Bio

Clinical Focus


  • Pediatric Rheumatology
  • systemic lupus erythematosus
  • lupus nephritis

Academic Appointments


Honors & Awards


  • site primary investigator for CARRA Registry, Childhood Arthritis and Rheumatology Research Alliance
  • ACR/ REF/ LRI Lupus Investigator Fellowship Award, American College of Rheumatology (2004-2007)

Boards, Advisory Committees, Professional Organizations


  • Member, American College of Rheumatology (2003 - Present)
  • Member, Childhood Arthritis and Rheumtology Research Alliance (CARRA) (2004 - Present)
  • Member, Pediatric Rheumatology Care and Outcomes Improvement Network (PR COIN) (2011 - Present)

Professional Education


  • Medical Education:Washington University School Of Medicine Registrar (1999) MO
  • Fellowship:Stanford University Pediatric Rheumatology Fellowship (2006) CA
  • Board Certification: Pediatrics, American Board of Pediatrics (2002)
  • Residency:UCLA Medical Center (2002) CA
  • Internship:UCLA Medical Center (2000) CA
  • Board Certification: Pediatric Rheumatology, American Board of Pediatrics (2006)
  • BA, UC Berkeley, Molecular & Cell Biology (1995)
  • MD, Washington University, Medicine (1999)
  • MS, Stanford University, Health Research and Policy (2007)

Community and International Work


  • Arthritis Foundation

    Topic

    juvenile arthritis

    Location

    Bay Area

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    Yes

Research & Scholarship

Current Research and Scholarly Interests


Pediatric Systemic Lupus Erythematosus;

Lupus Nephritis;

Racial/Ethnic Differences in Pediatric Lupus Patients

CARRA Registry

Clinical Trials


  • Observational Study of Pediatric Rheumatic Diseases: The CARRA Registry Recruiting

    Continuation of the CARRA Registry as described in the protocol will support data collection on patients with pediatric-onset rheumatic diseases. The CARRA Registry will form the basis for future CARRA studies. In particular, this observational registry will be used to answer pressing questions about therapeutics used to treat pediatric rheumatic diseases, including safety questions.

    View full details

Teaching

2018-19 Courses


Publications

All Publications


  • Pilot study comparing the childhood arthritis and rheumatology research alliance consensus treatment plans for induction therapy of juvenile proliferative lupus nephritis. Pediatric rheumatology online journal Cooper, J. C., Rouster-Stevens, K., Wright, T. B., Hsu, J. J., Klein-Gitelman, M. S., Ardoin, S. P., Schanberg, L. E., Brunner, H. I., Eberhard, B. A., Wagner-Weiner, L., Mehta, J., Haines, K., McCurdy, D. K., Phillips, T. A., Huang, Z., von Scheven, E., CARRA registry investigators 2018; 16 (1): 65

    Abstract

    BACKGROUND: To reduce treatment variability and facilitate comparative effectiveness studies, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) published consensus treatment plans (CTPs) including one for juvenile proliferative lupus nephritis (LN). Induction immunosuppression CTPs outline treatment with either monthly intravenous (IV) cyclophosphamide (CYC) or mycophenolate mofetil (MMF) in conjunction with one of three corticosteroid (steroid) CTPs: primarily oral, primarily IV or mixed oral/IV. The acceptability and in-practice use of these CTPs are unknown. Therefore, the primary aims of the pilot study were to demonstrate feasibility of adhering to the LN CTPs and delineate barriers to implementation in clinical care in the US. Further, we aimed to explore the safety and effectiveness of the treatments for induction therapy.METHODS: Forty-one patients were enrolled from 10 CARRA sites. Patients had new-onset biopsy proven ISN/RPS class III or IV proliferative LN, were starting induction therapy with MMF or IV CYC and high-dose steroids and were followed for up to 24months. Routine clinical data were collected at each visit. Provider reasons for CTP selection were assessed at baseline. Adherence to the CTPs was evaluated by provider survey and medication logs. Complete and partial renal responses were reported at 6months.RESULTS: The majority of patients were female (83%) with a mean age of 14.7years, SD 2.8. CYC was used more commonly than MMF for patients with ISN/RPS class IV LN (vs. class III), those who had hematuria, and those with adherence concerns. Overall adherence to the immunosuppression induction CTPs was acceptable with a majority of patients receiving the target MMF (86%) or CYC (63%) dose. However, adherence to the steroid CTPs was poor (37%) with large variability in dosing. Renal response endpoints were exploratory and did not show a significant difference between CYC and MMF.CONCLUSIONS: Overall, the immunosuppression CTPs were followed as intended in the majority of patients however, adherence to the steroid CTPs was poor indicating revision is necessary. In addition, our pilot study revealed several sources of treatment selection bias that will need to be addressed in for future comparative effectiveness research.

    View details for DOI 10.1186/s12969-018-0279-0

    View details for PubMedID 30348175

  • Adiposity in Juvenile Psoriatic Arthritis JOURNAL OF RHEUMATOLOGY Samad, A., Stoll, M. L., Lavi, I., Hsu, J. J., Strand, V., Robinson, T. N., Mellins, E. D., Zisman, D., CARRA Legacy Registry In 2018; 45 (3): 411–18

    Abstract

    Adult patients with psoriatic arthritis are at increased risk for obesity and metabolic syndrome, but data regarding adiposity in children with juvenile psoriatic arthritis (JPsA) are limited. Our study assessed adiposity in children with JPsA in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry.Patients with JPsA in the CARRA registry were divided into nonoverweight and overweight groups using recommendations from the US Centers for Disease Control, and differences in demographic and clinical characteristics between groups at baseline and after 1-year followup were assessed using chi-square test, Fisher's exact test, T test, or Mann-Whitney U test, as appropriate. The prevalence of overweight status in the JPsA registry patients was compared to rheumatoid factor-positive and -negative polyarticular juvenile idiopathic arthritis (RF+polyJIA; RF-polyJIA) registry cohorts and the US pediatric population, using a chi-square goodness-of-fit test.Overweight children represented 36.3% of this JPsA cohort (n = 320). Compared to nonoverweight children, they were significantly older at symptom onset and rheumatologist's first assessment, and scored significantly worse on patient/physician outcome measures. At 1-year followup, changes in body mass index were not associated with changes in clinical features or outcome measures. The prevalence of overweight and obesity in patients with JPsA was significantly higher than in RF+polyJIA patients, RF-polyJIA patients, and the US pediatric population.In this registry, almost 1 in 5 patients with JPsA were obese and more than one-third were overweight. This is significantly more than expected compared to the US pediatric population, and appropriate longterm followup of this JPsA subgroup is warranted.

    View details for DOI 10.3899/jrheum.170598

    View details for Web of Science ID 000426368000018

    View details for PubMedID 29247150

  • Resilience and Transition Readiness in Pediatric SLE Patients Lai, J., Nelson, L., Balboni, I., Lee, T., Hsu, J. WILEY. 2017
  • Corticosteroid Regimen Use in the Pilot Study of Consensus Treatment Plans for Induction Therapy in Childhood Proliferative Lupus Nephritis Cooper, J. C., Eberhard, B., Punaro, M., Ardoin, S. P., Brunner, H., Hsu, J., Wagner-Weiner, L., Klein-Gitelman, M., Rouster-Stevens, K. A., Schanberg, L. E., von Scheven, E., CARRA Investigators WILEY. 2017: 141–42
  • The Juvenile Psoriatic Arthritis Cohort in the CARRA Registry: Clinical Characteristics, Classification, and Outcomes JOURNAL OF RHEUMATOLOGY Zisman, D., Gladman, D. D., Stoll, M. L., Strand, V., Lavi, I., Hsu, J. J., Mellins, E. D. 2017; 44 (3): 342-351

    Abstract

    Children with clinically diagnosed juvenile psoriatic arthritis (JPsA) who were enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry (CARRA-JPsA) were classified according to pediatric International League of Associations for Rheumatology (ILAR) and adult criteria [Classification criteria for Psoriatic Arthritis (CASPAR)]. Data on demographic and clinical features at baseline and 1-year followup were analyzed and compared.Cross-sectional analysis was performed of CARRA-JPsA patients enrolled between May 2010 and December 2013 and stratified according to age at disease onset (≤ or > 4 yrs). Features of patients fulfilling ILAR and CASPAR criteria were compared at baseline and followup using chi square, Fisher's exact, Mann-Whitney-McNemar, Wilcoxon signed rank, and t tests, as appropriate.Among 361 children enrolled as CARRA-JPsA, 72.02% had symptom onset at > 4 years of age, with a male predominance and high prevalence of enthesitis. At followup, statistically significant improvements were reported in arthritis, dactylitis, enthesitis, psoriasis, sacroiliitis, and nail pitting, but not in health questionnaire (HQ) scores. Of the patients, 80.5% fulfilled ILAR criteria for JPsA. Fifty-two patients, whose disease fulfilled CASPAR criteria but had not been included in the JPsA cohort, manifested more enthesitis, sacroiliitis, inflammatory bowel disease and uveitis and less psoriasis.The data support division of patients with JPsA into 2 clinical subgroups, according to age at disease onset. Improvement in objective findings did not correlate with changes in HQ scores. Pediatric rheumatologists currently do not diagnose JPsA in all children whose disease manifestations meet CASPAR criteria. Unification of adult and pediatric PsA classification criteria warrants consideration.

    View details for DOI 10.3899/jrheum.160717

    View details for Web of Science ID 000396031600013

    View details for PubMedID 28148698

  • A Pilot Study of Consensus Treatment Plans for Induction Therapy in Childhood Proliferative Lupus Nephritis Cooper, J. C., Eberhard, B., Punaro, M., Ardoin, S. P., Brunner, H. I., Hsu, J., Wagner-Weiner, L., Rouster-Stevens, K., Schanberg, L. E., Klein-Gitelman, M., von Scheven, E., CARRA Registry Investigators WILEY. 2016
  • Discordance Between Physician, Patient, and Parent Disease Assessment Scores in Juvenile Idiopathic Arthritis Fox, E., Hsu, J., Lee, T., Sandborg, C., Simard, J. F. WILEY. 2016
  • Juvenile Psoriatic Arthritis Manifestations in a Cohort of 361 Patients from US and Canada Zisman, D., Stoll, M. L., Gladman, D. D., Strand, V., Lavi, I., Hsu, J., Mellins, E. D., CARRA Registry Investigators WILEY-BLACKWELL. 2015
  • Adiposity in Children with Juvenile Psoriatic Arthritis (JPsA) Samad, A., Stoll, M. L., Lavi, I., Gupta, K., Hsu, J., Strand, V., Mellins, E. D., Zisman, D., CARRA Registry Investigators WILEY-BLACKWELL. 2015
  • Novel Method to Collect Medication Adverse Events in Juvenile Arthritis: Results From the Childhood Arthritis and Rheumatology Research Alliance Enhanced Drug Safety Surveillance Project ARTHRITIS CARE & RESEARCH Ringold, S., Hendrickson, A., Abramson, L., Beukelman, T., Blier, P. R., Bohnsack, J., Chalom, E. C., Gewanter, H. L., Gottlieb, B., Hollister, R., Hsu, J., Hudgins, A., Ilowite, N. T., Klein-Gitelman, M., Lindsley, C., Lopez Benitez, J. M., Lovell, D. J., Mason, T., Milojevic, D., Moorthy, L. N., Nanda, K., Onel, K., Prahalad, S., Rabinovich, C. E., Ray, L., Rouster-Stevens, K., Ruth, N., Shishov, M., Spalding, S., Syed, R., Stoll, M., Vehe, R. K., Weiss, J. E., White, A. J., Wallace, C. A., Sobel, R. E. 2015; 67 (4): 529-537

    Abstract

    Few data are available regarding the rates of serious adverse events (SAEs) and important medical events (IMEs) outside of product-based registries and clinical trials for juvenile idiopathic arthritis (JIA). The Enhanced Drug Safety Surveillance Project (EDSSP) was developed to pilot a novel system to collect SAEs/IMEs in children with JIA. This analysis reports the results from this 4-year (2008-2012) EDSSP.Participating physicians were surveyed monthly to ascertain whether their JIA patients experienced an SAE or IME. Sites were surveyed every 6 months to determine the number of unique JIA patients seen at each site during that 6-month period. Reporting rates were calculated per 100 person-years and 95% confidence intervals (95% CIs) were calculated based on a Poisson distribution.Thirty-seven Childhood Arthritis and Rheumatology Research Alliance sites with 115 physicians participated. The mean response rate to the monthly surveys was 65%. There were 147 total SAEs and 145 total IMEs. The largest proportion of SAEs and IMEs occurred in children with polyarticular JIA (39% and 37%, respectively). The majority of SAEs and IMEs were reported for patients receiving therapy with biologic agents (76% and 69%, respectively). The total event rate for SAEs and IMEs combined was 1.07 events per 100 person-years (95% CI 0.95-1.19). The rates for SAEs and IMEs were 0.54 per 100 person-years (95% CI 0.45-0.63) and 0.53 per 100 person-years (95% CI 0.49-0.62), respectively.The EDSSP provided a simple tool for SAE/IME reporting within an established research network and resulted in a similar range of reported events as captured by a traditional product-based registry.

    View details for DOI 10.1002/acr.22487

    View details for Web of Science ID 000352111800010

    View details for PubMedID 25331530

  • Extension study of participants from the trial of early aggressive therapy in juvenile idiopathic arthritis. journal of rheumatology Wallace, C. A., Ringold, S., Bohnsack, J., Spalding, S. J., Brunner, H. I., Milojevic, D., Schanberg, L. E., Higgins, G. C., O'Neil, K. M., Gottlieb, B. S., Hsu, J., Punaro, M. G., Kimura, Y., Hendrickson, A. 2014; 41 (12): 2459-2465

    Abstract

    To follow children with juvenile idiopathic arthritis (JIA) who had completed at least 6 months of the TRial of Early Aggressive Therapy (TREAT) clinical study for an additional 2 years, describing safety of early aggressive treatment, disease activity, function, and duration of clinical inactive disease (CID) during followup.Children were treated as per provider's discretion. Physician, patient/parent, and laboratory measures of disease status as well as safety information were collected at clinic visits every 3 months for up to 2 years.Forty-eight children were followed for a mean of 28 months (range 12-42) beyond the end of the TREAT study. Half of patients were in CID for > 50% of their followup time. Overall, 88% of patients achieved CID at > 1 study visit and 54% achieved clinical remission while taking medication. Six patients were in CID for the duration of the study, and, of those, 2 achieved a full year of clinical remission while not taking medication. Active disease was mild: mean physician's global assessment 2.4, active joint count 3.5, parent global evaluation 2.4, Childhood Health Assessment Questionnaire 0.32, erythrocyte sedimentation rate 19 mm/h, and morning stiffness 23 min. There were no serious adverse events or adverse events reported at grade 3 or higher of Common Terminology Criteria for Adverse Events.Early aggressive therapy in this cohort of patients with polyarticular JIA who had high initial disease activity was associated with prolonged periods of CID in the majority of patients during followup. Those not in CID had low levels of disease activity.

    View details for DOI 10.3899/jrheum.140347

    View details for PubMedID 25179849

  • Consensus Treatment Plans for Induction Therapy in Childhood Proliferative Lupus Nephritis-Status of Use in Daily Clinical Care von Scheven, E., Punaro, M., Ardoin, S. P., Brunner, H., Hsu, J. J., Mehta, J., Wagner-Weiner, L., Klein-Gitelman, M., Stevens, K., Haines, K. A., Schanberg, L., Eberhard, B. WILEY-BLACKWELL. 2014: S35–S36

    View details for DOI 10.1002/art.38438

    View details for Web of Science ID 000349950900023

  • Results Of a 24 Month Extension Study In PatientsWhoParticipated In The Trial Of Early Aggressive Therapy In Polyarticular Juvenile Idiopathic Arthritis Wallace, C. A., Bonsack, J., Spalding, S. J., Brunner, H., O'Neil, K. M., Milojevic, D., Ringold, S., Schanberg, L. E., Higgins, G. C., Gottlieb, B. S., Hsu, J. J., Punaro, M. G., Kimura, Y., Hendrickson, A. F. WILEY-BLACKWELL. 2013: S116
  • European ancestry decreases the risk of early onset, severe lupus nephritis in a single center, multiethnic pediatric lupus inception cohort LUPUS Frankovich, J. D., Hsu, J. J., Sandborg, C. I. 2012; 21 (4): 421-429

    Abstract

    To determine whether pediatric SLE patients without European ancestry are at higher risk for development of severe lupus nephritis (ISN/RPS class III, IV or V).Ninety-eight of 101 patients with pediatric SLE (age <18 years at diagnosis) were enrolled. Race/ethnicity of four grandparents, socioeconomic status (SES) and language proficiency were collected. The primary outcome was time to development of severe lupus nephritis.Based on patient report of four grandparent ancestry, 29% had at least one grandparent of European ancestry (14% had all four grandparents of European ancestry). Patients without European ancestry were 46% Hispanic, 47% Asian, and 3% African American. In the entire 98 patient cohort, 12% had ≥3 different ancestries. Patients without European ancestry had significantly lower SES levels and English proficiency. There was no significant difference between patients with or without European ancestry in duration of SLE, age of onset, and lag time between symptoms and diagnosis. Patients with at least one grandparent of European ancestry had a decreased risk of developing severe lupus nephritis, which remained significant after controlling for age, gender, SES and English proficiency (hazard ratio 0.4, 95% confidence interval 0.2-0.9).This study demonstrates that presence of at least one grandparent of European ancestry decreases the risk of severe lupus nephritis, a finding that is not explained by measurable socioeconomic differences and language barriers.

    View details for DOI 10.1177/0961203312437805

    View details for Web of Science ID 000301583400008

    View details for PubMedID 22427363

  • Developing Consensus Treatment Plans for Proliferative Nephritis in Juvenile Systemic Lupus Erythematosus: Maintenance Therapy. Mina, R., Brunner, H., Eberhard, B., Punaro, M. G., Ardoin, S. P., Klein-Gitelman, M., Moorthy, L. N., Radhakrishna, S. M., Lo, M. S., Hollander, M. C., Muscal, E., Hsu, J. J., Wagner-Weiner, L., Levy, D. M., Wallace, C., Ilowite, N. T., von Scheven, E. WILEY-BLACKWELL. 2011: S1031
  • Premature Atherosclerosis in Pediatric Systemic Lupus Erythematosus ARTHRITIS AND RHEUMATISM Schanberg, L. E., Sandborg, C., Barnhart, H. X., Ardoin, S. P., Yow, E., Evans, G. W., Mieszkalski, K. L., Ilowite, N. T., Eberhard, A., Levy, D. M., Kimura, Y., von Scheven, E., Silverman, E., Bowyer, S. L., Punaro, L., Singer, N. G., Sherry, D. D., McCurdy, D., Klein-Gitelman, M., Wallace, C., Silver, R., Wagner-Weiner, L., Higgins, G. C., Brunner, H. I., Jung, L., Soep, J. B., Reed, A. 2009; 60 (5): 1496-1507

    Abstract

    To evaluate risk factors for subclinical atherosclerosis in a population of patients with pediatric systemic lupus erythematosus (SLE).In a prospective multicenter study, a cohort of 221 patients underwent baseline measurements of carotid intima-media thickness (CIMT) as part of the Atherosclerosis Prevention in Pediatric Lupus Erythematosus (APPLE) trial. SLE disease measures, medications, and traditional risk factors for atherosclerosis were assessed. A standardized protocol was used to assess the thickness of the bilateral common carotid arteries and the mean maximal IMT of 12 segments. Univariable analysis identified potential associations with CIMT, which were examined in multivariable linear regression modeling.Based on the mean-mean common or the mean-max CIMT as the dependent variable, univariable analysis showed significant associations of the following variables with increased CIMT: increasing age, longer SLE duration, minority status, higher body mass index (BMI), male sex, increased creatinine clearance, higher lipoprotein(a) level, proteinuria, azathioprine treatment, and prednisone dose. In multivariable modeling, both azathioprine use (P=0.005 for the mean-mean model and P=0.102 for the mean-max model) and male sex (P<0.001) were associated with increases in the mean-max CIMT. A moderate dosage of prednisone (0.15-0.4 mg/kg/day) was associated with decreases in the mean-max CIMT (P=0.024), while high-dose and low-dose prednisone were associated with increases in the mean-mean common CIMT (P=0.021) and the mean-max CIMT (P=0.064), respectively. BMI (P<0.001) and creatinine clearance (P=0.031) remained associated with increased mean-mean common CIMT, while increasing age (P<0.001) and increasing lipoprotein(a) level (P=0.005) were associated with increased mean-max CIMT.Traditional as well as nontraditional risk factors were associated with increased CIMT in this cohort of patients in the APPLE trial. Azathioprine treatment was associated with increased CIMT. The relationship between CIMT and prednisone dose may not be linear.

    View details for DOI 10.1002/art.24469

    View details for Web of Science ID 000266071700036

    View details for PubMedID 19404953

    View details for PubMedCentralID PMC2770725