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Schneider M, Schwarting A, Chehab G. [Update on lupus nephritis]. Z Rheumatol 2024:10.1007/s00393-024-01534-7. [PMID: 38935117 DOI: 10.1007/s00393-024-01534-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2024] [Indexed: 06/28/2024]
Abstract
In addition to the butterfly rash, lupus nephritis is the most specific manifestation of systemic lupus erythematosus (SLE). The perspective on this organ manifestation has fundamentally changed as well as the manifestation of SLE itself 40 years after the first multicenter clinical study on lupus nephritis. Even if there is a faint glimpse of hope of a cure, there is still the fight against the problem of nonresponders and also the progressive loss of organ function. This update gives an overview of the current importance of lupus nephritis in the context of the whole SLE disease, of the special features and on the options provided by the new diagnostic and therapeutic developments.
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Affiliation(s)
- M Schneider
- Klinik für Rheumatologie und Hiller Forschungszentrum Rheumatologie, UKD, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland.
- Klinik für Rheumatologie und Hiller Forschungszentrum Rheumatologie, UKD, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.
| | - A Schwarting
- Rheumatologie und Klinische Immunologie, Universitätsmedizin der Johannes-Gutenberg-Universität Mainz, Mainz, Deutschland
| | - G Chehab
- Klinik für Rheumatologie und Hiller Forschungszentrum Rheumatologie, UKD, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Deutschland
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Bawazir Y. Clinicopathological correlation of patients with lupus nephritis: Data from a tertiary center in Saudi Arabia. Medicine (Baltimore) 2024; 103:e37821. [PMID: 38579022 PMCID: PMC10994433 DOI: 10.1097/md.0000000000037821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 03/15/2024] [Indexed: 04/07/2024] Open
Abstract
Systemic lupus erythematosus mainly affects young women, and approximately half of systemic lupus erythematosus patients develop lupus nephritis (LN). However, data on the types and remission rates of LN in Saudi Arabia are limited. Therefore, we aimed to highlight the LN remission rates in our population. A retrospective record review was conducted between January 2007 and December 2020 in a tertiary center in the western region of Saudi Arabia to determine the remission rates among patients with biopsy-proven LN who met the EULAR\ACR 2019 classification criteria. We identified 59 patients with biopsy-proven LN, mostly in young women. The common histopathological pattern was Class IV LN in 26 patients (44%). Three induction protocols were identified, along with systemic steroids: the high-dose cyclophosphamide protocol in 21 patients (35.6%), low-dose protocol in 4 patients (6.8%), and mycophenolate mofetil (MMF) in 41 patients (69.5%). Partial response, defined as the reduction of the 24-hour proteinuria by 25% at 3 months and 50% at 6 months, was achieved in 18 patients (33.3%) at 3 months and decreased to 13 patients (24.1%) at 6 months. Complete clinical response, defined as 24-hour urinary protein between 500 and 700 mg at 12 months, was achieved in 44 patients (81.5%). Complete remission was higher among patients with Class IV LN (64.4%). The achievement of partial clinical response at 3 months was significantly lower among patients with hypertension (P = .041). This study presented the LN remission rates in a single center in Saudi Arabia. Similar to previous studies, Class IV LN were the most common histopathological finding in this study. Complete remission at 12 months was achieved in 44 (81%) patients. Delayed remission is associated with hypertension at the time of LN diagnosis.
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Affiliation(s)
- Yasser Bawazir
- Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Menn-Josephy H, Hodge LS, Birardi V, Leher H. Efficacy of Voclosporin in Proliferative Lupus Nephritis with High Levels of Proteinuria. Clin J Am Soc Nephrol 2024; 19:309-318. [PMID: 38110196 PMCID: PMC10937024 DOI: 10.2215/cjn.0000000000000297] [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: 04/19/2023] [Accepted: 12/11/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND In a phase 3 study of adults with active lupus nephritis, addition of voclosporin to mycophenolate mofetil (MMF) and low-dose glucocorticoids led to significant improvements in the proportion of participants achieving complete and partial renal response as well as sustained reduction in proteinuria. This analysis examined the efficacy and safety of voclosporin in a subgroup of the phase 3 study with proliferative lupus nephritis and high levels of proteinuria. METHODS Participants were randomized to oral voclosporin (23.7 mg twice daily) or placebo for 12 months; all participants received MMF and low-dose glucocorticoids. This analysis includes participants with class III or IV (±class V) lupus nephritis and baseline urine protein-creatinine ratio (UPCR) ≥3 g/g. Efficacy end points included complete renal response (UPCR ≤0.5 g/g with stable eGFR, low-dose glucocorticoids, and no rescue medication), partial renal response (≥50% reduction from baseline UPCR), and UPCR over time. Safety outcomes were also assessed. RESULTS A total of 148 participants were in the voclosporin ( n =76) and control ( n =72) arms. At 12 months, 34% and 11% of participants in the voclosporin and control arms, respectively, achieved a complete renal response (odds ratio, 4.43; 95% confidence interval [CI], 1.78 to >9.99; P = 0.001). A partial renal response was achieved by 65% of the voclosporin arm and 51% of the control arm at 12 months (odds ratio, 1.60; 95% CI, 0.8 to 3.20; P = 0.18). More voclosporin- than control-treated participants achieved UPCR ≤0.5 g/g (51% versus 26%), and voclosporin-treated participants met this end point significantly earlier (hazard ratio, 2.07; 95% CI, 1.19 to 3.60; P = 0.01). The incidence of adverse events was similar between the arms; mean eGFR values remained stable and within normal range in both arms. CONCLUSIONS Addition of voclosporin to MMF and low-dose glucocorticoids resulted in a significantly higher proportion of participants with proliferative lupus nephritis achieving complete and partial renal responses as well as earlier reductions in proteinuria, with no evidence of worsening kidney function.
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Affiliation(s)
| | - Lucy S. Hodge
- Aurinia Pharmaceuticals Inc., Edmonton, Alberta, Canada
| | | | - Henry Leher
- Aurinia Pharmaceuticals Inc., Edmonton, Alberta, Canada
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Kirsztajn GM, Moura AF, Rodrigues CIS, Sanders-Pinheiro H, Moura-Neto JA, Mansur J, Moura LRR, Bastos MG, Facca TA, Pacheco-Silva A. Kidney diseases in women: difference in risks and opportunities. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023S117. [PMID: 37556636 PMCID: PMC10411704 DOI: 10.1590/1806-9282.2023s117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/22/2023] [Indexed: 08/11/2023]
Affiliation(s)
- Gianna Mastroianni Kirsztajn
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Universidade Federal de São Paulo, Department of Medicine, Division of Nephrology – São Paulo (SP), Brazil
| | - Ana Flávia Moura
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Escola Bahiana de Medicina e Saúde Pública – Salvador (BA), Brazil
| | - Cibele Isaac Saad Rodrigues
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Pontifícia Universidade Católica de São Paulo, Faculdade de Ciências Médicas e da Saúde, Department of Medicine, Division of Nephrology – São Paulo (SP), Brazil
| | - Helady Sanders-Pinheiro
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Federal University of Juiz de Fora, Faculty of Medicine, Division of Nephrology – Juiz de Fora (MG), Brazil
| | - José A. Moura-Neto
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Escola Bahiana de Medicina e Saúde Pública – Salvador (BA), Brazil
| | - Juliana Mansur
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Universidade Federal de São Paulo, Department of Medicine, Division of Nephrology – São Paulo (SP), Brazil
- Hospital do Rim, Fundação Oswaldo Ramos – São Paulo (SP), Brazil
| | - Lúcio R. Requião Moura
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Universidade Federal de São Paulo, Department of Medicine, Division of Nephrology – São Paulo (SP), Brazil
- Hospital do Rim, Fundação Oswaldo Ramos – São Paulo (SP), Brazil
| | - Marcus Gomes Bastos
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Federal University of Juiz de Fora, Faculty of Medicine, Division of Nephrology – Juiz de Fora (MG), Brazil
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora – Suprema, Faculdade de Medicina, Centro Universitário Governador Ozanam Coelho – Ubá (MG), Brazil
| | - Thais Alquezar Facca
- Universidade Municipal de São Caetano do Sul, Department of Medicine – São Paulo (SP), Brazil
| | - Alvaro Pacheco-Silva
- Sociedade Brasileira de Nefrologia – São Paulo (SP), Brazil
- Universidade Federal de São Paulo, Department of Medicine, Division of Nephrology – São Paulo (SP), Brazil
- Hospital Israelita Albert Einstein – São Paulo (SP), Brazil
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Zhang D, Sun F, Chen J, Ding H, Wang X, Shen N, Li T, Ye S. Four trajectories of 24-hour urine protein levels in real-world lupus nephritis cohorts. RMD Open 2023; 9:rmdopen-2022-002930. [PMID: 37208030 DOI: 10.1136/rmdopen-2022-002930] [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: 12/12/2022] [Accepted: 04/20/2023] [Indexed: 05/21/2023] Open
Abstract
OBJECTIVES A 24-hour urine protein (24hUP) is a key measurement in the management of lupus nephritis (LN); however, trajectories of 24hUP in LN is poorly defined. METHODS Two LN cohorts that underwent renal biopsies at Renji Hospital were included. Patients received standard of care in a real-world setting and 24hUP data were collected over time. Trajectory patterns of 24hUP were determined using the latent class mixed modelling (LCMM). Baseline characters were compared among trajectories and multinomial logistic regression was used to determine independent risk factors. Optimal combinations of variables were identified for model construction and user-friendly nomograms were developed. RESULTS The derivation cohort composed of 194 patients with LN with 1479 study visits and a median follow-up of 17.5 (12.2-21.7) months. Four trajectories of 24hUP were identified, that is, Rapid Responders, Good Responders, Suboptimal Responders and Non-Responders, with the KDIGO renal complete remission rates (time to complete remission, months) of 84.2% (4.19), 79.6% (7.94), 40.4% (not applicable) and 9.8% (not applicable), respectively (p<0.001). The 'Rapid Responders' distinguish itself from other trajectories and a nomogram, composed of age, systemic lupus erythematosus duration, albumin and 24hUP yielded C-indices >0.85. Another nomogram to predict 'Good Responders' yielded C-indices of 0.73~0.78, which composed of gender, new-onset LN, glomerulosclerosis and partial remission within 6 months. When applied to the validation cohort with 117 patients and 500 study visits, nomograms effectively sorted out 'Rapid Responders' and 'Good Responders'. CONCLUSION Four trajectories of LN shed some light to guide the management of LN and further clinical trials design.
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Affiliation(s)
- Danting Zhang
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 2000 Jiangye Rd, Shanghai, 201112, China
| | - Fangfang Sun
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 2000 Jiangye Rd, Shanghai, 201112, China
| | - Jie Chen
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 2000 Jiangye Rd, Shanghai, 201112, China
| | - Huihua Ding
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 145 Shandong (M) Rd, Shanghai, 200001, China
| | - Xiaodong Wang
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 2000 Jiangye Rd, Shanghai, 201112, China
| | - Nan Shen
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 145 Shandong (M) Rd, Shanghai, 200001, China
| | - Ting Li
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 2000 Jiangye Rd, Shanghai, 201112, China
| | - Shuang Ye
- Department of Rheumatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, 2000 Jiangye Rd, Shanghai, 201112, China
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Shipa M, Santos LR, Nguyen DX, Embleton-Thirsk A, Parvaz M, Heptinstall LL, Pepper RJ, Isenberg DA, Gordon C, Ehrenstein MR. Identification of biomarkers to stratify response to B-cell-targeted therapies in systemic lupus erythematosus: an exploratory analysis of a randomised controlled trial. THE LANCET. RHEUMATOLOGY 2022; 5:e24-e35. [PMID: 36756239 PMCID: PMC9894756 DOI: 10.1016/s2665-9913(22)00332-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Systemic lupus erythematosus (SLE) is a complex autoimmune disease associated with widespread immune dysregulation and diverse clinical features. Immune abnormalities might be differentially associated with specific organ involvement or response to targeted therapies. We aimed to identify biomarkers of response to belimumab after rituximab to facilitate a personalised approach to therapy. Methods In this exploratory analysis of a randomised controlled trial (BEAT-LUPUS), we investigated immune profiles of patients with SLE recruited to the 52-week clinical trial, which tested the combination of rituximab plus belimumab versus rituximab plus placebo. We used machine learning and conventional statistics to investigate relevant laboratory and clinical biomarkers associated with major clinical response. BEAT LUPUS is registered at ISRCTN, 47873003, and is now complete. Findings Between Feb 2, 2017, and March 28, 2019, 52 patients were recruited to BEAT-LUPUS, of whom 44 provided clinical data at week 52 and were included in this analysis. 21 (48%) of 44 participants were in the belimumab group (mean age 39·5 years [SD 12·1]; 17 [81%] were female, four [19%] were male, 13 [62%] were White) and 23 (52%) were in the placebo group (mean age 42·1 years [SD 10·5]; 21 [91%] were female, two [9%] were male, 16 [70%] were White). Ten (48%) of 21 participants who received belimumab after rituximab and eight (35%) of 23 who received placebo after rituximab had a major clinical response at 52 weeks (between-group difference of 13% [95% CI -15 to 38]). We found a predictive association between baseline serum IgA2 anti-double stranded DNA (dsDNA) antibody concentrations and clinical response to belimumab after rituximab, with a between-group difference in major clinical response of 48% (95% CI 10 to 70) in patients with elevated baseline serum IgA2 anti-dsDNA antibody concentrations. Moreover, among those who had a major clinical response, serum IgA2 anti-dsDNA antibody concentrations significantly decreased from baseline only in the belimumab group. Increased circulating IgA2 (but not total) plasmablast numbers, and T follicular helper cell numbers predicted clinical response and were both reduced only in patients who responded to belimumab after rituximab. Serum IgA2 anti-dsDNA antibody concentrations were also associated with active renal disease, whereas serum IgA1 anti-dsDNA antibody and IFN-α concentrations were associated with mucocutaneous disease activity but did not predict response to B-cell targeted therapy. Patients with a high baseline serum interleukin-6 concentration were less likely to have a major clinical response, irrespective of therapy. Interpretation This exploratory study revealed the presence of distinct molecular networks associated with renal and mucocutaneous involvement, and response to B-cell-targeted therapies, which, if confirmed, could guide precision targeting of advanced therapies for this heterogenous disease. Funding Versus Arthritis, UCLH Biomedical Research Centre, LUPUS UK, and GSK.
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Affiliation(s)
- Muhammad Shipa
- Department of Rheumatology, University College London, London, UK
| | - Liliana R Santos
- Department of Rheumatology, University College London, London, UK
| | - Dao X Nguyen
- Department of Rheumatology, University College London, London, UK
| | | | - Mariea Parvaz
- Department of Rheumatology, University College London, London, UK
| | - Lauren L Heptinstall
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Ruth J Pepper
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - David A Isenberg
- Department of Rheumatology, University College London, London, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Michael R Ehrenstein
- Department of Rheumatology, University College London, London, UK,Correspondence to: Prof Michael R Ehrenstein, Department of Rheumatology, University College London, London WC1E 6JF, UK
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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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