risk of recurrent HE episodes. Though not statistically significant, patients with recurrent HE episodes required a longer duration of ASM use and exhibited a lower survival rate, highlighting the poor prognosis associated with recurrent HE. The kidney and non-kidney groups had similar rates of abnormal CT and MRI findings during HE episodes. However, between the non-recurrent and recurrent HE groups, those with recurrent HE episodes had more CT lesions, suggesting that recurrent episodes may cause further brain damage.

The present study described the clinical characteristics and outcomes of pediatric patients who developed HE, with a larger number than reported in the previous studies [6–8]. We also noted a group of patients with recurrent HE episodes, particularly in patients with small vessel vasculitis or post-HSCT. However, the present study had some limitations. Firstly, only a small proportion of patients with follow-up imaging and EEGs. Secondly, there were 3 patients who did not have any neurological imaging. Thirdly, the doses of steroids and other medications that might be related to the development of hypertension were not thoroughly reviewed. Finally, some patients were referred for follow-up at other medical facilities. Therefore, more patients could have developed a recurrent episode of HE without the researchers knowing. Further study with a more comprehensive neurological evaluation of children who develop HE is needed to determine the long-term outcomes of these patients.

In conclusion, the present study provides valuable information about the characteristics and outcomes of pediatric HE. Key findings include (1) patients with kidney diseases were older and developed HE at an earlier age compared to those without kidney diseases; (2) No difference in clinical manifestations, duration of ASM, and survival was detected between the kidney and non-kidney groups; (3) The recurrent HE group had a higher proportion of patients with small vessel vasculitis or post-HSCT. These findings highlight the importance of early recognition, blood pressure management, and targeted interventions for high-risk pediatric populations. In addition, patients with either small vessel vasculitis or calcineurin inhibitors used in post-HSCT who have developed an episode of HE should be carefully monitored for blood pressure, as they are at risk of recurrent episodes of HE.

Abbreviations

HE

hypertensive encephalopathy

BMI

body mass index

SBP

systolic blood pressure

DBP

diastolic blood pressure

eGFR

estimated glomerular filtration rate

CT

computerized tomography

MRI

magnetic resonance imaging

PRES

posterior reversible encephalopathy syndrome

CNS

central nervous system

EEG

electroencephalography

HSCT

hematopoietic stem cell transplantation

SLE

systemic lupus erythematosus

LN

lupus nephritis

Authors’ contributions

BW, CK, NN, SC, PS, KT and KP had substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; BW, CK and KP had significant contributions to drafting the article and revising it critically for important intellectual content; BW, CK, NN, SC, PS, KT and KP had approved the manuscript of the version to be published.

Funding

Not applicable.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The present study was approved, and informed consent was waived by the Ethics Committee for Human Research, Faculty of Medicine Ramathibodi Hospital, Mahidol University (MURA 2023/373) due to the retrospective design of the present study. The present study adhered to the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.