1
|
Yang P, Tang X, Li P, Liu Z, Zhang C, Wu Y, Zeng X, Wu Y. A nomogram to predict the risk of proliferative lupus nephritis in patients with systemic lupus erythematosus involving the kidneys. Clin Immunol 2024; 265:110296. [PMID: 38914361 DOI: 10.1016/j.clim.2024.110296] [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: 12/24/2023] [Revised: 06/04/2024] [Accepted: 06/20/2024] [Indexed: 06/26/2024]
Abstract
Proliferative lupus nephritis (PLN) is a serious organ-threatening manifestation of systemic lupus erythematosus (SLE) that is associated with high mortality and renal failure. Here, we analyzed data from 1287 SLE patients with renal manifestations, including 780 of which were confirmed as proliferative or non-proliferative LN patients by renal biopsy, divided into a training cohort (547 patients) and a validation cohort (233 patients). By applying a least absolute shrinkage and selection operator (LASSO) regression approach combined with multivariate logistic regression analysis to build a nomogram for prediction of PLN that was then assessed by receiver operating characteristic (ROC) curves, calibration curves, and clinical decision curves (DCA) in both the training and validation cohorts. The area under the ROC curve (AUC) of the model in the training cohort was 0.921 (95% confidence interval (CI): 0.895-0.946), the AUC of internal validation in the training cohort was 0.909 and the AUC of external validation was 0.848 (95% CI: 0.796-0.900). The nomogram showed good performance as evaluated using calibration and DCA curves. Taken together, our results indicate that our nomogram that comprises 12 significantly relevant variables could be clinically valuable to prognosticate on the risk of PLN in SLE, so as to improve patient prognoses.
Collapse
Affiliation(s)
- Panyu Yang
- Department of Laboratory Medicine, Department of Nephrology, West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610041, China; Sichuan Jinxin Xinan Women's and Children's Hospital, Chengdu 610041, China; Jintang First People's Hospital, Chengdu, 610499, China
| | - Xi Tang
- Department of Laboratory Medicine, Department of Nephrology, West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Penghao Li
- Sichuan Jinxin Xinan Women's and Children's Hospital, Chengdu 610041, China
| | - Zhongyu Liu
- Department of Laboratory Medicine, Department of Nephrology, West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chao Zhang
- Department of Laboratory Medicine, Department of Nephrology, West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yuxiang Wu
- Hainan Medical University, Haikou 571199, China
| | - Xiaoxi Zeng
- Department of Laboratory Medicine, Department of Nephrology, West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610041, China.
| | - Yongkang Wu
- Department of Laboratory Medicine, Department of Nephrology, West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610041, China; Jintang First People's Hospital, Chengdu, 610499, China.
| |
Collapse
|
2
|
Aliyi O, Worku B, Hassen M, Muhammed OS. Treatment outcome and survival status among adult patients treated for lupus nephritis in selected tertiary hospitals of Ethiopia. Sci Rep 2024; 14:5603. [PMID: 38454130 PMCID: PMC10920682 DOI: 10.1038/s41598-024-56317-6] [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: 02/26/2023] [Accepted: 03/05/2024] [Indexed: 03/09/2024] Open
Abstract
Lupus nephritis (LN) is kidney involvement of systematic lupus erythematous that ranges from mild to severe and occurs in 60% of adult patients. Despite advances in therapy, LN morbidity and mortality remains high. There is a paucity of data regarding adult LN patient's treatment outcome, survival status, and associated factors in developing countries, particularly in Ethiopia. This study aimed to assess the treatment outcome, survival status, and associated factors of adult patients treated for LN in two selected tertiary hospitals [Tikur Anbessa Specialized Hospital (TASH) and St. Paul's Hospital Millennium Medical College (SPHMMC)] of Addis Ababa, Ethiopia. A hospital-based retrospective cross-sectional multicenter study was conducted from January 1, 2016 to January 1, 2021. Socio-demographic, clinical, and treatment-related data were collected from patient's medical records by using a structured abstraction checklist. Descriptive statistics were used to summarize the quantitative data as appropriate. The modified Aspreva Lupus Management Study (mALMS) criteria was applied to categorize LN treatment outcomes into complete, partial, and non-response. Multinomial logistic regression analysis was performed to identify predictors of LN treatment outcome. Patients' survival was estimated by using Kaplan-Meier and Cox proportion regression analysis. P value < 0.05 was considered to declare statistical significance. A total of 200 LN patients were included in the final analysis. Amongst these, the majority of them (91.5%) were females. The median age of the patients was 28 (15-60) years. The mean duration of treatment follow-up was 28 months. The commonly prescribed immunosuppressive drugs during both the induction (49.5%) and maintenance (60%) phases were a combination of mycophenolate mofetil with prednisolone. Complete, partial, and non-responses at the last follow-up visit accounted for 66.5%, 18.0%, and 15.5%, respectively. Patient survival at the last follow-up visit was more than 90% for patients with complete response to the induction therapy. Non-response at the last follow-up visit was significantly associated with severe disease activity index (adjusted odds ratio [AOR] = 6.25, 95% confidence interval [CI] 1.49-26.10), presence of comorbidity (AOR = 0.21, 95% CI 0.05-0.92), baseline leucopenia (AOR = 14.2, 95% CI 1.04-201.3), partial response at the end of induction therapy (AOR = 32.63, 95% CI 1.4-736.0), and duration of induction therapy of greater than 6 months (AOR = 19.47, 95% CI 1.5-258.8). This study unveiled that lower numbers of LN patients were presented with non-response at the last follow-up visit and non-response to induction therapy was associated with lower patients' survival rates compared with complete or partial response.
Collapse
Affiliation(s)
- Oumer Aliyi
- Department of Pharmacy, College of Medicine and Health Sciences, Madda Walabu University, Bale Goba, Ethiopia
| | - Berhanu Worku
- Department of Internal Medicine, School of Medicine, College of Health Sciences, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Minimize Hassen
- Department of Clinical Pharmacy, School of Pharmacy, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Oumer Sada Muhammed
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| |
Collapse
|
3
|
Gao C, Bian X, Wu L, Zhan Q, Yu F, Pan H, Han F, Wang YF, Yang Y. A nomogram predicting the histologic activity of lupus nephritis from clinical parameters. Nephrol Dial Transplant 2024; 39:520-530. [PMID: 37667508 PMCID: PMC10899760 DOI: 10.1093/ndt/gfad191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND The 2021 clinical guidelines of the Kidney Disease: Improving Global Outcomes emphasize the importance of the histological activity index (AI) in the management of lupus nephritis (LN). Patients with LN and a high AI have poor renal outcomes and high rates of nephritic relapse. In this study we constructed prediction models for the AI in LN. METHODS The study population comprised 337 patients diagnosed with LN using kidney biopsy. The participants were randomly divided into training and testing cohorts. They were further divided into high-activity (AI >2) and low-activity (AI ≤2) groups. This study developed two clinical prediction models using logistic regression and least absolute shrinkage and selection operator (LASSO) analyses with laboratory test results collected at the time of kidney biopsy. The performance of models was assessed using 5-fold cross-validation and validated in the testing cohort. A nomogram for individual assessment was constructed based on the preferable model. RESULTS Multivariate analysis showed that higher mean arterial pressure, lower estimated glomerular filtration rate, lower complement 3 level, higher urinary erythrocytes count and anti-double-stranded DNA seropositivity were independent risk factors for high histologic activity in LN. Both models performed well in the testing cohort regarding the discriminatory ability to identify patients with an AI >2. The average area under the curve of 5-fold cross-validation was 0.855 in the logistic model and 0.896 in the LASSO model. A webtool based on the LASSO model was created for clinicians to enter baseline clinical parameters to produce a probability score of an AI >2. CONCLUSIONS The established nomogram provides a quantitative auxiliary tool for distinguishing LN patients with a high AI and helps physicians make clinical decisions in their comprehensive assessment.
Collapse
Affiliation(s)
- Cui Gao
- Department of Nephrology, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Xueyan Bian
- Department of Nephrology, First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Longlong Wu
- Department of Nephrology, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Qian Zhan
- Department of Nephrology, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Fengfei Yu
- Department of Nephrology, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Hong Pan
- Department of Nephrology, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
| | - Fei Han
- Kidney Disease Center, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Yong-Fei Wang
- School of Medicine and Warshel Institute for Computational Biology, Chinese University of Hong Kong, Shenzhen, Guangdong, China
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong, China
| | - Yi Yang
- Department of Nephrology, Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, Zhejiang, China
- International Institutes of Medicine, Zhejiang University, Yiwu, Zhejiang, China
| |
Collapse
|
4
|
Elaziz MMA, Gamal SM, Fayed A, Abu-Zaid MH, Ghoniem SA, Teleb DA. High- and low-dose cyclophosphamide in Egyptian lupus nephritis patients: a multicenter retrospective analysis. Z Rheumatol 2024; 83:115-123. [PMID: 37582953 PMCID: PMC10879243 DOI: 10.1007/s00393-023-01386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Lupus nephritis (LN) is a common serious presentation of systemic lupus erythematosus. Cyclophosphamide (CYC) and mycophenolate mofetil (MMF) are listed as the first-line drugs in induction therapy for LN. OBJECTIVE This study aimed to compare high- and low-dose CYC in a cohort of Egyptian LN patients. PATIENTS AND METHODS The data of 547 patients with class III/IV active LN who received CYC as induction therapy were retrospectively analyzed. Whereas 399 patients received 6‑monthly 0.5-1 g/m2 CYC doses, 148 patients received six biweekly 500 mg CYC doses. Demographic data, laboratory test results, and disease activity index were recorded and compared at presentation and at 6, 12, 18, 24, and 48 months of follow-up. RESULTS After 48 months, the proportion of patients maintaining normal creatinine levels was higher in the group receiving induction therapy with high-dose CYC (67.9%, 60.4%, p = 0.029), and these patients also had higher proteinuria remission at 36 (26.6%, 14.8%, p = 0.014) and 48 months (24.3%, 12.8%, p = 0.006). Comparison of patient outcomes according to both induction and maintenance therapy showed the best results in patients who received high-dose CYC and continued MMF as maintenance therapy. CONCLUSION High- and low-dose CYC are comparable in early phases of treatment. However, after a longer duration of follow-up, high-dose CYC was associated with higher remission rates in the current cohort.
Collapse
Affiliation(s)
| | - Sherif M Gamal
- Rheumatology and Rehabilitation Department, Faculty of medicine, Cairo University Hospital, Cairo University, Al Kasr Al Aini, Old Cairo, Cairo Governorate, 4240310, Cairo, Egypt
| | - Ahmed Fayed
- Department of Internal Medicine, Nephrology Unit, Cairo University Hospital, Cairo, Egypt
| | | | - Shada A Ghoniem
- Rheumatology and Rehabilitation Department, Faculty of medicine, Cairo University Hospital, Cairo University, Al Kasr Al Aini, Old Cairo, Cairo Governorate, 4240310, Cairo, Egypt.
| | - Doaa A Teleb
- Rheumatology and Rehabilitation Department, Faculty of medicine, Cairo University Hospital, Cairo University, Al Kasr Al Aini, Old Cairo, Cairo Governorate, 4240310, Cairo, Egypt
| |
Collapse
|
5
|
Gamal SM, Mokbel A, Niazy MH, Elgengehy FT, Elsaid NY, Fouad NA, Sobhy N, Tantawy M, Mohamed SS, Ghaleb RM, Abdelaleem EA, El-Zorkany B. Comorbidities among Egyptian systemic lupus erythematosus: The COMOSLE-EGYPT study. Chronic Illn 2023; 19:791-803. [PMID: 36373605 DOI: 10.1177/17423953221138921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To study the prevalence and impact of comorbidities among a cohort of patients with systemic lupus erythematosus (SLE). METHODS This study is retrospective, multicenter including 902 Egyptian patients with SLE. Medical records were reviewed for demographic data, clinical characteristics, routine laboratory findings, immunological profile, and medications. Moreover, SLE Disease Activity Index (SLEDAI), and the Systemic Lupus International Collaborating Clinics/American College Rheumatology Damage Index scores were calculated. RESULTS Comorbidities were found in 75.5% of the studied group with hypertension and dyslipidemia as the most frequent comorbidities (43.1% and 40.1%, respectively), followed by sicca features, avascular necrosis, diabetes, osteoporosis and renal failure (11.5%,9%, 9%,8.9%, and 7.1%, respectively). Multivariate regression model showed statistically significant relation between the presence of comorbid condition and each of age (P = 0.006), disease duration (P = 0.041), SLEDAI at onset (P < 0.001), cyclophosphamide intake (P = 0.001), and cumulative pulse intravenous methylprednisone (P < 0.001). Also, when adjusted to age and sex, those with multiple comorbid conditions had 18.5 increased odds of mortality compared to those without comorbidities (odds ratio (OR), 95% confidence interval (CI) = 18.5 (6.65-51.69)]. CONCLUSION Patients with SLE suffer from several comorbidities, with an increasing risk with age, longer disease duration, higher SLEDAI at onset, cyclophosphamide intake and cumulative pulse intravenous methylprednisone. Risk of mortality is exponentiated with multiple comorbidities.
Collapse
Affiliation(s)
| | - Abir Mokbel
- Rheumatology Department, Cairo University, Cairo, Egypt
- Health Research Methodology Department, McMaster University, Hamilton, Canada
| | - Marwa H Niazy
- Rheumatology Department, Cairo University, Cairo, Egypt
| | | | - Nora Y Elsaid
- Rheumatology Department, Cairo University, Cairo, Egypt
| | | | - Nesreen Sobhy
- Rheumatology Department, Cairo University, Cairo, Egypt
| | - Marwa Tantawy
- Rheumatology Department, Beni Suef University, Beni Suef, Egypt
| | | | | | | | | |
Collapse
|
6
|
Banos A, Bertsias G. Flares in Lupus Nephritis: Risk Factors and Strategies for Their Prevention. Curr Rheumatol Rep 2023; 25:183-191. [PMID: 37452914 PMCID: PMC10504124 DOI: 10.1007/s11926-023-01109-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE OF REVIEW Discuss the prognostic significance of kidney flares in patients with lupus nephritis, associated risk factors, and possible preventative strategies. RECENT FINDINGS Recently performed clinical trials and observational cohort studies underscore the high frequency of relapses of kidney disease, following initial response, in patients with proliferative and/or membranous lupus nephritis. Analysis of hard disease outcomes such as progression to chronic kidney disease or end-stage kidney disease, coupled with histological findings from repeat kidney biopsy studies, have drawn attention to the importance of renal function preservation that should be pursued as early as lupus nephritis is diagnosed. In this respect, non-randomized and randomized evidence have suggested a number of factors associated with reduced risk of renal flares such as attaining a very low level of proteinuria (< 700-800 mg/24 h by 12 months), using mycophenolate over azathioprine, adding belimumab to standard therapy, maintaining immunosuppressive/biological treatment for at least 3 to 5 years, and using hydroxychloroquine. Other factors that warrant further clarification include serological activity and the use of repeat kidney biopsy to guide the intensity and duration of treatment in selected cases. The results from ongoing innovative studies integrating kidney histological and clinical outcomes, together with an expanding spectrum of therapies in lupus nephritis, are expected to facilitate individual medical care and long-term disease and patient prognosis.
Collapse
Affiliation(s)
- Aggelos Banos
- Department of Rheumatology, 'Asklepieion' General Hospital, Voula, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation Academy of Athens, 115 27, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion and University of Crete Medical School, Voutes-Stavrakia, 71008, Heraklion, Greece.
- Institute of Molecular Biology and Biotechnology-FORTH, Heraklion, Greece.
| |
Collapse
|
7
|
Hailu GMT, Hussen SU, Getachew S, Berha AB. Management practice and treatment outcomes of adult patients with Lupus Nephritis at the Renal Clinic of St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. BMC Nephrol 2022; 23:214. [PMID: 35715762 PMCID: PMC9206350 DOI: 10.1186/s12882-022-02846-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/08/2022] [Indexed: 12/01/2022] Open
Abstract
Background Lupus nephritis (LN) is the most common severe complication of systemic lupus erythematosus (SLE) which results in high morbidity and mortality. Up to 60% of adult patients with SLE develop the renal disease with different severity. Even with potent anti-inflammatory and immunosuppressive therapies, many LN patients still progress to chronic kidney disease or end-stage renal disease. Thus, this study aimed to assess the management practice, treatment outcomes and to identify the associated factors of poor renal outcome in adult LN patients at the renal clinic of St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. Methods A retrospective cross-sectional study design was used to collect the data using an abstraction tool from patients’ records. The Kidney Disease Improving Global Outcomes (KDIGO) criteria were used to diagnose LN among SLE patients. Logistic regression was used to determine crude and adjusted odds ratio and a p-value of < 0.05 was considered statistically significant. Ethical approval was obtained from the ethical review committee of the School of Pharmacy, Addis Ababa University and institutional review board of St. Paul’s Hospital Millennium Medical College. Results Out of 168 study participants enrolled from September 1, 2016 to October 30, 2020, a total of 114 adult LN patients were included for final analysis. The mean (± SD) age of the LN patients at onset was 29.10 ± 9.67 years and 99 (86.8%) of all the patients were females. More than three-fourths (78.9%) of the LN patients had a good prognosis. However, 24 (21.1%) of the patients who didn’t achieve complete or partial remission had a poor prognosis. A kidney biopsy was done for 71 patients at initial presentation with class IV and III as the commonest class. The commonly prescribed immunosuppressive medications were cyclophosphamide as induction therapy in 67 (58.7%) and mycophenolate mofetil (MMF) as maintenance therapy in 76 (66.7%). Gastrointestinal intolerances like abdominal pain, nausea, or diarrhea from MMF were the most common 27(31.2%) treatment-related adverse events reported. Acute kidney injury (AKI) at onset (AOR = 4.83, P = 0.026), high serum creatinine (SCr) at six months (AOR = 0.12, P = 0.003), no response at six months to attain complete remission (AOR = 0.05, P = 0.041) and presence of flare (AOR = 0.04, P = 0.004) were predictors poor treatment outcomes. Conclusion Despite good response with the present immunosuppressive regimens, relapse, treatment-related complications and adverse events are major problems that require close monitoring. The results and identified gaps of this study are used as an input to improve the management practice of LN in the study setting. Overall, this study is comparable with other findings and strengthen the present available literatures. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02846-z.
Collapse
Affiliation(s)
- Gebre-Mariam Tsegay Hailu
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Shemsu Umer Hussen
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Seifemichael Getachew
- Department of Internal Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Alemseged Beyene Berha
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
| |
Collapse
|
8
|
Duran E, Yıldırım T, Taghiyeva A, Bilgin E, Arıcı M, Sağlam EA, Özen S, Üner M, Erdem Y, Kalyoncu U, Ertenli AI. Differences and similarities of proliferative and non-proliferative forms of biopsy-proven lupus nephritis: Single centre, cross-disciplinary experience. Lupus 2022; 31:1147-1156. [PMID: 35658643 PMCID: PMC9277329 DOI: 10.1177/09612033221106305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE We aimed to compare clinical features, outcomes, treatments, and to define the predictive factors of complete renal response (CRR) in patients with proliferative and non-proliferative lupus nephritis (LN). METHODS Patients with systemic lupus erythematosus (SLE) followed between 2014 and 2020 at Hacettepe University Hospitals and who had a kidney biopsy were the subject of the study. One hundered and sixteen patients' kidney biopsies reported as LN were evaluated retrospectively. Clinical characteristics and laboratory values at the time of kidney biopsy, histopathological forms of LN, and renal response (complete or partial) were recorded. We analyzed the association between CRR rates during the 2-year follow-up after induction therapy and the predictive factors for CRR. RESULTS Of 116 (93 females, 23 males) patients, 95 (81.9%) were in the proliferative group (class III and IV) and 21 (18.1%) were in the non-proliferative group (class II and V). In the proliferative group, the percentage of the patients with elevated basal creatinine levels, median daily proteinuria, anti-double-stranded DNA (dsDNA) positivity, low C3 and C4 levels, the presence of active urinary sediment, and median renal SLE Disease Activity Index (SLEDAI) scores at the time of kidney biopsy were significantly higher than the non-proliferative group. Renal response status during the 2-year follow-up after induction therapy was available for 99 patients. During this time, 70 (70.7%) patients had achieved CRR and time-to-CRR was similar between the proliferative and non-proliferative groups (p = 0.64, log-rank test). The Cox proportional hazards model showed that achievement of CRR was associated with female gender [HR: 2.15 (1.19-3.89 95% CI), p = 0.011], newly diagnosed SLE with renal biopsy [HR: 2.15 (1.26-3.67 95% CI), p = 0.005], hypertension [HR: 0.40 (0.27-0.94 95% CI), p = 0.032], eGFR increase [HR: 1.01 (1.00-1.01 95% CI), p = 0.046], and the presence of active urinary sediment [HR: 0.46 (0.22-0.96 95% CI), p = 0.039]. CONCLUSIONS Achieving CRR was similar in proliferative and non-proliferative LN patients, although certain laboratory parameters differed at the onset. Our results indicated the importance of kidney biopsy in the decision-making of treatment of SLE patients with renal involvement and that the defined factors associated with CRR achievement help to predict good renal response.
Collapse
Affiliation(s)
- Emine Duran
- Department of Internal Medicine, Division of Rheumatology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Tolga Yıldırım
- Department of Internal Medicine, Division of Nephrology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Arzu Taghiyeva
- Department of Internal Medicine, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Emre Bilgin
- Department of Internal Medicine, Division of Rheumatology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Mustafa Arıcı
- Department of Internal Medicine, Division of Nephrology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Emine Arzu Sağlam
- Department of Pathology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Özen
- Department of Pediatrics, Division of Rheumatology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Meral Üner
- Department of Pathology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Yunus Erdem
- Department of Internal Medicine, Division of Nephrology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Umut Kalyoncu
- Department of Internal Medicine, Division of Rheumatology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ali Ihsan Ertenli
- Department of Internal Medicine, Division of Rheumatology, RinggoldID:64005Hacettepe University Faculty of Medicine, Ankara, Turkey
| |
Collapse
|
9
|
McDonald S, Yiu S, Su L, Gordon C, Truman M, Lisk L, Solomons N, Bruce IN. Predictors of treatment response in a lupus nephritis population: lessons from the Aspreva Lupus Management Study (ALMS) trial. Lupus Sci Med 2022; 9:e000584. [PMID: 35640982 PMCID: PMC9157342 DOI: 10.1136/lupus-2021-000584] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/09/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To identify predictors of overall lupus and lupus nephritis (LN) responses in patients with LN. METHODS Data from the Aspreva Lupus Management Study (ALMS) trial cohort was used to identify baseline predictors of response at 6 months. Endpoints were major clinical response (MCR), improvement, complete renal response (CRR) and partial renal response (PRR). Univariate and multivariate logistic regressions with least absolute shrinkage and selection operator (LASSO) and cross-validation in randomly split samples were utilised. Predictors were ranked by the percentage of times selected by LASSO and prediction performance was assessed by the area under the receiver operating characteristics (AUROC) curve. RESULTS We studied 370 patients in the ALMS induction trial. Improvement at 6 months was associated with older age (OR=1.03 (95% CI: 1.01 to 1.05) per year), normal haemoglobin (1.85 (1.16 to 2.95) vs low haemoglobin), active lupus (British Isles Lupus Assessment Group A or B) in haematological and mucocutaneous domains (0.61 (0.39 to 0.97) and 0.50 (0.31 to 0.81)), baseline damage (SDI>1 vs =0) (0.38 (0.16 to 0.91)) and 24-hour urine protein (0.63 (0.50 to 0.80)). LN duration 2-4 years (0.43 (0.19 to 0.97) vs <1 year) and 24-hour urine protein (0.63 (0.45 to 0.89)) were negative predictors of CRR. LN duration 2-4 years (0.45 (0.24 to 0.83) vs <1 year) negatively predicted PRR. The AUROCs of models for improvement, CRR and PRR were 0.56, 0.55 and 0.51 respectively. CONCLUSIONS Baseline variables predicted 6-month outcomes in patients with SLE. While the modest performance of models emphasises the need for new biomarkers to advance this field, the factors identified can help identify those patients who may require novel treatment strategies.
Collapse
Affiliation(s)
- Stephen McDonald
- The Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Sean Yiu
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Li Su
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Matt Truman
- Aurinia Pharmaceuticals Inc, Victoria, British Columbia, Canada
| | - Laura Lisk
- Aurinia Pharmaceuticals Inc, Victoria, British Columbia, Canada
| | - Neil Solomons
- Aurinia Pharmaceuticals Inc, Victoria, British Columbia, Canada
| | - Ian N Bruce
- The Kellgren Centre for Rheumatology, NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Epidemiology Versus Arthritis, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
10
|
Abstract
Despite improvements in patient and renal death rates following the introduction of potent immunosuppressive drugs in earlier decades, a sizeable fraction of patients with lupus nephritis is burdened with suboptimal or delayed responses, relapses, chronic use of glucocorticoids and accrual of renal (chronic renal insufficiency) and extra-renal organ damage. The recently approved combinatory treatments comprising belimumab or voclosporin added to conventional agents, especially mycophenolate, hold promise for further improving disease outcomes and enabling a faster steroid tapering, thus being relevant to the treat-to-target context. However, it remains uncertain whether these dual regimens should become the first-line choice for all patients or instead be prioritized to certain subgroups. In the present article, we summarize the existing lupus nephritis management recommendations, followed by a critical appraisal of the randomized trials of belimumab and voclosporin, as well as the available data on obinutuzumab and other novel compounds under development. We conclude that pending the identification of accurate clinical, histological, or translational predictors for guiding personalized decisions, it is of utmost importance that lupus nephritis patients are monitored closely with appropriate treatment adjustments aiming at a prompt, deep response to ensure long-term preservation of kidney function.
Collapse
|
11
|
Long-term renal outcomes of mesangial proliferative lupus nephritis in Chinese patients. Clin Rheumatol 2021; 41:429-436. [PMID: 34549340 DOI: 10.1007/s10067-021-05909-y] [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: 01/18/2021] [Revised: 08/07/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aimed to explore the long-term outcomes of mesangial proliferative lupus nephritis (LN class II) and the factors associated with its relapse and histological transformation in Chinese patients. METHODS 104 SLE patients with biopsy-proven LN class II were included and divided into proteinuria group (proteinuria ≥ 0.4 g/24 h, with or without microscopic hematuria) and hematuria group (microscopic hematuria with proteinuria < 0.4 g/24 h).Patients were treated with glucocorticoid alone (GC monotherapy) or GC in combination with other immunosuppressant (combination therapy). The rates of remission, relapse, histological transformation, end-stage renal disease (ESRD), adverse events, and risk factors related to the outcomes were analyzed. RESULTS During the median follow-up of 77.5 (IQR 58-116.5) months, all the 104 patients achieved remission. Relapse occurred in 69 cases (66.3%), of which 37 were of renal relapse (35.6%). Histological transformation was found in 14 of the 16 (87.5%) cases who received repeated renal biopsy after renal relapse. At the end of follow-up, 3 (2.9%) patients developed ESRD. There were no significant differences in the rates of relapse, histological transformation, adverse events and in the time from remission to relapse between the proteinuria group and the hematuria group. In contrast, the cumulative relapse rate in the GC monotherapy group was much higher than that in the combination group (P < 0.01). Adverse events occurred in 55 (57.3%) patients during follow-up. CONCLUSIONS Patients with LN class II have high rates of relapse and renal histological transformation and need optimal maintenance therapy. KEY POINTS • The rates of relapse and histological transformation are high in patients with LN class II. • Patients with LN class II are suggested to receive combination therapy and consider repeat renal biopsy after renal relapse.
Collapse
|
12
|
Kostopoulou M, Fanouriakis A, Cheema K, Boletis J, Bertsias G, Jayne D, Boumpas DT. Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations. RMD Open 2021; 6:rmdopen-2020-001263. [PMID: 32699043 PMCID: PMC7425195 DOI: 10.1136/rmdopen-2020-001263] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/08/2020] [Accepted: 05/22/2020] [Indexed: 01/24/2023] Open
Abstract
Objectives To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations. Methods According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012. Results We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500–700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b). Conclusions There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.
Collapse
Affiliation(s)
- Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece .,Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, Athens, Greece, and Medical School, University of Cyprus, Nicosia, Cyprus
| |
Collapse
|
13
|
Urrego-Callejas T, Álvarez SS, Arias LF, Reyes BO, Vanegas-García AL, González LA, Muñoz-Vahos CH, Vásquez G, Quintana LF, Gómez-Puerta JA. Urinary levels of ceruloplasmin and monocyte chemoattractant protein-1 correlate with extra-capillary proliferation and chronic damage in patients with lupus nephritis. Clin Rheumatol 2020; 40:1853-1859. [PMID: 33079302 DOI: 10.1007/s10067-020-05454-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND AIM There are few studies of urinary biomarkers and histopathologic features in lupus nephritis (LN). The aim was to analyze the correlation between a wide panel of urinary biomarkers and serum concentrations of anti C1q antibodies with histological items of activity and chronicity on kidney biopsy in LN patients. METHODS Patients with systemic lupus erythematosus (SLE) according to American College of Rheumatology (ACR) criteria were included. LN diagnosis was based on ACR criteria. Histologic features of activity and chronicity indices were analyzed according to the Austin classification. Serum Anti C1q levels were determined by commercial ELISA. Urinary levels of transferrin, ceruloplasmin (CP), VCAM-1, TWEAK, monocyte chemoattractant protein-1 (MCP-1), neutrophil gelatinase-associated lipocalin (NGAL), and alpha-1-acid glycoprotein were measured by commercial ELISA. RESULTS We included 120 SLE patients (81% female, mean age 33.1 ± 9.3 years, 59.4% Mestizo, 37.8% Afro-Latin American): 64% had LN. Kidney biopsy was performed in 55 patients, but only 37 were made in our center. Anti C1q antibodies were associated with endocapillary proliferation. In patients with cellular crescents, urinary concentrations of CP were significantly higher. In patients with a chronicity index (CI) ≥ 4, fibrous crescents, tubular atrophy, and interstitial fibrosis, urinary MCP-1 levels were higher. CONCLUSIONS In SLE patients, serum anti C1q antibodies and urinary CP were associated with activity on kidney biopsy and MCP-1 with chronic damage. This panel of biomarkers could be validated in larger, multi-ethnic population as a complementary tool for better stratification of LN patients. Key Points • Urinary biomarkers are complementary useful tools for the assessment of SLE patients. • Urinary levels of CP correlated with activity findings on kidney biopsy in LN patients. • Urinary levels of MCP-1 correlated with chronic damage, especially with fibrous crescents, tubular atrophy, and interstitial fibrosis.
Collapse
Affiliation(s)
- Tomás Urrego-Callejas
- Grupo de Inmunología Celular e Inmunogenética, Universidad de Antioquia, Medellín, Colombia
| | - Simón Sandoval Álvarez
- Grupo de Inmunología Celular e Inmunogenética, Universidad de Antioquia, Medellín, Colombia
| | - Luis F Arias
- Departamento de Patología, Universidad de Antioquia y Hospital Universitario de San Vicente Fundación, Medellín, Colombia
| | - Blanca Ortiz Reyes
- Grupo de Inmunología Celular e Inmunogenética, Universidad de Antioquia, Medellín, Colombia
| | - Adriana L Vanegas-García
- Grupo de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia.,Servicio de Reumatología, Hospital Universitario de San Vicente Fundación, Medellín, Colombia
| | - Luis A González
- Grupo de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Carlos H Muñoz-Vahos
- Grupo de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia.,Servicio de Reumatología, Hospital Universitario de San Vicente Fundación, Medellín, Colombia
| | - Gloria Vásquez
- Grupo de Inmunología Celular e Inmunogenética, Universidad de Antioquia, Medellín, Colombia.,Grupo de Reumatología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Luis F Quintana
- Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Servicio de Nefrología y Trasplante Renal, Hospital Clinic, Barcelona, Spain
| | - José A Gómez-Puerta
- Grupo de Inmunología Celular e Inmunogenética, Universidad de Antioquia, Medellín, Colombia. .,Rheumatology Department, Hospital Clínic, Barcelona, Spain.
| |
Collapse
|
14
|
Mahajan A, Amelio J, Gairy K, Kaur G, Levy RA, Roth D, Bass D. Systemic lupus erythematosus, lupus nephritis and end-stage renal disease: a pragmatic review mapping disease severity and progression. Lupus 2020; 29:1011-1020. [PMID: 32571142 PMCID: PMC7425376 DOI: 10.1177/0961203320932219] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective The understanding of systemic lupus erythematosus (SLE) and lupus nephritis (LN) pathogenesis remains incomplete. This review assessed LN development in SLE, within-LN progression and progression to end-stage renal disease (ESRD). Methods A keyword-based literature search was conducted, and 26 publications were included. Results Overall, 7–31% of patients had LN at SLE diagnosis; 31–48% developed LN after SLE diagnosis, most within 5 years. Class IV was the most commonly found LN class and had the worst prognosis. Histological transformation occurred in 40–76% of patients, more frequently from non-proliferative rather than proliferative lesions. Cumulative 5- and 10-year ESRD incidences in patients with SLE were 3% and 4%, respectively, and 3–11% and 6–19%, respectively, in patients with SLE and LN. Conclusions Elevated serum creatinine was identified as a predictor of worsening disease state, and progression within LN classes and from SLE/LN to ESRD. This review highlights the substantial risk for developing LN and progressing to ESRD amongst patients with SLE.
Collapse
Affiliation(s)
| | - Justyna Amelio
- GlaxoSmithKline, Real World Evidence and Epidemiology, Stevenage, UK
| | - Kerry Gairy
- GlaxoSmithKline, Value Evidence and Outcomes, Brentford, UK
| | | | | | | | | |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Abstract
Lupus nephritis (LN) is a form of glomerulonephritis that constitutes one of the most severe organ manifestations of the autoimmune disease systemic lupus erythematosus (SLE). Most patients with SLE who develop LN do so within 5 years of an SLE diagnosis and, in many cases, LN is the presenting manifestation resulting in the diagnosis of SLE. Understanding of the genetic and pathogenetic basis of LN has improved substantially over the past few decades. Treatment of LN usually involves immunosuppressive therapy, typically with mycophenolate mofetil or cyclophosphamide and with glucocorticoids, although these treatments are not uniformly effective. Despite increased knowledge of disease pathogenesis and improved treatment options, LN remains a substantial cause of morbidity and death among patients with SLE. Within 10 years of an initial SLE diagnosis, 5-20% of patients with LN develop end-stage kidney disease, and the multiple comorbidities associated with immunosuppressive treatment, including infections, osteoporosis and cardiovascular and reproductive effects, remain a concern. Clearly, early and accurate diagnosis of LN and prompt initiation of therapy are of vital importance to improve outcomes in patients with SLE.
Collapse
|
17
|
Zhou J, Tao MJ, Jin LR, Sheng J, Li Z, Peng H, Xu L, Yuan H. Effectiveness and safety of common therapeutic drugs for refractory lupus nephritis: A network meta-analysis. Exp Ther Med 2020; 19:665-671. [PMID: 31897105 PMCID: PMC6923745 DOI: 10.3892/etm.2019.8257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 11/06/2019] [Indexed: 12/02/2022] Open
Abstract
Previous studies have indicated that various drugs may be beneficial for the treatment of patients with refractory lupus nephritis (RLN). The present study aimed to evaluate the effectiveness and safety of common therapeutic drugs for the treatment of RLN using a network meta-analysis (NMA). NMA was performed using Stata 14.0 software. The odds ratio (OR) and 95% CI were calculated. A total of 19 studies comprising 1,127 patients were included. Common therapeutic drugs for RLN included glucocorticoids (GC), cyclophosphamide (CTX), mycophenolate mofetil (MMF), tacrolimus (TAC), leflunomide (LEF), cyclosporine A and rituximab (RTX). Evaluation of the effectiveness revealed that MMF + GC produced significantly higher overall responses (i.e. complete remission plus partial remission) and that MMF + GC (OR=2.58; 95% CI, 1.67–3.97), CTX + RTX + GC (OR=3.89; 95% CI, 1.60–9.45), CTX + LEF + GC (OR=3.05; 95% CI, 1.05–8.84) and CTX + TAC + GC (OR=6.22; 95% CI, 1.93–20.05) had significantly higher overall responses compared with those to the traditional treatment regimen (CTX + GC). Ranking probability based on the surface under the cumulative ranking curve indicated that CTX + TAC + GC had the highest probability (80.6%) of being the best treatment for achieving an overall response. In the safety evaluation, MMF + GC had a lower risk of infection than CTX + GC (OR=0.32; 95% CI, 0.11,0.88). There were no statistically significant differences in adverse reactions, including gastrointestinal reactions and leukopenia between any two treatment regimens. In conclusion, the regimen of CTX + TAC + GC exhibited a trend in superiority regarding clinical efficacy among common therapeutic drug treatments for RLN, while the regimen of CTX + GC had a higher probability to cause adverse effects among the nine interventions compared.
Collapse
Affiliation(s)
- Jun Zhou
- Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, Anhui 241002, P.R. China
| | - Meng-Jun Tao
- Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, Anhui 241002, P.R. China
| | - Lai-Run Jin
- Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, Anhui 241002, P.R. China
| | - Jun Sheng
- Department of Rheumatology, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P.R. China
| | - Zhi Li
- Department of Rheumatology, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P.R. China
| | - Hui Peng
- Hospital Infection Control Office, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P.R. China
| | - Liang Xu
- Department of Rheumatology, Affiliated Yijishan Hospital of Wannan Medical College, Wuhu, Anhui 241001, P.R. China
| | - Hui Yuan
- Department of Epidemiology and Biostatistics, School of Public Health, Wannan Medical College, Wuhu, Anhui 241002, P.R. China
| |
Collapse
|
18
|
Lymphopenia in systemic lupus erythematosus patients: Is it more than a laboratory finding? THE EGYPTIAN RHEUMATOLOGIST 2020. [DOI: 10.1016/j.ejr.2019.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
|
19
|
Ichinose K, Kitamura M, Sato S, Fujikawa K, Horai Y, Matsuoka N, Tsuboi M, Nonaka F, Shimizu T, Fukui S, Umeda M, Koga T, Kawashiri S, Iwamoto N, Tamai M, Nakamura H, Origuchi T, Nishino T, Kawakami A. Factors predictive of long-term mortality in lupus nephritis: a multicenter retrospective study of a Japanese cohort. Lupus 2019; 28:295-303. [DOI: 10.1177/0961203319826690] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Lupus nephritis (LN) is a major determinant of mortality in systemic lupus erythematosus (SLE). Here we evaluated the association between complete renal response (CR) and mortality in LN. Methods We retrospectively analyzed the cases of 172 of 201 patients with LN for whom data on the therapeutic response at 6 and 12 months after induction therapy were available. The patients underwent a renal biopsy at Nagasaki University Hospital and community hospitals in Nagasaki between the years 1990 and 2016. We determined the CR rates at 6 and 12 months after induction therapy initiation and evaluated the predictive factors for CR and their relationship with mortality. We performed univariate and multivariable competing risks regression analyses to determine the factors predictive of CR. The patients' survival data were analyzed by the Kaplan–Meier method with a log-rank test. Results The median follow-up duration after renal biopsy was 120 months (interquartile range: 60.3–191.8 months). The 5-, 10-, 15- and 20-year survival rates of our cohort were 99.3, 94.6, 92.0 and 85.4%, respectively. During follow-up, nine patients (5.2%) died from cardiovascular events, infection, malignancy and other causes. The multivariate analysis revealed that the following factors were predictive of CR. At 6 months: male gender (odds ratio (OR) 0.23, 95% confidence interval (CI) 0.08–0.65, p = 0.0028), proteinuria (g/gCr) (OR 0.83, 95% CI 0.71–0.97, p = 0.0098) and index of activity (0–24) (OR 0.84, 95% CI 0.71–0.99, p = 0.0382). At 12 months: male gender (OR 0.25, 95% CI 0.09–0.67, p = 0.0043) and index of activity (0–24) (OR 0.82, 95% CI 0.69–0.98, p = 0.0236). The Kaplan–Meier analysis showed that compared to not achieving CR at 12 months, achieving CR at 12 months was significantly correlated with the survival rate (OR 0.18, 95% CI 0.04–0.92, p = 0.0339). Conclusions Our results suggest that the survival rate of patients with LN is associated with the achievement of CR at 12 months after induction therapy, and that male gender and a higher index of activity (0–24) are the common predictive factors for failure to achieve CR at 6 and 12 months.
Collapse
Affiliation(s)
- K Ichinose
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - M Kitamura
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | - S Sato
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - K Fujikawa
- Department of Rheumatology, Japan Community Health care Organization Isahaya General Hospital, Isahaya, Japan
| | - Y Horai
- Department of Rheumatology, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Omura, Japan
| | - N Matsuoka
- Nagasaki Medical Hospital of Rheumatology, Nagasaki, Japan
| | - M Tsuboi
- Nagasaki Medical Hospital of Rheumatology, Nagasaki, Japan
| | - F Nonaka
- Department of Internal Medicine, Sasebo City General Hospital, Sasebo, Japan
| | - T Shimizu
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - S Fukui
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - M Umeda
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Koga
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - S Kawashiri
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - N Iwamoto
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - M Tamai
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - H Nakamura
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Origuchi
- Department of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - T Nishino
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | - A Kawakami
- Department of Immunology and Rheumatology, Unit of Advanced Preventive Medical Sciences, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| |
Collapse
|
20
|
Tang KT, Tseng CH, Hsieh TY, Chen DY. Induction therapy for membranous lupus nephritis: a systematic review and network meta-analysis. Int J Rheum Dis 2018; 21:1163-1172. [PMID: 29879319 DOI: 10.1111/1756-185x.13321] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Kuo-Tung Tang
- Division of Allergy, Immunology and Rheumatology; Taichung Veterans General Hospital; Taichung Taiwan
| | - Chien-Hua Tseng
- Division of Pulmonary Medicine; Department of Internal Medicine; Shuang Ho Hospital; Taipei Medical University; Taipei Taiwan
- Institute of Epidemiology and Preventive Medicine; National Taiwan University; Taipei Taiwan
| | - Tsu-Yi Hsieh
- Division of Allergy, Immunology and Rheumatology; Taichung Veterans General Hospital; Taichung Taiwan
| | - Der-Yuan Chen
- Translational Medicine Laboratory; Rheumatic Diseases Research Center; China Medical University Hospital; Taichung Taiwan
- Rheumatology and Immunology Center; China Medical University Hospital; Taichung Taiwan
- School of Medicine; China Medical University; Taichung Taiwan
| |
Collapse
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Zhang RJ, Zhang X, Chen J, Shao M, Yang Y, Balaubramaniam B, Sun XL, Ambrus JL, He J, Li ZG. Serum soluble CD25 as a risk factor of renal impairment in systemic lupus erythematosus - a prospective cohort study. Lupus 2018; 27:1100-1106. [PMID: 29482443 DOI: 10.1177/0961203318760993] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Objective Serum soluble CD25 (sCD25) could be used as a biomarker for disease activity in conditions associated with T-cell activation including various autoimmune diseases. This study aimed to explore the role of sCD25 as an indicator of disease activity and organ involvement in patients with systemic lupus erythematosus (SLE). Methods Serum samples were collected from 107 SLE patients and 92 age-matched healthy controls (HCs). All patients were followed up for 24 weeks, and sCD25 was measured by enzyme-linked immunosorbent assay. Clinical and laboratory data were recorded at baseline and then every two weeks until week 24. The Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI)-2K was adopted for assessing disease activity at all visits. Results Serum sCD25 levels were significantly increased in SLE patients compared to those in HCs ( p < 0.001). More patients in the high-sCD25 group had lupus nephritis, arthritis and vasculitis ( p = 0.010, p = 0.023 and p = 0.042, respectively). SLEDAI-2K, erythrocyte sedimentation rate, C-reactive protein and 24-hour urinary protein excretion were all associated with high levels of sCD25 ( p < 0.001, p = 0.002, p = 0.038 and p = 0.029, respectively). During the 24-week follow-up, more patients in the high-sCD25 group developed renal impairment (48% vs 6.2%, p = 0.005), and higher levels of sCD25 ( p = 0.033) were found at the time of onset of renal disease. Conclusions Serum sCD25 is a hallmark of disease activity and a predictor of renal disease in patients with SLE.
Collapse
Affiliation(s)
- R J Zhang
- 1 Department of Rheumatology and Immunology, 71185 Peking University People's Hospital , Beijing, China.,2 Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - X Zhang
- 1 Department of Rheumatology and Immunology, 71185 Peking University People's Hospital , Beijing, China.,2 Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - J Chen
- 1 Department of Rheumatology and Immunology, 71185 Peking University People's Hospital , Beijing, China.,2 Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - M Shao
- 1 Department of Rheumatology and Immunology, 71185 Peking University People's Hospital , Beijing, China.,2 Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Y Yang
- 1 Department of Rheumatology and Immunology, 71185 Peking University People's Hospital , Beijing, China.,2 Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - B Balaubramaniam
- 3 Department of Medicine, Division of Allergy, Immunology and Rheumatology, SUNY at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - X L Sun
- 1 Department of Rheumatology and Immunology, 71185 Peking University People's Hospital , Beijing, China
| | - J L Ambrus
- 3 Department of Medicine, Division of Allergy, Immunology and Rheumatology, SUNY at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - J He
- 1 Department of Rheumatology and Immunology, 71185 Peking University People's Hospital , Beijing, China.,2 Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| | - Z G Li
- 1 Department of Rheumatology and Immunology, 71185 Peking University People's Hospital , Beijing, China.,2 Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis (BZ0135), Beijing, China
| |
Collapse
|