Treatment of Proliferative Lupus Nephritis—A Critical Approach

MYH9 and APOL1 gene polymorphisms and the risk of CKD in patients with lupus nephritis from an admixture population

MYH9 polymorphisms have been described to be associated with the risk of CKD in non-diabetic nephropathy, HIV nephropathy and FSGS. Predominating in black descendants, MHY9 genetic variants could partially explain the excess risk of CKD associated with African ancestry. However, recent data suggests that APOL1 gene co-segregate with MYH9, and could be the gene truly associated with CKD risk. In this study, we evaluated the role of MYH9 and APOL1 gene polymorphisms in the risk of CKD in Brazilian patients with lupus nephritis (LN). A retrospective analysis of 196 LN patients was done. MYH9 rs4821480, rs2032487, rs4821481 and rs3752462, APOL 1rs73885319, rs16996616, rs60910145, rs71785313, and APOL3 rs11089781 gene polymorphisms were determined. Genetic ancestry was ascertained both by autossomal ancestry and mitochondrial haplogroup. Primary outcome was defined as doubling of serum creatinine (DC) or end stage renal disease (ESRD). Sixty-two patients presented the PO. In our population, MYH9 and APOL1 were not in LD. None APOL polymorphism was associated with the PO, whereas rs3752462 MYH9 polymorphism showed a positive association (HR3.72, 95%CI 1.47–9.38, p = 0.005). When we analyzed the MYH9 E1 haplotype, the GCCT carriers (1 or 2 alelles present in 29.7% in the PO group vs. 18.5% in controls) showed a significant association to the risk of PO, even after adjustments for baseline estimated creatinine clearance and autossomal ancestry (HR 2.0, 95%CI 1.2–3.4, p = 0.01). Our results show that in our population MYH9, but not APOL1, gene polymorphisms confer an increased risk of CKD in LN patients, independently of race.

Features and outcomes of lupus nephritis in Morocco: analysis of 114 patients

Background

There is wide variation in clinical presentation and outcome of lupus nephritis (LN) among different ethnic groups. Few data for LN exist on North Africans, especially those from Morocco. The aim of our study was to review retrospectively the features and outcome of LN in Moroccan patients.

Patients and methods

We performed a single-center retrospective study. A total of 114 patients with LN were included. All patients met American Rheumatism Association criteria. LN was classified according to the International Society of Nephrology/Renal Pathology Society classification. We adopted previously defined outcome criteria for LN.

Results

There were 101 females and 13 males, with a mean age of 29.9 years. At first presentation, we noted hypertension in 33%, hematuria in 76%, nephrotic syndrome in 53%, and renal failure in 60% of cases. Renal biopsy revealed predominant proliferative classes in more than 80% of patients. Patients received different regimens mainly based on intravenous cyclophosphamide. After a mean follow-up of 22 months, remission occurred in 45.5%, relapses in 82%, end-stage renal failure in 21%, and death in 16% of cases. Infection and neurological and cardiovascular diseases were the most frequent causes of death.

Conclusion

LN seems to be severe in our study, with a predominance of proliferative forms, severe renal manifestations, and poor renal and overall survival.

ABIN1 dysfunction as a genetic basis for lupus nephritis

The genetic factors underlying the pathogenesis of lupus nephritis associated with systemic lupus erythematosus are largely unknown, although animal studies indicate that nuclear factor (NF)-κB is involved. We reported previously that a knockin mouse expressing an inactive form of ABIN1 (ABIN1[D485N]) develops lupus-like autoimmune disease and demonstrates enhanced activation of NF-κB and mitogen-activated protein kinases in immune cells after toll-like receptor stimulation. In the current study, we show that ABIN1[D485N] mice develop progressive GN similar to class III and IV lupus nephritis in humans. To investigate the clinical relevance of ABIN1 dysfunction, we genotyped five single-nucleotide polymorphisms in the gene encoding ABIN1, TNIP1, in samples from European-American, African American, Asian, Gullah, and Hispanic participants in the Large Lupus Association Study 2. Comparing cases of systemic lupus erythematosus with nephritis and cases of systemic lupus erythematosus without nephritis revealed strong associations with lupus nephritis at rs7708392 in European Americans and rs4958881 in African Americans. Comparing cases of systemic lupus erythematosus with nephritis and healthy controls revealed a stronger association at rs7708392 in European Americans but not at rs4958881 in African Americans. Our data suggest that variants in the TNIP1 gene are associated with the risk for lupus nephritis and could be mechanistically involved in disease development via aberrant regulation of NF-κB and mitogen-activated protein kinase activity.

Health-related quality of life in patients with systemic lupus erythematosus and proliferative lupus nephritis

This study investigated the influence of two different treatments for a kidney inflammation (i.e. proliferative lupus nephritis) on health-related quality of life (HRQoL) in patients with the chronic auto-immune disease systemic lupus erythematosus (SLE). One treatment protocol, the National Institutes of Health (NIH) protocol, was characterized by a high dose of cyclophosphamide (CYC, an immunosuppressive drug), and the second treatment, the Euro-Lupus protocol, involved a low-dose CYC. Thirty-two SLE patients were included based on the received treatment for an episode of proliferative lupus nephritis, according to either the Euro-Lupus or the NIH protocol. The two groups were compared on HRQoL as measured by the SF-36 and the SLE Symptom Checklist (SSC). The Euro-Lupus group (N = 16) tended to show a higher HRQoL than the NIH group (N = 16) on four of seven scales of the SF-36. In addition, the Euro-Lupus group experienced less burden from nausea or vomiting than the NIH group as assessed by the SSC. Fatigue was the most disturbing symptom in both groups. The most burdensome aspects of treatment were related to chemotherapy (55.2%) and use of prednisone (34.5%). Patients with a low HRQoL and high levels of fatigue were more likely to have low levels of serum complement C4 (i.e. elevated immune activity). In conclusion, patients who are treated according to the Euro-Lupus protocol may experience a higher HRQoL than patients who receive the NIH treatment. However, chemotherapy remains burdensome in the low-dose treatment regimen. Potential interventions to further enhance the HRQoL in SLE patients with proliferative lupus nephritis are discussed.

[A patient with systemic lupus erythematosus and lupus nephritis: a 12-year follow-up]

INTRODUCTION

Systemic lupus erythematosus (SLE) is a chronic immunological disease causing a significant morbidity and mortality in younger women and involving several organs and systems, most often the kidneys, being consequently the incidence of lupus nephritis (LN) about 60%.

CASE REPORT

We reported a 57 year-old patient with the diagnosed SLE in 1995. Pathohistological analysis of kidney biopsy revealed LN type V. The patient was treated with corticosteroid pulses and azathioprine during one year. A remission was achieved and maintained with prednisone, 15 mg daily. Nephrotic relapse was diagnosed in 2006 and the second kidney biopsy revealed recent kidney infarction due to extensive vasculitis. Soon, a cerebrovascul insult developed and CT-scan revealed endocranial infarctus. The patient was treated with corticosteroids and cyclophosphamide pulses (totally VI monthly pulses), and also with low-molecular heparine, anticoagulants and salicylates because of the right leg phlebothrombosis. After the pulses, the patient was adviced to take prednisone 20 mg daily and azothioprine 100 mg daily, and 6 months later mycophenolate mofetil because of persistent active serological immunological findings (ANA 1:320) and nephrotic syndrome. Mycophenolate mofetil was efficient in inducing and maintaining remission of nephrotic syndrome.

CONCLUSION

The aim of LN treatment is to achieve and maintain remission, improve patients' outcome, reduce the toxicity of immunosuppressive drugs and the incidence of relapses.Mycophenolate mofetil was shown to be efficient in inducing and maintaining remission of nephrotic syndrome in the frame of LN.

Illness perceptions in patients with systemic lupus erythematosus and proliferative lupus nephritis

This study investigated the illness perceptions of patients with systemic lupus erythematosus (SLE) and whether perceptions are influenced by type of treatment for proliferative lupus nephritis. In addition, the illness perceptions of SLE patients were compared with those of patients with other chronic illnesses. Thirty-two patients who had experienced at least one episode of proliferative lupus nephritis were included. Patients were treated with either a high or low-dose cyclophosphamide (CYC) regimen (National Institutes of Health [NIH] vs. Euro-Lupus protocol). Illness perceptions were measured with the Brief Illness Perception Questionnaire (B-IPQ) and a drawing assignment. The low-dose CYC group perceived their treatment as more helpful than the high-dose CYC group. In comparison with patients with asthma, SLE patients showed more negative illness perceptions on five of the eight illness perception domains. Drawings of the kidney provided additional information about perceptions of treatment effectiveness, kidney function and patients' understanding of their illness. Drawing characteristics showed associations with perceptions of consequences, identity, concern and personal control. These findings suggest that the type of treatment SLE patients with proliferative lupus nephritis receive may influence perceptions of treatment effectiveness. In addition, patients' drawings reveal perceptions of damage caused by lupus nephritis to the kidneys and the extent of relief provided by treatment. The finding that SLE is experienced as a more severe illness than other chronic illnesses supports the need to more frequently assess and aim to improve psychological functioning in SLE patients.

[Pregnancy and lupus nephritis: report of 20 cases]

AIM

Pregnancies in women with lupus nephritis (LN) are a high-risk situation. The aim of this study is to evaluate the impact of pregnancy on LN on either maternal and fetal prognosis.

PATIENTS AND METHODS

It is a retrospective study of 20 pregnancies in 12 women with lupus nephritis.

RESULTS

There were 19 live births and five fetal losses. LN flares were observed in 50 % of the cases during pregnancy and 25 % after delivery.

CONCLUSION

Pregnancies in women with LN require a multidisciplinary monitoring and intense maternal and fetal care.

Association of the MCP-1 −2518 A/G Polymorphism and No Association of Its Receptor CCR2 −64 V/I Polymorphism with Lupus Nephritis

Objective.

To evaluate whether the A/G polymorphism at position −2518 in the regulatory region of the monocyte chemoattractant protein-1 (MCP-1) or the V/I polymorphism at position −64 of the receptor, CCR2, are associated with lupus nephritis (LN) or any clinical characteristics of the disease or with renal survival in a patient population.

Methods.

We selected 197 patients with lupus nephritis and 220 matched healthy controls for study. MCP-1 and CCR2 genotyping was performed by polymerase chain reaction. Clinical and laboratory data were compiled from patients’ charts over followup that ranged from 6 months to 10 years.

Results.

The G/G genotype of MCP-1 was more common in LN patients (p = 0.019), while the A allele was associated with healthy controls (p = 0.007) as was the V allele of CCR2 (p = 0.046) compared to LN patients. Clinical index measures [SLE Disease Activity Index (SLEDAI)], immunological markers, renal histology, renal function at enrollment, and renal survival were not influenced by these polymorphisms. A less aggressive renal disease, measured by renal SLEDAI index, was associated with the V allele of the CCR2 gene polymorphism.

Conclusion.

These findings support that MCP-1 −2518 G/G is associated with LN but there was no association of this genotype with renal function or renal survival. When studying CCR2 −64 V/I polymorphism we showed a positive association of the V allele with healthy controls but no association of the genotype with LN patients.

The clinical relevance of a repeat biopsy in lupus nephritis flares

BACKGROUND

The clinical utility of performing repeat biopsies during lupus nephritis flares is questionable and data pointing towards frequent class switches are based on the old WHO classification. This retrospective study investigates the hypothesis that clinically relevant switches from proliferative to non-proliferative lesions and vice versa as determined by the new ISN/RPS classification are a rare event and that repeat biopsies are unnecessary in many cases.

METHODS

Thirty-five patients with lupus nephritis and one or more repeat renal biopsies were included. Eighty-four biopsies were blindly reassessed according to the ISN/RPS classification.

RESULTS

Twenty-five patients had one repeat biopsy, 6 patients had two and 4 patients had three repeat biopsies. Forty-nine comparisons between reference and repeat biopsies could be made. In 25 cases (54.3%), there was no shift in ISN/RPS class on repeat biopsies. In 41 instances, paired biopsies showed proliferative lesions both on reference and repeat biopsies, whereas five of six cases with non-proliferative lesions on a reference biopsy switched to proliferative lesions on a repeat biopsy. Clinically significant class switches during lupus nephritis flares were more frequent in patients with non-proliferative lesions in their reference biopsy (P < 0.001).

CONCLUSION

The results show that patients with proliferative lesions in the original biopsy rarely switch to a pure non-proliferative nephritis during a flare. Therefore, a repeat biopsy during a lupus nephritis flare is frequently not necessary if proliferative lesions were found in the reference biopsy. However, in the case of a non-proliferative lesion in the reference biopsy, class switches are frequently found and repeat biopsies are advisable.

Lactoferrin is associated with a decrease in oocyte depletion in mice receiving cyclophosphamide

OBJECTIVE

To investigate new important molecules involved in the regulation of chemotherapy-induced ovarian damage and, based on those results, to examine the effect of lactoferrin on cyclophosphamide (CPM)-induced ovarian failure.

DESIGN

Complementary DNA microarray and the administration of lactoferrin.

SETTING

Experimental animal study.

ANIMAL(S)

Female imprinting control region mice.

INTERVENTION(S)

Administration of CPM to mice, isolation of ovaries, isolation of RNA, microarray hybridization, and statistical analysis. According to the results of the microarray assay, administration of lactoferrin to CPM-treated mice, isolation of ovaries, isolation of RNA, and evaluation using quantitative polymerase chain reaction and histomorphometric analyses.

MAIN OUTCOME MEASURE(S)

A list of nine down-regulated and two up-regulated genes with reliable hybridization signals was obtained. Several target molecules were then investigated.

RESULT(S)

Among the listed genes, we focused on the mouse lactoferrin gene, because of its CPM-induced expression pattern and its multiple novel functions. Oral administration of bovine lactoferrin prevented down-regulation of the ovulation-related, Adamts1 and partial recovery of follicle depletion induced by CPM treatment.

CONCLUSION(S)

The present report suggests that lactoferrin helps to rescue the ability to ovulate and partially to prevent oocyte depletion in mouse ovaries.

[Treatment of lupus nephritis]

Lupus nephritis is a relevant source of morbidity and mortality in patients with systemic lupus erythematosus. The standard therapy of remission induction in severe lupus nephritis is based on the use of monthly intravenous cyclophosphamide. Recent data have established that the maintenance of remission in lupus nephritis can be achieved with azathioprine or mycophenolate mofetil, with less adverse effects than quarterly intravenous cyclophosphamide. In recent years, a number of controlled randomized clinical trials have been published, opening new therapeutic options in the induction of remission in lupus nephritis, such as less aggressive regimens of intravenous cyclophosphamide or mycophenolate mofetil. Further studies are needed for establishing the optimal therapy of lupus nephritis patients.

Novel therapies of lupus nephritis

PURPOSE OF REVIEW

To review the results of the current therapy of lupus nephritis, highlighting successes and pitfalls, and summarizing the evidence available on the new agents

RECENT FINDINGS

The established treatment of lupus nephritis with aggressive immunosuppression, based on cyclophosphamide and steroids, has improved the outcome of lupus nephritis, but is burdened with significant adverse effects. The search for alternative, less toxic, therapeutic strategies has prompted a number of clinical studies, mycophenolate mofetil being the agent most studied. Results of trials showed that this drug is equally effective with fewer toxic complications than standard therapy, but its long-term efficacy is not yet known. During the last few years experimental studies in the pathogenesis of lupus nephritis have provided an enormous improvement in our knowledge and have offered the possibility to attempt targeting the disease with a more selective approach. The evidence for the role of these new therapies is reviewed.

SUMMARY

While the current alternative to standard therapy, i.e. mycophenolate mofetil, still needs to be confirmed with well designed, properly powered studies, new therapeutic agents, targeted to the pathogenetic mechanism of the disease, are promising improved efficacy with less toxicity.