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Pappa M, Kosmetatou M, Pieta A, Nikoloudaki M, Liapis NM, Tsalapaki C, Chalkia A, Argyriou E, Dimitroulas T, Cheila M, Demirtzoglou G, Papagoras C, Goules A, Katsiari C, Vassilopoulos D, Sidiropoulos P, Boki KA, Sfikakis PP, Liapis G, Gakiopoulou H, Voulgari PV, Boumpas DT, Bertsias G, Tektonidou MG, Fanouriakis A. Attainment of EULAR/ERA-EDTA targets of therapy with current immunosuppressive regimens and adjustments in treatment: a multicentre, real-life observational study. RMD Open 2024; 10:e004437. [PMID: 39299738 PMCID: PMC11429000 DOI: 10.1136/rmdopen-2024-004437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 08/03/2024] [Indexed: 09/22/2024] Open
Abstract
OBJECTIVE To estimate real-life European Alliance of Associations for Rheumatology (EULAR)/European Renal Association (ERA)-European Dialysis and Transplantation Association (EDTA) response rates and predictors for no response in patients with lupus nephritis (LN) managed with conventional immunosuppressive therapies. METHODS Ambidirectional cohort study of patients with new-onset LN (period 2014-to date). Response rates in the first year were calculated, and all treatment modifications were recorded. Univariate and multivariate regression analyses were performed to assess determinants of failure to respond at 12 months. RESULTS 140 patients were included (81.4% women, median (IQR) age at LN diagnosis 38 (22) years). Among them, 32.1% presented with nephrotic range proteinuria, 28.6% with glomerular filtration rate <60 mL/min, 76.6% had proliferative and 19.7% class V LN. Initial treatment consisted of cyclophosphamide in 51.4% of patients (84.7% high-dose, 15.3% low-dose) and mycophenolate in 32.1%. 120 patients had available data at 12 months. EULAR/ERA-EDTA renal response rates at 3, 6 and 12 months were achieved by 72.6%, 78.5% % and 69.2% of patients, respectively. In multivariate analysis, increased Chronicity Index at baseline was associated with failure to achieve either complete or partial response at 12 months (OR 2.26, 95% CI 1.35 to 3.77). Notably, 20% of patients required treatment modifications due to suboptimal response during the first 12 months, with the addition of or switch to a different immunosuppressive drug in seven and nine patients, respectively. CONCLUSIONS More than two-thirds of patients with LN attain EULAR/ERA-EDTA response rates by 12 months, but 20% require therapy modifications within this time period. Patients with increased chronicity in baseline biopsy, when combined with histological activity, are at higher risk for a lack of clinical response.
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Affiliation(s)
- Maria Pappa
- National and Kapodistrian University of Athens, School of Medicine, Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Athens, Greece
| | - Maria Kosmetatou
- National and Kapodistrian University of Athens, “Attikon” University Hospital, Rheumatology Unit, Fourth Department of Internal Medicine, Athens, Greece
| | - Antigone Pieta
- University of Ioannina, Department of Rheumatology, School of Health Sciences, Faculty of Medicine, Ioannina, Greece
| | - Myrto Nikoloudaki
- Medical School and University Hospital of Iraklio, Rheumatology and Clinical Immunology, University of Crete, Iraklio, Greece
| | - Nektarios Marios Liapis
- Faculty of Medicine, School of Health Sciences, University General Hospital of Larissa, Department of Rheumatology and Clinical Immunology, Larissa, Greece
| | - Christina Tsalapaki
- National and Kapodistrian University of Athens, General Hospital of Athens Hippokration, Clinical Immunology- Rheumatology Unit, 2nd department of Medicine and Laboratory, Athens, Greece
| | - Aglaia Chalkia
- General Hospital of Athens Hippokration, Nephrology Department, Athens, Greece
| | - Evangelia Argyriou
- Rheumatology Unit, Sismanogleio General Hospital of Athens, Athens, Greece
| | - Theodoros Dimitroulas
- Medical School, Aristotle University of Thessaloniki, Fourth Department of Internal Medicine, Hippokration University Hospital, Thessaloniki, Greece
| | - Myrto Cheila
- Evangelismos General Hospital of Athens, Rheumatology Clinic, Athens, Greece
| | - Georgios Demirtzoglou
- National and Kapodistrian University of Athens, “Attikon” University Hospital, Rheumatology Unit, Fourth Department of Internal Medicine, Athens, Greece
| | - Charalampos Papagoras
- University Hospital of Alexandroupolis, First Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Andreas Goules
- National and Kapodistrian University of Athens, Department of Pathophysiology, School of Medicine, Athens, Greece
| | - Christina Katsiari
- School of Health Sciences, University General Hospital of Larissa, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, Larissa, Greece
| | - Dimitrios Vassilopoulos
- National and Kapodistrian University of Athens, General Hospital of Athens Hippokration, Clinical Immunology- Rheumatology Unit, 2nd department of Medicine and Laboratory, Athens, Greece
| | - Prodromos Sidiropoulos
- Medical School and University Hospital of Iraklio, Rheumatology and Clinical Immunology, University of Crete, Iraklio, Greece
| | - Kyriaki A Boki
- Rheumatology Unit, Sismanogleio General Hospital of Athens, Athens, Greece
| | - Petros P Sfikakis
- National and Kapodistrian University of Athens, School of Medicine, Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Athens, Greece
| | - George Liapis
- National and Kapodistrian University of Athens, School of Medicine, First Department of Pathology, Laiko General Hospital, Athens, Greece
| | - Harikleia Gakiopoulou
- National and Kapodistrian University of Athens, School of Medicine, First Department of Pathology, Laiko General Hospital, Athens, Greece
| | - Paraskevi V Voulgari
- Faculty of Medicine, University of Ioannina, Department of Rheumatology, School of Health Sciences, Ioannina, Greece
| | - Dimitrios T Boumpas
- National and Kapodistrian University of Athens, “Attikon” University Hospital, Rheumatology Unit, Fourth Department of Internal Medicine, Athens, Greece
| | - George Bertsias
- Medical School and University Hospital of Iraklio, Rheumatology and Clinical Immunology, University of Crete, Iraklio, Greece
| | - Maria G Tektonidou
- National and Kapodistrian University of Athens, School of Medicine, Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology Unit, National and Kapodistrian University of Athens, Athens, Greece
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Vélez-Verbel M, Aroca-Martínez G, Vélez-Verbel D, Domínguez-Vargas A, Vallejo-Patiño M, Sarmiento-Gutierrez J, Gomez-Escorcia L, Musso CG, González-Torres HJ. Clinical and Immunological Factors Associated with the Progression of Lupus Nephritis in a Population from the Colombian Caribbean. Biomedicines 2024; 12:2047. [PMID: 39335560 DOI: 10.3390/biomedicines12092047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/29/2024] [Accepted: 06/03/2024] [Indexed: 09/30/2024] Open
Abstract
Lupus nephritis represents a significant immune-mediated glomerulonephritis, constituting the most important organ involvement induced by systemic lupus erythematosus (SLE), with variable epidemiology and clinical presentation among populations. OBJECTIVE to identify clinical and immunological factors associated with the progression of lupus nephritis in a population from the Colombian Caribbean. METHODS we evaluated 401 patients diagnosed with SLE and lupus nephritis, treated at a reference center in the Colombian Caribbean, gathering data recorded in medical records. RESULTS A proportion of 87% were female, with a median age of 42 years. Most patients presented with proliferative classes (90%), with class IV being the most common (70%). A proportion of 52% of patients did not respond to treatment, which is described as the lack of complete or partial response, while 28% had a complete response. A significant decrease in hemoglobin, glomerular filtration rate, and proteinuria was identified by the third follow-up (p < 0.001), along with an increase in creatinine, urea, and hematuria (p < 0.001). Patients with initial proteinuria > 2 g/day were found to be 27 times more likely to be non-responders (p < 0.001). Mortality was associated with the presence of serum creatinine >1.5 mg/dL (p = 0.01) (OR: 1.61 CI 95% 0.75-3.75) and thrombocytopenia (p = 0.01) (OR: 0.36; CI 95% 0.12-0.81). CONCLUSIONS identifying factors of progression, non-response, and mortality provides an opportunity for more targeted and personalized intervention, thereby improving care and outcomes for patients with lupus nephritis.
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Affiliation(s)
- María Vélez-Verbel
- Centro de Investigaciones en Ciencias de la Vida, Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 080001, Colombia
| | - Gustavo Aroca-Martínez
- Centro de Investigaciones en Ciencias de la Vida, Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 080001, Colombia
- Departamento de Nefrología, Clínica de la Costa, Barranquilla 080001, Colombia
| | - David Vélez-Verbel
- Departamento de Medicina Interna, Clínica del Río, Magangué 132520, Colombia
| | - Alex Domínguez-Vargas
- División Ciencias de la Salud, Universidad del Norte, Barranquilla 080001, Colombia
- Data Analysis and Mining Department, D&P Consulting Service SAS, Barranquilla 080001, Colombia
| | - Manuela Vallejo-Patiño
- Centro de Investigaciones en Ciencias de la Vida, Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 080001, Colombia
| | - Joanny Sarmiento-Gutierrez
- Centro de Investigaciones en Ciencias de la Vida, Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 080001, Colombia
- Departamento de Nefrología, Clínica de la Costa, Barranquilla 080001, Colombia
| | | | - Carlos G Musso
- Centro de Investigaciones en Ciencias de la Vida, Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 080001, Colombia
- Nephrology Department, Hospital Italiano de Buenos Aires, Buenos Aires C1000, Argentina
| | - Henry J González-Torres
- Centro de Investigaciones en Ciencias de la Vida, Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 080001, Colombia
- Data Analysis and Mining Department, D&P Consulting Service SAS, Barranquilla 080001, Colombia
- Doctorado en Ciencias Biomédicas, Universidad del Valle, Cali 760001, Colombia
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Punnanitinont A, Kasperek EM, Zhu C, Yu G, Miecznikowski JC, Kramer JM. TLR7 activation of age-associated B cells mediates disease in a mouse model of primary Sjögren's disease. J Leukoc Biol 2024; 115:497-510. [PMID: 37930711 PMCID: PMC10990110 DOI: 10.1093/jleuko/qiad135] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023] Open
Abstract
Primary Sjögren's disease (pSD) (also referred to as Sjögren's syndrome) is an autoimmune disease that primarily occurs in women. In addition to exocrine gland dysfunction, pSD patients exhibit B cell hyperactivity. B cell-intrinsic TLR7 activation is integral to the pathogenesis of systemic lupus erythematosus, a disease that shares similarities with pSD. The role of TLR7-mediated B cell activation in pSD, however, remains poorly understood. We hypothesized that age-associated B cells (ABCs) were expanded in pSD and that TLR7-stimulated ABCs exhibited pathogenic features characteristic of disease. Our data revealed that ABC expansion and TLR7 expression were enhanced in a pSD mouse model in a Myd88-dependent manner. Splenocytes from pSD mice showed enhanced sensitivity to TLR7 agonism as compared with those derived from control animals. Sort-purified marginal zone B cells and ABCs from pSD mice showed enhanced inflammatory cytokine secretion and were enriched for antinuclear autoantibodies following TLR7 agonism. Finally, IgG from pSD patient sera showed elevated antinuclear autoantibodies, many of which were secreted preferentially by TLR7-stimulated murine marginal zone B cells and ABCs. These data indicate that pSD B cells are hyperresponsive to TLR7 agonism and that TLR7-activated B cells contribute to pSD through cytokine and autoantibody production. Thus, therapeutics that target TLR7 signaling cascades in B cells may have utility in pSD patients.
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Affiliation(s)
- Achamaporn Punnanitinont
- Department of Oral Biology, School of Dental Medicine, The University at Buffalo, State University of New York, Buffalo, NY USA
| | - Eileen M. Kasperek
- Department of Oral Biology, School of Dental Medicine, The University at Buffalo, State University of New York, Buffalo, NY USA
| | - Chengsong Zhu
- Department of Immunology, Microarray & Immune Phenotyping Core Facility, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Guan Yu
- Department of Biostatistics, School of Public Health and Health Professions, The University at Buffalo, State University of New York, Buffalo, NY USA
| | - Jeffrey C. Miecznikowski
- Department of Biostatistics, School of Public Health and Health Professions, The University at Buffalo, State University of New York, Buffalo, NY USA
| | - Jill M. Kramer
- Department of Oral Biology, School of Dental Medicine, The University at Buffalo, State University of New York, Buffalo, NY USA
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4
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Fanouriakis A, Kostopoulou M, Andersen J, Aringer M, Arnaud L, Bae SC, Boletis J, Bruce IN, Cervera R, Doria A, Dörner T, Furie RA, Gladman DD, Houssiau FA, Inês LS, Jayne D, Kouloumas M, Kovács L, Mok CC, Morand EF, Moroni G, Mosca M, Mucke J, Mukhtyar CB, Nagy G, Navarra S, Parodis I, Pego-Reigosa JM, Petri M, Pons-Estel BA, Schneider M, Smolen JS, Svenungsson E, Tanaka Y, Tektonidou MG, Teng YO, Tincani A, Vital EM, van Vollenhoven RF, Wincup C, Bertsias G, Boumpas DT. EULAR recommendations for the management of systemic lupus erythematosus: 2023 update. Ann Rheum Dis 2024; 83:15-29. [PMID: 37827694 DOI: 10.1136/ard-2023-224762] [Citation(s) in RCA: 57] [Impact Index Per Article: 57.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To update the EULAR recommendations for the management of systemic lupus erythematosus (SLE) based on emerging new evidence. METHODS An international Task Force formed the questions for the systematic literature reviews (January 2018-December 2022), followed by formulation and finalisation of the statements after a series of meetings. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned, and participants finally provided their level of agreement with each item. RESULTS The Task Force agreed on 5 overarching principles and 13 recommendations, concerning the use of hydroxychloroquine (HCQ), glucocorticoids (GC), immunosuppressive drugs (ISDs) (including methotrexate, mycophenolate, azathioprine, cyclophosphamide (CYC)), calcineurin inhibitors (CNIs, cyclosporine, tacrolimus, voclosporin) and biologics (belimumab, anifrolumab, rituximab). Advice is also provided on treatment strategies and targets of therapy, assessment of response, combination and sequential therapies, and tapering of therapy. HCQ is recommended for all patients with lupus at a target dose 5 mg/kg real body weight/day, considering the individual's risk for flares and retinal toxicity. GC are used as 'bridging therapy' during periods of disease activity; for maintenance treatment, they should be minimised to equal or less than 5 mg/day (prednisone equivalent) and, when possible, withdrawn. Prompt initiation of ISDs (methotrexate, azathioprine, mycophenolate) and/or biological agents (anifrolumab, belimumab) should be considered to control the disease and facilitate GC tapering/discontinuation. CYC and rituximab should be considered in organ-threatening and refractory disease, respectively. For active lupus nephritis, GC, mycophenolate or low-dose intravenous CYC are recommended as anchor drugs, and add-on therapy with belimumab or CNIs (voclosporin or tacrolimus) should be considered. Updated specific recommendations are also provided for cutaneous, neuropsychiatric and haematological disease, SLE-associated antiphospholipid syndrome, kidney protection, as well as preventative measures for infections, osteoporosis, cardiovascular disease. CONCLUSION The updated recommendations provide consensus guidance on the management of SLE, combining evidence and expert opinion.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, INSERM UMR-S 1109, Centre National de Référence des Maladies Auto-immunes Systémiques Rares (RESO), Strasbourg, France
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology Research and Hanyang Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK; National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charite Universitätsmedizin Berlin; Deutsches Rheumaforschungszentrum, Berlin, Germany
| | - Richard A Furie
- Division of Rheumatology, Northwell Health, Great Neck, New York City, New York, USA
| | - Dafna D Gladman
- Lupus Program, Centre for Prognosis Studies in the Rheumatic Disease, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Frederic A Houssiau
- Service de Rhumatologie, Cliniques Universitaires Saint-Luc and Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Luís Sousa Inês
- Department of Rheumatology, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal; School of Health Sciences, Universidade da Beira Interior, Covilha, Portugal
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - László Kovács
- Department of Rheumatology and Immunology, Faculty of Medicine, University of Szeged, Hungary
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
| | - Eric F Morand
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Gabriella Moroni
- Department of Biomedical Sciences Humanitas University, Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Johanna Mucke
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - György Nagy
- Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Sandra Navarra
- Section of Rheumatology, Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - José M Pego-Reigosa
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) - VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - Michelle Petri
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bernardo A Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Joint Academic Rheumatology Program, Athens, Greece
| | - Yk Onno Teng
- Centre of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Chris Wincup
- Department of Rheumatology, King's College Hospital, London, UK
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Greece, University Hospital of Heraklion, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece, Medical School, University of Cyprus, Nicosia, Cyprus
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González-García A, Cusácovich I, Ruiz-Irastorza G. Treatment of systemic lupus erythematosus: new therapeutic options. Rev Clin Esp 2023; 223:629-639. [PMID: 38000622 DOI: 10.1016/j.rceng.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune inflammatory disease of unknown cause, with heterogeneity in its clinical presentation, as well as variability in its clinical course and prognosis. The current goal of treatment is to achieve disease remission or a state of low activity, and thereby improve the patient's quality of life. Biological therapy in lupus, unlike other entities, although it has not been fully established, in recent years it has burst onto the scene with important therapeutic novelties. This review aims to update the therapeutic tools for the treatment of SLE focusing on the new molecules that have achieved the objectives of their clinical trials.
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Affiliation(s)
- A González-García
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - I Cusácovich
- Servicio de Medicina Interna, Hospital Clínico Universitario, Valladolid, Spain
| | - G Ruiz-Irastorza
- Unidad de Enfermedades Autoinmunes, Servicio de Medicina Interna, BioCruces Bizkaia Health Research Institute, Hospital Universitario Cruces, UPV/EHU, Barakaldo, Bizkaia, Spain
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6
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Cunha RN, Saraiva L, Jesus D, Doria A, da Silva JP, Inês LS. Predictors of flare in SLE patients fulfilling lupus low disease activity state: a cohort study of 292 patients with 36-month follow-up. Rheumatology (Oxford) 2023; 62:3627-3635. [PMID: 36847423 DOI: 10.1093/rheumatology/kead097] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/25/2023] [Accepted: 02/16/2023] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVES The treatment target in SLE should be maintained stable by preventing flares. The objectives were to identify predictors of flare in patients attaining lupus low disease activity state (LLDAS), and to assess whether remission with no glucocorticoids is associated with lower risk of flares. METHODS This was a cohort study of SLE patients followed in a referral centre over 3 years. Baseline was the first visit where each patient attained LLDAS. Flares up to 36 months' follow-up were identified by three instruments: revised Safety of Estrogen in Lupus Erythematosus National Assessment (SELENA) Flare Index (r-SFI), SLEDAI-2000 (SLEDAI-2K) and SLE Disease Activity Score (SLE-DAS). Demographic, clinical and laboratory parameters at baseline were evaluated as predictors of flare, with distinct models for each flare instrument, using survival analysis with univariate followed by multivariate Cox regression. Hazard ratios (HR) were determined with 95% CI. RESULTS A total of 292 patients fulfilling LLDAS were included. Over follow-up, 28.4%, 24.7% and 13.4% of the patients developed one or more flare, according to r-SFI, SLE-DAS and SLEDAI-2K definitions, respectively. After multivariate analysis, the predictors of SLE-DAS flares were presence of anti-U1-ribonucleoprotein (anti-U1RNP) (HR = 2.16, 95% CI 1.30, 3.59), SLE-DAS score at baseline (HR = 1.27, 95% CI 1.04, 1.54) and immunosuppressants (HR = 2.43, 95% CI 1.43, 4.09). These predictors were equally significant for r-SFI and SLEDAI-2K flares. Remitted patients with no glucocorticoids presented a lower risk of SLE-DAS flares (HR = 0.60, 95% CI 0.37, 0.98). CONCLUSION In patients with LLDAS, anti-U1RNP, disease activity scored by SLE-DAS and SLE requiring maintenance immunosuppressants predict higher risk of flare. Remission with no glucocorticoids is associated with lower risk of flares.
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Affiliation(s)
- Rita N Cunha
- Rheumatology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Liliana Saraiva
- Rheumatology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Diogo Jesus
- Rheumatology Department, Centro Hospitalar de Leiria, Leiria, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - José P da Silva
- Rheumatology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Institute for Clinical and Biomedical Research-ICBR, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Luís S Inês
- Rheumatology Department, Hospitais da Universidade de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
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Banos A, Bertsias G. Flares in Lupus Nephritis: Risk Factors and Strategies for Their Prevention. Curr Rheumatol Rep 2023; 25:183-191. [PMID: 37452914 PMCID: PMC10504124 DOI: 10.1007/s11926-023-01109-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Aggelos Banos
- Department of Rheumatology, 'Asklepieion' General Hospital, Voula, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation Academy of Athens, 115 27, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion and University of Crete Medical School, Voutes-Stavrakia, 71008, Heraklion, Greece.
- Institute of Molecular Biology and Biotechnology-FORTH, Heraklion, Greece.
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Fanouriakis A, Bertsias G, Liapis G, Marinaki S, Papagianni A, Stangou M, Garyfallos A, Lionaki S, Tektonidou MG, Boletis JN, Boumpas DT. Multidisciplinary approach to lupus nephritis: Clinical pearls, pitfalls, and positioning of newly-approved agents. Lupus 2023; 32:1155-1163. [PMID: 37499240 DOI: 10.1177/09612033231191944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Lupus nephritis (LN) is a major course of morbidity and mortality in patients with systemic lupus erythematosus (SLE), best managed by a multidisciplinary group. To this end, we gathered a group of rheumatologists, nephrologists and a nephropathologist to review current evidence regarding diagnosis and management of LN. In this consensus paper, we summarize the key points from this meeting and provide practice guidelines for the management of kidney involvement in SLE, in view of emerging new data concerning novel agents approved recently. Renal biopsy is indispensable for the management of LN. Yet, important pearls and pitfalls need to be considered regarding indications and interpretation, which are summarized in informative tables. In new-onset LN, experts agreed that, although belimumab may be added from disease onset, patients with moderate to severe proliferative nephritis (defined as: NIH activity index > 5 plus ≥ 1 of the following: (i) NIH chronicity index > 2, (ii) proteinuria > 3 g/24 h, and (iii) increase in serum creatinine > 20%) may be more likely to benefit the most. In all other patients who have already started standard-of-care treatment with either mycophenolate mofetil (MMF) or cyclophosphamide (CY), belimumab could be considered in cases with an inadequate clinical response by 3 months, or in cases that experience a nephritic flare following initial response, or have an inability to reduce the dose of glucocorticoids. In all circumstances, the drug should be given as add-on therapy, that is, in combination with a standard-of-care therapy (MMF or CY). Voclosporin could be considered for up to 3 years, in combination with MMF, in patients with heavy proteinuria (well above the nephrotic range), wherein a quick reduction of protein loss in urine is desirable to avoid the complications of the nephrotic syndrome, either as part of the initial regimen, or in cases of inadequate reduction of proteinuria with MMF. In view of the potential scarring effects, long-term administration beyond the first year requires further documentation.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology, "Attikon" University Hospital of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Herakilon, Greece
- Institute of Molecular Biology and Biotechnology, Foundation or Research and Technology - Hellas (FORTH), Heraklion, Greece
| | - George Liapis
- First Department of Pathology, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Smaragdi Marinaki
- Department of Nephrology and Renal Transplantation, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Stangou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandros Garyfallos
- 4th Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sophia Lionaki
- Department of Nephrology, "Attikon" University Hospital of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria G Tektonidou
- First Department of Propaedeutic Internal Medicine, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - John N Boletis
- Department of Nephrology and Renal Transplantation, Laiko General Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology, "Attikon" University Hospital of Athens, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Biomedical Research Foundation of the Academy of Athens, Laboratory of Autoimmunity and Inflammation, Athens, Greece
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Konieczny A, Kasenberg I, Mikołajczak A, Donizy P, Hałoń A, Krajewska M. Baseline Proteinuria and Serum Creatinine Concentration as Clinical Predictors of Complete Renal Response in Patients with Lupus Nephritis: A Single-Center Experience. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15909. [PMID: 36497983 PMCID: PMC9737901 DOI: 10.3390/ijerph192315909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/21/2022] [Accepted: 11/25/2022] [Indexed: 06/17/2023]
Abstract
The aim of the study was to identify robust predictors of complete renal response (CRR), within 36 months, in a single-center cohort of lupus nephritis (LN) patients. Patients with biopsy-confirmed LN who underwent kidney biopsy between 1 January 2010 and 31 December 2020 were included and followed up for at least 6 months. CRR was defined as a reduction of urinary protein-to-creatinine ratio (UPCR) below 0.50 g/g. We evaluated baseline demographic, laboratory, and biopsy characteristics as potential predictors of CRR, and selected the variables further evaluated with Kaplan−Meier curves and log-rank tests. The traits with a p-value < 0.1 were later tested with both uni- and multivariable Cox proportional hazard models. Our sample consisted of 57 patients (84% females, median age 32 years), out of which 63.2% reached CRR within 36 months. The initial UPCR and estimated glomerular filtration rate (eGFR) were the only variables in multivariable Cox regression model, which were selected through backward elimination, with a significance threshold <0.05 (HR = 0.77, p = 0.01 and HR = 1.02, p = 0.001). Our results confirmed the role of initial UPCR and serum creatinine concentration (sCr) as predictors of CRR in LN.
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Affiliation(s)
- Andrzej Konieczny
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Izabela Kasenberg
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Aleksandra Mikołajczak
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Piotr Donizy
- Division of Clinical Pathology, Department of Clinical and Experimental Pathology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Agnieszka Hałoń
- Division of Clinical Pathology, Department of Clinical and Experimental Pathology, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Magdalena Krajewska
- Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
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B Cell Kinetics upon Therapy Commencement for Active Extrarenal Systemic Lupus Erythematosus in Relation to Development of Renal Flares: Results from Three Phase III Clinical Trials of Belimumab. Int J Mol Sci 2022; 23:ijms232213941. [PMID: 36430417 PMCID: PMC9698874 DOI: 10.3390/ijms232213941] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/09/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
Renal flares constitute major determinants of poor prognosis in people living with systemic lupus erythematosus (SLE). The aim of the present study was to investigate changes in B cell subsets in relation to renal flares upon initiation of standard therapy (ST) plus belimumab or placebo in patients with SLE. Using data from the BLISS-76, BLISS-SC, and BLISS Northeast Asia trials, we investigated associations of relative to baseline rapid (through week 8) and early (through week 24) percentage changes in circulating CD19+ B cell subsets characterised through flow cytometry, anti-dsDNA antibodies, and complement levels with the occurrence of renal flares over one year. Patients who developed renal flares showed more prominent rapid decreases in CD19+CD20+CD138+ short-lived plasma cells (-50.4% vs. -16.7%; p = 0.019) and CD19+CD20-CD27bright plasmablasts (-50.0% vs. -29.9%; p = 0.020) compared to non-flaring patients, followed by a subsequent return. Less prominent rapid reductions in CD19+CD27-CD24brightCD38bright transitional B cells (-42.9% vs. -75.0%; p = 0.038) and CD19+CD20-CD138+ peripheral long-lived plasma cells (-11.3% vs. -29.2%; p = 0.019) were seen in belimumab-treated-but not placebo-treated-patients who developed renal flares compared to belimumab-treated patients who did not. Rapid and early changes in anti-dsDNA or complement levels showed no clear association with renal flares. In summary, a rapid drop followed by a subsequent return in circulating short-lived plasma cells and plasmablasts upon treatment for active extra-renal SLE portended renal flares, indicating a need for therapeutic adjustments in patients showing such B cell patterns. Rapid decreases in transitional B cells and peripheral long-lived plasma cells upon belimumab therapy commencement may signify a greater protection against renal flares. B cell kinetics may prove useful in early drug evaluation.
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Park DJ, Joo YB, Bang SY, Lee J, Lee HS, Bae SC. Predictive Factors for Renal Response in Lupus Nephritis: A Single-center Prospective Cohort Study. JOURNAL OF RHEUMATIC DISEASES 2022; 29:223-231. [PMID: 37476428 PMCID: PMC10351413 DOI: 10.4078/jrd.22.0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 07/22/2023]
Abstract
Objective To identify the predictive factors for renal response in patients with lupus nephritis (LN). Methods Patients and data were extracted from a prospective systemic lupus erythematosus cohort in Korea, in which clinical data were collected at 0, 3, 6, and 12 months after induction therapy. Treatment response of LN were evaluated as a complete response (CR), partial response (PR), or non-response (NR) at 3, 6, and 12 months, respectively. Predictive factors for CR at 6 months were evaluated using multivariable Poisson regression analysis. Results A total of 75 patients with LN who underwent biopsy was enrolled. The mean age at diagnosis of LN was 28.9±9.7 years, and 68 (90.7%) were female. The frequencies of classes III, IV, III+V, IV+V, and V were 20.0%, 44.0%, 16.0%, 12.0%, and 8.0%, respectively. Compared to relapsed LN, new-onset LN showed a lower percentage of glomerulosclerosis (45.5% vs. 76.2%, p=0.013). The overall proportions of CR, PR, and NR at 6 and 12 months were 52.0%, 26.7%, 21.3% and 50.7%, 24.0%, 25.3%, respectively. In multivariate analysis, age at enrollment (odds ratio [OR]=1.02, p=0.022), relapsed LN (OR=0.71, p=0.037), anti-Ro antibody (OR=0.67, p=0.014), and class III LN (OR=1.48, p=0.001) were associated with CR at 6 months. Conclusion In our prospective cohort, class III LN was a good predictive factor for CR at 6 months in patients with LN, whereas younger age, relapsed LN, and anti-Ro antibody were poor predictive factors.
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Affiliation(s)
- Dae Jin Park
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Young Bin Joo
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - So-Young Bang
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Jiyoung Lee
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Hye-Soon Lee
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
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Kapsia E, Marinaki S, Michelakis I, Liapis G, Sfikakis PP, Boletis J, Tektonidou MG. Predictors of Early Response, Flares, and Long-Term Adverse Renal Outcomes in Proliferative Lupus Nephritis: A 100-Month Median Follow-Up of an Inception Cohort. J Clin Med 2022; 11:jcm11175017. [PMID: 36078950 PMCID: PMC9457419 DOI: 10.3390/jcm11175017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Objective: To define predictors of response, time to response, flares, and long-term renal outcome in an inception cohort of proliferative lupus nephritis (PLN). Methods: We included 100 patients (80% female; mean age 31 ± 13 years) with biopsy-proven PLN (III, IV, III/IV + V). Clinical, laboratory, histological and therapeutical parameters were recorded at baseline, 6, 9, 12, 18, 24, 36, 72 months, time of flare, and last follow-up visit. Logistic and Cox-regression models were applied. Results: After induction treatment (69% received cyclophosphamide (CYC) and 27% mycophenolic acid (MPA)), partial (PR) or complete (CR) response was achieved in 59% (26% CR, 33% PR) and 67% (43% CR, 24% PR) of patients at 3 and 6 months, respectively; median time to PR was 3 months (IQR 5) and median time to CR was 6 months (IQR 9). Baseline proteinuria <1.5 g/day correlated with a shorter time to CR (HR 1.77) and with CR at 3, 6, and 9 months (OR 9.4, OR 5.3 and OR 3.7, respectively). During 100-month median follow-up, 33% of patients had ≥1 renal flares (median time: 38 months). Proteinuria >0.8 g/day at 12 months was associated with a higher risk of flares (OR 4.12), while MPA and mixed classes with lower risk (OR 0.14 and OR 0.13, respectively). Baseline proteinuria >2 g/day and 12-month proteinuria >0.8 g/day correlated with a shorter time to flare (HR 2.56 and HR 2.57, respectively). At the end of follow-up, 10% developed stage 3–4 chronic kidney disease (CKD), and 12% end-stage renal disease (ESRD). Twelve-month proteinuria >0.8 g/day (OR 10.8) and interstitial fibrosis/tubular atrophy >25% (OR 7.7) predicted CKD or ESRD at last visit. Conclusions: Baseline proteinuria <1.5 g/day predicted time to CR. Twelve-month proteinuria >0.8 g/day correlated with flares (ever) and time to flare and, along with baseline interstitial fibrosis/tubular atrophy >25%, predicted CKD or ESRD at the last visit.
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Affiliation(s)
- Eleni Kapsia
- Department of Nephrology and Renal Transplantation, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Smaragdi Marinaki
- Department of Nephrology and Renal Transplantation, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Ioannis Michelakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - George Liapis
- Department of Pathology, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Petros P. Sfikakis
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - John Boletis
- Department of Nephrology and Renal Transplantation, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Maria G. Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
- Correspondence: ; Tel.: +30-2107462710
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Renal response and its predictive factors of lupus nephritis: a 2-year real-world study of 56 hospital-based patients. Clin Rheumatol 2022; 41:3363-3371. [PMID: 35854166 DOI: 10.1007/s10067-022-06258-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 06/13/2022] [Accepted: 06/19/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Our aim was to evaluate the renal response rate of patients with lupus nephritis (LN) undergoing standard treatment during a 2-year follow-up and to investigate its predictive factors. METHODS A prospective cohort study that enrolled 56 clinically diagnosed LN patients with urinary protein positivity was carried out. All patients underwent standard treatment. All patients were followed up at 6-month intervals for 2 years. Data on renal response and clinical characteristics were collected and analyzed. RESULTS Among 56 patients, 27 (48.2%) and 13 (23.2%) patients achieved complete renal response (CR) and partial renal response (PR) at 6 months after induction therapy, respectively, and 42 (75.0%) and 4 (7.1%) patients developed CR and PR at 2 years. Among patients who achieved PR at 6 months, 90.0% achieved CR at 24 months, while only 37.5% of the patients who were unresponsive at 6 months achieved CR. In the multivariable Cox proportional-hazards model, female (OR 6.51, 95% CI 1.23-34.52, p = 0.028), disease duration (OR 0.84, 95% CI 0.73-0.98, p = 0.021), achieving PR within 6 months (OR 8.09, 95% CI 2.06-31.73, p = 0.003), and urine protein/creatinine ratio (UPCR) (OR 0.998, 95% CI 0.996-1.000, p = 0.025) were found to be predictive factors of CR. CONCLUSION A total of 48.2% of patients achieved CR at 6 months of induction therapy, and the response rates gradually increased to 60.7%, 64.3%, and 75.0% at 12, 18, and 24 months. Besides, female, disease duration, partial response within 6 months, and UPCR were predictive factors for a complete renal response. Key Points • We evaluate the renal response rates in Chinese patients with lupus nephritis in the real world for 2 years. • A total of 48.2% and 75.0% of patients achieved a complete response after standard treatment for 6 months and 2 years. • Female, disease duration, partial response within 6 months, and UPCR are predictors of complete renal response.
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Proliferative Lupusnephritis: Welche Parameter sagen renale
Prognose voraus? AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1732-5079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Bis zu 60% der Patientinnen und Patienten mit einem systemischen
Lupus erythematodes (SLE) leiden an einer Lupusnephritis. Die
ungünstigste Prognose hat dabei die proliferative Verlaufsform. Ein
Forscherteam aus Portugal und den Niederlanden ging nun im Rahmen einer
retrospektiven Studie der Frage nach, anhand welcher Faktoren die renale
Prognose der Betroffenen vorhergesagt werden kann.
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Abstract
Despite improvements in patient and renal death rates following the introduction of potent immunosuppressive drugs in earlier decades, a sizeable fraction of patients with lupus nephritis is burdened with suboptimal or delayed responses, relapses, chronic use of glucocorticoids and accrual of renal (chronic renal insufficiency) and extra-renal organ damage. The recently approved combinatory treatments comprising belimumab or voclosporin added to conventional agents, especially mycophenolate, hold promise for further improving disease outcomes and enabling a faster steroid tapering, thus being relevant to the treat-to-target context. However, it remains uncertain whether these dual regimens should become the first-line choice for all patients or instead be prioritized to certain subgroups. In the present article, we summarize the existing lupus nephritis management recommendations, followed by a critical appraisal of the randomized trials of belimumab and voclosporin, as well as the available data on obinutuzumab and other novel compounds under development. We conclude that pending the identification of accurate clinical, histological, or translational predictors for guiding personalized decisions, it is of utmost importance that lupus nephritis patients are monitored closely with appropriate treatment adjustments aiming at a prompt, deep response to ensure long-term preservation of kidney function.
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Troyer B, Rodgers J, Wolf BJ, Oates JC, Drake RR, Nowling TK. Glycosphingolipid Levels in Urine Extracellular Vesicles Enhance Prediction of Therapeutic Response in Lupus Nephritis. Metabolites 2022; 12:134. [PMID: 35208209 PMCID: PMC8876142 DOI: 10.3390/metabo12020134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 11/28/2022] Open
Abstract
The development of nephritis increases the risk of morbidity and mortality in systemic lupus erythematosus (SLE) patients. While standard induction therapies, such as mycophenolate mofetil (MMF) induce clinical remission (i.e., complete response) in approximately 50% of SLE patients with nephritis, many patients fail to respond. Therapeutic response is often not assessed until 6-12 months after beginning treatment. Those patients that fail to respond to treatment continue to accumulate organ damage, thus, there is a critical need to predict which patients will fail therapy before beginning treatment, allowing physicians to optimize therapy. Our previous studies demonstrated elevated urine, but not serum, glycosphingolipids (GSLs) in SLE patients with nephritis compared to SLE patients without nephritis, suggesting the urine GSLs were derived from the kidney. In this study, we measured the GSLs hexosylceramide and lactosylceramide in extracellular vesicles isolated from longitudinal urine samples of LN patients that were treated with MMF for 12 months. GSL levels were significantly elevated in the baseline samples (prior to treatment) of non-responders compared to complete responders. While a few other proteins measured in the whole urine were higher in non-responders at baseline, only GSLs demonstrated a significant ability to discriminate treatment response in lupus nephritis patients.
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Affiliation(s)
- Brian Troyer
- Department of Medicine, Rheumatology Division, Medical University of South Carolina, Charleston, SC 29425, USA; (B.T.); (J.R.); (J.C.O.)
| | - Jessalyn Rodgers
- Department of Medicine, Rheumatology Division, Medical University of South Carolina, Charleston, SC 29425, USA; (B.T.); (J.R.); (J.C.O.)
| | - Bethany J. Wolf
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - James C. Oates
- Department of Medicine, Rheumatology Division, Medical University of South Carolina, Charleston, SC 29425, USA; (B.T.); (J.R.); (J.C.O.)
- Rheumatology Section, Ralph H. Johnson VA Medical Center, Charleston, SC 29403, USA
| | - Richard R. Drake
- Department of Cell and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Tamara K. Nowling
- Department of Medicine, Rheumatology Division, Medical University of South Carolina, Charleston, SC 29425, USA; (B.T.); (J.R.); (J.C.O.)
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Antimalarial treatment and minimizing prednisolone are associated with lower risk of infection in SLE: a 24-month prospective cohort study. Clin Rheumatol 2021; 41:1069-1078. [PMID: 34782940 DOI: 10.1007/s10067-021-05988-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/03/2021] [Accepted: 11/07/2021] [Indexed: 12/16/2022]
Abstract
INTRODUCTION/OBJECTIVES Infections are a major cause of morbidity and death in systemic lupus erythematosus (SLE). Perfecting the understanding of contributors to infection burden in SLE is pivotal to improve management and outcomes. This study aims to identify clinical predictors of infection in SLE. METHOD We conducted a prospective cohort study at a referral SLE clinic. Infections were identified at each visit and categorized as (a) any type, (b) serious, (c) non-serious, and (d) bacterial. Survival analysis followed by multivariate Cox regression with an estimation of hazard ratios (HR) with 95% confidence intervals (95%CI) was performed. RESULTS We included 259 patients during a mean follow-up of 23.3 ± 5.7 months. The incidence rate of infection of any type was 59.3 cases per 100 patient-years. Multivariate Cox models showed that (a) prednisolone ≥ 7.5 mg/day (HR = 1.95, 95%CI 1.26-3.03) and female gender (HR = 2.08, 95%CI 1.12-3.86) were associated with higher risk of infection of any type; (b) prednisolone ≥ 10 mg/day was associated with higher (HR = 4.32, 95%CI 1.39-13.40), and antimalarials with lower risk (HR = 0.18, 95%CI 0.06-0.51) of serious infection; (c) female gender (HR = 1.92, 95%CI 1.04-3.57) and prednisolone ≥ 7.5 mg/day (HR = 1.89, 95%CI 1.21-2.96) were associated with higher risk of non-serious infection; (d) antimalarials were associated with lower (HR = 0.49, 95%CI 0.26-0.93) and female gender (HR = 5.12; 95%CI 1.62-16.18) with higher risk of bacterial infection. CONCLUSIONS The risk of infection was higher in females in this young, well-controlled, low-comorbidity SLE cohort. Antimalarials were associated with lower and prednisolone ≥ 7.5 mg with higher risk of infection. Key Points • Lupus patients treated with prednisolone ≥ 7.5 mg/day were 89% more likely to present infections. • Lupus patients receiving prednisolone ≥ 10 mg/day were four times more likely to present serious infections. • Lupus patients receiving antimalarials were 82% less likely to present serious infections.
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