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Mihailovic J, Ribi C, Chizzolini C, Trendelenburg M, Von Kempis J, Dahdal S, Huynh-Do U. Worse cardiovascular and renal outcome in male SLE patients. Sci Rep 2023; 13:18628. [PMID: 37903784 PMCID: PMC10616173 DOI: 10.1038/s41598-023-45171-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 10/17/2023] [Indexed: 11/01/2023] Open
Abstract
Systemic lupus erythematosus (SLE) in males is rare and poorly understood. Thus, still little is known about sex differences in SLE. We set out to identify sex differences regarding clinical manifestations as well as renal and cardiovascular outcomes of SLE. We analyzed patient data from the Swiss SLE Cohort Study. Cumulative clinical manifestations according to the updated American College of Rheumatology criteria were recorded at inclusion. Cardiovascular events were recorded within Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SLICC-SDI). Renal failure was defined as eGFR < 15 ml/min/1.73 m2, initiation of renal replacement therapy or doubling of serum creatinine which were all assessed yearly or documented as end stage renal disease in SLICC-SDI. Risk differences were calculated using logistic regression and cox regression models. We analyzed 93 men and 529 women with a median follow up time of 2 years. Males were significantly older at diagnosis (44.4 versus 33.1 years, p < 0.001) and had less often arthritis (57% versus 74%, p = 0.001) and dermatological disorders (61% versus 76%, p < 0.01). In multivariate analysis female sex remained a significantly associated with arthritis and dermatological disorders. In multivariate analysis men had a significantly higher hazard ratio of 2.3 for renal failure (95% confidence interval (95%-CI) 1.1-5.2, p < 0.04). Total SLICC-SDI Score was comparable. Men had significantly more coronary artery disease (CAD) (17% versus 4%, p < 0.001) and myocardial infarction (10% versus 2%, p < 0.01). In multivariate analysis, male sex remained a significant risk factor for CAD (odds ratio (OR) 5.6, 95%-CI 2.3-13.7, p < 0.001) and myocardial infarction (OR 8.3, 95%-CI 2.1-32.6, p = 0.002). This first sex study in a western European population demonstrates significant sex differences in SLE. Male sex is a risk factor for cardiovascular events and renal failure in SLE. Potential etiological pathomechanisms such as hormonal or X-chromosomal factors remain to be further investigated.
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Affiliation(s)
- Jelena Mihailovic
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Camillo Ribi
- Division of Clinical Immunology and Allergy, University Hospital Lausanne, Lausanne, Switzerland
| | - Carlo Chizzolini
- Pathology and Immunology, School of Medicine, Geneva University, Geneva, Switzerland
| | - Marten Trendelenburg
- Division of Internal Medicine and Clinical Immunology Laboratory, Department of Biomedicine, University Hospital Basel, Basel, Switzerland
| | - Johannes Von Kempis
- Division of Rheumatology and Immunology, Department of Internal Medicine, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Suzan Dahdal
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension Inselspital, University Hospital Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
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Conte C, Antonelli G, Melica ME, Tarocchi M, Romagnani P, Peired AJ. Role of Sex Hormones in Prevalent Kidney Diseases. Int J Mol Sci 2023; 24:ijms24098244. [PMID: 37175947 PMCID: PMC10179191 DOI: 10.3390/ijms24098244] [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: 03/31/2023] [Revised: 04/29/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Chronic kidney disease (CKD) is a constantly growing global health burden, with more than 840 million people affected worldwide. CKD presents sex disparities in the pathophysiology of the disease, as well as in the epidemiology, clinical manifestations, and disease progression. Overall, while CKD is more frequent in females, males have a higher risk to progress to end-stage kidney disease. In recent years, numerous studies have highlighted the role of sex hormones in the health and diseases of several organs, including the kidney. In this review, we present a clinical overview of the sex-differences in CKD and a selection of prominent kidney diseases causing CKD: lupus nephritis, diabetic kidney disease, IgA nephropathy, and autosomal dominant polycystic kidney disease. We report clinical and experimental findings on the role of sex hormones in the development of the disease and its progression to end-stage kidney disease.
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Affiliation(s)
- Carolina Conte
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Giulia Antonelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Maria Elena Melica
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
| | - Mirko Tarocchi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
| | - Paola Romagnani
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Anna Julie Peired
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
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Abstract
There is increasing understanding that a multifaceted interplay of sex-dependent genetic and immune dysregulation underpins the development of glomerular disorders. Regional and ethnic variations in glomerular disease incidence make delineating the effects of sex and gender on disease pathophysiology more complex, but there is a marked paucity of research in this area. This review article presents a summary of the current understanding of sex and gender in glomerular disease, highlighting the broader effects of sex and gender on autoimmunity, clinical presentations, and pathophysiology of individual glomerular diseases, as well as exploring sex, gender, and glomerular disease within a wider socioenvironmental context. It is important to specifically consider the effects of sex and gender when presenting and analyzing clinical and scientific studies on glomerular disease. Failure to do so risks promoting disparities within health care provision, neglecting opportunities to identify sex-specific biomarkers, and potentially hindering the development of sex-specific therapies.
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Affiliation(s)
- Hannah Beckwith
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
| | - Liz Lightstone
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Steve McAdoo
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
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Chen MJ, Ang HD, Phang KF, Teo DB. Needle in the Haystack: Autoimmune Hemolytic Anemia in a Male with Systemic Lupus Erythematosus. Am J Med 2021; 134:e579-e581. [PMID: 34343510 DOI: 10.1016/j.amjmed.2021.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Meng Jia Chen
- Medical Student, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hao Duan Ang
- Medical Student, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kee Fong Phang
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore
| | - Desmond B Teo
- Division of Advanced Internal Medicine, Department of Medicine, National University Hospital, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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Role of clinicopathological features for the early prediction of prognosis in lupus nephritis. Immunol Res 2021; 69:285-294. [PMID: 33954909 DOI: 10.1007/s12026-021-09201-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
Ambiguities remain regarding the role of clinicopathological characteristics in the early prediction of the prognosis of lupus nephritis (LN). Systemic lupus erythematosus (SLE) patients who completed routine follow-up were identified and retrospectively reviewed for eligible cases. Poor prognosis was defined as all-cause mortality or a persistent decrease of eGFR greater than half the baseline level or progression to end-stage renal disease (ESRD). An optimal Cox regression model was constructed for the early prediction of a poor prognosis for LN. Among the 2163 SLE patients, 376 eligible LN cases were enrolled in the study, with a median follow-up time of 55 [27.0, 87.0] months. The male-to-female ratio was 1:7.2, and 37 patients (9.8%) progressed to the composite endpoint. The ISN/RPS class was significantly associated with proteinuria levels (P-value < 0.001), and class IV/IV + V patients, but not class V patients, had the most severe proteinuria. Our optimal multivariate Cox regression model indicated that sex, ISN/RPS class, tubular atrophy/interstitial fibrosis, serum albumin, tertiles of proteinuria, and their interaction were independently associated with a poor prognosis. ROC analysis and external validation demonstrated that our model was efficient and robust for distinguishing LN patients with a poor prognosis. Our study constructed a robust and early predictive model for convenience in clinical practice to identify poor prognosis in LN patients. We found a significant interaction effect between proteinuria and serum albumin for the prediction of poor prognosis. LN patients with low-level proteinuria and hypoalbuminemia exhibit an increased hazard of progression to poor outcomes.
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Oelzner P, Wolf G. Risikostratifizierung ausgewählter schwerer
Organbeteiligungen bei Systemischer Sklerose und bei
Lupus-Nephritis. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1403-5137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungInterstitielle 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.
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Affiliation(s)
- Peter Oelzner
- Rheumatologie/Osteologie, Klinik für Innere Medizin
III, Universitätsklinikum Jena, Jena, Deutschland
| | - Gunter Wolf
- Nephrologie, Klinik für Innere Medizin III,
Universitätsklinikum Jena , Jena, Deutschland
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Maningding E, Dall'Era M, Trupin L, Murphy LB, Yazdany J. Racial and Ethnic Differences in the Prevalence and Time to Onset of Manifestations of Systemic Lupus Erythematosus: The California Lupus Surveillance Project. Arthritis Care Res (Hoboken) 2020; 72:622-629. [PMID: 31115180 DOI: 10.1002/acr.23887] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/26/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The California Lupus Surveillance Project (CLSP) is a population-based registry of individuals with systemic lupus erythematosus (SLE) residing in San Francisco County, California from 2007 to 2009, with a special focus on Asian/Pacific Islander and Hispanic patients. We used retrospective CLSP data to analyze racial and ethnic differences in lupus manifestations and in the timing and risk of developing severe manifestations. METHODS A total of 724 patients with SLE were retrospectively identified. Prevalence ratios (PRs) of SLE manifestations were calculated using Poisson regression models stratified by race/ethnicity and adjusted for sex, age at SLE diagnosis, and disease duration. We studied onset of severe SLE manifestations after SLE diagnosis using Kaplan-Meier methods to examine time-to-event and Cox proportional hazards regression models to estimate hazard ratios (HRs). White patients were the referent group in all analyses. RESULTS African Americans, Asian/Pacific Islanders, and Hispanic patients had increased prevalence of renal manifestations (PR 1.74 [95% confidence interval (95% CI) 1.40-2.16], PR 1.68 [95% CI 1.38-2.05], and PR 1.35 [95% CI 1.05-1.74], respectively). Furthermore, African Americans had increased prevalence of neurologic manifestations (PR 1.49 [95% CI 1.12-1.98]), and both African Americans (PR 1.09 [95% CI 1.04-1.15]) and Asian/Pacific Islanders (PR 1.07 [95% CI 1.01-1.13]) had increased prevalence of hematologic manifestations. African Americans, Asian/Pacific Islanders, and Hispanic patients, respectively, had higher risk of developing lupus nephritis (HR 2.4 [95% CI 1.6-3.8], HR 4.3 [95% CI 2.9-6.4], and HR 2.3 [95% CI 1.4-3.8]) and thrombocytopenia (HR 2.3 [95% CI 1.1-4.4], HR 2.3 [95% CI 1.3-4.2], and HR 2.2 [95% CI 1.1-4.7]). Asian/Pacific Islander and Hispanic patients had higher risk of developing antiphospholipid syndrome (HR 2.5 [95% CI 1.4-4.4] and HR 2.6 [95% CI 1.3-5.1], respectively). CONCLUSION This is the first epidemiologic study comparing lupus manifestations among 4 major racial and ethnic groups. We found substantial differences in the prevalence of several clinical SLE manifestations among racial/ethnic groups and discovered that African Americans, Asian/Pacific Islanders, and Hispanic patients are at increased risk of developing several severe manifestations following a diagnosis of SLE.
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Affiliation(s)
| | | | | | - Louise B Murphy
- Centers for Disease Control and Prevention, Atlanta, Georgia, GE
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Saleh M, Eltoraby EE, Tharwat S, Nassar MK. Clinical and histopathological features and short-term outcomes of lupus nephritis: a prospective study of 100 Egyptian patients. Lupus 2020; 29:993-1001. [PMID: 32493152 DOI: 10.1177/0961203320928424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Mohammed Saleh
- Nephrology unit, Internal Medicine Department, The Ministry of Health and Population of Egypt, Egypt
| | - Ehab E Eltoraby
- Rheumatology and Immunology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Egypt
| | - Samar Tharwat
- Rheumatology and Immunology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Egypt
| | - Mohammed Kamal Nassar
- Mansoura Nephrology and Dialysis Unit (MNDU), Internal Medicine Department, Faculty of Medicine, Mansoura University, Egypt
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Andeen NK, Troxell ML, Riazy M, Avasare RS, Lapasia J, Jefferson JA, Akilesh S, Najafian B, Nicosia RF, Alpers CE, Smith KD. Fibrillary Glomerulonephritis: Clinicopathologic Features and Atypical Cases from a Multi-Institutional Cohort. Clin J Am Soc Nephrol 2019; 14:1741-1750. [PMID: 31685544 PMCID: PMC6895488 DOI: 10.2215/cjn.03870319] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 08/02/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Fibrillary GN has been defined as an immune complex-mediated GN with amyloid-like fibrils larger than amyloid which are IgG positive and Congo red negative. With discovery of DNAJB9 as a highly sensitive and specific marker for fibrillary GN, the specificity of the morphologic criteria for establishing the diagnosis of fibrillary GN has come into question. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We sought to (1) determine anatomic characteristics that best define fibrillary GN and (2) identify clinical and pathologic features that predict outcomes. RESULTS We retrospectively reviewed kidney biopsies from patients diagnosed with fibrillary GN or suspected fibrillary GN between 1997 and 2017 (n=266, 65% female, median age 61). Approximately 11% of kidney biopsies had one or more unusual feature including monotypic deposits, Congo red positivity, or unusual fibril diameter. Fibrillary GN as a possible monoclonal gammopathy of renal significance represented <1% of cases. Immunostaining for DNAJB9 confirmed fibrillary GN in 100% of cases diagnosed as fibrillary GN and 79% of atypical cases diagnosed as possible fibrillary GN. At a median time of 24 months (interquartile range, 8-46 months) after biopsy (n=100), 53% of patients reached the combined primary outcome of ESKD or death, 18% had CKD, and 18% had partial remission. On multivariable analysis, male sex (adjusted hazard ratio [aHR], 3.82; 95% confidence interval [95% CI], 1.97 to 7.37) and eGFR were the most significant predictors of primary outcome (aHR of 8.02 if eGFR <30 ml/min per 1.73 m2 [95% CI, 1.85 to 34.75]; aHR of 6.44 if eGFR 30 to <45 ml/min per 1.73 m2 [95% CI, 1.38 to 29.99]). Immunosuppressive therapy with rituximab was significantly associated with stabilization of disease progression. CONCLUSIONS Detection of DNAJB9 is a useful diagnostic tool for diagnosing atypical forms of fibrillary GN. The outcomes for fibrillary GN are poor and progression to ESKD is influenced predominantly by the degree of kidney insufficiency at the time of diagnosis and male sex. Rituximab may help preserve kidney function for select patients with fibrillary GN. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_11_04_CJN03870319.mp3.
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Affiliation(s)
- Nicole K. Andeen
- Department of Pathology, St. Paul Hospital, University of British Columbia, Vancouver, Canada
| | - Megan L. Troxell
- Division of Nephrology, Department of Medicine, Oregon Health & Science University, Portland Oregon
| | - Maziar Riazy
- Nephrology Service Line, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California
| | | | - Jessica Lapasia
- Nephrology Service Line, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California
| | | | | | | | - Roberto F. Nicosia
- Department of Pathology, University of Washington; and
- Seattle Veterans Affairs Medical Center, Seattle, Washington
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10
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Okabayashi Y, Tsuboi N, Haruhara K, Kanzaki G, Koike K, Miyazaki Y, Kawamura T, Ogura M, Yokoo T. Remission of proteinuria under therapeutic intervention and the renal outcomes in Japanese patients with lupus nephritis class III and IV. Mod Rheumatol 2019; 30:125-131. [PMID: 30557058 DOI: 10.1080/14397595.2018.1558948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
AbstractsBackground: Recent studies have identified the significance of proteinuria levels after initial induction therapies on the renal outcomes in patients with proliferative lupus nephritis, but the issue has not been evaluated in Japanese patients.Methods: Based on the ISN/RPS classification, only patients diagnosed with lupus nephritis class III or IV were included. The remission of proteinuria 12 months after diagnosis, as well as the clinicopathological features at diagnosis, on renal outcomes was examined retrospectively. Renal progression was defined as a 50% decrease in the estimated glomerular filtration rate or the development of end-stage renal disease.Results: This study included 82 Japanese patients with a median follow-up period of seven years. Although all patients received intensive induction therapy, 15 patients (18%) showed progression. Proteinuric remission 12 months after diagnosis predicted a good renal outcome by multivariate analysis. A receiver-operating characteristic analysis of 38 patients whose quantitative urinary protein excretion levels at 12 months were available for analysis showed that a cut-off value of 0.8 g/day predicted renal progression most effectively. Neither the renal function nor proteinuria level at diagnosis were associated with the renal outcomes.Conclusion: In Japanese patients with lupus nephritis class III or IV, proteinuria levels after 12 months under intensive therapy predicted renal outcomes more accurately than did factors identified at diagnosis.
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Affiliation(s)
- Yusuke Okabayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kotaro Haruhara
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Go Kanzaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoichi Miyazaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuya Kawamura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Ogura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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11
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Moroni G, Vercelloni PG, Quaglini S, Gatto M, Gianfreda D, Sacchi L, Raffiotta F, Zen M, Costantini G, Urban ML, Pieruzzi F, Messa P, Vaglio A, Sinico RA, Doria A. Changing patterns in clinical-histological presentation and renal outcome over the last five decades in a cohort of 499 patients with lupus nephritis. Ann Rheum Dis 2018; 77:1318-1325. [PMID: 29730634 DOI: 10.1136/annrheumdis-2017-212732] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 04/13/2018] [Accepted: 04/16/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To evaluate changes in demographic, clinical and histological presentation, and prognosis of lupus nephritis (LN) over time. PATIENTS AND METHODS We studied a multicentre cohort of 499 patients diagnosed with LN from 1970 to 2016. The 46-year follow-up was subdivided into three periods (P): P1 1970-1985, P2 1986-2001 and P3 2002-2016, and patients accordingly grouped based on the year of LN diagnosis. Predictors of patient and renal survival were investigated by univariate and multivariate proportional hazards Cox regression analyses. Survival curves were compared using the log-rank test. RESULTS A progressive increase in patient age at the time of LN diagnosis (p<0.0001) and a longer time between systemic lupus erythematosus onset and LN occurrence (p<0.0001) was observed from 1970 to 2016. During the same period, the frequency of renal insufficiency at the time of LN presentation progressively decreased (p<0.0001) and that of isolated urinary abnormalities increased (p<0.0001). No changes in histological class and activity index were observed, while chronicity index significantly decreased from 1970 to 2016 (p=0.023). Survival without end-stage renal disease (ESRD) was 87% in P1, 94% in P2% and 99% in P3 at 10 years, 80% in P1 and 90% in P2 at 20 years (p=0.0019). At multivariate analysis, male gender, arterial hypertension, absence of maintenance immunosuppressive therapy, increased serum creatinine, and high activity and chronicity index were independent predictors of ESRD. CONCLUSIONS Clinical presentation of LN has become less severe in the last years, leading to a better long-term renal survival.
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Affiliation(s)
- Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | | | - Silvana Quaglini
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine, DIMED, University of Padua, Padua, Italy
| | | | - Lucia Sacchi
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Francesca Raffiotta
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Margherita Zen
- Division of Rheumatology, Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Gloria Costantini
- Division of Rheumatology, Department of Medicine, DIMED, University of Padua, Padua, Italy
| | | | | | - Piergiorgio Messa
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Augusto Vaglio
- Nephrology Unit, University Hospital, Parma, Parma, Italy
| | | | - Andrea Doria
- Division of Rheumatology, Department of Medicine, DIMED, University of Padua, Padua, Italy
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12
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Feldman CH, Broder A, Guan H, Yazdany J, Costenbader KH. Sex Differences in Health Care Utilization, End-Stage Renal Disease, and Mortality Among Medicaid Beneficiaries With Incident Lupus Nephritis. Arthritis Rheumatol 2018; 70:417-426. [PMID: 29193893 PMCID: PMC5826885 DOI: 10.1002/art.40392] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 11/22/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVE While systemic lupus erythematosus and lupus nephritis (LN) disproportionately affect females, previous studies suggest that males may experience poorer outcomes. We undertook this study to investigate sex differences in health care utilization, end-stage renal disease (ESRD), and mortality among patients with LN receiving Medicaid, public insurance for low-income individuals. METHODS Within the Medicaid Analytic eXtract (MAX) from 29 states (from 2000 to 2010), we used billing claims to identify individuals ages 5-65 years with incident LN (positive predictive value 80%). MAX data were linked to the US Renal Data System to determine ESRD and to Social Security Death Index files to determine death. We estimated adjusted incidence rate ratios (IRRs) by sex for health care utilization using Poisson regression, and we used multivariable proportional hazards models to compare risks of ESRD and death by sex. RESULTS Of 2,750 patients with incident LN, 283 (10%) were male. The mean ± SD follow-up period for both sexes was 3.1 ± 2.3 years. The mean ± SD age was 29.6 ± 13.9 years among females and 24.7 ± 14.1 years among males (P < 0.01). Males had fewer outpatient visits (IRR 0.88 [95% confidence interval (95% CI) 0.80-0.97]) and fewer emergency department visits (IRR 0.75 [95% CI 0.63-0.90]). The 5-year cumulative incidence of ESRD was 22.3% in males and 21.2% in females. The 5-year cumulative incidence of death was 9.4% in males and 9.8% in females. Comparing males to females, there were no sex differences in ESRD (subdistribution hazard ratio [HR] 1.05 [95% CI 0.76-1.45]) or death (HR 0.81 [95% CI 0.47-1.35]). CONCLUSION In this cohort of patients with incident LN, ESRD and mortality were extremely high overall but were not increased among males compared to females. In this vulnerable population, biologic and health care utilization differences by sex may not significantly affect outcomes.
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Affiliation(s)
- Candace H. Feldman
- Division of Rheumatology, Immunology & Allergy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Anna Broder
- Department of Medicine (Rheumatology), Montefiore Medical Systems and Albert Einstein College of Medicine, Bronx, NY
| | - Hongshu Guan
- Division of Rheumatology, Immunology & Allergy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Jinoos Yazdany
- Division of Rheumatology, Department of Medicine, UCSF, San Francisco, CA
| | - Karen H. Costenbader
- Division of Rheumatology, Immunology & Allergy, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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13
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Momtaz M, Fayed A, Wadie M, Gamal SM, Ghoniem SA, Sobhy N, Kamal Elden NM, Hamza WM. Retrospective analysis of nephritis response and renal outcome in a cohort of 928 Egyptian lupus nephritis patients: a university hospital experience. Lupus 2017; 26:1564-1570. [DOI: 10.1177/0961203317716320] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Aim We aim to describe the pattern of response to treatment in a cohort of Egyptian lupus nephritis (LN) patients and to define variable prognostic factors. Methods We retrospectively analyzed records of 928 systemic lupus erythematosus (SLE) patients (898 females, 30 males) with biopsy-confirmed LN seen between 2006 and 2012 at Cairo University hospitals. Results Our study involved 928 SLE patients with a mean age of 26.25 ± 6.487 years, mean LN duration at time of renal biopsy 6.48 ± 4.27 months, mean SLEDAI 28.22 ± 11.7, and mean follow-up duration of 44.14 ± 17.34 months. Induction treatment achieved remission in 683 patients. Remission was achieved in all 32 patients with class II LN, compared to 651/896 (72.7%) patients in classes III, IV, and V. Induction by intravenous (IV) cyclophosphamide achieved response in 435/575 (75.7%) patients, while induction by mycophenolate mofetil (MMF) resulted in response in 216/321 (67.3%) patients ( p = 0.0068). Nephritic flares were least observed when MMF was used for maintenance (30/239 (12.6%) patients), compared to 71/365 patients (19.5%) ( p = 0.0266) when azathioprine (AZA) was used, and 22/79 patients (27.8%) ( p = 0.002) with IV cyclophosphamide. Class IV LN, high chronicity index, presence of crescents, and interstitial fibrosis in biopsies were all associated with chronic kidney disease (CKD) development eventually ( p < 0.001, p = 0.005, p = 0.012, and p = 0.031, respectively). By the end of the study duration, 305 (32.7%) patients had CKD. Logistic regression detected that high baseline serum creatinine, failure to achieve remission, hypertension, and nephritic flare were the main risk factors for poor renal outcome ( p < 0.001, p < 0.001, p = 0.004, and p < 0.001, respectively). The 5 years’ mortality was 69 (7.4%) patients with sepsis being the main cause of death. Conclusion IV cyclophosphamide superseded as induction treatment, while MMF was the best maintenance treatment. High serum creatinine, hypertension, and nephritic flare were the main risk factors for poor renal outcome.
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Affiliation(s)
- M Momtaz
- Department of Internal Medicine, Cairo University Hospital, Cairo, Egypt
| | - A Fayed
- Department of Internal Medicine, Cairo University Hospital, Cairo, Egypt
| | - M Wadie
- Department of Internal Medicine, Cairo University Hospital, Cairo, Egypt
| | - S M Gamal
- Rheumatology and Rehabilitation Department, Cairo University Hospital, Cairo, Egypt
| | - S A Ghoniem
- Rheumatology and Rehabilitation Department, Cairo University Hospital, Cairo, Egypt
| | - N Sobhy
- Rheumatology and Rehabilitation Department, Cairo University Hospital, Cairo, Egypt
| | - N M Kamal Elden
- Public Health Department, Cairo University Hospital, Cairo, Egypt
| | - W M Hamza
- Pathology Department, Cairo University Hospital, Cairo, Egypt
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14
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Urrestarazú A, Otatti G, Silvariño R, Garau M, Coitiño R, Alvarez A, Gonzalez E, Gadola L, Praga M, Noboa O. Lupus Nephritis in Males: Clinical Features, Course, and Prognostic Factors for End-Stage Renal Disease. Kidney Int Rep 2017; 2:905-912. [PMID: 29270496 PMCID: PMC5733876 DOI: 10.1016/j.ekir.2017.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 05/22/2017] [Accepted: 05/25/2017] [Indexed: 10/31/2022] Open
Abstract
Introduction Because of their rarity in men, systemic lupus erythematous and lupus nephritis (LN) are poorly understood in men. Our aim was to analyze the clinical presentation and course of histology-proven systemic lupus erythematous and LN in males and to determine the risk factors for progression to end-stage renal disease. Methods Fifty patients from 2 historical cohorts in Spain (Hospital 12 de Octubre) and Uruguay were retrospectively analyzed and compared with a female cohort matched for age and disease characteristics. Results The median age at the time of renal biopsy was 27 years (range, 8-79 years). The main forms of presentation were nephrotic syndrome in 26 of 50 patients (52%), and class IV LN in 34 of 50 (68%). After treatment, 21 patients (45.6%) achieved complete renal remission. During follow-up, 12 patients required renal replacement therapy, and 3 patients died of infectious causes. When patients who required renal replacement therapy were compared with those who did not require it, several parameters showed significant differences (P < 0.05) at the time of renal biopsy: estimated glomerular filtration rate < 60 ml/min, hypertension, hypoalbuminemia, and concomitant visceral involvement (neurologic, cardiovascular, and/or pulmonary). In the multivariate analysis, only estimated glomerular filtration rate < 60 ml/min persisted as a risk factor for progression to end-stage renal disease. When compared with a cohort of female patients with LN, there were no significant differences in remission or renal survival. Discussion LN in males usually presents as nephrotic syndrome, and type IV LN is the most frequent form. An estimated glomerular filtration rate < 60 ml/min at the time of renal biopsy is associated with poor renal outcomes. There were no differences in remission or progression of LN in males when compared with a cohort of female patients with LN.
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Affiliation(s)
- Andrés Urrestarazú
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Gabriela Otatti
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Ricardo Silvariño
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Mariela Garau
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Ruben Coitiño
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.,ISN Fellow Hospital 12 de Octubre, Madrid, Spain
| | | | - Esther Gonzalez
- Servicio de Nefrología, Hospital 12 de Octubre, Madrid, Spain
| | - Liliana Gadola
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Manuel Praga
- Servicio de Nefrología, Hospital 12 de Octubre, Madrid, Spain
| | - Oscar Noboa
- Centro de Nefrología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
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Sex-specific effects of LiCl treatment on preservation of renal function and extended life-span in murine models of SLE: perspective on insights into the potential basis for survivorship in NZB/W female mice. Biol Sex Differ 2016; 7:31. [PMID: 27354902 PMCID: PMC4924261 DOI: 10.1186/s13293-016-0085-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 06/22/2016] [Indexed: 11/10/2022] Open
Abstract
Considerable research effort has been invested in attempting to understand immune dysregulation leading to autoimmunity and target organ damage. In systemic lupus erythematosus (SLE), patients can develop a systemic disease with a number of organs involved. One of the major target organs is the kidney, but patients vary in the progression of the end-organ targeting of this organ. Some patients develop glomerulonephritis only, while others develop rapidly progressive end organ failure. In murine models of SLE, renal involvement can also occur. Studies performed over the past several years have indicated that treatment with LiCl of females, but not males of the NZB/W model, at an early age during the onset of disease, can prevent development of end-stage renal disease in a significant percentage of the animals. While on Li treatment, up to 80 % of the females can exhibit long-term survival with evidence of mild glomerulonephritis which does not progress to renal failure in spite of on-going autoimmunity. Stopping the treatment led to a reactivation of the disease and renal failure. Li treatment of other murine models of SLE was less effective and decreased survivorship in male BxSB mice, exhibited little effect on male MRL-lpr mice, and only modestly improved survivorship in female MRL-lpr mice. This perspective piece discusses the findings of several related studies which support the concept that protecting target organs such as the kidney, even in the face of continued immune insults and some inflammation, can lead to prolonged survival with retention of organ function. Some possible mechanisms for the effectiveness of Li treatment in this context are also discussed. However, the detailed mechanistic basis for the sex-specific effects of LiCl treatment particularly in the NZB/W model remains to be elucidated. Elucidating such details may provide important clues for development of effective treatment for patients with SLE, ~90 % of which are females.
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Yang J, Liang D, Zhang H, Liu Z, Le W, Zhou M, Hu W, Zeng C, Liu Z. Long-term renal outcomes in a cohort of 1814 Chinese patients with biopsy-proven lupus nephritis. Lupus 2015; 24:1468-78. [PMID: 26139236 DOI: 10.1177/0961203315593166] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 06/02/2015] [Indexed: 11/16/2022]
Abstract
In the present study, we observed the renal outcomes in a cohort of 1814 Chinese patients with biopsy-proven lupus nephritis (LN) and evaluated the risk factors associated with poor renal prognosis. The 5 -, 10 -, 15 - and 20-year renal survival rates were 93.1%, 87.9%, 81.0% and 68.3%, respectively. Gender, LN duration, mean arterial pressure (MAP), proteinuria, serum creatinine, haemoglobin and pathological classification at the time of biopsy were independent risk factors for end-stage renal disease (ESRD). The long-term renal outcomes of patients with class II LN were unfavorable as opposed to those with class V. Additionally, the time-average proteinuria (TA-Pro) and the time-average mean arterial pressure (TA-MAP) during the follow-up were important risk factors for ESRD, with better predictive values than the baseline proteinuria and MAP. The results underscore the need for proteinuria and blood pressure control during follow-up in patients with LN; proteinuria levels should be controlled at least to < 1.0 g/24 h, and optimally to < 0.5 g/24 h; MAP should not exceed 96.5 mmHg. More attention should be paid to class II LN and emphasis should be placed on recurrence prevention of class II LN.
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Affiliation(s)
- J Yang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - D Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - H Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - Z Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - W Le
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - M Zhou
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - W Hu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - C Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
| | - Z Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, China
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Mahmoud GA, Zayed HS, Ghoniem SA. Renal outcomes among Egyptian lupus nephritis patients: a retrospective analysis of 135 cases from a single centre. Lupus 2015; 24:331-8. [PMID: 25609684 DOI: 10.1177/0961203314567751] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The objective of this paper is to describe renal outcomes in a group of Egyptian patients with lupus nephritis and to identify variable prognostic factors. PATIENTS AND METHODS The records of 135 patients (129 females, six males) with biopsy-proven lupus nephritis seen between 1999 and 2011 at Kasr Al-Aini Hospital, Cairo University, were reviewed and included in a retrospective analysis. Biopsies were classified according to the WHO classification. Renal outcomes were defined according to the Renal Subcommittee of Renal Insufficiency of the American College of Rheumatology. RESULTS The mean follow-up period was 55.64 ± 25.68 (range 4-156) months. Thirty-nine patients (29.9%) developed an adverse final outcome. This composite outcome, defined as persistent elevation of serum creatinine ≥ 1.2 mg/dl, chronic renal insufficiency, end-stage renal disease or death, was seen in 12 (8.9%), seven (5.2%), three (2.2%) and 17 (12.6%) patients, respectively. The overall patient survival was 93.5% and 87.5% at five and 10 years, respectively. Factors associated with an adverse outcome included male gender (p = 0.037), hypertension at nephritis onset (p = 0.001), serum creatinine ≥1.2 mg/dl (p < 0.001), urinary casts (p = 0.006), anticardiolipin antibodies (p = 0.03), class IV nephritis (p < 0.001), hyaline thrombosis (0.003), glomerular sclerosis (p = 0.002), tubular atrophy(p < 0.001), interstitial fibrosis (p < 0.001) and a higher chronicity index (p = 0.006). Time-dependent factors associated with an adverse outcome included failure to achieve remission within the first year, uncontrolled hypertension, persistently low C3 and development of flares (p = 0.003, < 0.001, = 0.004, = 0.003, respectively). CONCLUSION The association of several adverse prognostic factors with the development of poor renal outcome has been confirmed in this study.
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Affiliation(s)
- G A Mahmoud
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Egypt
| | - H S Zayed
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Egypt
| | - S A Ghoniem
- Rheumatology and Rehabilitation Department, Faculty of Medicine, Cairo University, Egypt
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Tang Y, Zhang X, Ji L, Mi X, Liu F, Yang L, Qin W. Clinicopathological and outcome analysis of adult lupus nephritis patients in China. Int Urol Nephrol 2015; 47:513-20. [PMID: 25563231 DOI: 10.1007/s11255-014-0903-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 12/20/2014] [Indexed: 02/05/2023]
Abstract
BACKGROUND The objective of this study was to assess clinicopathological characteristics and outcomes of lupus nephritis adult patients in China. METHODS Clinicopathological features, treatment strategies, responses and outcome of 681 adult patients with biopsy-proved lupus nephritis were retrospectively analyzed. RESULTS Six hundred and eighty-one LN patients were included and followed up for 52.5 ± 14.1 months. Differences in age, disease duration, BP, proteinuria, serum albumin, creatinine, ANCA-positive ratio and SLEDAI scores were noticed between male and female patients, indicating severer disease in male patients. LN IV patients were much severer in systemic damage as well as immunological changes. During follow-up, 354 patients achieved CR, 107 patients achieved PR, 95 patients progressed to ESRD and 36 patients died. Prognosis and treatment response of patients with different histological types differ apparently. Renal outcome of patients with LN II and III was benign, while LN IV, V and VI was poor. Cyclophosphamide was effective in most patients. MMF and CNI could be used as salvage treatment. In multivariate analysis, BP, sCr, hypocomplementemia, severe proliferative lesion (LN IV or VI) and SLEDAI score were recognized as independent indicators of poor renal outcome. Infections, especially pulmonary fungus infection, thrombotic microangiopathy are the most common causes of death in LN patients. CONCLUSIONS Clinicopathological characteristics, treatment responses and long-term outcomes differ remarkably in LN patients with different gender and pathological subtypes. New indicators of poor renal outcome were identified. Infections and TTP were the most common causes of death in LN patients.
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Affiliation(s)
- Yi Tang
- Division of Nephrology, West China Hospital of Sichuan University, 37# Guoxue Rd, Chengdu, Sichuan, China
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Bertsias G, Fanouriakis AC, Boumpas DT. Systemic lupus erythematosus. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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20
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Relationship between hypoalbuminemia, hyperlipidemia and renal severity in patients with lupus nephritis: a prospective study. Cent Eur J Immunol 2014; 39:243-52. [PMID: 26155131 PMCID: PMC4440014 DOI: 10.5114/ceji.2014.43730] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/12/2014] [Indexed: 12/29/2022] Open
Abstract
Aim of the study The purpose is to evaluate the relationship between hypoalbuminemia, hyperlipidemia, nephrotic and renal severity in patients with lupus nephritis. Material and methods Autoantibodies and serological parameters were measured and analyzed in 429 patients with lupus nephritis in a single centre. Results The prevalence for anti-dsDNA, anti-nucleosome and anti-histone was higher in the nephrotic syndrome (NS) patients than that in non-NS patients (p < 0.0001 for all comparisons). The NS patients had a higher proportion of diffuse proliferative renal lesions (69.05%) and membranous lesions (68.00%). Serum total cholesterol and albumin levels were associated with activity and severity of renal disease. The levels of proteinuria and serum albumin were positively correlated with activity and chronicity index (p < 0.001 for all correlations). The incidence of a poor renal outcome (p = 0.0461) in the NS patients was significantly increased. On the other hand, the remission rate (p = 0.0002) was significantly reduced and recurrence rate (p = 0.0027) was significantly increased in NS patients. Conclusions This paper highlights that nephrotic-range proteinuria, elevated total cholesterol level and decreased serum albumin levels may reflect the activity and severity of renal damage in SLE patients.
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Abstract
Systemic lupus erythematosus (SLE) is a multisystem disease affecting many organs. Varying degrees of renal involvement are seen in up to 60% of adults with SLE, and severe lupus nephritis (LN) (World Health Organization class III and above) progresses to end-stage kidney disease (ESKD) within 15 years of diagnosis in 10% to 30% of patients. In fact, renal injury is the most important predictor of mortality in patients with SLE. Identifying patients at risk of progression to ESKD and providing them with aggressive and appropriate immunosuppressive therapy are important factors that affect the morbidity and mortality of LN patients. Management of LN-related ESKD requires attention to persistent activity of SLE and need for continuous immunosuppressive treatment because a decrease in SLE activity in this population can improve their outcome.
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Lin WH, Guo CY, Wang WM, Yang DC, Kuo TH, Liu MF, Wang MC. Incidence of progression from newly diagnosed systemic lupus erythematosus to end stage renal disease and all-cause mortality: a nationwide cohort study in Taiwan. Int J Rheum Dis 2013; 16:747-53. [PMID: 24382283 DOI: 10.1111/1756-185x.12208] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM End-stage renal disease (ESRD) is a common finding in systemic lupus erythematosus (SLE) and may contribute to mortality. The purpose of the study was to investigate the incidence of ESRD and all-cause mortality and their risk factors in patients newly diagnosed with SLE in Taiwan. METHODS This nationwide cohort study used data from the National Health Insurance Research Database. We identified 4130 newly diagnosed SLE patients at risk for ESRD during 2000-2002; among them, 103 developed ESRD by the end of 2008. Additional 412 age- and sex-matched incident ESRD non-SLE patients served as controls for the survival analysis. RESULTS Of the newly diagnosed SLE patients, 2.5% developed ESRD. Age (adjusted hazards ratio [HR] 0.66 for each 1-year increase; 95% confidence interval [CI] 0.47-0.94) and male gender (adjusted HR 2.24; 95% CI 1.4-3.6) were significantly associated with ESRD development. Survival analysis conducted after ESRD development revealed a higher mortality risk among the older patients (HR 1.04; 95% CI 1.02-1.05). Survival analysis in the younger population (age < 40 years) after ESRD development revealed a significant mortality risk among SLE patients (HR 2.73; 95% CI 1.22-6.07). CONCLUSION In the follow-up of newly diagnosed SLE patients in Taiwan, younger age and male gender were risk factors for ESRD development. After entering ESRD, these risk factors had different impacts on mortality. Despite the overall improvement in care of patients with lupus nephritis, survival is still poorer in the younger age population.
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Affiliation(s)
- Wei-Hung Lin
- Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Targeting the B-cell pathway in lupus nephritis: current evidence and future perspectives. ScientificWorldJournal 2013; 2013:745239. [PMID: 24191142 PMCID: PMC3804405 DOI: 10.1155/2013/745239] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 09/03/2013] [Indexed: 12/28/2022] Open
Abstract
Nephritis represents a frequent, severe complication of systemic lupus erythematosus. Autoantibodies appear to be fundamental in the pathogenesis of lupus nephritis. Several hypotheses are currently experimentally tested to further elucidate the direct induction of inflammation through interaction of the pathological autoantibodies with intrinsic glomerular components and the triggering of a complement-driven autoinflammatory cascade. B-cells have, in the last decade, emerged as a promising new therapeutic target, as biological treatments successfully attempting B-cell depletion, inhibition of B-cell proliferation and differentiation, or modulation of B-cell function have become bioengineered. Clinical trials have so far proved controversial regarding the efficacy of these new agents. Thus, despite the short and long-term side effects associated with immunosuppressive treatment alternative emerging treatments are still regarded "rescue" regimens in refractory patients. In an effort to accurately evaluate the potential of these therapies in lupus nephritis, several issues have been raised mainly in terms of patient selection criteria and trial duration. This review aims to expand on the proposed pathophysiologic mechanisms implicating the B-cell pathway in the pathogenesis of lupus nephritis and summarize current knowledge obtained from clinical trials introducing these biologics in its treatment. Finally, it will elaborate on potential applications of currently available biologic agents and forthcoming treatment options.
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Alonso MD, Martínez-Vázquez F, Riancho-Zarrabeitia L, Díaz de Terán T, Miranda-Filloy JA, Blanco R, González-Juanatey C, Llorca J, González-Gay MA. Sex differences in patients with systemic lupus erythematosus from Northwest Spain. Rheumatol Int 2013; 34:11-24. [DOI: 10.1007/s00296-013-2798-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 06/04/2013] [Indexed: 10/26/2022]
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Abstract
During the course of systemic lupus erythematosus (SLE) 30-90% of patients develop a renal manifestation which has proven to be decisive for morbidity and mortality. Histologically six different classes have been described leading to different treatment strategies. In mesangial proliferative lupus nephritis (class II) extrarenal manifestations determine the immunosuppressive treatment. However, in class III and IV (focal or diffuse proliferative manifestation) cyclophosphamide or possibly mycophenolate mofetil (MMF) as an alternative is necessary. In membranous lupus nephritis (class V) dual renin-angiotensin aldosterone (RAAS) blockade is most important. With class I (minimal mesangial lupus nephritis) and class VI (sclerosis) no immunosuppressive therapy is needed. New treatment options concentrate on B-cell depletion, inhibition of cytokines and co-stimulatory molecules. Recently, for the first time in SLE, a monoclonal antibody (belimumab) against B lymphocyte-stimulating factor (Blys) has been approved for treatment in combination with standard therapy.
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Vozmediano C, Rivera F, López-Gómez JM, Hernández D. Risk factors for renal failure in patients with lupus nephritis: data from the spanish registry of glomerulonephritis. NEPHRON EXTRA 2012; 2:269-77. [PMID: 23139689 PMCID: PMC3493001 DOI: 10.1159/000342719] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Lupus nephritis (LN) is a severe complication of systemic lupus erythematosus. Data from national registries based on renal biopsies are scarce. The aim of our study was to analyze the demographic characteristics, clinicopathological correlations, and risk factors associated with renal failure in patients with LN at the time of renal biopsy. METHODS We performed a cross-sectional observational study based on data from the Spanish Registry of Glomerulonephritis for the years 1994-2009. The outcome measure was the presence of renal failure (eGFR <60 ml/min/1.73 m(2)). We also recorded age, gender, proteinuria levels, hypertension, and histological class. RESULTS We collected 17,525 native renal biopsies, of which 1,648 biopsies showed LN lesions. In total, 609 patients (37%) showed renal failure at the time of renal biopsy. The univariate analysis showed that these patients were older, had higher levels of proteinuria, and a higher prevalence of hypertension than the group with eGFR ≥60 ml/min/ 1.73 m(2). The histological class of LN was recorded for 566 patients, and multivariate logistic regression analysis showed that the independent risk factors for renal failure at the time of renal biopsy were age (OR 1.03; 95% CI 1.01-1.04), male gender (OR 1.94; 95% CI 1.12-3.10), hypertension (OR 3.18; 95% CI 2.16-4.67), proteinuria (OR 1.15; 95% CI 1.08-1.24), and histological classes III and IV (OR 1.82; 95% CI 1.16-2.87). CONCLUSIONS Data from the Spanish Registry of Glomerulonephritis provide valuable information about risk factors for renal failure in patients with LN at the time of renal biopsy.
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Affiliation(s)
- Carmen Vozmediano
- Department of Nephrology, Hospital General Universitario Ciudad Real, Ciudad Real, Spain
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Wang YF, Xu YX, Tan Y, Yu F, Zhao MH. Clinicopathological characteristics and outcomes of male lupus nephritis in China. Lupus 2012; 21:1472-81. [PMID: 22898536 DOI: 10.1177/0961203312458467] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The objective of this article is to assess clinicopathological characteristics and outcomes of patients with male lupus nephritis in a cohort of Chinese patients. METHODS Clinical, pathological and outcome data of lupus nephritis patients with different gender were retrospectively analyzed and compared. RESULTS Among 315 patients with renal biopsy-proven lupus nephritis, 45 were male and 270 were female. The average ages of disease onset of the male and female patients were comparable. The interval between presentation of lupus nephritis and diagnosis was significantly longer in the male group than in female group (p = 0.003). Clinical presentation was similar except that males had a significantly lower proportion of alopecia (p = 0.005). In laboratory data, male lupus nephritis patients had higher hemoglobin (p = 0.023) and higher serum creatinine (p < 0.001) than female patients. As for pathological classification and index, no significant difference was found between the two groups. The male patients presented with significantly lower ratios of complete remission and partial remission, and higher ratios of treatment failure and relapse than the female group. Regarding long-term survival and renal outcome, male patients had significantly worse prognosis than females (p = 0.005). CONCLUSIONS The male lupus nephritis presented with later diagnosis, worse renal function, lower remission rate and higher relapse rate compared with female patients. The male patients had significantly higher mortality and poorer renal outcome.
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Affiliation(s)
- Y-F Wang
- Renal Division, Department of Medicine, Peking University First Hospital, China.
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Gender differences in the pathogenesis and outcome of lupus and of lupus nephritis. Clin Dev Immunol 2012; 2012:604892. [PMID: 22690240 PMCID: PMC3368358 DOI: 10.1155/2012/604892] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Accepted: 03/14/2012] [Indexed: 12/21/2022]
Abstract
Systemic Lupus Erythematosus (SLE) typically affects females at far greater rates than males; however male SLE patients often have more severe disease than females. The gender disparities have been reported in clinical manifestations and in serological and hematological indices as well. In particular, SLE complicated with nephritis is more frequent in men than women, and several groups identified male gender as a risk factor for progression to renal failure. The specific differences in pathogenesis amongst genders have yet to be conclusively defined, though genetic, hormonal, and immune responses have been analyzed thus far. Further research is warranted to further elucidate these differences and permit the development of gender-tailored treatment regimens.
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