Long-term renal outcomes in multi-ethnic Southeast Asians with lupus nephritis: a retrospective cohort study

Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations

Objectives

To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations.

Methods

According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012.

Results

We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500–700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b).

Conclusions

There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.

Risikostratifizierung ausgewählter schwerer Organbeteiligungen bei Systemischer Sklerose und bei Lupus-Nephritis

Interstitielle Lungenerkrankung (ILD), pulmonal-arterielle Hypertonie (PAH), kardiale Beteiligung und renale Krise sind schwere Prognose-bestimmende Manifestationen der Systemischen Sklerose (SSc). Digitale Ulcerationen führen zu erheblicher Beeinträchtigung von Erwerbsfähigkeit und Lebensqualität. Im Rahmen der Betreuung von SSc-Patienten ist daher eine Risikostratifizierung in Hinblick auf Entwicklung und Progression dieser schweren Manifestationen von wesentlicher Bedeutung. Risikofaktoren für die Entwicklung einer SSc-ILD sind diffuse cutane Sklerodermie (dcSSc), männliches Geschlecht und der Nachweis von Topoisomerase-I-Antikörpern. Ausmaß und Verlauf der SSc-ILD sind variabel. Klinik, Ausgangsbefund und Dynamik der Lungenfunktion und hochauflösendes CT (HR-CT) des Thorax werden genutzt, um frühzeitig Patienten zu identifizieren, welche einer Immunsuppression bedürfen und von jenen zu unterscheiden, bei denen zunächst engmaschige Verlaufskontrollen vertretbar sind. Zu den Risikofaktoren einer SSc-PAH zählen langer Krankheitsverlauf, hohes Lebensalter bei Beginn der SSc, schwere Raynaud-Symptomatik, schwere digitale Ischämien sowie Teleangiektasien, der Nachweis von Centromer-Antikörpern sowie Antikörpern gegen Endothelin-A-Rezeptor und Angiotensin-1-Rezeptor und Hyperurikämie. Bei etablierter PAH erfolgt die Risikostratifizierung auf Basis der kalkulierten 1-Jahres-Mortaliät. Zur Kalkulation der 1-Jahresmortalität werden anamnestische und klinische Parameter wie Symptomprogression, Auftreten von Synkopen, Vorhandensein klinischer Zeichen einer Rechtsherzinsuffizienz, funktionelle WHO-Klasse, funktionsdiagnostische, laborchemische, echokardiografische sowie hämodynamische Parameter herangezogen. Nach den aktuellen Empfehlungen zur Therapie der PAH ist eine primäre Kombinationstherapie zumindest ab WHO-Funktionsklasse III und einem intermediären Risiko (1-Jahres-Mortalität≥5%) indiziert. Wesentliche Risikofaktoren einer kardialen Beteiligung bei SSc sind höheres Lebensalter, dcSSc und der Nachweis von Topoisomerase I-Antikörpern. Zu den Risikofaktoren der renalen Krise bei SSc zählen dcSSc, männliches Geschlecht, der Nachweis von RNA-Polymerase III-Antikörpern, vorbestehende Proteinurie, aber auch eine Vortherapie mit Glukokortikoiden, ACE-Hemmern und Cyclosporin. Digitale Ulcera (DU) treten bei ca. 50% der Patienten auf. Risikofaktoren von DU sind dcSSc, Nachweis von Topoisomerase I-Antikörpern, früher Beginn der Raynaud-Symptomatik, hoher Rodnan Skin Score und männliches Geschlecht. Entscheidendes Therapieziel bei der Lupus-Nephritis (LN) ist der Erhalt einer normalen Nierenfunktion und die Vermeidung einer terminalen Niereninsuffizienz, welche mit einer erhöhten Letalität assoziiert ist. Zu den Risikofaktoren eines ungünstigen Langzeitverlaufs der LN zählen v. a. eine initiale irreversible Nierenfunktionseinschränkung im Zusammenhang mit irreversiblen chronischen Läsionen in der Nierenbiopsie, unzureichend kontrollierte arterielle Hypertonie, ausgeprägte initiale Proteinurie und männliches Geschlecht. Eine effektive Reduktion der Proteinurie auf<0,5–0,8 g/d innerhalb von 12 Monaten nach Beginn der Remissionsinduktion signalisiert dagegen eine günstige Prognose. Frühestmögliche Diagnose der LN und umgehende auf dem Befund der Nierenbiopsie basierende Therapie sowie Reinduktion bei ausbleibender Remission sind entscheidend für eine Minimierung der Risikos.

Spectrum of Morphologic Features of Lupus Nephritis According to Nephrology/Renal Pathology Society (ISN/RPS) Classification

Introduction

Lupus nephritis is one of the most important secondary glomerulopathy and a significant cause of chronic renal failure. Early diagnosis is key to improved prognosis. The International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification stratifies renal biopsy evaluation in different classes that correlates with clinical renal outcome. In the current study, we aimed to evaluate the proportion of patients in each class of lupus nephritis in our population.

Methods

We evaluated renal biopsies of 128 patients that fulfilled the clinical and serologic criteria of lupus nephritis. The histologic classification was done according to the ISN/RPS classification, and immunofluorescence studies were performed. Active and chronic lesions were assessed on renal biopsy, and association of different histopatholgic parameters with lupus classes was done.

Results

The mean age was 28.85±12.24 years. Most of the patients were from age group ≤25 years (48.4%). Active lesions were seen in 66 (51.6%) patients, with endocapillary hypercellularity being the most common active lesion type, i.e. 81.8%. Chronic lesions were noted in 42 (32.8%) patients, with glomerular sclerosis being the most common chronic lesion type, i.e. 69%. Majority of the patients belonged to class IV (46.9%). Females were more likely to present at advanced lupus stage compared to males, and older patients (>50 years) had a higher chance to present at a late stage (class IV and higher). Active lesions were significantly found more frequently in classes III and IV, while chronic lesions were more likely to present in classes III to V.

Conclusion

We found that a significant proportion of patients of lupus nephritis in our population presents at an advanced stage as more than 60% patients were of class IV or higher. This signifies lack of appropriate clinical surveillance of patients and assessment of renal functions early in disease course. This also necessitates revision of our locoregional protocols to manage lupus nephritis patients and a need to perform a renal biopsy early in disease course.

Synergistic impact of pre-diabetes and immunosuppressants on the risk of diabetes mellitus during treatment of glomerulonephritis and renal vasculitis

Background

Glomerulonephritis is often treated with kidney-saving, but potentially diabetogenic immunosup­pressants such as glucocorticosteroids and calcineurin inhibitors. Unfortunately, there are little data on dysglycemia before and after diagnosis and during treatment of glomerulonephritis. We aimed to evaluate the occurrence and risk factors for pre-diabetes and incident diabetes among non-diabetic patients with glomerular disease with or without treatment with immunosuppressants.

Methods

A single-center, retrospective cohort study was performed on 229 non-diabetic immunosuppressant-naïve adults diagnosed with glomerulonephritis and renal vasculitis. Patients with known diabetes and prior immunosuppressant treatment were excluded. Outcomes of new-onset pre-diabetes and new-onset diabetes were defined according to American Diabetic Association criteria.

Results

Pre-diabetes was present pre-biopsy in 74 of the 229 patients (32.3%). During the median follow-up of 34.0 (23.3-47.5) months, 29 patients (12.7%) developed new-onset diabetes and 58 (25.3%) had new-onset pre-diabetes. Immunosuppressive therapy in patients with pre-existing pre-diabetes was associated with increased odds of new-onset diabetes compared to those without either risk factor (26.0% versus 5.0%; odds ratio, 6.67; 95% confidence interval [CI], 1.41 to 31.64), P = 0.02).

Conclusion

New-onset diabetes after immunosuppressant treatment occurred in one-quarter of patients with glomerulonephritis and pre-existing pre-diabetes. Physicians should screen for pre-diabetes when planning treatment with immunosuppressants, as its presence significantly increases the risk of diabetes mellitus.

Clinical and histopathological features and short-term outcomes of lupus nephritis: a prospective study of 100 Egyptian patients

OBJECTIVE

The short-term outcomes of lupus nephritis (LN) are variable and unpredictable among individuals. We aimed to evaluate the clinical and histopathological features and short-term renal outcomes in LN patients.

METHODS

This was a prospective cohort study carried out at nephrology and rheumatology units in Egypt between 2018 and 2019. A total of 100 patients with biopsy-proven LN were studied. Patients were evaluated for response after six months.

RESULTS

The female-to-male ratio was 8.1:1. About 70% of patients were hypertensive at disease onset, with rates for classes I, II, III, IV, V and VI LN being 1%, 7%, 20%, 53%, 14% and 6%, respectively. Among the immunosuppressive drugs used for induction, mycophenolate mofetil (MMF) represented the most commonly used (44%) followed by cyclophosphamide (CYC; 37%). After six months of follow-up, about two thirds of patients achieved remission. There was no significant difference in remission rate between MMF and CYC. On multivariate analysis, serum creatinine (SCr) at presentation was the most significant predictor of renal recovery. According to the receiver operating characteristic curve, the cut-off value of SCr was 1.6 mg/dL, with a sensitivity of 76% and specificity of 71% predicting renal recovery. Repeat renal biopsy was needed in 10 patients; class and treatment strategy changed in 40% and 70% of them, respectively.

CONCLUSION

Our findings in Egyptian LN patients compare favourably with most studies.