Usefulness of ISN/RPS classification of lupus nephritis

About 50-80% of patients with lupus suffer from lupus nephritis which is one of major causes of morbidity and mortality. Renal pathologists and nephrologists should evaluate the degree of histological damages to establish therapeutic plans for lupus nephritis. In order to standardize definitions, to emphasize clinically relevant lesions, and to improve interobserver reproducibility, the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification was proposed. Recently, several retrospective validation studies concerning the utility of the ISN/RPS classification, especially among class IV, were performed. In these reports, reproducibility is improved by the definition of diagnostic term, but the outcome related with classification, especially in class IV, is controversial. We performed retrospective analysis of 99 biopsy-proven subjects with lupus nephritis in our facility using the ISN/RPS classification. The class IV-G group tended to exhibit a worse renal outcome, but the difference compared with IV-S was not significant. In a Cox proportional hazards models, Independent histological predictors of poor renal outcome were extracapillary proliferation, glomerular sclerosis and fibrous crescents, while hyaline thrombi and fibrous adhesions were of favorable renal outcome. Both were similarly observed in IV-G and IV-S. The more qualitative categorization by the response to standard treatment may be needed to emphasize clinically relevant lesion related to renal outcome.

A clinicopathological study of lupus nephritis in children

To assess clinical characteristics, pathological findings, and therapeutic response in children with lupus nephritis (LN), we retrospectively studied 25 children under 16 years of age with LN at the Abozar children's hospital from 1995 to 2006. The study included 13(65%) girls and 7(35%) boys. The mean age at the time of diagnosis of SLE was 10.2 (+/- 4.8) years. Eighteen patients (90%) were more than 8 years old. Sixty percent of the patients presented as nephritic-nephrotic syndrome. All the patients underwent percutaneous renal biopsy and were followed up for at least 36 months. The clinical and serologic parameters at the time of renal biopsy were recorded. Twenty patients were treated with the following regimens: one (class I) with low dose prednisone, 7 (class II, III) with high-dose of prednisone, 12 (class IV) with high-dose prednisone plus 13 intermittent intravenous cyclophosphamide (CTX) pulses (monthly for 6 months and then every 3 months), followed by mycophenolate mofetil (MMF) as maintenance therapy. Remission was achieved in 17 (85%) cases; one required hemodialysis and 2 died due to renal failure and central nervous system involvement. Among 12 cases with class IV, 11 responded to prednisone and intravenous CTX pulses. We conclude that i.v. pulses of CTX induced clinical remission of renal disease in the majority of children with severe LN. MMF maintenance therapy was effective after induction of remission in refractory cases. However, this study was performed in a small number of subjects, further studies to confirm the long-term efficacy and safety of CTX pulse therapy on larger numbers of patients are warranted.

[Types of lupus nephritis exacerbations: prognostic significance]

AIM

To characterize the course of lupus nephritis (LN) in terms of demographic indices (sex, age of renal disease onset), the presence of antiphospholipid syndrome (APS) and to ascertain a prognostic role of the disease exacerbations.

MATERIAL AND METHODS

A total of 121 LN patients were followed up from 1997 to 2004 (mean duration of the follow-up 5.6 +/- 6.4 years). A LN course was characterized by the presence of a complete or partial remission, exacerbation of the disease, repeated hospitalisations. Two types of exacerbations were considered: proteinuric, running with progressive proteinuria and normal renal function (type 1); functional, running with elevation of blood creatinine (type 2).

RESULTS

Exacerbations were observed in one third of the examinees, 70% of them ran with renal dysfunction. Exacerbations occurred more frequently in males than in females (50 vs 27%, respectively; p = 0.08) and in patients with early onset of LN (at the age of 40 years and younger, 80 vs 60%, respectively; p < 0.05). Exacerbations of type 2 occurred in males, in patients with early onset of renal damage and in APS association. It is shown that LN exacerbations, their incidence and type (a functional type) have a negative influence on renal survival of the patients.

CONCLUSION

Identification of groups of LN patients at high risk of exacerbations and unfavourable prognostic role of exacerbations dictates the necessity of due immunosuppressive therapy for maintenance of remission.

Lupus nephritis. Clinicopathological correlation

OBJECTIVE

To classify all renal biopsies of lupus nephritis patients presenting in the last 10 years, according to the modified World Health Organization (WHO) classification using the facilities of light, fluorescent, and electron microscopy. To assess the activity and chronicity indices of renal biopsies according to the National Institute of Health protocol, and to correlate the histological findings with the clinical features of the patients presented up to the time of biopsy.

METHODS

Seventy-eight patients with lupus nephritis, biopsied over 10 years between January 1995 to December 2005 in King Abdul-Aziz University Hospital, Jeddah, Kingdom of Saudi Arabia were reviewed by 2 histopathologists with the assistance of a nephrologist.

RESULTS

The predominant histological type was WHO class IV. Patients of this class were more commonly associated with microhematuria, elevated proteinuria, and renal insufficiency. Active and chronic lesions were more likely to occur in patients of class III/IV. These patients were also more likely to have evidence of clinical renal disease than patients in class II. There was a significant association between nephrotic syndrome and class V lupus nephritis.

CONCLUSION

Although the clinical and pathological correlation demonstrated a significant relationship between underlying histopathology and the clinical course of the patient, however, the biopsy findings did not uniformly correlate with the clinical features. Moreover, the status prediction of lupus nephritis patients based on clinical information alone was significantly enhanced by information obtained from renal biopsy.

The pathology of lupus nephritis

An international working group of clinicians and pathologists met in 2003 under the auspices of the International Society of Nephrology (ISN) and the Renal Pathology Society (RPS) to revise and update the 1982 and 1995 World Health Organization classification of lupus glomerulonephritis. This article compares and contrasts the ISN/RPS classification and the antecedent World Health Organization classifications. Although systemic lupus erythematosus is the prototypical systemic immune-complex disease, several non-immune-complex mechanisms of glomerular injury and dysfunction have been proposed, and this article summarizes the evidence supporting the pathogenic mechanisms of lupus vasculitis, glomerular capillary thrombosis, and lupus podocytopathy. The most significant and controversial feature of the ISN/RPS classification is the separation of diffuse glomerulonephritis into separate classes with either segmental (class IV-S) or global (class IV-G) lesions. Several groups have tested the prognostic significance of this separation, and this article discusses the implications of these studies for the ISN/RPS classification.

A pilot study on tacrolimus treatment in membranous or quiescent lupus nephritis with proteinuria resistant to angiotensin inhibition or blockade

Persistent proteinuria in patients with quiescent lupus can result from membranous lupus nephritis and/or glomerular scarring following previous flares. This pilot study examined the effects of tacrolimus over two years in six patients with membranous/inactive lupus nephritis and persistent proteinuria despite angiotensin inhibition/blockade. Tacrolimus treatment reduced proteinuria and increased serum albumin (time effect, P = 0.047 and 0.032 respectively). Compared with baseline levels, proteinuria improved by more than 50% in five patients (83.3%) and hypoalbuminaemia was corrected in four patients. The efficacy was most prominent in four patients with biopsy-proven membranous lupus nephritis, whose protienuria improved by over 80%. One patient developed biopsy-proven chronic nephrotoxicity after 10 months of tacrolimus treatment, despite non-excessive blood levels. These data suggest that tacrolimus is an effective treatment for proteinuria due to membranous lupus nephritis, but should probably be reserved for patients who are refractory to other non-nephrotoxic treatments, in view of the potential risk of subclinical nephrotoxicity.

The ISN/RPS 2003 classification of lupus nephritis: an assessment at 3 years

The 2003 International Society of Nephrology (ISN)/Renal Pathology Society (RPS) Classification of lupus nephritis (LN) was designed to eliminate ambiguities and standardize definitions. Major changes from the 1982 Modified WHO Classification include the elimination of the normal biopsy category and the subcategories of membranous Class V, the introduction of sharper distinctions between the classes, and the addition of subcategories within diffuse LN (class IV) for predominantly segmental (LN IV-S) and global (LN IV-G) lesions. It stipulates that sclerotic glomeruli owing to scarred LN should be taken into account when assessing the percentage of glomeruli affected by LN. Since its publication, the ISN/RPS classification has been used successfully in a number of clinical-pathologic studies. Several studies addressing the relationship between LN IV-S and LN IV-G have failed to identify a significantly worse outcome in IV-S than IV-G, although there were some differences in presenting clinical and pathologic features. Importantly, the ISN/RPS classification has achieved its goal of improved interobserver reproducibility. Its use has increased the percentage of LN biopsies meeting criteria for class IV. As it gains widespread acceptance, the ISN/RPS classification is already providing a standardized approach to renal biopsy interpretation needed to compare outcome data across centers.

Clinicopathological correlations of paediatric lupus nephritis

The International Society of Nephrology and Renal Pathology Society Working Group revised the histopathological classification of lupus nephritis (LN) in 2003. We studied the clinical outcome of 39 children (85% female) aged 3.3-18.0 (median 13.7) years who underwent 49 percutaneous renal biopsies at 0.1-7.8 (median 1.0) years from diagnosis of systemic lupus erythematosus (SLE) at our centre over 10 years. All renal biopsies were reviewed and reclassified according to the new criteria by one histopathologist: 2%, 13%, 15%, 51% and 20% of all cases were classes I-V, respectively (with no cases of class VI LN) and 12% overlap cases (4% classes III and V, 8% classes IV and V). Patients were followed up for 1.3-15.4 (median 5.5) years with renal and overall survival rates of 90% and 92%, respectively. Half of the children with LN have features of class IV LN, with diffuse global (class IV-G) LN associated with the worst clinical outcome and the three most severe cases of chronic renal failure with estimated glomerular filtration rates (GFRs) <25 ml/min per 1.73 m(2) in patients with diffuse global sclerosing [class IV-G(C)] LN. The new classification allows expanded histopathological grading of LN with further delineation of classes III and IV with activity and chronicity indices.

Human Clinical Trials in Lupus Nephritis

Improved patient survival after treatment of lupus nephritis with corticosteroids, immunosuppressants, and renal replacement therapy allows greater emphasis on long-term management issues. In particular, the recent focus has been on therapies to treat nephritis with fewer adverse effects compared with cyclophosphamide and immunosuppressive regimens. Issues complicating clinical trial design in lupus nephritis have severely limited comparisons across trials. These issues, including recognition and stratification of high-risk populations, comparable remission and response criteria, and appropriate use and interpretation of activity and damage indices have been the subject of much discussion and emerging consensus. Mycophenolate mofetil (MMF) has been used in the field of transplantation for more than 10 years. After initial anecdotal reports describing the benefits of MMF in the treatment of lupus nephritis, randomized controlled trials have established a role for MMF in the treatment of lupus nephritis. A host of newer agents including rituximab, abatacept, and monoclonal antibodies blocking costimulatory targets are in current clinical trials for lupus nephritis. As long-term outcomes in lupus nephritis improve, the toxicity of therapy and risk of relapse become increasingly important determinants of the choice of therapeutic agents.

Current issues in pediatric lupus nephritis: role of revised histopathological classification

Childhood-onset systemic lupus erythematosus (SLE) has an unpredictable natural history with variable clinical manifestations. The prognosis of SLE is linked closely to renal involvement with lupus nephritis (LN), which is more severe in patients with childhood-onset compared with adult-onset disease. The histopathological classification of LN facilitates treatment decisions, protocols, and clinical research. After the World Health Organization and modified WHO classifications of LN from 1974 to 1995, the International Society of Nephrology and Renal Pathology Society Working Group revised the histopathological classification of LN. The reclassification was published in 2004 after their consensus conference held at Columbia University in New York in May 2002. The aims of the reclassification were to standardize definitions, emphasize clinically relevant lesions, and encourage uniform and reproducible reporting among centers. Although the revised classification is time-consuming, it is important for future international collaboration on multicenter trials of disease-modifying agents. The prognosis of SLE and LN is linked to the histopathology of the renal lesion, but the clinical manifestations of LN, including nephrotic syndrome and hypertension, cannot predict the degree of renal involvement. However, we are many years away from completely understanding the etiopathogenesis of LN and the predictive role of the revised histological classification for direction of patient management.

Retrospective analysis of patients with lupus nephritis: data from a large clinical immunological center in Hungary

The aim of this study was to review the development, histological type and outcome of 117 patients with lupus nephritis managed and followed by the Division of Clinical Immunology, 3rd Department of Internal Medicine, University of Debrecen, Debrecen, Hungary. The method used was a retrospective study in 117 patients with lupus nephritis followed between 1974 and 2004. The average occurrence of lupus nephritis was 3 (women) and 4.4 (men) years later after the diagnosis of systemic lupus erythematosus, 43 (46.2%) patients had class IV lupus nephritis. The initial therapy was intravenous cyclophosphamide treatment for 6 months in 37 (31.6%) patients. End-stage renal disease had developed in nine (7.6%) patients. The 5-year survival rate was 99.1%. Despite the well-known and proved risk factors like hypertension, high serum creatinine, renal failure at onset or membranous glomerulonephritis, the outcome of the disease in our patient population was more favourable than one would expect according to the data available in the literature. The authors would like to draw attention to the importance of systematic care of patients with systemic lupus erythematosus, which may lead to a better clinical outcome.

Interobserver reproducibility and application of the ISN/RPS classification of lupus nephritis-a UK-wide study

We sought to assess the interobserver variation of the new International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification of lupus nephritis when compared with the previous World Health Organization classification, when used by pathologists throughout the UK. We also sought differences in how the 2 classifications were applied to a single set of biopsies. Twenty unselected renal biopsies showing lupus nephritis were circulated to pathologists in the UK National Renal Pathology External Quality Assessment Scheme, before the ISN/RPS scheme was published, with a request to apply the World Health Organization classification. The same slides were recirculated approximately 1 year later with a request to apply the ISN/RPS classification. A significant improvement in interobserver reproducibility was demonstrated by the new classification (kappa 0.53 vs. 0.44, P = 0.002). The reproducibility of the assessment of disease activity and chronicity remains suboptimal (kappa = 0.33). The new classification tends to produce more diagnoses of Class IV lupus nephritis, with fewer diagnoses of Classes III and V. The improvement in interobserver reproducibility indicates that an important aim of the new classification has been achieved. Further work is needed to determine whether the increase in diagnosis of Class IV nephritis represents an improvement in biopsy interpretation or a divergence from the previous classification, as the latter could undermine attempts to relate results from the new system to treatment strategies based on clinical trials which used the old.

Outcomes in African Americans and Hispanics with lupus nephritis

Poor outcomes have been reported in African Americans and Hispanics compared to Caucasians with lupus nephritis. The purpose of this retrospective analysis was to identify independent predictors of outcomes in African Americans and Hispanics with lupus nephritis. In total, 93 African Americans, 100 Hispanics, and 20 Caucasians with a mean age of 28 +/- 13 years and an annual household income of 32.9 +/- 17.3 (in 1000 US dollars) were studied. World Health Organization (WHO) lupus nephritis classes II, III, IV, and V were seen in 9, 13, 52, and 26%, respectively. Important baseline differences were higher mean arterial pressure (MAP) in African Americans compared to Hispanics and Caucasians (107 +/- 19, 102 +/- 15, and 99 +/- 13 mmHg, P < 0.05), and higher serum creatinine (1.66 +/- 1.3, 1.25 +/- 1.0, and 1.31 +/- 1.0 mg/dl, P < 0.025). African Americans had lower hematocrit compared to Hispanics and Caucasians (29 +/- 5, and 31 +/- 6, and 32 +/- 7%, P < 0.05), and lower annual household income (30.8 +/- 14.9, 33.1 +/- 15.9, and 42.2 +/- 29.3 in 1000 US dollars; P < 0.05). Lower prevalence of WHO class IV was seen in Caucasians (30%) compared to Hispanics (57%, P = 0.03) and African Americans (51%, P = 0.09). Development of doubling creatinine or end-stage renal disease was higher in African Americans and Hispanics than in Caucasians (31, 18, and 10%; P < 0.05), as was the development of renal events or death (34, 20, and 10%; P < 0.025). Our results suggest that both biological factors indicating an aggressive disease and low household income are common in African Americans and Hispanics with lupus nephritis, and outcomes in these groups are worse than in Caucasians.

Class IV-S versus class IV-G lupus nephritis: clinical and morphologic differences suggesting different pathogenesis

BACKGROUND

A recently proposed reclassification of lupus nephritis divides class IV (diffuse proliferative) lupus nephritis into those cases with predominantly segmental proliferative lesions (class IV-S) and those with predominantly global proliferative lesions (class IV-G). This report explores the validity of this distinction and possible differences in pathogenesis between the 2 types of lesions.

METHODS

Patients from a previously reported series of severe lupus nephritis, with initial biopsies (Bx1) and control biopsies (Bx2) at 6 months after induction therapy were reclassified according to the newly proposed classification. From the original series of 65 patients, 15 patients were reclassified as having class IV-S lesions and 31 patients class IV-G lesions. Clinical data at both biopsies and follow-up were available on all patients selected.

RESULTS

Patients with IV-G lesions had worse proteinuria, lower serum hemoglobins, lower CH50s, and likely higher SCrs (P = .06) and lower C3s (P = .08) than class IV-S patients. Serum CH50 and C3 correlated negatively with severity of class IV-G lesions, but not at all with class IV-S lesions. Patients with class IV-G lesions had greater overall immune deposits and subendothelial deposits on IF and greater hyaline deposits on light microscopy. By contrast, class IV-S showed predominant mesangial deposits and a much higher rate of glomerular fibrinoid necroses (13.3 +/- 15.3% vs. 5.6 +/- 8.0% of viable glomeruli, P = .03). Other distinctions included the fact that membranoproliferative features were found only in class IV-G lesions, and glomerular monocyte/macrophages were much more frequent in this group than in class IV-S lesions (1.77 +/- 0.92 vs. 0.86 +/- 0.77, P = .008). Finally, class IV-G frequently involved all viable glomeruli (74.2% of cases), whereas segmental proliferative lesions never did (P < .0001). Survivals from doubling of SCr at 10 years did not differ between the 2 types at Bx1: 72.5% segmental versus 60.4% global, P= .53. However, among those with persistent lesions at Bx 2 (11 IV-S and 9 IV-G), there was a dramatic difference in 10-year survivals between IV-S lesions (63.6%) and IV-G lesions (0%), P = .08.

CONCLUSION

There are definite clinical and morphologic differences between class IV-S and IV-G lesions. Data suggest that class IV-G lesions behave as an immune complex disease, having positive correlations with extent of immune deposits and negative correlations with serum complement levels, the model traditionally assumed for lupus nephritis as a whole. However, in class IV-S lesions, the presence of proportionally greater glomerular fibrinoid necroses and lack of correlation with extent of immune deposits suggest that these lesions may have a different pathogenesis.

[Rescue therapy in lupus nephritis patients with mycophenolate mofetil]

BACKGROUND

Long term cyclophosfamide combinated steroids therapy improves renal survival in patients with Proliferate Lupus Nephritis, with considerable toxic effects. In lately years MMF, a immune suppressor used in transplant, seems to be effective in selected cases of Lupus Nephritis.

METHODS

We will describe six patients with Lupus Nephritis class IV and V (OMS Classification), that what different causes they must be treated with MMF like rescue drug. This stabilizes the renal function, controls LES activity and allows reductions or end of corticoids.

RESULTS

In tree cases we achievement total remission, two show partial remission and we had a fail because plaquetopenia and severe leucopenia with serious sepsis to give rise to neumopaty; this patient broke off the treatment. One presented Zoster Herpes that was treated with Aciclovir and temporary treatment break off.

CONCLUSION

MMF was effective to get remission in NL and maintain inactive LES, so it must to be considering as rescue therapy, or maintenance treatment after cyclosphosfamide induction. In patients where fertility is important must be considering like elective drug. Is necessary long time patients follow up to asses' effectiveness in renal survival, like cyclophosfamide.

USEFULNESS OF COMPLEMENT SPLIT PRODUCT, Bb, AS A CLINICAL MARKER FOR DISEASE ACTIVITY OF LUPUS NEPHRITIS

To evaluate the usefulness of Bb, a split product of complement factor B, as a clinical marker for disease activity of lupus nephritis, we measured the Bb concentration of sera from 42 patients with lupus nephritis. Serum Bb levels were significantly higher in patients with active nephritis (active nephritis group, n= 30) than in patients with nephritis in remission (remission group, n=12) (14.3+/-8.3 versus 7.4+/-5.9 microg/ml; p = 0.012). In contrast, there was no significant difference in serum C3 levels between active nephritis group and remission group (42.5+/-20.9 versus 44.7+/-15.9 mg/dl ; p = 0.77). In the comparison of Bb levels between active nephritis group and remission group, the sensitivity was 66.6%, specificity was 83.3%, and the positive and negative likelihood ratios were 3.95% and 0.41%, respectively. The present results suggest that serum Bb level is a useful clinical marker for disease activity in lupus nephritis.