Lupus nephritis - An update on disparities affecting african americans

Flares in Lupus Nephritis: Risk Factors and Strategies for Their Prevention

PURPOSE OF REVIEW

Discuss the prognostic significance of kidney flares in patients with lupus nephritis, associated risk factors, and possible preventative strategies.

RECENT FINDINGS

Recently performed clinical trials and observational cohort studies underscore the high frequency of relapses of kidney disease, following initial response, in patients with proliferative and/or membranous lupus nephritis. Analysis of hard disease outcomes such as progression to chronic kidney disease or end-stage kidney disease, coupled with histological findings from repeat kidney biopsy studies, have drawn attention to the importance of renal function preservation that should be pursued as early as lupus nephritis is diagnosed. In this respect, non-randomized and randomized evidence have suggested a number of factors associated with reduced risk of renal flares such as attaining a very low level of proteinuria (< 700-800 mg/24 h by 12 months), using mycophenolate over azathioprine, adding belimumab to standard therapy, maintaining immunosuppressive/biological treatment for at least 3 to 5 years, and using hydroxychloroquine. Other factors that warrant further clarification include serological activity and the use of repeat kidney biopsy to guide the intensity and duration of treatment in selected cases. The results from ongoing innovative studies integrating kidney histological and clinical outcomes, together with an expanding spectrum of therapies in lupus nephritis, are expected to facilitate individual medical care and long-term disease and patient prognosis.

Analysis of Cutaneous Lupus Hospitalizations: A United States National Population-Based Study

Background There are limited studies analyzing cutaneous lupus erythematosus (CLE) hospitalizations. In this study, we aimed to analyze baseline demographics of systemic lupus erythematosus (SLE) and CLE patients, identify the most common reasons for hospitalizations, and find out the hospitalization outcomes.  Materials and methods We performed the analysis using the National (Nationwide) Inpatient Sample (NIS) database between 2016 and 2019. For the CLE cohort, data for adults aged 18 years and older with the primary or secondary diagnosis of CLE using International Classification of Disease - 10th revision (ICD-10) codes were extracted. For comparison, the SLE cohort was identified by patients aged 18 years and older with primary or secondary diagnoses of SLE using ICD-10 codes. Chi-squared test was used to compare baseline demographic characteristics. Multivariable logistic and linear regression was used to calculate outcomes of interest. Results In comparison to the SLE cohort, the CLE cohort was not only older in age and lower percentage female, but also had shorter length of stay, less total hospital charge, and the majority had Medicare as primary insurance. The SLE cohort included predominantly African American patients while the CLE cohort was majority Caucasian patients. The cardiovascular risks were more prevalent in the CLE cohort and most commonly admitted for sepsis, cardiovascular disease, and mental health disorders. Conclusion Our study highlights the importance of outpatient follow-up in CLE patients to closely monitor cardiovascular risk factors, early identification of infections, and routine mental health screenings to reduce hospitalizations and resource utilization.

The Cleveland Clinic Kidney Biopsy Epidemiological Project

BACKGROUND

The kidney biopsy is the gold standard for diagnosing glomerular diseases. Large-scale, epidemiologic studies describing the prevalence of kidney diseases are lacking, especially in the United States. We aimed to determine the spectrum of biopsy-proven kidney disease across the Cleveland Clinic enterprise.

METHODS

We identified all patients with a native kidney biopsy performed or reviewed at the Cleveland Clinic from January 2015 to September 2021. Retrospective chart review was performed to obtain clinical and demographic characteristics. Results were stratified by age, sex, race, and location to determine epidemiologic trends.

RESULTS

Of >9600 patients, we excluded transplant and donor biopsies and unavailable records, and included 4128 patients with native kidney biopsy data. The median age was 60 years, with 46% female patients. Self-reported racial demographics included 73% White, 22% Black, 3% multiracial, and 2% Asian background, with 5% Hispanic. Common diagnoses were: FSGS (n=633, 15%), diabetic kidney disease (DKD) (n=602, 15%), IgA nephropathy (n=319, 8%), lupus nephritis (LN) (n=289, 7%), pauci-immune glomerulonephritis (n=275, 7%), membranous nephropathy (n=211, 5%), and amyloidosis (n=110, 3%). There were 3322 patients in Ohio, with 361 patients in Florida. Using multivariate analysis, those aged >70 years were more likely to have FSGS, whereas those <45 years were more likely to have IgA nephropathy or LN. Males were more likely to have FSGS or IgAN, and less likely to have LN. Black patients were more likely to have FSGS, DKD, or LN. Hispanic patients were more likely to have DKD. Finally, patients in Florida were more likely to have LN. There was no change in the disease spectrum before and during the COVID-19 pandemic.

CONCLUSION

Our study catalogs the spectrum of biopsy-proven kidney disease across the Cleveland Clinic enterprise. This lays the foundation for glomerular disease clinical trials, and highlights the need for a standardized national kidney biopsy registry to bolster glomerular and kidney disease research in the United States.

Determination of the main causes, outcome, and prognostic factors of patients with rheumatologic diseases admitted to the medical intensive care unit in Southern Iran

BACKGROUND

Systemic rheumatic diseases (SRD) are a heterogeneous group of diseases that can involve several organ systems and occasionally requires intensive care unit (ICU) admission because of severe systemic disease, life-threatening organ involvement, or complication of treatment. The objective of this study is to determine the causes, outcome, and prognostic factors of patients with rheumatologic diseases admitted in teaching medical ICUs in southern Iran.

METHODS

A retrospective case review of all patients with rheumatologic diseases admitted in the academic medical ICUs in two referral hospitals in southern Iran, from March 2015 to January 2020. Patients' data were documented from their hospital records and the cause of admission, in-hospital outcome, and prognostic factors was evaluated.

RESULTS

Ninety-one patients were included, of which 71.4% were female. Systemic lupus erythematosus (54.9%) was the most common disease. Nineteen (20.9%) patients were new cases of rheumatological disease. The most frequent symptom for admittance was dyspnea (54.9%) and hemoptysis (20.9%). The in-hospital mortality rate was 48%, and the leading cause of death was infection (29 patients; 65.5%) followed by disease activity (18 patients; 40.9%). Also, the death of 29.5% of patients was presumed due to both disease activity and infection. Factors associated with mortality included renal insufficiency (p < 0.028), infection (p < 0.001), pneumonia (p < 0.042), dyspnea (p < 0.042), loss of consciousness (p < 0.046), azathioprine consumption (p < 0.004) during 1 month before ICU admission, mechanical ventilation (p < 0.001), renal replacement therapy (p < 0.001), CNS involvement (p < 0.009), and ICU medications such as cyclosporine and azathioprine (0.03 and 0.03, respectively) or treatments such as plasmapheresis (p < 0.018).

CONCLUSION

The ICU mortality rate of patients with SRD was high. Infection and disease exacerbation are the leading reasons for ICU admission in systemic rheumatic diseases. Intensivists must keep in mind that SRD exacerbation may require immunosuppressive agents along with lifesaving interventions, more particularly in newly diagnosed SRDs. Key Points • The ICU mortality rate of patients with SRD was high. • Infection and disease exacerbation are the leading reasons for ICU admission in systemic rheumatic diseases. • 63.8% of our patients fall into this category of new cases of rheumatologic disease and disease flare-up.