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Mannemuddhu SS, Shoemaker LR, Bozorgmehri S, Borgia RE, Gupta N, Clapp WL, Zeng X, Modica RF. Does kidney biopsy in pediatric lupus patients "complement" the management and outcomes of silent lupus nephritis? Lessons learned from a pediatric cohort. Pediatr Nephrol 2023; 38:2669-2678. [PMID: 36688943 PMCID: PMC10393877 DOI: 10.1007/s00467-022-05859-w] [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: 03/01/2022] [Revised: 12/10/2022] [Accepted: 12/10/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Silent lupus nephritis (SLN) is systemic lupus erythematosus (SLE) without clinical and laboratory features of kidney involvement but with biopsy-proven nephritis. This study aims to describe and compare the baseline characteristics and outcomes of pediatric SLN with overt LN (OLN) and to identify associated risk factors and biochemical markers. METHODS In this retrospective, observational study, multivariate logistic regression and receiver operating characteristic (ROC) analyses studied age, sex, race, serum complements, anti-double-stranded-DNA antibody, anti-Smith antibody, eGFR, and proliferative nephritis. RESULTS In our cohort of 69 patients, 47 were OLN, and 22 were SLN. OLN (OR = 4.9, p = 0.03) and non-African Americans (AA) (OR = 13.0, p < 0.01) had higher odds, and increasing C3 and C4 were associated with lower odds of proliferative nephritis (OR 0.95 and 0.65 per one unit increase in C3 and C4, respectively, p < 0.01). They demonstrated a good discriminative ability to detect proliferative nephritis as assessed by the area under the ROC curve (C3 = 0.78, C4 = 0.78). C3 and C4 in proliferative SLN and OLN were comparable and significantly lower than their non-proliferative counterparts. No association was observed between age, sex, anti-double-stranded-DNA antibody, anti-Smith antibody, eGFR, and proliferative nephritis. Proliferative SLN and OLN patients received similar treatments. Adverse events were identified in the proliferative OLN only. CONCLUSIONS Lower complement levels are associated with proliferative lesions in pediatric LN-both SLN and OLN. The non-AA population had higher odds of having proliferative nephritis than the AA. Prospective, randomized, long-term follow-up of proliferative SLN patients is needed to ascertain the beneficial effect of early diagnosis and treatment. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Sai Sudha Mannemuddhu
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA.
- Pediatric Nephrology, East Tennessee Children's Hospital, 2100 Clinch Avenue, MOB, Suite 310, Knoxville, TN, 37916, USA.
- Department of Medicine, University of Tennessee, Knoxville, TN, USA.
| | - Lawrence R Shoemaker
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Shahab Bozorgmehri
- Department of Medicine, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA
| | - R Ezequiel Borgia
- Department of Pediatrics, Division of Rheumatology, University of Florida-School of Medicine, Gainesville, FL, USA
- Department of Pediatrics, Division of Allergy, Immunology, and Rheumatology, University Hospitals Rainbow Babies and Children's Hospital, Cleveland, OH, USA
| | - Nirupama Gupta
- Department of Pediatrics, Division of Nephrology, University of Florida-School of Medicine, Gainesville, FL, USA
- Blue Jay Pediatrics, Leesburg, VA, USA
| | - William L Clapp
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Xu Zeng
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida-School of Medicine, Gainesville, FL, USA
| | - Renee F Modica
- Department of Pediatrics, Division of Rheumatology, University of Florida-School of Medicine, Gainesville, FL, USA
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Wang DC, Xu WD, Wang SN, Wang X, Leng W, Fu L, Liu XY, Qin Z, Huang AF. Lupus nephritis or not? A simple and clinically friendly machine learning pipeline to help diagnosis of lupus nephritis. Inflamm Res 2023:10.1007/s00011-023-01755-7. [PMID: 37300586 DOI: 10.1007/s00011-023-01755-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/17/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
OBJECTIVE Diagnosis of lupus nephritis (LN) is a complex process, which usually requires renal biopsy. We aim to establish a machine learning pipeline to help diagnosis of LN. METHODS A cohort of 681 systemic lupus erythematosus (SLE) patients without LN and 786 SLE patients with LN was established, and a total of 95 clinical, laboratory data and 17 meteorological indicators were collected. After tenfold cross-validation, the patients were divided into training set and test set. The features selected by collective feature selection method of mutual information (MI) and multisurf were used to construct the models of logistic regression, decision tree, random forest, naive Bayes, support vector machine (SVM), light gradient boosting (LGB), extreme gradient boosting (XGB), and artificial neural network (ANN), the models were compared and verified in post-analysis. RESULTS Collective feature selection method screens out antistreptolysin (ASO), retinol binding protein (RBP), lupus anticoagulant 1 (LA1), LA2, proteinuria and other features, and the hyperparameter optimized XGB (ROC: AUC = 0.995; PRC: AUC = 1.000, APS = 1.000; balance accuracy: 0.990) has the best performance, followed by LGB (ROC: AUC = 0.992; PRC: AUC = 0.997, APS = 0.977; balance accuracy: 0.957). The worst performance is naive Bayes model (ROC: AUC = 0.799; PRC: AUC = 0.822, APS = 0.823; balance accuracy: 0.693). In the composite feature importance bar plots, ASO, RF, Up/Ucr, and other features play important roles in LN. CONCLUSION We developed and validated a new and simple machine learning pathway for diagnosis of LN, especially the XGB model based on ASO, LA1, LA2, proteinuria, and other features screened out by collective feature selection.
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Affiliation(s)
- Da-Cheng Wang
- Department of Evidence-Based Medicine, Southwest Medical University, 1 Xianglin Road, Luzhou, Sichuan, China
| | - Wang-Dong Xu
- Department of Evidence-Based Medicine, Southwest Medical University, 1 Xianglin Road, Luzhou, Sichuan, China
| | - Shen-Nan Wang
- Luzhou Meteorological Bureau, 3 Songshan Road, Luzhou, Sichuan, China
| | - Xiang Wang
- Luzhou Meteorological Bureau, 3 Songshan Road, Luzhou, Sichuan, China
| | - Wei Leng
- Luzhou Meteorological Bureau, 3 Songshan Road, Luzhou, Sichuan, China
| | - Lu Fu
- Laboratory Animal Center, Southwest Medical University, 1 Xianglin Road, Luzhou, Sichuan, China
| | - Xiao-Yan Liu
- Department of Evidence-Based Medicine, Southwest Medical University, 1 Xianglin Road, Luzhou, Sichuan, China
| | - Zhen Qin
- Department of Rheumatology and Immunology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, China
| | - An-Fang Huang
- Department of Rheumatology and Immunology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, China.
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Al Arfaj AS, Khalil N. Levels of Proteinuria and Renal Pathology in Systemic Lupus Erythematosus Patients. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2023; 34:154-160. [PMID: 38146725 DOI: 10.4103/1319-2442.391894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
According to the current guidelines, renal biopsies are performed in systemic lupus erythematosus (SLE) patients for proteinuria of 0.5 g/24 h or higher. Renal pathology may be present in patients with lower-level proteinuria (<0.5 g/24 h). We aimed to review the renal histopathology in SLE patients, with lower levels of proteinuria. In this retrospective study, we retrieved SLE patients' data, including 24-h urinary protein excretion and renal histopathology results. We compared various parameters in different lupus nephritis (LN) classes and in different levels of proteinuria (urinary protein <0.5 g, 0.5 to <1 g, and ≥1 g per 24 h). Out of 476 patients, 274 (57.6%) had proteinuria of <0.5 g, 44 (9.2%) had 0.5 to <1 g, and 158 (33.2%) had ≥1 g per 24 h. SLE patients with proteinuria of <0.5 g/24 h were found to have LN, including the proliferative classes. Of the 299 LN cases confirmed by a renal biopsy, low-level proteinuria (<0.5 g) was found in 39.8% of all LN patients, in 50% of patients with Class III LN, 33.3% of those with Class IV LN, 31.4% of those with Class V LN, and 41.4% of those with other LN classes (II/V, III/V, and IV/V). Overall, 35.9% (87/242) of patients with the proliferative LN classes (III, IV, V, II/V, III/V and IV/V) had low-level proteinuria of <0.5 g/24 h. SLE patients with low-level proteinuria had significant renal pathology. Our study suggests there is a need to perform renal biopsies at lower levels of proteinuria.
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Affiliation(s)
- Abdurhman Saud Al Arfaj
- Department of Medicine, Division of Rheumatology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Najma Khalil
- College of Medicine Research Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Carlucci PM, Li J, Fava A, Deonaraine KK, Wofsy D, James JA, Putterman C, Diamond B, Davidson A, Fine DM, Monroy-Trujillo J, Atta MG, DeJager W, Guthridge JM, Haag K, Rao DA, Brenner MB, Lederer JA, Apruzzese W, Belmont HM, Izmirly PM, Zaminski D, Wu M, Connery S, Payan-Schober F, Furie R, Dall'Era M, Cho K, Kamen D, Kalunian K, Anolik J, Barnas J, Ishimori M, Weisman MH, Buyon JP, Petri M. High incidence of proliferative and membranous nephritis in SLE patients with low proteinuria in the Accelerating Medicines Partnership. Rheumatology (Oxford) 2022; 61:4335-4343. [PMID: 35212719 PMCID: PMC9629353 DOI: 10.1093/rheumatology/keac067] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/17/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Delayed detection of LN associates with worse outcomes. There are conflicting recommendations regarding a threshold level of proteinuria at which biopsy will likely yield actionable management. This study addressed the association of urine protein:creatinine ratios (UPCR) with clinical characteristics and investigated the incidence of proliferative and membranous histology in patients with a UPCR between 0.5 and 1. METHODS A total of 275 SLE patients (113 first biopsy, 162 repeat) were enrolled in the multicentre multi-ethnic/racial Accelerating Medicines Partnership across 15 US sites at the time of a clinically indicated renal biopsy. Patients were followed for 1 year. RESULTS At biopsy, 54 patients had UPCR <1 and 221 had UPCR ≥1. Independent of UPCR or biopsy number, a majority (92%) of patients had class III, IV, V or mixed histology. Moreover, patients with UPCR <1 and class III, IV, V, or mixed had a median activity index of 4.5 and chronicity index of 3, yet 39% of these patients had an inactive sediment. Neither anti-dsDNA nor low complement distinguished class I or II from III, IV, V or mixed in patients with UPCR <1. Of 29 patients with baseline UPCR <1 and class III, IV, V or mixed, 23 (79%) had a UPCR <0.5 at 1 year. CONCLUSION In this prospective study, three-quarters of patients with UPCR <1 had histology showing class III, IV, V or mixed with accompanying activity and chronicity despite an inactive sediment or normal serologies. These data support renal biopsy at thresholds lower than a UPCR of 1.
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Affiliation(s)
- Philip M Carlucci
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Jessica Li
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Andrea Fava
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | | | - David Wofsy
- Rheumatology Division, Department of Medicine, Russell/Engleman Rheumatology Research Center, University of California San Francisco, San Francisco, CA
| | - Judith A James
- Department of Medicine, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Chaim Putterman
- Division of Rheumatology, Department of Microbiology and Immunology, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
- Azrieli Faculty of Medicine, Bar-Ilan University, Zefat, Israel
| | - Betty Diamond
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, NY
| | - Anne Davidson
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, NY
| | - Derek M Fine
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Jose Monroy-Trujillo
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Mohamed G Atta
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Wade DeJager
- Department of Medicine, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Joel M Guthridge
- Department of Medicine, Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Kristin Haag
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Deepak A Rao
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Michael B Brenner
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - James A Lederer
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - William Apruzzese
- Division of Rheumatology, Inflammation, Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - H Michael Belmont
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Peter M Izmirly
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Devyn Zaminski
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Ming Wu
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Sean Connery
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Fernanda Payan-Schober
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Richard Furie
- Division of Rheumatology, Department of Medicine, Northwell Health, Great Neck, NY
| | - Maria Dall'Era
- Rheumatology Division, Department of Medicine, Russell/Engleman Rheumatology Research Center, University of California San Francisco, San Francisco, CA
| | - Kerry Cho
- Nephrology Division, Department of Medicine, University of California San Francisco, San Francisco, CA
| | - Diane Kamen
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Kenneth Kalunian
- Department of Medicine, University of California San Diego School of Medicine, La Jolla, CA
| | - Jennifer Anolik
- Department of Medicine, Division of Allergy, Immunology, and Rheumatology, University of Rochester Medical Center, Rochester, NY
| | - Jennifer Barnas
- Department of Medicine, Division of Allergy, Immunology, and Rheumatology, University of Rochester Medical Center, Rochester, NY
| | - Mariko Ishimori
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael H Weisman
- Division of Rheumatology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jill P Buyon
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Michelle Petri
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD
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OUP accepted manuscript. J Appl Lab Med 2022; 7:1450-1467. [DOI: 10.1093/jalm/jfac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/25/2022] [Indexed: 11/14/2022]
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Retrospective review of the clinical and laboratory data in silent lupus nephritis. Int Urol Nephrol 2021; 54:1933-1938. [PMID: 34853989 DOI: 10.1007/s11255-021-03066-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To determine the ratio of renal disease necessitating immunosuppressive treatment in lupus patients who are clinically asymptomatic by means of renal disease. It was also examined whether silent lupus nephritis is associated with any of the non-renal clinical findings. METHODS All kidney biopsies performed in lupus patients between 1990 and 2009 at the Rheumatology Department of Ege University Faculty of Medicine were retrospectively screened. Among the 258 kidney biopsies screened, 54 had no clinical renal findings but had active disease together with anti-dsDNA positivity and/or hypocomplementemia. Patients were classified into two groups who require and do not require immunosuppressive therapy according to their final pathological results at biopsy. The frequency of serious renal involvement in the sample was calculated. Then subgroups were compared with each other in terms of the clinical and laboratory features using Statistical Package for Social Sciences version 13 software. RESULTS Thirteen of the 54 patients (24%) had severe renal involvement requiring immunosuppressant therapy. When the groups were compared to each other, it was found that serositis and hematologic involvement were significantly more frequent in patients who needed immunosuppressive treatment (42.9% versus 10.0%; p = 0.003 and 64.3% versus 37.5; p = 0.039). CONCLUSION Even in the absence of clinical renal manifestations, active patients at high risk of renal disease such as hypocomplementemia, anti-ds DNA positivity may have severe renal disease requiring immunosuppressive treatment. Thus, renal biopsy indications in lupus patients should better be revaluated.
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Bedair RN, Amin Ismail MM, Gaber EW, Kader Mahmoud RA, Mowafy MN. Study of the relationship between urinary level of uromodulin, renal involvement and disease activity in patients with systemic lupus erythrematosus. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:32-43. [PMID: 32129195 DOI: 10.4103/1319-2442.279959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a multifactorial chronic inflammatory autoimmune connective tissue disease. Lupus nephritis (LN) is a common and serious complication of SLE which can progress to end-stage renal disease. Renal biopsy is the gold standard in the diagnosis and classification of LN, but since it is an invasive procedure, it is neither desirable nor applicable for all cases. This has led to the search for an alternative, noninvasive, site-specific, and immune process-related biomarkers. Uromodulin (Tamm-Horsfall glycoprotein) is the most abundant urinary protein expressed exclusively by the thick ascending limb cells and released into urine of healthy controls. Studies showed that it may act as a danger signaling molecule eliciting an inflammatory response following conditions that damage the nephron integrity and leading to uromodulin release into the interstitial space. This study aimed to assess uromodulin as a screening biomarker of tubulointerstitial involvement in patients with SLE and to elucidate its correlation with disease activity and progression. The study was conducted on 70 patients divided into two groups: control group (Group I) consisted of 20 apparently healthy volunteers of comparable age and sex to the patients' group, and 50 SLE patients (Group II) diagnosed according to the 2012 Systemic Lupus Collaborating Clinics (SLICC) classification criteria. Group II was further subdivided into 23 patients without manifestations of LN (Group II A) and 27 patients with manifestations of LN (Group II B). Urinary uromodulin level showed statistically significant difference among the studied groups, being lowest among the LN patients with a mean value 5.6 ± 3.4, in SLE patients without nephritis 9.9 ± 5.2 and 12.9 ± 4.6 in the control group. Urinary uromodulin also correlated positively with estimated glome- rular filtration rate. A negative correlation was found between urinary uromodulin and serum creatinine, 24 h urinary proteins and SLICC renal activity score. No statistically significant correlation was found between urinary uromo- dulin and SLE disease activity index. Thus, decreasing urinary uromodulin levels can be a marker for renal involvement and tubulo- interstitial nephritis in active SLE patients and a marker for chronic kidney disease and nephron loss in the absence of activity markers.
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Affiliation(s)
- Rania Nabil Bedair
- Department of Chemical Pathology, Medical Research Institute, Alexandria University, Egypt
| | | | - Eman Wagdy Gaber
- Department of Experimental and Clinical Internal Medicine, Medical Research Institute, Alexandria University, Egypt
| | | | - Mohamed Nader Mowafy
- Department of Experimental and Clinical Internal Medicine, Medical Research Institute, Alexandria University, Egypt
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Gasparotto M, Gatto M, Binda V, Doria A, Moroni G. Lupus nephritis: clinical presentations and outcomes in the 21st century. Rheumatology (Oxford) 2020; 59:v39-v51. [PMID: 33280015 PMCID: PMC7751166 DOI: 10.1093/rheumatology/keaa381] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/28/2020] [Indexed: 01/17/2023] Open
Abstract
Lupus nephritis (LN) is a frequent and severe manifestation of SLE. Along the decades, the epidemiology of LN and its clinical presentation have been changing. However, even though retrospective cohort studies report a decreased mortality rate and an improvement in the disease prognosis, the percentage of patients progressing into end stage renal disease (ESRD) keeps steady despite the improvements in therapeutic strategies. Current in-use medications have been available for decades now, yet over the years, regimens for optimizing their efficacy and minimizing toxicity have been developed. Therapeutic research is now moving towards the direction of precision medicine and several new drugs, targeting selectively different pathogenetic pathways, are currently under evaluation with promising results. In this review, we address the main changes and persistent unmet needs in LN management throughout the past decades, with a focus on prognosis and upcoming treatments.
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Affiliation(s)
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Valentina Binda
- Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Chedid A, Rossi GM, Peyronel F, Menez S, Atta MG, Bagnasco SM, Arend LJ, Rosenberg AZ, Fine DM. Low-Level Proteinuria in Systemic Lupus Erythematosus. Kidney Int Rep 2020; 5:2333-2340. [PMID: 33305127 PMCID: PMC7710831 DOI: 10.1016/j.ekir.2020.09.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction In patients with systemic lupus erythematosus (SLE) without concurrent active urinary sediment or unexplained acute kidney injury (AKI), current guidelines recommend performing a kidney biopsy in those with at least 500 mg/24-hour (European League Against Rheumatism/European Renal Association-European Dialysis and Transplant Association [EULAR/ERA-EDTA]) or 1000 mg/24-hour (American College of Rheumatology [ACR]) proteinuria. To evaluate the relevance of these indications, we studied histopathologic findings in patients with SLE with proteinuria below these cutoffs. Methods We retrospectively reviewed the clinical, laboratory and histological characteristics of patients with SLE with <1000 mg/24-hour proteinuria (or mg/g urinary protein-to-creatinine ratio [UPCR]) who underwent their first kidney biopsy between 2003 and 2018. Results We identified 87 patients with SLE with proteinuria less than 1000 mg/24-hour (or mg/g UPCR); 52 of 87 (60%) with isolated proteinuria, that is, without AKI or active urinary sediment (hematuria). Histologic evidence of lupus nephritis (LN) was present in 40 of 52 (76%). Of the 40 patients with LN, 12 had class I or II, 14 had class III or IV, 8 had class V, 6 had a combined proliferative and membranous LN. Non-lupus diagnoses included focal segmental glomerulosclerosis, acute interstitial nephritis, and others. Patient’s age, low C3, low C4, and positivity for anti-double-stranded DNA (anti-dsDNA) antibodies predicted the histological diagnosis of LN on univariate logistic regression; however, a multivariate model including these parameters as independent covariates failed to predict LN. Conclusions Patients with SLE with low-level proteinuria may have significant lupus- or non–lupus-related kidney disease with management implications. There was a significant burden of severe forms of LN. The presence of LN was not predicted by laboratory abnormalities. Based on our findings, we suggest current guidelines be revised to expand kidney biopsy indications to include isolated proteinuria of any grade.
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Affiliation(s)
- Alice Chedid
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Giovanni M Rossi
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
- Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Francesco Peyronel
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| | - Steven Menez
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mohamed G Atta
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Serena M Bagnasco
- Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Lois J Arend
- Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Avi Z Rosenberg
- Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Derek M Fine
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ishimori S, Kaito H, Shima Y, Kamioka I, Hamahira K, Nozu K, Nakanishi K, Tanaka R, Yoshikawa N, Iijima K. Clinicopathological characteristics and renal outcomes of childhood-onset lupus nephritis with acute kidney injury: A multicenter study. Mod Rheumatol 2018; 29:970-976. [DOI: 10.1080/14397595.2018.1532861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Shingo Ishimori
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
- Department of Pediatrics, Kakogawa Central City Hospital, Hyogo, Japan
| | - Hiroshi Kaito
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Ichiro Kamioka
- Department of Pediatrics, Kakogawa Central City Hospital, Hyogo, Japan
| | - Kiyoshi Hamahira
- Department of Pediatrics, Himeji Red-Cross Hospital, Hyogo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Koichi Nakanishi
- Department of Pediatrics, Ryukyu University Graduate School of Medicine, Okinawa, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children’s Hospital, Hyogo, Japan
| | | | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Hyogo, Japan
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Wakiguchi H, Takei S, Kubota T, Miyazono A, Kawano Y. Treatable renal disease in children with silent lupus nephritis detected by baseline biopsy: association with serum C3 levels. Clin Rheumatol 2016; 36:433-437. [DOI: 10.1007/s10067-016-3491-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 10/21/2016] [Accepted: 11/20/2016] [Indexed: 12/29/2022]
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Burling F, Ng J, Thein H, Ly J, Marshall MR, Gow P. Ethnic, clinical and immunological factors in systemic lupus erythematosus and the development of lupus nephritis: results from a multi-ethnic New Zealand cohort. Lupus 2016; 16:830-7. [PMID: 17895308 DOI: 10.1177/0961203307080225] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The aim of this study was to identify risk factors for lupus nephritis including clinical, laboratory, and ethnic factors in a cohort of lupus patients in New Zealand. A retrospective study of patients from two teaching hospitals in Auckland, New Zealand. Patients were selected if they had attended as either an inpatient, or a rheumatology outpatient between 2000 and 2005. 170 patients had SLE according to ACR classification. Lupus nephritis (LN) was diagnosed according to ACR criteria. Clinical, laboratory, and ethnic data were gathered from the patient notes. Twenty-four patients had LN at diagnosis and 32 patients developed LN after diagnosis. LN was associated with serositis ( P = 0.008), cutaneous vasculitis ( P = 0.026), anaemia ( P = 0.005), CRP elevation >6 months ( P < 0.001), hypocomplementaemia >6 months ( P < 0.0001). Patients with elevated doublestranded DNA (dsDNA) (>5 × normal) were more likely to develop type IV LN ( P = 0.0096). Forty-one percent of patients were Caucasian, 12% Maori, 23% Pacific People, 16% Asian, 6% Indian. Maori patients with SLE (odds ratio (OR) = 8.47, 95% confidence interval (CI) = 2.11—33.96, P = 0.002), and Pacific People (OR = 3.11, 95% CI = 1.29—11.48, P = 0.014) had increased risk for developing LN. Anaemia at presentation (hazard ratio (HR) 3.2, 95% CI = 1.4—7.1, P = 0.004), and low complement >6 months (HR = 3.4, 95% CI = 1.4—8.7, P = 0.008) were independent risk factors for developing LN after SLE diagnosis. In New Zealand, Pacific People and Maori patients with SLE have a higher incidence of LN, and patients with anaemia and hypocomplementaemia are more likely to develop LN after diagnosis. Patients with high dsDNA levels are more likely to develop Type IV lupus nephritis. Lupus (2007) 16, 830—837.
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Affiliation(s)
- F Burling
- Department of Medicine, Middlemore Hospital, Private Bag 93311, Auckland, New Zealand.
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14
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Qi C, Wang L, Zhang M, Shao X, Chang X, Fan Z, Cao Q, Mou S, Wang Q, Yan Y, Desir G, Ni Z. Serum Renalase Levels Correlate with Disease Activity in Lupus Nephritis. PLoS One 2015; 10:e0139627. [PMID: 26431044 PMCID: PMC4592194 DOI: 10.1371/journal.pone.0139627] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/14/2015] [Indexed: 12/21/2022] Open
Abstract
Introduction Lupus nephritis (LN) is among the most serious complications of systemic lupus erythematosus (SLE), which causes significant morbidity and mortality. Renalase is a novel, kidney-secreted cytokine-like protein that promotes cell survival. Here, we aimed to investigate the relationship of serum renalase levels with LN and its role in the disease progression of LN. Methods For this cross-sectional study, 67 LN patients and 35 healthy controls were enrolled. Seventeen active LN patients who received standard therapies were followed up for six months. Disease activity was determined by the SLE Disease Activity–2000 (SLEDAI-2K) scoring system and serum renalase amounts were determined by ELISA. Predictive value of renalase for disease activity was assessed. Furthermore, the expression of renalase in the kidneys of patients and macrophage infiltration was assessed by immunohistochemistry. Results Serum renalase amounts were significantly higher in LN patients than in healthy controls. Moreover, patients with proliferative LN had more elevated serum renalase levels than Class V LN patients. In proliferative LN patients, serum renalase levels were significantly higher in patients with active LN than those with inactive LN. Serum renalase levels were positively correlated with SLEDAI-2K, 24-h urine protein excretion, ds-DNA and ESR but inversely correlated with serum albumin and C3. Renalase amounts decreased significantly after six-months of standard therapy. The performance of renalase as a marker for diagnosis of active LN was 0.906 with a cutoff value of 66.67 μg/ml. We also observed that the amount of renalase was significantly higher in glomerular of proliferative LN along with the co-expression of macrophages. Conclusion Serum renalase levels were correlated with disease activity in LN. Serum renalase might serve as a potential indicator for disease activity in LN. The marked increase of glomerular renalase and its association with macrophages suggest that it might play an important role in disease progression of LN.
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Affiliation(s)
- Chaojun Qi
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Ling Wang
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- * E-mail: (ZN); (LW)
| | - Minfang Zhang
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xinghua Shao
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xinbei Chang
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhuping Fan
- Health Care Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Cao
- Health Care Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shan Mou
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qin Wang
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yucheng Yan
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Gary Desir
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, Yale University, New Haven, Connecticut, United States of America
| | - Zhaohui Ni
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- * E-mail: (ZN); (LW)
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Ishizaki J, Saito K, Nawata M, Mizuno Y, Tokunaga M, Sawamukai N, Tamura M, Hirata S, Yamaoka K, Hasegawa H, Tanaka Y. Low complements and high titre of anti-Sm antibody as predictors of histopathologically proven silent lupus nephritis without abnormal urinalysis in patients with systemic lupus erythematosus. Rheumatology (Oxford) 2014; 54:405-12. [PMID: 25183834 DOI: 10.1093/rheumatology/keu343] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The aim of this study was to clarify the clinical characteristics and predictors of silent LN (SLN), a type of LN in SLE without abnormal urinalysis or renal impairment. METHODS Of 182 patients who underwent renal biopsy, 48 did not present with abnormal urinalysis or renal impairment at the time of biopsy. The patients with LN (SLN group, n = 36) and those without LN (non-LN group, n = 12) were compared with respect to their baseline characteristics. Bivariate analysis comprised Fisher's exact test and the Mann-Whitney test, whereas multivariate analysis employed binomial logistic regression analysis. RESULTS LN was histopathologically identified in 36 of 48 patients. According to the International Society of Nephrology/Renal Pathology Society classification, 72% of the SLN patients were classified as having class I/II, with a further 17% having class III/IV. Bivariate analyses indicated that platelet count, serum albumin, complement components (C3 and C4), complement haemolytic activity (CH50), anti-Sm antibody titre and anti-ribonucleoprotein antibody titre were significantly different between groups. Multivariate analysis indicated that CH50 and C3 titres were significantly lower in the SLN group, whereas anti-Sm antibody titre was significantly higher. The cut-off titre, calculated based on the receiver operating characteristic curve for CH50, was 33 U/ml, with a sensitivity and specificity of 89% and 83%, respectively. The cut-off titre for anti-Sm antibodies was 9 U/ml, with a sensitivity and specificity of 74% and 83%, respectively. CONCLUSION Low titres of CH50 and C3 and a high titre of anti-Sm antibody were identified as predictors of SLN.
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Affiliation(s)
- Jun Ishizaki
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan. First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Kazuyoshi Saito
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Masao Nawata
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Yasushi Mizuno
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Mikiko Tokunaga
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Norifumi Sawamukai
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Masahito Tamura
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Shintaro Hirata
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Kunihiro Yamaoka
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Hitoshi Hasegawa
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan
| | - Yoshiya Tanaka
- First Department of Internal Medicine, Second Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health and Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Matsuyama, Japan.
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Haas M, Rastaldi MP, Fervenza FC. Histologic classification of glomerular diseases: clinicopathologic correlations, limitations exposed by validation studies, and suggestions for modification. Kidney Int 2013; 85:779-93. [PMID: 24088958 DOI: 10.1038/ki.2013.375] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 07/18/2013] [Accepted: 07/25/2013] [Indexed: 12/16/2022]
Abstract
The value of classification systems applied to the examination of renal biopsies is based on several factors: first, on the ability to provide efficient communication between pathologists and between pathologists and clinicians; second, on the possibility to implement diagnostic information with prognostic indication. Even more important, the practical value of a classification is proved by the ability of providing elements that guide therapeutic decisions and can be used in the follow-up of the patient. With these aims, new histologic classification systems have been proposed in the last decade for lupus nephritis and IgA nephropathy under the leadership of the Renal Pathology Society and the International Society of Nephrology. These classifications have gained a significant level of worldwide acceptance and have been the subject of multiple single-center and multicenter validation studies, which have underpinned their clinical benefits and limitations and served to highlight remaining questions and difficulties of interpretation of the biopsy sample. More recently, a classification system has also been proposed for ANCA-associated crescentic glomerulonephritis (ANCA-GN), although the validation process for this is still in an early stage. In this review, we examine in some detail the ISN/RPS classification for lupus nephritis and the Oxford classification for IgA nephropathy, with emphasis on clinicopathologic correlations, their value for and evolving impact on clinical studies and clinical practice, and their significant limitations in this regard as exposed by validation studies. We also suggest possible ways by which these classifications might be modified to make them more applicable to clinical practice. Finally, we more briefly discuss the newly proposed classification for ANCA-GN.
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Affiliation(s)
- Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Maria P Rastaldi
- Renal Research Laboratory, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Fondazione D'Amico per la Ricerca sulle Malattie Renali, Milano, Italy
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Torabinejad S, Mardani R, Habibagahi Z, Roozbeh J, Khajedehi P, Pakfetrat M, Banihashemi MA, Banihashemi SJ. Urinary monocyte chemotactic protein-1 and transforming growth factor-β in systemic lupus erythematosus. Indian J Nephrol 2012; 22:5-12. [PMID: 22279336 PMCID: PMC3263065 DOI: 10.4103/0971-4065.91179] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The purpose of this investigation was to assess the correlation of two biomarkers with the occurrence of renal flares in systemic lupus erythematosus (SLE). Urine levels of monocyte chemotactic protein-1 (MCP-1) and transforming growth factor beta (TGF-β) were measured at baseline, and at two and four months in five groups of patients: 25 lupus nephritis patients with active disease (active LN), 10 lupus nephritis patients with SLE in remission (remission LN), 25 patients with clinical active SLE and without nephritis (active NLN), 10 patients without nephritis with SLE in remission (remission NLN) and 10 healthy controls. We used repeated measurement and ANOVA with Duncan's post hoc to analyze the data; the urine level of the two proteins could distinguish the groups based on the existence of lupus nephritis and/or activity of SLE disease. Furthermore we performed receiver operating curve analysis to identify a cutoff point with a good sensitivity and specificity to diagnose lupus nephritis with either one of the urine proteins. Finally the samples from active LN were grouped according to whether they were Class IV or other classes. Baseline urinary MCP-1, but not TGF-β, was significantly different between the classes. Further investigation into the use of these cytokines in a prospective study is needed to determine their capacity as diagnostic tools for renal flares.
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Affiliation(s)
- S Torabinejad
- Shiraz Nephrology Urology Research Center, Zand Avenue, Shiraz, Iran
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Borchers AT, Leibushor N, Naguwa SM, Cheema GS, Shoenfeld Y, Gershwin ME. Lupus nephritis: a critical review. Autoimmun Rev 2012; 12:174-94. [PMID: 22982174 DOI: 10.1016/j.autrev.2012.08.018] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2012] [Indexed: 01/18/2023]
Abstract
Lupus nephritis remains one of the most severe manifestations of systemic lupus erythematosus associated with considerable morbidity and mortality. A better understanding of the pathogenesis of lupus nephritis is an important step in identifying more targeted and less toxic therapeutic approaches. Substantial research has helped define the pathogenetic mechanisms of renal manifestations and, in particular, the complex role of type I interferons is increasingly recognized; new insights have been gained into the contribution of immune complexes containing endogenous RNA and DNA in triggering the production of type I interferons by dendritic cells via activation of endosomal toll-like receptors. At the same time, there have been considerable advances in the treatment of lupus nephritis. Corticosteroids have long been the cornerstone of therapy, and the addition of cyclophosphamide has contributed to renal function preservation in patients with severe proliferative glomerulonephritis, though at the cost of serious adverse events. More recently, in an effort to minimize drug toxicity and achieve equal effectiveness, other immunosuppressive agents, including mycophenolate mofetil, have been introduced. Herein, we provide a detailed review of the trials that established the equivalency of these agents in the induction and/or maintenance therapy of lupus nephritis, culminating in the recent publication of new treatment guidelines by the American College of Rheumatology. Although newer biologics have been approved and continue to be a focus of research, they have, for the most part, been relatively disappointing compared to the effectiveness of biologics in other autoimmune diseases. Early diagnosis and treatment are essential for renal preservation.
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Affiliation(s)
- Andrea T Borchers
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States
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Urine levels of HMGB1 in Systemic Lupus Erythematosus patients with and without renal manifestations. Arthritis Res Ther 2012; 14:R184. [PMID: 22892043 PMCID: PMC3580580 DOI: 10.1186/ar4015] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Accepted: 08/14/2012] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Lupus nephritis (LN) is a severe and frequent manifestation of systemic lupus erythematosus (SLE). Its pathogenesis has not been fully elucidated but immune complexes are considered to contribute to the inflammatory pathology in LN. High Mobility Group Box 1 (HMGB1) is a nuclear non-histone protein which is secreted from different types of cells during activation and/or cell death and may act as a pro-inflammatory mediator, alone or as part of DNA-containing immune complexes in SLE. Urinary excretion of HMGB1 might reflect renal inflammatory injury. To assess whether urinary HMGB1 reflects renal inflammation we determined serum levels of HMGB1 simultaneously with its urinary levels in SLE patients with and without LN in comparison to healthy controls (HC). We also analyzed urinary HMGB1 levels in relation with clinical and serological disease activity. METHODS The study population consisted of 69 SLE patients and 17 HC. Twenty-one patients had biopsy proven active LN, 15 patients had a history of LN without current activity, and 33 patients had non-renal SLE. Serum and urine levels of HMGB1 were both measured by western blotting. Clinical and serological parameters were assessed according to routine procedures. In 17 patients with active LN a parallel analysis was performed on the expression of HMGB1 in renal biopsies. RESULTS Serum and urinary levels of HMGB1 were significantly increased in patients with active LN compared to patients without active LN and HC. Similarly, renal tissue of active LN patients showed strong expression of HMGB1 at cytoplasmic and extracellular sites suggesting active release of HMGB1. Serum and urinary levels in patients without active LN were also significantly higher compared to HC. Urinary HMGB1 levels correlated with SLEDAI, and showed a negative correlation with complement C3 and C4. CONCLUSION Levels of HMGB1 in urine of SLE patients, in particular in those with active LN, are increased and correlate with SLEDAI scores. Renal tissue of LN patients shows increased release of nuclear HMGB1 compared to control renal tissue. HMGB1, although at lower levels, is, however, also present in the urine of patients without active LN. These data suggest that urinary HMGB1 might reflect both local renal inflammation as well as systemic inflammation.
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Singh S, Wu T, Xie C, Vanarsa K, Han J, Mahajan T, Oei HB, Ahn C, Zhou XJ, Putterman C, Saxena R, Mohan C. Urine VCAM-1 as a marker of renal pathology activity index in lupus nephritis. Arthritis Res Ther 2012; 14:R164. [PMID: 22788914 PMCID: PMC3580557 DOI: 10.1186/ar3912] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 07/13/2012] [Indexed: 11/30/2022] Open
Abstract
Introduction Although renal pathology is highly predictive of the disease course in lupus nephritis, it cannot be performed serially because of its invasive nature and associated morbidity. The goal of this study is to investigate whether urinary levels of CXC ligand 16 (CXCL16), monocyte chemotactic protein-1 (MCP-1) or vascular cell adhesion molecule-1 (VCAM-1) in patients with lupus nephritis are predictive of particular features of renal pathology in renal biopsies obtained on the day of urine procurement. Methods CXCL16, MCP-1, and VCAM-1 levels were measured in urine samples from 74 lupus nephritis patients and 13 healthy volunteers. Of the patients enrolled, 24 patients had a concomitant kidney biopsy performed at the time of urine collection. In addition, patients with other renal diatheses were also included as controls. Results All three molecules were elevated in the urine of systemic lupus erythematosus patients, although VCAM-1 (area under curve = 0.92) and MCP-1 (area under curve = 0.87) were best at distinguishing the systemic lupus erythematosus samples from the healthy controls, and were also most strongly associated with clinical disease severity and active renal disease. For patients in whom concurrent renal biopsies had also been performed, urine VCAM-1 exhibited the strongest association with the renal pathology activity index and glomerulonephritis class IV, although it correlated negatively with the chronicity index. Interestingly, urinary VCAM-1 was also elevated in anti-neutrophil cytoplasmic antibodies-associated glomerulonephritis, focal segmental glomerulosclerosis and membranous nephropathy but not in minimal-change disease. Conclusion Urinary VCAM-1 emerges as a reliable indicator of the activity:chronicity ratios that mark the underlying renal pathology in lupus nephritis. Since VCAM-1 is involved in the acute phase of inflammation when leukocytic infiltration is ongoing, longitudinal studies are warranted to establish whether tracking urine VCAM-1 levels may help monitor clinical and pathological disease activity over time.
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Abstract
INTRODUCTION Lupus nephritis (LN) is an ominous complication of systemic lupus erythematosus, and the risk factors for the disease progression are not well characterized. METHODS In a retrospective study, the authors evaluated the mode of presentation and outcomes of 163 consecutive patients with biopsy-proven LN, who presented to the center between January 1999 and September 2008. Using stepwise logistic regression analysis, the authors assessed risk factors independently associated with response to treatment and to progression to end-stage renal disease (ESRD) in proliferative LN (PLN). RESULTS Ninety percent of the patients belonged to minority population. Among 122 patients with class III and IV LN (PLN), 76 patients received intravenous cyclophosphamide and 38 patients received mycophenolate for induction, whereas 34 patients received intravenous cyclophosphamide and 63 patients received mycophenolate for maintenance. Thirty-six (30%) patients with PLN progressed to ESRD, and 3 patients died over a mean follow-up of 37.5 months. In multivariate analysis, chronicity index (CI) (P = 0.0007) and hypertension (P = 0.042) positively correlated with progression to ESRD and death, and CI was associated with increased probability of nonresponse to treatment (P = 0.001). In addition, mycophenolate as maintenance agent was associated with increased likelihood of sustained complete remission and partial remission (P = 0.045). CONCLUSIONS In patients with LN, hypertension and a high CI are independent risk factors for progression to ESRD or death. Furthermore, a high CI is associated with poor response, and mycophenolate as a maintenance agent may improve the response to treatment.
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Wakasugi D, Gono T, Kawaguchi Y, Hara M, Koseki Y, Katsumata Y, Hanaoka M, Yamanaka H. Frequency of class III and IV nephritis in systemic lupus erythematosus without clinical renal involvement: an analysis of predictive measures. J Rheumatol 2011; 39:79-85. [PMID: 22089455 DOI: 10.3899/jrheum.110532] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To determine the frequency of International Society of Nephrology/Renal Pathology Society (ISN/RPS) class III or IV lupus nephritis in patients with systemic lupus erythematosus (SLE) without clinical renal involvement. METHODS We investigated the renal pathology of 195 patients with SLE, including 86 patients without clinical renal involvement. RESULTS Lupus nephritis other than class I was found in 58% of the patients without clinical renal involvement, and class III and IV nephritis was found in 15% of these patients. To reveal the predictive measures involved in class III or IV lupus nephritis, we explored the clinical measures in patients with SLE who did not have clinical renal involvement. Anti-dsDNA antibody titers were significantly higher (p = 0.0266) and C3 values were significantly lower (p = 0.0073) in patients with class III or IV lupus nephritis than in patients without class III or IV lupus nephritis. The sensitivity and specificity values were 77% and 73%, respectively, for cutoff levels of both 40 IU/ml for anti-dsDNA antibodies and 55 mg/dl for C3 (OR 8.8, p = 0.0011). CONCLUSION The frequency of nephritis, including ISN/RPS class III and IV, was unexpectedly high in SLE patients without clinical renal involvement. ISN/RPS class III or IV lupus nephritis could be hidden in patients with SLE who present both a high titer of anti-dsDNA antibody and a low concentration of C3, even when they have clinically normal urinary findings and renal function.
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Affiliation(s)
- Daisuke Wakasugi
- Institute of Rheumatology, Tokyo Women's Medical University, 10-22 Kawada-cho, Shinjuku-Ku, Tokyo 162-0054, Japan
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Gentiletti J, McCloskey LJ, Artlett CM, Peters J, Jimenez SA, Christner PJ. Demonstration of Autoimmunity in the Tight Skin-2 Mouse: A Model for Scleroderma. THE JOURNAL OF IMMUNOLOGY 2005; 175:2418-26. [PMID: 16081813 DOI: 10.4049/jimmunol.175.4.2418] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The tight skin-2 (Tsk2/+) mouse has been proposed as an animal model of systemic sclerosis (SSc) because this animal exhibits increased collagen synthesis and accumulation in the dermis. The Tsk2/+ mouse also has been reported to have a mononuclear cell infiltrate in the dermis; however, to date no evidence of autoimmunity has been described in this animal model. We report here that Tsk2/+ mice harbor numerous autoantibodies in their plasma including some, which are similar to those, present in SSc patients. Immunofluorescence with HEp-2 cells revealed the presence of anti-nuclear Abs (ANAs) in the plasma of 92% of the Tsk2/+ mice. In contrast, <5% of cage-mated CAST/ei mice had a positive ANA and none of the C3H/HeJ age-matched controls were positive. Homogenous, speckled, rim, nucleolar, centromere as well as combinations of these patterns were observed. The proportion of Tsk2/+ animals with a positive ANA increased slightly with age. ELISAs showed that 93% of the Tsk2/+ animals were positive for anti-Scl70, 82% for anti-centromere, 5% for anti-RNP/Sm, and none were positive for anti-RNA-polymerase II Abs. Indirect immunofluorescence with Crithidia luciliae and ELISA for anti-dsDNA Abs showed that 76% of Tsk2/+ mice were positive for this autoantibody. The high frequency of anti-Scl70 and anti-centromere autoantibodies indicates that Tsk2/+ mice display some humoral immune alterations which are similar to those found in patients with SSc. However, the Tsk2/+ mice also develop autoantibodies to dsDNA and a majority of the mice develop multiple autoantibody specificities (anti-Scl70, anti-CENP-B, and anti-dsDNA) indicating that the mouse may be a useful model to study autoimmunity in a wider spectrum of connective tissue diseases.
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MESH Headings
- Age Factors
- Animals
- Antibodies, Antinuclear/biosynthesis
- Antibodies, Antinuclear/metabolism
- Antibodies, Antinuclear/physiology
- Autoantigens/metabolism
- Autoimmune Diseases/genetics
- Autoimmune Diseases/immunology
- Autoimmune Diseases/physiopathology
- Disease Models, Animal
- Enzyme-Linked Immunosorbent Assay
- Female
- Fluorescent Antibody Technique, Indirect
- Humans
- Male
- Mice
- Mice, Inbred C3H
- Mice, Inbred MRL lpr
- Mice, Mutant Strains
- Scleroderma, Systemic/genetics
- Scleroderma, Systemic/immunology
- Scleroderma, Systemic/physiopathology
- Sex Factors
- Skinfold Thickness
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Affiliation(s)
- Julieta Gentiletti
- Division of Rheumatology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
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