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Liu L, de Leeuw K, Arends S, Doornbos-van der Meer B, Bulthuis MLC, van Goor H, Westra J. Biomarkers of Oxidative Stress in Systemic Lupus Erythematosus Patients with Active Nephritis. Antioxidants (Basel) 2023; 12:1627. [PMID: 37627622 PMCID: PMC10451241 DOI: 10.3390/antiox12081627] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/11/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Oxidative stress plays an important role in systemic lupus erythematosus (SLE) and especially in lupus nephritis (LN). The aim of this study was to compare redox-related biomarkers between patients with active LN, quiescent SLE (Q-SLE) and healthy controls (HC) and to explore their association with clinical characteristics such as disease activity in patients. We investigated levels of plasma free thiols (R-SH, sulfhydryl groups), levels of soluble receptor for advanced glycation end products (sRAGE) and levels of malondialdehyde (MDA) in SLE patients with active LN (n = 23), patients with quiescent SLE (n = 47) and HC (n = 23). Data of LN patients who previously participated in Dutch lupus nephritis studies and longitudinal samples up to 36 months were analyzed. Thiol levels were lower in active LN at baseline and Q-SLE patients compared to HC. In generalized estimating equation (GEE) modelling, free thiol levels were negatively correlated with the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) over time (p < 0.001). sRAGE and MDA were positively correlated with the SLEDAI over time (p = 0.035 and p = 0.016, respectively). These results indicate that oxidative stress levels in LN patients are increased compared to HC and associated with SLE disease activity. Therefore, interventional therapy to restore redox homeostasis may be useful as an adjunctive therapy in the treatment of oxidative damage in SLE.
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Affiliation(s)
- Lu Liu
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands; (L.L.); (K.d.L.); (S.A.); (B.D.-v.d.M.)
| | - Karina de Leeuw
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands; (L.L.); (K.d.L.); (S.A.); (B.D.-v.d.M.)
| | - Suzanne Arends
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands; (L.L.); (K.d.L.); (S.A.); (B.D.-v.d.M.)
| | - Berber Doornbos-van der Meer
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands; (L.L.); (K.d.L.); (S.A.); (B.D.-v.d.M.)
| | - Marian L. C. Bulthuis
- Department of Pathology and Medical Biology, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands; (M.L.C.B.); (H.v.G.)
| | - Harry van Goor
- Department of Pathology and Medical Biology, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands; (M.L.C.B.); (H.v.G.)
| | - Johanna Westra
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands; (L.L.); (K.d.L.); (S.A.); (B.D.-v.d.M.)
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Moroni G, Porata G, Raffiotta F, Frontini G, Calatroni M, Reggiani F, Banfi G, Ponticelli C. Predictors of increase in chronicity index and of kidney function impairment at repeat biopsy in lupus nephritis. Lupus Sci Med 2022; 9:9/1/e000721. [PMID: 35973744 PMCID: PMC9386217 DOI: 10.1136/lupus-2022-000721] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/30/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Based on available data, the histological predictors of long-term outcome of lupus nephritis (LN) are not clearly defined. Aims of this retrospective study were: (i) to evaluate the change of chronicity index from the first to second kidney biopsy and to find the predictors of chronicity index increase and (ii) to detect the clinical/histological features at first and at second kidney biopsy associated with long-term kidney function impairment. METHODS Among 203 biopsy proven LN subjects, 61 repeated kidney biopsy 49 months after the first biopsy. The reasons for repeated biopsy were: nephritic flares in 25 (41%), proteinuric flares in 21 (36%) of patients and protocol biopsy in 14 (23%) of cases. RESULTS During 23-year follow-up, 25 patients presented a decrease in glomerular filtration rate (eGFR) ≥30%. At repeat biopsy, chronicity index increased in 44 participants (72%) and did not increase in 17 (28%). Nephritic syndrome and serum creatinine >1.6 mg/dL at presentation correlated with chronicity index increase (p=0.031, 0.027, respectively), cyclophosphamide therapy tended to protect against chronicity index increase (p=0.059). Kidney flares occurred in 53.6% of patients with vs 23.5% of those without chronicity index increase (p=0.035). Chronicity index increases of 3.5 points in patients with kidney flares vs 2 in those without flares (p=0.001). At second, but not at first kidney biopsy, two different models predicted eGFR decrease at multivariate analysis. The first included activity index >3 (OR: 3.230; p=0.013) and chronicity index >4 (OR: 2.905; p=0.010), and the second model included moderate/severe cellular/fibrocellular crescents (OR: 4.207; p=0.010) and interstitial fibrosis (OR: 2.525; p=0.025). CONCLUSION At second biopsy, chronicity index increased in 3/4 of participants. Its increase was predicted by kidney dysfunction at presentation and occurrence of LN flares. Kidney function impairment was predicted by both activity and chronicity index and by some of their components at repeated biopsy, but not at first biopsy.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy .,Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Giulia Porata
- U.O. Nefrologia e Dialisi, ASST Santi Paolo e Carlo, Milano, Italy
| | | | - Giulia Frontini
- Nefrologia, Dialisi e Trapianto di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco Reggiani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Rozzano, Italy
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Obrișcă B, Vornicu A, Procop A, Herlea V, Terinte-Balcan G, Gherghiceanu M, Ismail G. A Histology-Guided Approach to the Management of Patients with Lupus Nephritis: Are We There Yet? Biomedicines 2022; 10:biomedicines10061409. [PMID: 35740431 PMCID: PMC9220241 DOI: 10.3390/biomedicines10061409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Renal involvement is a frequent complication of systemic lupus erythematosus (SLE). It occurs in up to two-thirds of patients, often early during the disease course, and is the most important predictor of the morbidity and mortality of SLE patients. Despite tremendous improvements in the approach of the lupus nephritis (LN) therapy, including the recent approval of two new disease-modifying therapies, up to 50% of patients do not obtain a renal response and up to 25% will eventually progress to end-stage renal disease (ESRD) within 10 years of diagnosis. Given the lack of correlation between clinical features and histological lesions, there is an increasing need for a histology-guided approach to the management of patients with LN. Apart from the initial diagnosis of type and severity of renal injury in SLE, the concept of a repeat kidney biopsy (either in a for-cause or a per-protocol scenario) has begun to gain increasing popularity in the nephrology community. Herein, we will provide a comprehensive overview of the most important areas of utility of the kidney biopsy in patients with LN.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alexandru Procop
- Department of Pathology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.P.); (V.H.)
| | - Vlad Herlea
- Department of Pathology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.P.); (V.H.)
| | - George Terinte-Balcan
- Ultrastructural Pathology, “Victor Babes” National Institute of Pathology, 050097 Bucharest, Romania; (G.T.-B.); (M.G.)
| | - Mihaela Gherghiceanu
- Ultrastructural Pathology, “Victor Babes” National Institute of Pathology, 050097 Bucharest, Romania; (G.T.-B.); (M.G.)
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence:
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Hsieh TY, Lin YC, Hung WT, Chen YM, Wen MC, Chen HH, Lin WY, Hsieh CW, Lin CT, Lai KL, Tang KT, Tseng CW, Huang WN, Chen YH, Tsai SC, Wu YD. Change of Renal Gallium Uptake Correlated with Change of Inflammation Activity in Renal Pathology in Lupus Nephritis Patients. J Clin Med 2021; 10:jcm10204654. [PMID: 34682781 PMCID: PMC8541120 DOI: 10.3390/jcm10204654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/04/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Lupus nephritis (LN) often lead to end-stage renal disease in systemic lupus erythematosus patients. This study aimed to investigate the clinical application of renal gallium-67 scans for determining renal histological parameters in LN patients. Methods: Between 2006 and 2018, 237 biopsy-proven and 35 repeat biopsies LN patients who underwent renal gallium scans before or after biopsy were included for analysis. The classification and scoring of LN were assessed according to the International Society of Nephrology/Renal Pathology Society. A delayed 48-h gallium scan was performed and interpreted by semiquantitative methods using left kidney/spine (K/S) ratio. The renal histological results were compared with gallium uptake. Results: Out of 237 participants, 180 (76%) had proliferative LN. Baseline gallium left K/S ratio was significantly higher in class IV LN as compared to class III (median (interquartile range, IQR): 1.16 (1.0–1.3), 0.95 (0.9–1.1), respectively, p < 0.001). Furthermore, changes in gallium uptake between two biopsies were positively correlated with changes activity index (r = 0.357, p = 0.035), endocapillary hypercellularity (r = 0.385, p = 0.032), and neutrophils infiltration (r = 0.390, p = 0.030) in renal pathology. Conclusions: Renal gallium uptake is associated with active inflammation in LN. Changes in renal gallium uptake positively correlated with changes in activity index in renal pathology.
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Affiliation(s)
- Tsu-Yi Hsieh
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Education, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yi-Ching Lin
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-C.L.); (W.-Y.L.)
- Department of Public Health, China Medical University, Taichung 40447, Taiwan
| | - Wei-Ting Hung
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Education, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yi-Ming Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
| | - Mei-Chin Wen
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Hsin-Hua Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Wan-Yu Lin
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-C.L.); (W.-Y.L.)
| | - Chia-Wei Hsieh
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Ching-Tsai Lin
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
| | - Kuo-Tung Tang
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
| | - Chih-Wei Tseng
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
| | - Wen-Nan Huang
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Shih-Chuan Tsai
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-C.L.); (W.-Y.L.)
- Department of Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology, Taichung 406053, Taiwan
- Correspondence: (S.-C.T.); (Y.-D.W.)
| | - Yi-Da Wu
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Correspondence: (S.-C.T.); (Y.-D.W.)
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Ren HJ, Sun YL, Yuan B. Chinese patent medicine Bailing capsule for treating lupus nephritis: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e17041. [PMID: 31517824 PMCID: PMC6750295 DOI: 10.1097/md.0000000000017041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Treatment of lupus nephritis (LN) remains challenging. LN remains the primary source of morbidity and mortality in patients with systemic lupus erythematosus. Chinese patent medicine Bailing capsule is commonly used for the treatment of LN. However, there is no consensus on the difference in clinical efficacy compared with routine treatment. Therefore, we plan to perform a systematic review and meta-analysis to review the clinical efficacy and safety of Bailing capsule for LN. METHODS Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Chinese National Knowledge Infrastructure, Chinese Biomedical Database, Wanfang database, and VIP information database will be searched from their inception until January 2019. The meta-analysis will be conducted with Review Manager 5.3 software to systematically review the clinical efficacy and safety of Bailing capsule for LN. The primary outcome will include clinical effective rate, and the secondary outcomes will include Systemic Lupus Erythematosus Disease Activity Index, serum creatinine, 24-hour urine protein quantity, complement 3, and adverse effects. RESULTS This analysis will provide useful information about clinical efficacy and safety of Bailing capsule for LN. CONCLUSIONS Our study will generate strong evidence of Bailing capsule for patients with LN and provide suggestions for clinical practice.
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Abstract
Systemic lupus erythematosus is the most characteristic of auto-immune disorders that can lead to tissue damage in many organs, including kidney. Lupus nephritis occurs in 10 to 40% of lupus patients. Its clinical hallmark is the appearance of a proteinuria as soon as a 0.5 g/g or 0.5 g/d threshold, which calls for a renal histological evaluation in order to determine the lupus nephritis severity and the need for specific therapy. More than half of renal biopsies lead to the diagnosis of active lupus nephritis-class III or class IV A according to the ISN/RPS classification-that are the most severe in regards to renal prognosis and mortality. Their treatment aims to their clinical remission and to the prevention of relapse with minimal adverse effects for eventually the preservation of renal function, the prevention of other irreversible damage, and the reduction of risk of death. The remission is obtained through induction therapies of which the association of high dose steroids and cyclophosphamide is the most experienced. When this association must be challenged by the prevention of side-effect, in particular infertility, mycophenolate can be given instead of cyclophosphamide. Maintenance therapy, for the prevention of relapse, consists in mycophenolate or in azathioprine, mycophenolate being the most efficient however associated with a high risk of teratogenicity. Withdrawal of maintenance therapy is possible after two to three years in absence of high risk factors of relapse of lupus nephritis, however a reliable assessment of the risk of relapse is still lacking. Only pure membranous lupus nephritis (pure class V) associated with high level proteinuria requires specific therapies that usually associates steroids and an immunosuppressive drug. However, their choice hierarchy and even the use of less immunosuppressive strategies remain to be determined in terms of benefice over risk ratios. In spite of its trigger effect on lupus activity, pregnancy can be safe and successful if scheduled in the lowest risk periods with close multidisciplinary monitoring before, during and after. When necessary, renal replacement therapy does not require specific adaptation, renal transplantation is the best option when possible, as early as possible.
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Affiliation(s)
- Quentin Raimbourg
- Service de néphrologie, hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris cedex 18, France; Université Paris Diderot, 5, rue Thomas-Mann, 75013 Paris, France; Inserm U1149, Département hospitalo-universitaire (DHU) Fibrosis-Inflammation-Remodeling (FIRE), 16, rue Henri Huchard, 75890 Paris cedex 18, France
| | - Éric Daugas
- Service de néphrologie, hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris cedex 18, France; Université Paris Diderot, 5, rue Thomas-Mann, 75013 Paris, France; Inserm U1149, Département hospitalo-universitaire (DHU) Fibrosis-Inflammation-Remodeling (FIRE), 16, rue Henri Huchard, 75890 Paris cedex 18, France.
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Fava A, Petri M. Systemic lupus erythematosus: Diagnosis and clinical management. J Autoimmun 2019; 96:1-13. [PMID: 30448290 PMCID: PMC6310637 DOI: 10.1016/j.jaut.2018.11.001] [Citation(s) in RCA: 330] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is a worldwide chronic autoimmune disease which may affect every organ and tissue. Genetic predisposition, environmental triggers, and the hormonal milieu, interplay in disease development and activity. Clinical manifestations and the pattern of organ involvement are widely heterogenous, reflecting the complex mosaic of disrupted molecular pathways converging into the SLE clinical phenotype. The SLE complex pathogenesis involves multiple cellular components of the innate and immune systems, presence of autoantibodies and immunocomplexes, engagement of the complement system, dysregulation of several cytokines including type I interferons, and disruption of the clearance of nucleic acids after cell death. Use of immunomodulators and immunosuppression has altered the natural course of SLE. In addition, morbidity and mortality in SLE not only derive from direct immune mediated tissue damage but also from SLE and treatment associated complications such as accelerated coronary artery disease and increased infection risk. Here, we review the diagnostic approach as well as the etiopathogenetic rationale and clinical evidence for the management of SLE. This includes 1) lifestyle changes such as avoidance of ultraviolet light; 2) prevention of comorbidities including coronary artery disease, osteoporosis, infections, and drug toxicities; 3) use of immunomodulators (i.e. hydroxychloroquine and vitamin D); and 4) immunosuppressants and targeted therapy. We also review new upcoming agents and regimens currently under study.
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Affiliation(s)
- Andrea Fava
- Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA
| | - Michelle Petri
- Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA.
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An Y, Zhou Y, Bi L, Liu B, Wang H, Lin J, Xu D, Wang M, Zhang J, Wang Y, An Y, Zhu P, Xie R, Zhang Z, Mei Y, Liu X, Deng X, Yao Z, Zhang Z, Wang Y, Xiao W, Shen H, Yang X, Xu H, Yu F, Wang G, Lu X, Li Y, Li Y, Zuo X, Li Y, Liu Y, Zhao Y, Guo J, Sun L, Zhao M, Li Z. Combined immunosuppressive treatment (CIST) in lupus nephritis: a multicenter, randomized controlled study. Clin Rheumatol 2018; 38:1047-1054. [PMID: 30488367 DOI: 10.1007/s10067-018-4368-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The standard strategy for treating lupus nephritis comprises glucocorticoids together with either intravenous cyclophosphamide or oral mycophenolate mofetil, but the low remission rate is still a challenge in practice. This study was aimed to seek higher remission rate of lupus nephritis using a combined strategy. METHOD A 24-week trial was conducted in 17 rheumatology or nephrology centers in China. A total of 191 lupus nephritis patients were randomized to follow a combined immunosuppressive treatment (CIST) with intravenous cyclophosphamide, an oral immunosuppressive agent, namely mycophenolate mofetil, azathioprine or leflunomide, and hydroxychloroquine (n = 95), or receive intravenous cyclophosphamide alone (n = 96) for 24 weeks. Glucocorticoid was given to both groups. The primary end point was a complete remission with a most stringent standard as proteinuria < 150 mg per 24 h, normal urinary sediment, serum albumin, and renal function at 24 weeks. The secondary end point was treatment failure at 24 weeks. RESULTS At week 24, both the rate of complete remission (39.5%) and total response (87.2%) was higher in the combined group, compared with CYC group (20.8% and 68.8%, p < 0.05). The cumulative probability of complete remission was also higher in the combined group (p = 0.013). In addition, the combined treatment was superior to routine CYC with less treatment failure (12.8% vs.31.2%, p < 0.001). No difference was found between the incidences of severe adverse events in the two arms: 3.2% (3/95 combined group) vs.4.2% (4/96 CYC group). CONCLUSION Treatment with a combined immunosuppressive agent is superior to routine CYC only therapy in lupus nephritis.
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Affiliation(s)
- Yuan An
- Department of Rheumatology and Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Yunshan Zhou
- Department of Rheumatology and Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Liqi Bi
- Department of Rheumatology, China Japan Union Hospital, Jilin University, Changchun, China
| | - Bo Liu
- Department of Rheumatology, China Japan Union Hospital, Jilin University, Changchun, China
| | - Hong Wang
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Jin Lin
- Department of Rheumatology and Immunology, First Affiliated Hospital, Zhejing University, Hangzhou, China
| | - Danyi Xu
- Department of Rheumatology and Immunology, First Affiliated Hospital, Zhejing University, Hangzhou, China
| | - Mei Wang
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Jing Zhang
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Yongfu Wang
- Department of Rheumatology, First Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Yan An
- Department of Rheumatology, First Affiliated Hospital of Baotou Medical College, Baotou, China
| | - Ping Zhu
- Department of Clinical Immunology, Fourth Military Medical University Xijing Hospital, Xi'an, China
| | - Ronghua Xie
- Department of Clinical Immunology, Fourth Military Medical University Xijing Hospital, Xi'an, China
| | - Zhiyi Zhang
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yifang Mei
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiangyuan Liu
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
| | - Xiaoli Deng
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
| | - Zhongqiang Yao
- Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing, China
| | - Zhuoli Zhang
- Department of Rheumatology and Immunology, Peking University First Hospital, Beijing, China
| | - Yu Wang
- Department of Rheumatology and Immunology, Peking University First Hospital, Beijing, China
| | - Weiguo Xiao
- Department of Rheumatology and Immunology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Hui Shen
- Department of Rheumatology and Immunology, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xiuyan Yang
- Department of Rheumatology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Hanshi Xu
- Department of Rheumatology, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Feng Yu
- Department of Nephrology, Peking University First Hospital, Beijing, China
| | - Guochun Wang
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Beijing, China
| | - Xin Lu
- Department of Rheumatology and Immunology, China-Japan Friendship Hospital, Beijing, China
| | - Yang Li
- Department of Rheumatology and Immunology, Second Clinical Hospital, Harbin Medical University, Harbin, China
| | - Yingnan Li
- Department of Rheumatology and Immunology, Second Clinical Hospital, Harbin Medical University, Harbin, China
| | - Xiaoxia Zuo
- Department of Rheumatology and Immunology, Xiangya Hospital Central South University, Changsha, China
| | - Yisha Li
- Department of Rheumatology and Immunology, Xiangya Hospital Central South University, Changsha, China
| | - Yi Liu
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Zhao
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Jianping Guo
- Department of Rheumatology and Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Lingyun Sun
- Department of Rheumatology and Immunology, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China
| | - Minghui Zhao
- Department of Nephrology, Peking University First Hospital, Beijing, China
| | - Zhanguo Li
- Department of Rheumatology and Immunology, Peking University People's Hospital, 11 Xizhimen South Street, Xicheng District, Beijing, 100044, China.
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De Rosa M, Azzato F, Toblli JE, De Rosa G, Fuentes F, Nagaraja HN, Nash R, Rovin BH. A prospective observational cohort study highlights kidney biopsy findings of lupus nephritis patients in remission who flare following withdrawal of maintenance therapy. Kidney Int 2018; 94:788-794. [DOI: 10.1016/j.kint.2018.05.021] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 05/12/2018] [Accepted: 05/17/2018] [Indexed: 10/28/2022]
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10
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Nossent J, Raymond W, Kang A, Wong D, Ognjenovic M, Chakera A. The current role for clinical and renal histological findings as predictor for outcome in Australian patients with lupus nephritis. Lupus 2018; 27:1838-1846. [PMID: 30092734 DOI: 10.1177/0961203318792361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objectives To investigate the current demographic, clinical and histological characteristics of patients with lupus nephritis (LN) in Western Australia (WA) with regards to their predictive value for patient and renal outcome. Methods Retrospective study of adult systemic lupus erythematosus (SLE) patients with a first renal biopsy demonstrating LN between 1997 and 2017 at a metropolitan tertiary hospital in WA. Clinical data were collected at baseline and last follow-up with renal biopsy findings classified by International Society of Nephrology (ISN) criteria. Annual incidence rates (AIRs)/100,000, Kaplan-Meyer curves and Cox regression hazard ratio for independent predictors for patient and renal survival were applied. Results The AIR was 3.3, 3.1 and 0.4 for Asian ( n = 29), Indigenous Australian (IA) ( n = 11) and Caucasian ( n = 43) patients, respectively ( p < 0.01). There was no significant subgroup difference regarding ISN class (proliferative 66%, membranous 19%, mesangial 15%), levels of proteinuria (median PCR 300 mg/mmol) or frequency of raised creatinine (31%), anti-dsDNA antibody (89%) or hypocomplementaemia (88%). Treatment included corticosteroids (91%), cyclophosphamide (30%), mycophenolate (67%) and antihypertensive drugs (67%). Five- (81%) and 10-year (70%) survival was lower for IAs than for Caucasians and Asians (95% each at both time points) ( p = 0.016). Five- and 10-year renal survival (endpoint renal replacement therapy (RRT)) was 86% and 64% for IA vs 100% for Asian, 100% and 96% for Caucasian patients ( p = 0.02). IA background was the only independent predictor for poor patient survival and together with male gender also for renal survival. Only 25% of all patients remained free of any organ damage with non-renal damage observed in 53% of survivors. Conclusions LN incidence in WA was 0.75/100,000 with the lowest rate observed in Caucasians. While Asian patients have the same favourable outlook as Caucasians, the outcome is much bleaker for IA patients. Other clinical and histological findings did not predict outcomes, and importantly more than half of all surviving patients accrued non-renal damage.
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Affiliation(s)
- J Nossent
- 1 School of Medicine, Faculty of Health Science, University of Western Australia, Perth, Australia.,4 Department of Rheumatology, Sir Charles Gairdner Hospital, Perth, Australia
| | - W Raymond
- 1 School of Medicine, Faculty of Health Science, University of Western Australia, Perth, Australia
| | - A Kang
- 2 Path West Laboratory Medicine, Anatomical Pathology, QEII Medical Centre, Perth, Australia
| | - D Wong
- 2 Path West Laboratory Medicine, Anatomical Pathology, QEII Medical Centre, Perth, Australia
| | - M Ognjenovic
- 1 School of Medicine, Faculty of Health Science, University of Western Australia, Perth, Australia
| | - A Chakera
- 1 School of Medicine, Faculty of Health Science, University of Western Australia, Perth, Australia.,3 Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, Australia
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11
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Tunnicliffe DJ, Palmer SC, Henderson L, Masson P, Craig JC, Tong A, Singh‐Grewal D, Flanc RS, Roberts MA, Webster AC, Strippoli GFM. Immunosuppressive treatment for proliferative lupus nephritis. Cochrane Database Syst Rev 2018; 6:CD002922. [PMID: 29957821 PMCID: PMC6513226 DOI: 10.1002/14651858.cd002922.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cyclophosphamide, in combination with corticosteroids, has been first-line treatment for inducing disease remission for proliferative lupus nephritis, reducing death at five years from over 50% in the 1950s and 1960s to less than 10% in recent years. Several treatment strategies designed to improve remission rates and minimise toxicity have become available. Treatments, including mycophenolate mofetil (MMF) and calcineurin inhibitors, alone and in combination, may have equivalent or improved rates of remission, lower toxicity (less alopecia and ovarian failure) and uncertain effects on death, end-stage kidney disease (ESKD) and infection. This is an update of a Cochrane review first published in 2004 and updated in 2012. OBJECTIVES Our objective was to assess the evidence and evaluate the benefits and harms of different immunosuppressive treatments in people with biopsy-proven lupus nephritis. The following questions relating to management of proliferative lupus nephritis were addressed: 1) Are new immunosuppressive agents superior to or as effective as cyclophosphamide plus corticosteroids? 2) Which agents, dosages, routes of administration and duration of therapy should be used? 3) Which toxicities occur with the different treatment regimens? SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 2 March 2018 with support from the Cochrane Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any immunosuppressive treatment for biopsy-proven class III, IV, V+III and V+VI lupus nephritis in adult or paediatric patients were included. DATA COLLECTION AND ANALYSIS Data were abstracted and the risks of bias were assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) and measures on continuous scales calculated as mean differences (MD) with 95% confidence intervals (CI). The primary outcomes were death (all causes) and complete disease remission for induction therapy and disease relapse for maintenance therapy. Evidence certainty was determined using GRADE. MAIN RESULTS In this review update, 26 new studies were identified, to include 74 studies involving 5175 participants overall. Twenty-nine studies included children under the age of 18 years with lupus nephritis, however only two studies exclusively examined the treatment of lupus nephritis in patients less than 18 years of age.Induction therapy Sixty-seven studies (4791 participants; median 12 months duration (range 2.5 to 48 months)) reported induction therapy. The effects of all treatment strategies on death (all causes) and ESKD were uncertain (very low certainty evidence) as this outcome occurred very infrequently. Compared with intravenous (IV) cyclophosphamide, MMF may have increased complete disease remission (RR 1.17, 95% CI 0.97 to 1.42; low certainty evidence), although the range of effects includes the possibility of little or no difference.Compared to IV cyclophosphamide, MMF is probably associated with decreased alopecia (RR 0.29, 95% CI 0.19 to 0.46; 170 less (129 less to 194 less) per 1000 people) (moderate certainty evidence), increased diarrhoea (RR 2.42, 95% CI 1.64 to 3.58; 142 more (64 more to 257 more) per 1000 people) (moderate certainty evidence) and may have made little or no difference to major infection (RR 1.02, 95% CI 0.67 to 1.54; 2 less (38 less to 62 more) per 1000 people) (low certainty evidence). It is uncertain if MMF decreased ovarian failure compared to IV cyclophosphamide because the certainty of the evidence was very low (RR 0.36, 95% CI 0.06 to 2.18; 26 less (39 less to 49 more) per 1000 people). Studies were not generally designed to measure ESKD.MMF combined with tacrolimus may have increased complete disease remission (RR 2.38, 95% CI 1.07 to 5.30; 336 more (17 to 1048 more) per 1000 people (low certainty evidence) compared with IV cyclophosphamide, however the effects on alopecia, diarrhoea, ovarian failure, and major infection remain uncertain. Compared to standard of care, the effects of biologics on most outcomes were uncertain because of low to very low certainty of evidence.Maintenance therapyNine studies (767 participants; median 30 months duration (range 6 to 63 months)) reported maintenance therapy. In maintenance therapy, disease relapse is probably increased with azathioprine compared with MMF (RR 1.75, 95% CI 1.20 to 2.55; 114 more (30 to 236 more) per 1000 people (moderate certainty evidence). Multiple other interventions were compared as maintenance therapy, but patient-outcome data were sparse leading to imprecise estimates. AUTHORS' CONCLUSIONS In this review update, studies assessing treatment for proliferative lupus nephritis were not designed to assess death (all causes) or ESKD. MMF may lead to increased complete disease remission compared with IV cyclophosphamide, with an acceptable adverse event profile, although evidence certainty was low and included the possibility of no difference. Calcineurin combined with lower dose MMF may improve induction of disease remission compared with IV cyclophosphamide, but the comparative safety profile of these therapies is uncertain. Azathioprine may increase disease relapse as maintenance therapy compared with MMF.
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Affiliation(s)
- David J Tunnicliffe
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Lorna Henderson
- NHS LothianRenal DepartmentRoyal Infirmary of EdinburghEdinburghUKEH16 4SA
| | - Philip Masson
- Royal Free London NHS Foundation TrustDepartment of Renal MedicineLondonUK
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Allison Tong
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Davinder Singh‐Grewal
- The Sydney Children's Hospitals NetworkDepartment Paediatric RheumatologyThe Children's Hospital at WestmeadCnr Hainsworth and Hawkesbury RoadsWestmeadNSWAustralia2145
| | - Robert S Flanc
- Monash Medical CentreDepartment of NephrologyClayton RdClaytonVICAustralia3168
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
| | - Angela C Webster
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
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Abstract
Systemic lupus erythematosus (SLE) is a systemic disease of unknown aetiology with variable course and prognosis. Lupus nephritis (LN) is one of the important disease manifestations of SLE with considerable influence on patient outcomes. Immunosuppression therapy has made it possible to control the disease with improved life expectancy and quality of life. In the last few decades, various studies across the globe have clarified the role, dose and duration of immunosuppression currently in use and also provided evidence for new agents such as mycophenolate mofetil, calcineurin inhibitors and rituximab. However, there is still a need to develop new and specific therapy with less adverse effects. In this review, the current evidence of the treatment of LN and its evolution, and new classification criteria for SLE have been discussed. Also, rationale for low-dose intravenous cyclophosphamide as induction agent followed by azathioprine as maintenance agent has been provided with emphasis on individualized and holistic approach.
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Affiliation(s)
- Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College (IGMC), Shimla, India
| | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College (IGMC), Shimla, India
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Narváez J, Ricse M, Gomà M, Mitjavila F, Fulladosa X, Capdevila O, Torras J, Juanola X, Pujol-Farriols R, Nolla JM. The value of repeat biopsy in lupus nephritis flares. Medicine (Baltimore) 2017; 96:e7099. [PMID: 28614228 PMCID: PMC5478313 DOI: 10.1097/md.0000000000007099] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Whether a repeat renal biopsy is helpful during lupus nephritis (LN) flares remains debatable. In order to analyze the clinical utility of repeat renal biopsy in this complex situation, we retrospectively reviewed our series of 54 LN patients who had one or more repeat biopsies performed only on clinical indications. Additionally, we reviewed 686 well-documented similar cases previously reported (PubMed 1990-2015).The analysis of all patients reviewed showed that histological transformations are common during a LN flare, ranging from 40% to 76% of cases. However, the prevalence of transformations and the clinical value of repeat biopsy vary when they are analyzed according to proliferative or nonproliferative lesions.The great majority of patients with class II (78% in our series and 77.5% in the literature review) progressed to a higher grade of nephritis (classes III, IV, or V), resulting in worse renal prognosis. The frequency of pathological conversion in class V is lower (33% and 43%, respectively) but equally clinically relevant, since almost all cases switched to a proliferative class. Therefore, repeat biopsy is highly advisable in patients with nonproliferative LN at baseline biopsy, because these patients have a reasonable likelihood of switch to a proliferative LN that may require more aggressive immunosuppression.In contrast, the majority of patients (82% and 73%) with proliferative classes in the reference biopsy (III, IV or mixed III/IV + V), remained into proliferative classes on repeat biopsy. Although rebiopsy in this group does not seem as necessary, it is still advisable since it will allow us to identify the 18% to 20% of patients that switch to a nonproliferative class. In addition, consistent with the reported clinical experience, repeat biopsy might also be helpful to identify selected cases with clear progression of proliferative lesions despite the initial treatment, for whom it is advisable to intensify inmunosuppression. Thus, our experience and the literature data support that repeat biopsy also brings more advantges than threats in this group.The results of the repeat biopsy led to a change in the immunosuppresive treatment in more than half of the patients on average, intensifying it in the majority of the cases, but also reducing it in 5% to 30%.
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Affiliation(s)
| | | | | | | | - Xavier Fulladosa
- Department of Nephrology, Unitat Funcional de Malalties Autoinmunes Sistèmiques (UFMAS), Hospital Universitari de Bellvitge—IDIBELL, Barcelona, Spain
| | | | - Joan Torras
- Department of Nephrology, Unitat Funcional de Malalties Autoinmunes Sistèmiques (UFMAS), Hospital Universitari de Bellvitge—IDIBELL, Barcelona, Spain
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14
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Rijnink EC, Teng YO, Wilhelmus S, Almekinders M, Wolterbeek R, Cransberg K, Bruijn JA, Bajema IM. Clinical and Histopathologic Characteristics Associated with Renal Outcomes in Lupus Nephritis. Clin J Am Soc Nephrol 2017; 12:734-743. [PMID: 28473317 PMCID: PMC5477219 DOI: 10.2215/cjn.10601016] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 02/01/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The prognostic significance of histopathologic (sub)classes in the current classification of lupus nephritis (LN) is controversial. We analyzed clinical and histopathologic predictors of renal outcome in LN outside the framework of the classification. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Variables (50 histopathologic and ten clinical) were tested in mixed, linear, and Cox regression models for their association with renal flare, ESRD, and eGFR during follow-up (1, 5, and 10 years) in 105 patients with LN who underwent biopsy from 1987 to 2011. The Cockcroft-Gault (normalized to a body surface area of 1.73 m2) and Schwartz formulas were used to calculate eGFR for adults and children, respectively. RESULTS During median follow-up of 9.9 years (25th-75th percentile, 5.9-13.8), 47 patients experienced a renal flare and 21 progressed to ESRD. Renal flare was predicted by fibrinoid necrosis (hazard ratio [HR], 1.04 per %; 95% confidence interval [95% CI], 1.00 to 1.07) and nonwhite race (HR, 2.23; 95% CI, 1.23 to 4.04). ESRD was predicted by fibrinoid necrosis (HR, 1.08 per %; 95% CI, 1.02 to 1.13), fibrous crescents (HR, 1.09 per %; 95% CI, 1.02 to 1.17), interstitial fibrosis/tubular atrophy (IF/TA) ≥25% (HR, 3.89; 95% CI, 1.25 to 12.14), eGFR at baseline (HR, 0.98 per ml/min per 1.73 m2; 95% CI, 0.97 to 1.00), and nonwhite race (HR, 7.16; 95% CI, 2.34 to 21.91). A higher mean eGFR during follow-up was associated with normal glomeruli (+0.2 ml/min per 1.73 m2 per %; 95% CI, 0.1 to 0.4). Like ESRD, a lower eGFR during follow-up was associated with fibrous crescents, IF/TA≥25%, and nonwhite race, as well as with cellular/fibrocellular crescents (-0.4 ml/min per 1.73 m2 per %; 95% CI, -0.6 to -0.2) and age (-0.8 ml/min per 1.73 m2 per year; 95% CI, -1.2 to -0.4). CONCLUSION The LN classification should include an index of evidence-based prognosticators. Awaiting validation of a formal index, we suggest that at least fibrinoid necrosis, fibrous crescents, and IF/TA warrant explicit independent scoring to assess the risk of progressive renal dysfunction in conjunction with clinical findings.
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Affiliation(s)
| | - Y.K. Onno Teng
- Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands; and
| | | | | | | | - Karlien Cransberg
- Department of Pediatric Nephrology, Erasmus University Medical Center–Sophia Children’s Hospital, Rotterdam, The Netherlands
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15
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Tesar V, Hruskova Z. Understanding Histolopathologic Characteristics to Predict Renal Outcomes in Lupus Nephritis. Clin J Am Soc Nephrol 2017; 12:711-712. [PMID: 28473316 PMCID: PMC5477205 DOI: 10.2215/cjn.03490317] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
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16
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Kajawo S, Botha FCJ, Okpechi IG. Clinico-pathological features of repeat renal biopsies in patients with lupus nephritis at Groote Schuur Hospital, Cape Town. Lupus 2017; 26:1339-1346. [DOI: 10.1177/0961203317695466] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Repeat renal biopsies in patients with lupus nephritis are usually done to guide treatment or to establish disease chronicity. Their value is not clear from available literature. There are also no available data in Africa to guide clinicians. Methods This was a retrospective study of patients undergoing a repeat renal biopsy between January 2003 and December 2014 from a single centre in Cape Town, South Africa. Relevant demographic, clinical and histological records of patients with repeat renal biopsies were documented. Comparison of data from first and second renal biopsy was performed. Results Forty-four patients had at least two biopsies done during the study period. Most patients were females (81.8%). The mean biopsy interval was 2.8 ± 1.8 (range 0.38–9.4) years. Proteinuria was the main indication for the repeat biopsy (36.1%). The glomerular filtration rate and proteinuria worsened between the two biopsies ( p = 0.001 and 0.019, respectively) suggesting disease progression. Most patients (65.4%) with a non-proliferative class of lupus nephritis at first biopsy progressed into a proliferative class, whereas patients with initial proliferative lupus nephritis at first biopsy (77.8%) remained as proliferative at repeat biopsy. Treatment was changed in 85% of patients at second biopsy. Conclusion Repeat renal biopsies in patients with lupus nephritis presents a useful means of assessing disease progression and provides guidance regarding modification of treatment. More studies are, however, required to evaluate the value of repeat biopsies and perhaps the need for protocol renal biopsies in patients with lupus nephritis.
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Affiliation(s)
- S Kajawo
- Division of Nephrology and Hypertension, University of Cape Town, South Africa
- Division of Clinical Practice and Patient Care, National University of Science and Technology, Bulawayo, Zimbabwe
| | - F C J Botha
- Division of Anatomical Pathology, University of Cape Town; and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - I G Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, South Africa
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17
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Abstract
Since its incorporation into clinical practice in the 1950s, the percutaneous kidney biopsy has played an important role in advancing our understanding of lupus nephritis (LN). The biopsy findings have been used to classify and subgroup LN in order to obtain an accurate diagnosis and also to inform treatment decisions and predict prognosis. Several classifications schemes have been applied clinically however despite this evolution in histopathologic classification, our ability to predict treatment response and determine prognosis remains limited. In this review we will examine the evolving role of the kidney biopsy in the management of LN, including the potentially larger role the biopsy could play in the future.
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Affiliation(s)
- Samir V Parikh
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anthony Alvarado
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ana Malvar
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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18
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Moroni G, Depetri F, Ponticelli C. Lupus nephritis: When and how often to biopsy and what does it mean? J Autoimmun 2016; 74:27-40. [PMID: 27349351 DOI: 10.1016/j.jaut.2016.06.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 01/30/2023]
Abstract
Renal disease is a frequent complication of SLE which can lead to significant illness and even death. Today, a baseline renal biopsy is highly recommended for all subjects with evidence of lupus nephritis. Biopsy allows the clinician to recognize and classify different forms of autoimmune lupus glomerulonephritis, and to detect other glomerular diseases with variable pathogenesis which are not directly related to autoimmune reactivity, such as lupus podocytopathy. Moreover, not only glomerular diseases, but other severe forms of renal involvement, such as tubulo-interstitial nephritis or thrombotic microangiopathy may be detected by biopsy in lupus patients. Thus, an accurate definition of the nature and severity of renal involvement is mandatory to assess the possible risk of progression and to establish an appropriate treatment. The indications to repeat biopsy are more controversial. Some physicians recommend protocol biopsies to recognize the possible transformation from one class to another one, or to identify silent progression of renal disease, others feel that good clinical monitoring is sufficient to assess prognosis and to make therapeutic decisions. At any rate, although any decision should always be taken by considering the clinical conditions of the patient, there are no doubts that repeat renal biopsy may represent a useful tool in difficult cases to evaluate the response to therapy, to modulate the intensity of treatment, and to predict the long-term renal outcome both in quiescent lupus and in flares of activity.
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Affiliation(s)
- Gabriella Moroni
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milano, Italy.
| | - Federica Depetri
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milano, Italy.
| | - Claudio Ponticelli
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
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Abstract
The natural course of systemic lupus erythematosus (SLE) is characterized by periods of disease activity and remissions. Prolonged disease activity results in cumulative organ damage. Lupus nephritis is one of the most common and devastating manifestations of SLE. In the era of changing therapy to less toxic regimens, some authors have stated that if mycophenolate mofetil can be used for the induction and maintenance treatment in all histological classes of lupus nephritis, renal biopsy can be omitted. This article aims to answer the question of what brings the bigger risk: renal biopsy or its abandonment.
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20
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Wilhelmus S, Bajema IM, Bertsias GK, Boumpas DT, Gordon C, Lightstone L, Tesar V, Jayne DR. Lupus nephritis management guidelines compared. Nephrol Dial Transplant 2015; 31:904-13. [PMID: 25920920 DOI: 10.1093/ndt/gfv102] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 03/21/2015] [Indexed: 01/07/2023] Open
Abstract
In the past years, many (randomized) trials have been performed comparing the treatment strategies for lupus nephritis. In 2012, these data were incorporated in six different guidelines for treating lupus nephritis. These guidelines are European, American and internationally based, with one separate guideline for children. They offer information on different aspects of the management of lupus nephritis including induction and maintenance treatment of the different histological classes, adjunctive treatment, monitoring of the patient, definitions of response and relapse, indications for (repeat) renal biopsy, and additional challenges such as the presence of vascular complications, the pregnant SLE patient, treatment in children and adolescents and considerations about end-stage renal disease and transplantation. In this review, we summarize the guidelines, determine the common ground between them, highlight the differences and discuss recent literature.
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Affiliation(s)
- Suzanne Wilhelmus
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - George K Bertsias
- Rheumatology, Clinical Immunology and Allergy, Medical School, University of Crete, Iraklion, Greece Infections and Immunity Division, IMBB-FORTH, Iraklion, Greece
| | - Dimitrios T Boumpas
- Infections and Immunity Division, IMBB-FORTH, Iraklion, Greece Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Caroline Gordon
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, The Medical School, University of Birmingham, Birmingham, UK
| | - Liz Lightstone
- Section of Renal Medicine and Vascular Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Vladimir Tesar
- Department of Nephrology, 1st School of Medicine, Charles University, Prague, Czech Republic
| | - David R Jayne
- Addenbrooke's Hospital, Lupus and Vasculitis Unit, Cambridge, UK
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Bertsias G, Fanouriakis AC, Boumpas DT. Systemic lupus erythematosus. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Rezaieyazdi Z, Tavakoli T, Khajehdaluee M, Honarmand S. Efficacy of long-term maintenance therapy with mycophenolate mofetil in lupus nephritis. SPRINGERPLUS 2014; 3:638. [PMID: 25392806 PMCID: PMC4227986 DOI: 10.1186/2193-1801-3-638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 09/29/2014] [Indexed: 01/09/2023]
Abstract
Background Mycophenolate mofetil (MMF) has long been used to manage lupus nephritis. Despite research on its long-term efficacy, it is still warranted to conduct further investigation regarding its indications, safety and outcome. This study was intended to evaluate our proposed protocol in maintenance therapy with MMF. Twenty-four lupus nephritis patients were registered prior to their receiving 3–6 month induction therapy with monthly iv pulses of cyclophosphamide (CYC), followed by 24 month maintenance therapy using MMF and steroid. We defined end points as achievement of complete and partial remission, relapse, refractory to therapy as well as end stage renal disease (ESRD) and death. Friedman and repeated measurement tests were used to assess the effect of treatment on parameters over time. Complete renal remission was achieved in 79.16% until the end of the last follow up with an average period of 12.45 ± 7.37 months since treatment commenced. Significant statistical differences were seen regarding proteinuria, hematuria, leukocyturia, plasma creatinine, C3, C4 before and after therapy (P < 0.05): plasma creatinine and proteinurea falling from 0.96 ± 0.65 to 0.75 ± 0.19 mg/dl (P < 0.14) and from 1.64 ± 1.12 to 0.27 ± 0.60 gr/24 h (P < 0.001). By the end of 24-month, 95.8% of patients had been in remission. Four episodes of relapse ended in remission followed by retreatment. No life-threatening side effects were observed in 66.6% of patients with fourteen cases of infection (58.3%). None of them developed ESRD. Maintenance therapy with MMF was shown to yield favorable outcome with minimal complications, in treating lupus nephritis (IRCT2012071710313N1).
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Affiliation(s)
- Zahra Rezaieyazdi
- Rheumatic Diseases Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Tahmine Tavakoli
- Internal Medicine, Brigand University of Medical Sciences, Brigand, Iran
| | | | - Shahram Honarmand
- Rheumatic Diseases Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Rovin BH, Parikh SV, Alvarado A. The kidney biopsy in lupus nephritis: is it still relevant? Rheum Dis Clin North Am 2014; 40:537-52, ix. [PMID: 25034161 DOI: 10.1016/j.rdc.2014.04.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The kidney biopsy is the standard of care for diagnosis of lupus nephritis and remains necessary to ensure accurate diagnosis and guide treatment. Repeat biopsy should be considered when therapy modifications are necessary, as in cases with incomplete or no response, or when stopping therapy for those in remission. There are several promising biomarkers of kidney disorders; however, these markers need to be validated in a prospective clinical trial before being applied clinically. Molecular analysis may provide the information presently lacking from current evaluation of kidney disorders and may better inform on prognosis and treatment considerations.
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Affiliation(s)
- Brad H Rovin
- Nephrology Division, Department of Internal Medicine, Ohio State University Wexner Medical Center, 395 West 12th Avenue, Columbus, OH 43210, USA.
| | - Samir V Parikh
- Nephrology Division, Department of Internal Medicine, Ohio State University Wexner Medical Center, 395 West 12th Avenue, Columbus, OH 43210, USA
| | - Anthony Alvarado
- Nephrology Division, Department of Internal Medicine, Ohio State University Wexner Medical Center, 395 West 12th Avenue, Columbus, OH 43210, USA
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Cybulsky AV, Walsh M, Knoll G, Hladunewich M, Bargman J, Reich H, Humar A, Samuel S, Bitzan M, Zappitelli M, Dart A, Mammen C, Pinsk M, Muirhead N. Canadian Society of Nephrology Commentary on the 2012 KDIGO Clinical Practice Guideline for Glomerulonephritis: Management of Glomerulonephritis in Adults. Am J Kidney Dis 2014; 63:363-77. [DOI: 10.1053/j.ajkd.2013.12.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 12/03/2013] [Indexed: 01/14/2023]
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Alvarado AS, Malvar A, Lococo B, Alberton V, Toniolo F, Nagaraja HN, Rovin BH. The value of repeat kidney biopsy in quiescent Argentinian lupus nephritis patients. Lupus 2014; 23:840-7. [PMID: 24401872 DOI: 10.1177/0961203313518625] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 12/05/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND The duration of maintenance therapy after induction therapy for lupus nephritis has not been rigorously established. A common practice is to maintain immunosuppression for 1-2 years after complete remission, and longer for partial remission. The present work addresses whether a repeat kidney biopsy might be informative in deciding who should continue immunosuppression after complete or partial remission. METHODS The practice in a large Buenos Aires nephrology unit is to repeat a kidney biopsy before finalizing the decision to withdraw or continue immunosuppression. This work reports on a cohort of 25 Hispanic patients that had two or more kidney biopsies, the last occurring after at least 24 months of clinically quiescent disease. RESULTS Despite normalization of serum creatinine and reduction of proteinuria to <500 mg/d, 30% of patients still had significant activity at the last biopsy. Conversely, 60% of patients with ongoing proteinuria (500-1000 mg/d), or stable but abnormal serum creatinine, had no activity by biopsy. Univariate association analyses demonstrated that improvement in the activity index (AI) of the last biopsy was associated with choice of induction therapy (cyclophosphamide or mycophenolate), improvement in serum creatinine over the first six months of treatment, and improvement in complement component C4. By multivariate regression analyses, two AI prediction models emerged. Cyclophosphamide plus change in serum creatinine or cyclophosphamide plus change in C4 accounted for 50% of the improvement in AI. CONCLUSION These data suggest that a repeat biopsy may be useful in making the decision to withdraw or continue maintenance immunosuppression.
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Affiliation(s)
- A S Alvarado
- Nephrology Division, The Ohio State University Wexner Medical Center, Ohio, USA
| | - A Malvar
- Nephrology Division, Hospital Fernandez, Buenos Aires, Argentina
| | - B Lococo
- Nephrology Division, Hospital Fernandez, Buenos Aires, Argentina
| | - V Alberton
- Pathology Department, Hospital Fernandez, Buenos Aires, Argentina
| | - F Toniolo
- Centro de Diagnostico Patologico, Buenos Aires, Argentina
| | - H N Nagaraja
- The Ohio State University College of Public Health, Ohio, USA
| | - B H Rovin
- Nephrology Division, The Ohio State University Wexner Medical Center, Ohio, USA
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Abstract
Lupus nephritis is one of the most common and serious complications of systemic lupus erythematosus (SLE) in childhood affecting more than 80% of patients. Treatment of this complication has undergone significant evolution in recent years. A series of randomized controlled trials has clarified the role of a variety of immunomodulating regimens including some novel biologic medications. This review touches on the major trials that have influenced practice and shaped current thinking about the treatment of proliferative lupus glomerulonephritis.
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Tesar V. Rare transformation in repeat renal biopsies suggests a different pathogenesis of segmental and global lesions in proliferative lupus nephritis. Nephrol Dial Transplant 2013; 28:2929-32. [DOI: 10.1093/ndt/gft343] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Henderson L, Masson P, Craig JC, Flanc RS, Roberts MA, Strippoli GFM, Webster AC. Treatment for lupus nephritis. Cochrane Database Syst Rev 2012; 12:CD002922. [PMID: 23235592 DOI: 10.1002/14651858.cd002922.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cyclophosphamide, in combination with corticosteroids has been used to induce remission in proliferative lupus nephritis, the most common kidney manifestation of the multisystem disease, systemic lupus erythematosus. Cyclophosphamide therapy has reduced mortality from over 70% in the 1950s and 1960s to less than 10% in recent years. Cyclophosphamide combined with corticosteroids preserves kidney function but is only partially effective and may cause ovarian failure, infection and bladder toxicity. Several new agents, including mycophenolate mofetil (MMF), suggest reduced toxicity with equivalent rates of remission. This is an update of a Cochrane review first published in 2004. OBJECTIVES To assess the benefits and harms of different immunosuppressive treatments in biopsy-proven proliferative lupus nephritis. SEARCH METHODS For this update, we searched the Cochrane Renal Group's Specialised Register (up to 15 April 2012) through contact with the Trials' Search Coordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any treatments for biopsy-proven lupus nephritis in both adult and paediatric patients with class III, IV, V +III and V +IV lupus nephritis were included. All immunosuppressive treatments were considered. DATA COLLECTION AND ANALYSIS Data were abstracted and quality assessed independently by two authors, with differences resolved by discussion. Dichotomous outcomes were reported as risk ratio (RR) and measurements on continuous scales reported as mean differences (MD) with 95% confidence intervals (CI). MAIN RESULTS We identified 50 RCTs involving 2846 participants. Of these, 45 studies (2559 participants) investigated induction therapy, and six studies (514 participants), considered maintenance therapy.Compared with intravenous (IV) cyclophosphamide, MMF was as effective in achieving stable kidney function (5 studies, 523 participants: RR 1.05, 95% CI 0.94 to 1.18) and complete remission of proteinuria (6 studies, 686 participants: RR 1.16, 95% CI 0.85 to 1.58). No differences in mortality (7 studies, 710 participants: RR 1.02, 95% CI 0.52 to 1.98) or major infection (6 studies, 683 participants: RR 1.11, 95% CI 0.74 to 1.68) were observed. A significant reduction in ovarian failure (2 studies, 498 participants: RR 0.15, 95% CI 0.03 to 0.80) and alopecia (2 studies, 522 participants: RR 0.22, 95% CI 0.06 to 0.86) was observed with MMF. In maintenance therapy, the risk of renal relapse (3 studies, 371 participants: RR 1.83, 95% CI 1.24 to 2.71) was significantly higher with azathioprine compared with MMF. Multiple other interventions were compared but outcome data were relatively sparse. Overall study quality was variable. The internal validity of the design, conduct and analysis of the included RCTs was difficult to assess in some studies because of the omission of important methodological details. No study adequately reported all domains of the risk of bias assessment so that elements of internal bias may be present. AUTHORS' CONCLUSIONS MMF is as effective as cyclophosphamide in inducing remission in lupus nephritis, but is safer with a lower risk of ovarian failure. MMF is more effective than azathioprine in maintenance therapy for preventing relapse with no increase in clinically important side effects. Adequately powered trials with long term follow-up are required to more accurately define the risks and eventual harms of specific treatment regimens.
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Affiliation(s)
- Lorna Henderson
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead,Australia.
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Giannico G, Fogo AB. Lupus Nephritis: Is the Kidney Biopsy Currently Necessary in the Management of Lupus Nephritis? Clin J Am Soc Nephrol 2012; 8:138-45. [DOI: 10.2215/cjn.03400412] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Borchers AT, Leibushor N, Naguwa SM, Cheema GS, Shoenfeld Y, Gershwin ME. Lupus nephritis: a critical review. Autoimmun Rev 2012; 12:174-94. [PMID: 22982174 DOI: 10.1016/j.autrev.2012.08.018] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2012] [Indexed: 01/18/2023]
Abstract
Lupus nephritis remains one of the most severe manifestations of systemic lupus erythematosus associated with considerable morbidity and mortality. A better understanding of the pathogenesis of lupus nephritis is an important step in identifying more targeted and less toxic therapeutic approaches. Substantial research has helped define the pathogenetic mechanisms of renal manifestations and, in particular, the complex role of type I interferons is increasingly recognized; new insights have been gained into the contribution of immune complexes containing endogenous RNA and DNA in triggering the production of type I interferons by dendritic cells via activation of endosomal toll-like receptors. At the same time, there have been considerable advances in the treatment of lupus nephritis. Corticosteroids have long been the cornerstone of therapy, and the addition of cyclophosphamide has contributed to renal function preservation in patients with severe proliferative glomerulonephritis, though at the cost of serious adverse events. More recently, in an effort to minimize drug toxicity and achieve equal effectiveness, other immunosuppressive agents, including mycophenolate mofetil, have been introduced. Herein, we provide a detailed review of the trials that established the equivalency of these agents in the induction and/or maintenance therapy of lupus nephritis, culminating in the recent publication of new treatment guidelines by the American College of Rheumatology. Although newer biologics have been approved and continue to be a focus of research, they have, for the most part, been relatively disappointing compared to the effectiveness of biologics in other autoimmune diseases. Early diagnosis and treatment are essential for renal preservation.
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Affiliation(s)
- Andrea T Borchers
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States
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Bertsias GK, Tektonidou M, Amoura Z, Aringer M, Bajema I, Berden JHM, Boletis J, Cervera R, Dörner T, Doria A, Ferrario F, Floege J, Houssiau FA, Ioannidis JPA, Isenberg DA, Kallenberg CGM, Lightstone L, Marks SD, Martini A, Moroni G, Neumann I, Praga M, Schneider M, Starra A, Tesar V, Vasconcelos C, van Vollenhoven RF, Zakharova H, Haubitz M, Gordon C, Jayne D, Boumpas DT. Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis 2012; 71:1771-82. [PMID: 22851469 PMCID: PMC3465859 DOI: 10.1136/annrheumdis-2012-201940] [Citation(s) in RCA: 679] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To develop recommendations for the management of adult and paediatric lupus nephritis (LN). METHODS The available evidence was systematically reviewed using the PubMed database. A modified Delphi method was used to compile questions, elicit expert opinions and reach consensus. RESULTS Immunosuppressive treatment should be guided by renal biopsy, and aiming for complete renal response (proteinuria <0.5 g/24 h with normal or near-normal renal function). Hydroxychloroquine is recommended for all patients with LN. Because of a more favourable efficacy/toxicity ratio, as initial treatment for patients with class III-IV(A) or (A/C) (±V) LN according to the International Society of Nephrology/Renal Pathology Society 2003 classification, mycophenolic acid (MPA) or low-dose intravenous cyclophosphamide (CY) in combination with glucocorticoids is recommended. In patients with adverse clinical or histological features, CY can be prescribed at higher doses, while azathioprine is an alternative for milder cases. For pure class V LN with nephrotic-range proteinuria, MPA in combination with oral glucocorticoids is recommended as initial treatment. In patients improving after initial treatment, subsequent immunosuppression with MPA or azathioprine is recommended for at least 3 years; in such cases, initial treatment with MPA should be followed by MPA. For MPA or CY failures, switching to the other agent, or to rituximab, is the suggested course of action. In anticipation of pregnancy, patients should be switched to appropriate medications without reducing the intensity of treatment. There is no evidence to suggest that management of LN should differ in children versus adults. CONCLUSIONS Recommendations for the management of LN were developed using an evidence-based approach followed by expert consensus.
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Affiliation(s)
- George K Bertsias
- Department of Medicine, Rheumatology, Clinical Immunology and Allergy, University of Crete, Iraklion, Greece
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Chan TM. Recent progress in the treatment of proliferative lupus nephritis. Am J Med 2012; 125:642-8. [PMID: 22608789 DOI: 10.1016/j.amjmed.2012.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2011] [Revised: 12/22/2011] [Accepted: 01/04/2012] [Indexed: 02/02/2023]
Abstract
The recent decades have witnessed significant progress in the treatment of lupus nephritis. Existing immunosuppressive regimens have been refined to enhance efficacy and reduce adverse effects, resulting in improvements in renal and patient survival and patients' quality of life. This review focuses on the new treatments that have emerged over the past 2 decades. The data and methodology of important clinical trials are discussed to highlight the important findings and their limitations. The role of mycophenolate mofetil as induction or maintenance immunosuppressive treatment is discussed in detail. Racial variations in prognosis and treatment response are evident. With increasing treatment options and better appreciation of patient characteristics that impact on response and tolerance, the management of lupus nephritis has become more individualized. The choice and the dosing regimen of immunosuppressive agents should take into account factors such as race, type of lupus nephritis, disease severity, renal reserve, and prior disease course, to aim for an optimal balance of benefit and risk.
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Affiliation(s)
- Tak Mao Chan
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, China.
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Hahn BH, McMahon MA, Wilkinson A, Wallace WD, Daikh DI, FitzGerald JD, Karpouzas GA, Merrill JT, Wallace DJ, Yazdany J, Ramsey-Goldman R, Singh K, Khalighi M, Choi SI, Gogia M, Kafaja S, Kamgar M, Lau C, Martin WJ, Parikh S, Peng J, Rastogi A, Chen W, Grossman JM. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken) 2012. [DOI: 10.1002/acr.21664 5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Hahn BH, McMahon MA, Wilkinson A, Wallace WD, Daikh DI, Fitzgerald JD, Karpouzas GA, Merrill JT, Wallace DJ, Yazdany J, Ramsey-Goldman R, Singh K, Khalighi M, Choi SI, Gogia M, Kafaja S, Kamgar M, Lau C, Martin WJ, Parikh S, Peng J, Rastogi A, Chen W, Grossman JM. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken) 2012; 64:797-808. [PMID: 22556106 PMCID: PMC3437757 DOI: 10.1002/acr.21664] [Citation(s) in RCA: 934] [Impact Index Per Article: 77.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Bevra H Hahn
- School of Medicine, University of California-Los Angeles, CA 90095-1670, USA.
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Recent progress in the treatment of lupus nephritis. Mod Rheumatol 2012; 22:803-13. [PMID: 22584472 DOI: 10.1007/s10165-012-0655-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 04/18/2012] [Indexed: 10/28/2022]
Abstract
The treatment of lupus nephritis has seen significant advances during the past decade mainly due to the publication of well-designed randomized clinical trials (RCTs). The choice of treatment is guided by the histopathologic classification but is also influenced by demographic, clinical, and laboratory characteristics that allow for the identification of patients at risk for more aggressive disease. For the induction arm, low-dose cyclophosphamide regimens and mycophenolate mofetil have been validated as alternatives to the established National Institutes of Health regimen of high-dose cyclophosphamide; for the maintenance phase, azathioprine and mycophenolate compete for treatment of first choice. Rituximab is efficacious in real-life clinical practice but ineffective in clinical trials. The role of recently approved belimumab in lupus nephritis eagerly awaits further documentation. Aggressive management of comorbid conditions, such as hypertension and dyslipidemia, is of utmost importance. Here, we review the latest advances in lupus nephritis therapy with a focus on recent RCTs as well as new biologic agents under development. Furthermore, we propose a therapeutic algorithm in an effort to facilitate clinical decision-making in this gradually changing landscape. Upcoming European and American recommendations should provide further clarification.
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Ruiz-Irastorza G, Espinosa G, Frutos MA, Jiménez Alonso J, Praga M, Pallarés L, Rivera F, Robles Marhuenda Á, Segarra A, Quereda C. [Diagnosis and treatment of lupus nephritis]. Rev Clin Esp 2012; 212:147.e1-30. [PMID: 22361331 DOI: 10.1016/j.rce.2012.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- G Ruiz-Irastorza
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital Universitario Cruces, UPV/EHU, Barakaldo, Bizkaia, España.
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van der Vlag J, Berden JHM. Lupus nephritis: role of antinucleosome autoantibodies. Semin Nephrol 2011; 31:376-89. [PMID: 21839371 DOI: 10.1016/j.semnephrol.2011.06.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The discovery of autoantigen clustering in blebs at the surface of apoptotic cells boosted research on the role of apoptosis in systemic lupus erythematosus (SLE) and led to the discovery of autoantigen modification during apoptosis. Normally, apoptotic cells are cleared efficiently and swiftly. However, it became clear that in SLE insufficient removal of apoptotic material leads to the release of these modified autoantigens. This creates the danger that these modified autoantigens are recognized by the immune system. Indeed, dendritic cells, the professional antigen-presenting cells, phagocytose these modified autoantigens, which leads to maturation and induction of a proinflammatory state of these dendritic cells. As a consequence, they present these modified autoantigens to T cells in an immunogenic way, which become activated and stimulate autoreactive B cells to secrete autoantibodies. In this review the currently available evidence for the sequential steps in the pathogenesis of SLE is discussed. Furthermore, the mechanisms responsible for the nephritogenicity of antinucleosome antibodies are reviewed. This will reveal that nucleosomes are not only a major driving force in the formation of antinuclear antibodies, but also play a pivotal role in the development of tissue lesions by mediating binding of autoantibodies to basement membranes as exemplified for the kidney.
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Affiliation(s)
- Johan van der Vlag
- Nephrology Research Laboratory, Nijmegen Centre for Molecular Life Sciences, Nijmegen, The Netherlands
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Gonadotropin Releasing Hormone Agonists May Minimize Cyclophosphamide Associated Gonadotoxicity in SLE and Autoimmune Diseases. Semin Arthritis Rheum 2011; 41:346-52. [DOI: 10.1016/j.semarthrit.2011.05.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 05/25/2011] [Accepted: 05/25/2011] [Indexed: 01/08/2023]
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Repeat kidney biopsies fail to detect differences between azathioprine and mycophenolate mofetil maintenance therapy for lupus nephritis: data from the MAINTAIN Nephritis Trial. Nephrol Dial Transplant 2011; 27:1924-30. [DOI: 10.1093/ndt/gfr553] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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Zhang X, Nagaraja HN, Nadasdy T, Song H, McKinley A, Prosek J, Kamadana S, Rovin BH. A composite urine biomarker reflects interstitial inflammation in lupus nephritis kidney biopsies. Kidney Int 2011; 81:401-6. [PMID: 21993584 DOI: 10.1038/ki.2011.354] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The initial treatment of lupus nephritis is usually based on a renal biopsy. Subsequent disease flares, however, are often treated without the benefit of kidney pathology because repeat biopsies are infrequent. A noninvasive, real-time method to assess renal pathology would be useful to adjust treatment and improve outcome. To develop such a method we collected urine samples at or close to the time of 64 biopsies from 61 patients with lupus nephritis to identify potential biomarkers of tubulointerstitial inflammation and correlated these to biopsy parameters scored by a renal pathologist using a semiquantitative scale. Linear discriminant analysis was used to weight variables and derive composite biomarkers that identified the level of tubulointerstitial inflammation based on urine concentrations of monocyte chemotactic protein-1, hepcidin (a marker of active lupus), and liver fatty acid-binding protein. The discriminant function that described the most accurate composite biomarkers included urine monocyte chemotactic protein-1 and serum creatinine as the independent variables. This composite had sensitivity, specificity, positive predictive value, and negative predictive value of 100, 81, 67, and 100%, respectively. Only 14% of the biopsies were misclassified. Thus, specific renal pathologic lesions can be modeled by composite biomarkers to noninvasively follow and adjust the treatment of lupus nephritis reflecting renal injury.
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Affiliation(s)
- Xiaolan Zhang
- Division of Nephrology, Department of Medicine, The Ohio State University College of Medicine, Columbus, Ohio 43210, USA
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Hsu CY, Chiu WC, Yang TS, Chen CJ, Chen YC, Lai HM, Yu SF, Su YJ, Cheng TT. Age- and gender-related long-term renal outcome in patients with lupus nephritis. Lupus 2011; 20:1135-41. [DOI: 10.1177/0961203311404912] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To investigate age- and gender-related long-term renal outcome in patients with lupus nephritis (LN). Methods: This is a retrospective, chart review study of patients with LN at Chang Gung Memorial Hospital, Kaohsiung, between January 1986 and June 2004. All had undergone a renal biopsy that showed LN. The end point of outcome was chronic renal insufficiency (CRI), which was defined as ‘doubling of baseline serum creatinine lasting for at least 6 months with a value at least 2 mg/dl.’ The patients were categorized by age tertiles and gender. A 5-year survival curve was constructed to study the effect of age and gender on the outcome. Results: In total, 121 sets of patient data were evaluated. The study group included 104 women and 17 men. Of the study patients, 26 (21%) developed CRI after 5 years of follow-up. There was no significant difference among age groups in developing CRI ( p = 0.23). In terms of gender, men had worse long-term renal outcome ( p = 0.004) than women. Conclusions: The long-term renal outcome of the LN patients did not differ among age groups, but was worse in men.
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Affiliation(s)
- C-Y Hsu
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - W-C Chiu
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - T-S Yang
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - C-J Chen
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Y-C Chen
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - H-M Lai
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - S-F Yu
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Y-J Su
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - T-T Cheng
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital – Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Toong C, Adelstein S, Phan TG. Clearing the complexity: immune complexes and their treatment in lupus nephritis. Int J Nephrol Renovasc Dis 2011; 4:17-28. [PMID: 21694945 PMCID: PMC3108794 DOI: 10.2147/ijnrd.s10233] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Indexed: 12/25/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a classic antibody-mediated systemic autoimmune disease characterised by the development of autoantibodies to ubiquitous self-antigens (such as antinuclear antibodies and antidouble-stranded DNA antibodies) and widespread deposition of immune complexes in affected tissues. Deposition of immune complexes in the kidney results in glomerular damage and occurs in all forms of lupus nephritis. The development of nephritis carries a poor prognosis and high risk of developing end-stage renal failure despite recent therapeutic advances. Here we review the role of DNA-anti-DNA immune complexes in the pathogenesis of lupus nephritis and possible new treatment strategies aimed at their control.
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Affiliation(s)
- Catherine Toong
- Department of Clinical Immunology, Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW, Australia
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46
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Bertsias G, Sidiropoulos P, Boumpas DT. Systemic lupus erythematosus. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00132-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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47
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Treatment of non-renal lupus. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00131-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Proliferative lupus nephritis is the most severe form of lupus nephritis. Outcomes of this disease are affected by ethnicity, clinical characteristics, irreversible damage on renal biopsy, initial response to treatment and future disease course (for example, the occurrence of renal flares). Initial intensive (induction) treatment of proliferative lupus nephritis is aimed at achieving remission, but optimal duration and intensity are not well defined. A combination of intravenous cyclophosphamide and corticosteroids have been shown to decrease the risk of end-stage renal disease, but are associated with substantial acute toxic effects (such as infections) and chronic toxic effects (such as ovarian failure). In white populations, low-dose cyclophosphamide is a reasonable alternative to high-dose cyclophosphamide as it is similarly effective and associated with less toxicity. Mycophenolate mofetil is as effective as high-dose intravenous cyclophosphamide in terms of inducing remission and similar in terms of safety. Although most patients respond to induction treatment, remission is often only achieved after patients are switched to maintenance treatment. As maintenance treatment, mycophenolate mofetil is superior to azathioprine and azathioprine is similarly effective to ciclosporin in terms of prevention or reducing the risk of relapse. Rituximab should be reserved for patients with refractory disease. Treatment of lupus nephritis should be individually tailored to patients, with more aggressive therapy reserved for patients at high risk of renal dysfunction and progression of renal disease.
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49
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Hebert LA, Rovin BH. Oral cyclophosphamide is on the verge of extinction as therapy for severe autoimmune diseases (especially lupus): should nephrologists care? Nephron Clin Pract 2010; 117:c8-14. [PMID: 20689319 DOI: 10.1159/000319641] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Some day we will have powerful targeted therapies for autoimmune diseases. Remission will be induced efficiently. Side effects will be mere ripples. Unfortunately, that day is not imminent. Current therapies are powerful but with unintended targets and side effects that can be equivalent to a sea change. For SLE, the current competition to select the 'gold standard' immunosuppressant has come down to two regimens: intravenous cyclophosphamide (IVCY, standard NIH protocol or its variations) versus oral mycophenolate (MMF). Until recently, IVCY reigned as the gold standard, a title it achieved through a curious journey that did not involve rigorous head-to-head competition. Oral cyclophosphamide (POCY) has not been invited to the current competition to select the gold standard immunosuppressant despite the substantial evidence that POCY can perform at least as well as IVCY or mycophenolate, and compared to IVCY, is far less expensive, easier for the patient, and maybe more effective in African-Americans. Here, we state the case for POCY as therapy for severe autoimmune diseases. We suggest that if POCY is allowed to compete, it will not disappoint.
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Affiliation(s)
- Lee A Hebert
- Department of Internal Medicine, The Ohio State University Medical Center, Columbus, Ohio 43210, USA.
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