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Reynolds ML, Gibson KL, Manuck TA, Poulton CJ, Blazek L, Stuebe AM, Hogan SL, Falk RJ, Derebail VK. Lupus nephritis kidney biopsy characteristics and preterm birth. FRONTIERS IN NEPHROLOGY 2024; 4:1402597. [PMID: 39139800 PMCID: PMC11319279 DOI: 10.3389/fneph.2024.1402597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/09/2024] [Indexed: 08/15/2024]
Abstract
Individuals with lupus nephritis (LN) are at high risk of adverse maternal and fetal outcomes in pregnancy. Outside of pregnancy, proliferative lesions on kidney biopsies are associated with disease progression, but these have not been consistently associated with increased risk in pregnancy. This retrospective, single-center study examines how histologic findings, the timing from kidney biopsy to pregnancy, and the clinical features in the first trimester are associated with preterm birth among individuals with LN. Among 35 deliveries in 31 women, the mean gestational age at delivery was 33.8 weeks. The presence of a urine protein-to-creatinine ratio >0.5 g/g in the first trimester was associated with preterm delivery (81% vs. 36%, p = 0.04). Preterm birth was more common in individuals with glomerular crescents on biopsy (89% in those with >20% crescents vs. 50% in those with <20%, p = 0.06). A pregnancy occurring within 2 years after a kidney biopsy was more likely to result in preterm birth than if the biopsy was performed more than 2 years prior to conception (82% vs. 23%, p = 0.01). The time from diagnostic biopsy may be a surrogate for disease activity, and a 2-year delay from biopsy might allow sufficient time to achieve disease remission. Overall, these data could aid family planning discussions and promote preconception disease optimization for patients and their providers.
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Affiliation(s)
- Monica L. Reynolds
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Keisha L. Gibson
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Tracy A. Manuck
- University of North Carolina (UNC) Maternal and Fetal Medicine, Division of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caroline J. Poulton
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lauren Blazek
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Alison M. Stuebe
- University of North Carolina (UNC) Maternal and Fetal Medicine, Division of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Susan L. Hogan
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ronald J. Falk
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Vimal K. Derebail
- University of North Carolina (UNC) Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Nunes MST, Barbosa Jorge L, Yu L, Woronik V, Bitencourt Dias C. Epidemiological, immunological, and treatment response profile of patients with lupus nephritis in Brazil. Lupus 2024; 33:650-658. [PMID: 38514381 DOI: 10.1177/09612033241240869] [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] [Indexed: 03/23/2024]
Abstract
BACKGROUND AND HYPOTHESIS Brazil has the largest number of individuals of African descent outside Africa and a very admixed population. Among cases of lupus nephritis (LN) in the country, there are differences in incidence, and even in severity, depending on the location and characteristics of the population studied. The aim of this study was to describe the clinical and epidemiological characteristics of LN in Brazil, as well as to determine which of those characteristics would be risk factors for a poor renal prognosis. METHODS This was a retrospective, descriptive observational study of patients diagnosed with LN who underwent kidney biopsy between 1999 and 2015 in the Nephrology Department of the Hospital das Clínicas, in São Paulo, Brazil. Data were collected from electronic medical records. RESULTS We evaluated 398 patients, among who 94.1% and 77.7% tested positive for antinuclear antibodies and anti-DNA antibodies, respectively, whereas 33.7% showed the full-house pattern. The time from LN symptom onset to biopsy was <6 months in 47.5% (early biopsy group) and ≥6 months in 52.5% (late biopsy group). In the early biopsy group, the chronicity index was lower and the activity index was higher. Multivariate analysis showed that a higher chronicity index was the only independent risk factor for progression to requiring kidney replacement therapy. CONCLUSION Late biopsy seems to be associated with negative renal outcomes in LN. However, it seems that a higher chronicity index is the main predictor of a poor renal outcome among patients with LN in Brazil.
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Affiliation(s)
- Mariana Sousa Teixeira Nunes
- Laboratory of Renal Pathophysiology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lectícia Barbosa Jorge
- Laboratory of Renal Pathophysiology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Luis Yu
- Laboratory of Renal Pathophysiology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Viktoria Woronik
- Laboratory of Renal Pathophysiology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Cristiane Bitencourt Dias
- Laboratory of Renal Pathophysiology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
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Wang J, Zhu M, Jiao C, Xu X, Xu F, Liang D, Liu Z, Chen Y, Zhang H. Association of regulatory T cells with renal outcomes in patients with proliferative lupus nephritis. Lupus 2023; 32:1237-1244. [PMID: 37695664 DOI: 10.1177/09612033231201619] [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] [Indexed: 09/12/2023]
Abstract
BACKGROUND Despite progress in the diagnosis and treatment of proliferative lupus nephritis (PLN), the prognosis remains unfavorable. Previous investigations have suggested that the deficiency of regulatory T cells (Tregs) is involved in the pathogenesis of systemic lupus erythematosus (SLE) and lupus nephritis (LN). But the prognostic value of Tregs in PLN remains controversial. This study aimed to investigate the association of Tregs with renal outcomes in patients with PLN. METHODS The baseline and follow-up data of patients with biopsy-proven PLN were collected in this study. All patients were divided into two groups according to whether the renal endpoint event occurred. Clinicopathologic features and therapeutic responses were compared between the two groups. Cox regression analyses curve fitting and threshold effect analysis were implemented to investigate the relationship between Tregs level and the long-term renal outcomes. The renal endpoint was defined as end-stage kidney disease (ESKD) or doubling the SCr value. RESULTS A total of 405 PLN patients were included. After a follow-up of 71.53 (53.13-97.47) months, 42 (10.4%) patients reached the renal endpoint. The Treg cell counts (16/μL) in the renal endpoint group were significantly decreased than that in the non-renal endpoint group (p < 0.001). Univariate and multivariate Cox regression analyses showed that the high level of Tregs was an independent protective factor for the long-term renal prognosis of PLN. Smooth curve fitting of the generalized additive mixed model analysis indicated that the risk of renal endpoint first decreased with Tregs and then slightly increased along with Treg cell levels. The segmented linear model revealed that when Treg cell counts <46/μL, the risk of renal endpoint decreased by 6.8% for every 1 μL increase in Treg levels (p = 0.0029). CONCLUSION Treg cell counts are closely related to the long-term renal outcomes of patients with PLN, and increasing Treg cell levels may play an important role in improving the prognosis of the kidney, but there may be a turning point (i.e., threshold effect) at the Treg cell counts that leads to directional changes in the renal outcomes.
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Affiliation(s)
- Jingjing Wang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Mengyue Zhu
- Department of Nephrology, Northern Jiangsu People's Hospital, Yangzhou, China
| | - Chenfeng Jiao
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Xiaodong Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Feng Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Dandan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Zhengzhao Liu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yinghua Chen
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Haitao Zhang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Ekrikpo U, Obiagwu P, Chika-Onu U, Yadla M, Karam S, Tannor EK, Bello AK, Okpechi IG. Epidemiology and Outcomes of Glomerular Diseases in Low- and Middle-Income Countries. Semin Nephrol 2023; 42:151316. [PMID: 36773418 DOI: 10.1016/j.semnephrol.2023.151316] [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: 02/11/2023]
Abstract
Glomerular diseases account for a significant proportion of chronic kidney disease in low-income and middle-income countries (LMICs). The epidemiology of glomerulonephritis is characterized inadequately in LMICs, largely owing to unavailable nephropathology services or uncertainty of the safety of the kidney biopsy procedure. In contrast to high-income countries where IgA nephropathy is the dominant primary glomerular disease, focal segmental glomerulosclerosis is common in large populations across Latin America, Africa, Middle East, and South East Asia, while IgA nephropathy is common in Chinese populations. Despite having a high prevalence of known genetic and viral risk factors that trigger focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis also is common in adults and children in some African countries. Treatment of glomerular diseases in adults and children in LMICs largely is dependent on corticosteroids in combination with other immunosuppressive therapy, which often is cyclophosphamide because of its ready availability and low cost of treatment, despite significant adverse effects. Partial and/or complete remission status reported from studies of glomerular disease subtypes vary across LMIC regions, with high rates of kidney failure, mortality, and disease, and treatment complications often reported. Improving the availability of nephropathology services and ensuring availability of specific therapies are key measures to improving glomerular disease outcomes in LMICs.
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Affiliation(s)
- Udeme Ekrikpo
- Department of Medicine, University of Uyo, Uyo, Nigeria
| | - Patience Obiagwu
- Department of Paediatrics, Bayero University, Aminu Kano Teaching Hospital, Kano, Nigeria
| | - Ugochi Chika-Onu
- Department of Medicine, College of Medicine, University of Nigeria, Ituku-Ozalla, Enugu, Nigeria
| | - Manjusha Yadla
- Department of Nephrology, Gandhi Medical College, Hyderabad, Telangana, India
| | - Sabine Karam
- Division of Nephrology, University of Minnesota, Minnesota, MN; Division of Nephrology, Faculty of Medicine and Medical Sciences, University of Balamand, Balamand, Lebanon
| | - Elliot K Tannor
- Department of Medicine, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Aminu K Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Ikechi G Okpechi
- Department of Medicine, University of Alberta, Edmonton, Canada; Division of Nephrology, University of Cape Town, Cape Town, South Africa.
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Park DJ, Joo YB, Bang SY, Lee J, Lee HS, Bae SC. Predictive Factors for Renal Response in Lupus Nephritis: A Single-center Prospective Cohort Study. JOURNAL OF RHEUMATIC DISEASES 2022; 29:223-231. [PMID: 37476428 PMCID: PMC10351413 DOI: 10.4078/jrd.22.0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 07/22/2023]
Abstract
Objective To identify the predictive factors for renal response in patients with lupus nephritis (LN). Methods Patients and data were extracted from a prospective systemic lupus erythematosus cohort in Korea, in which clinical data were collected at 0, 3, 6, and 12 months after induction therapy. Treatment response of LN were evaluated as a complete response (CR), partial response (PR), or non-response (NR) at 3, 6, and 12 months, respectively. Predictive factors for CR at 6 months were evaluated using multivariable Poisson regression analysis. Results A total of 75 patients with LN who underwent biopsy was enrolled. The mean age at diagnosis of LN was 28.9±9.7 years, and 68 (90.7%) were female. The frequencies of classes III, IV, III+V, IV+V, and V were 20.0%, 44.0%, 16.0%, 12.0%, and 8.0%, respectively. Compared to relapsed LN, new-onset LN showed a lower percentage of glomerulosclerosis (45.5% vs. 76.2%, p=0.013). The overall proportions of CR, PR, and NR at 6 and 12 months were 52.0%, 26.7%, 21.3% and 50.7%, 24.0%, 25.3%, respectively. In multivariate analysis, age at enrollment (odds ratio [OR]=1.02, p=0.022), relapsed LN (OR=0.71, p=0.037), anti-Ro antibody (OR=0.67, p=0.014), and class III LN (OR=1.48, p=0.001) were associated with CR at 6 months. Conclusion In our prospective cohort, class III LN was a good predictive factor for CR at 6 months in patients with LN, whereas younger age, relapsed LN, and anti-Ro antibody were poor predictive factors.
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Affiliation(s)
- Dae Jin Park
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Young Bin Joo
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - So-Young Bang
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Jiyoung Lee
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Hye-Soon Lee
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
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Gui Y, Bai W, Xu J, Duan X, Zhan F, Zhao C, Jiang Z, Li Z, Wu L, Liu S, Yang M, Wei W, Wang Z, Zhao J, Wang Q, Leng X, Tian X, Li M, Zhao Y, Zeng X. Sex differences in systemic lupus erythematosus (SLE): an inception cohort of the Chinese SLE Treatment and Research Group (CSTAR) registry XVII. Chin Med J (Engl) 2022; 135:2191-2199. [PMID: 36525605 PMCID: PMC9771188 DOI: 10.1097/cm9.0000000000002360] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The onset and clinical presentation of systemic lupus erythematosus (SLE) are sex-related. Few studies have investigated the distinctions in clinical characteristics and treatment preferences in male and female SLE patients in the initial cohort. This study aimed to improve the understanding of Chinese SLE patients by characterizing the different sexes of SLE patients in the inception cohort. METHODS Based on the initial patient cohort established by the Chinese SLE Treatment and Research Group, a total of 8713 patients (795 men and 7918 women) with newly diagnosed SLE were enrolled between April 2009 and March 2021. Of these, 2900 patients (347 men and 2553 women) were eligible for lupus nephritis (LN). A cross-sectional analysis of the baseline demographic characteristics, clinical manifestations, laboratory parameters, organ damage, initial treatment regimens, and renal pathology classification was performed according to sex. RESULTS In the SLE group, as compared to female patients, male patients had a later age of onset (male vs. female: 37.0 ± 15.8 years vs. 35.1 ± 13.7 years, P = 0.006) and a higher SLE International Collaborative Clinic/American College of Rheumatology damage index score (male vs. female: 0.47 ± 1.13 vs. 0.34 ± 0.81, P = 0.015), LN (male vs. female: 43.6% vs. 32.2%, P < 0.001), fever (male vs. female: 18.0% vs. 14.6%, P = 0.010), thrombocytopenia (male vs. female: 21.4% vs. 18.5%, P = 0.050), serositis (male vs. female: 14.7% vs. 11.7%, P = 0.013), renal damage (male vs. female: 11.1% vs. 7.4%, P < 0.001), and treatment with cyclophosphamide (CYC) (P < 0.001). The frequency of leukopenia (male vs. female: 20.5% vs. 25.4%, P = 0.002) and arthritis (male vs. female: 22.0% vs. 29.9%, P < 0.001) was less in male patients with SLE. In LN, no differences were observed in disease duration, SLE Disease Activity Index score, renal biopsy pathological typing, or 24-h urine protein quantification among the sexes. In comparisons with female patients with LN, male patients had later onset ages (P = 0.026), high serum creatinine (P < 0.001), higher end-stage renal failure rates (P = 0.002), musculoskeletal damage (P = 0.023), cardiovascular impairment (P = 0.009), and CYC use (P = 0.001); while leukopenia (P = 0.017), arthritis (P = 0.014), and mycophenolate usage (P = 0.013) rates were lower. CONCLUSIONS Male SLE patients had more severe organ damage and a higher LN incidence compared with female SLE patients; therefore, they may require more aggressive initial treatment compared to female patients.
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Affiliation(s)
- Yinli Gui
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
- Department of Rheumatology, The People's Hospital of Zhengzhou, Zhengzhou, Henan 450003, China
| | - Wei Bai
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Jian Xu
- Department of Rheumatology, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan 650032, China
| | - Xinwang Duan
- Department of Rheumatology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Feng Zhan
- Department of Rheumatology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570311, China
| | - Chen Zhao
- Department of Rheumatology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi 530021, China
| | - Zhenyu Jiang
- Department of Rheumatology, The Bethune First Hospital of Jilin University, Changchun, Jilin 130021, China
| | - Zhijun Li
- Department of Rheumatology, The Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, China
| | - Lijun Wu
- Department of Rheumatology, The People's Hospital of Xinjiang Autonomous Region, Urumqi, Xinjiang 830001, China
| | - Shengyun Liu
- Department of Rheumatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan 450052, China
| | - Min Yang
- Department of Rheumatology and Immunology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Wei Wei
- Department of Rheumatology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Ziqian Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Jiuliang Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Qian Wang
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Xiaomei Leng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Xinping Tian
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Ministry of Science & Technology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (PUMCH), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing 100730, China
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Kapsia E, Marinaki S, Michelakis I, Liapis G, Sfikakis PP, Boletis J, Tektonidou MG. Predictors of Early Response, Flares, and Long-Term Adverse Renal Outcomes in Proliferative Lupus Nephritis: A 100-Month Median Follow-Up of an Inception Cohort. J Clin Med 2022; 11:jcm11175017. [PMID: 36078950 PMCID: PMC9457419 DOI: 10.3390/jcm11175017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 08/20/2022] [Accepted: 08/22/2022] [Indexed: 12/02/2022] Open
Abstract
Objective: To define predictors of response, time to response, flares, and long-term renal outcome in an inception cohort of proliferative lupus nephritis (PLN). Methods: We included 100 patients (80% female; mean age 31 ± 13 years) with biopsy-proven PLN (III, IV, III/IV + V). Clinical, laboratory, histological and therapeutical parameters were recorded at baseline, 6, 9, 12, 18, 24, 36, 72 months, time of flare, and last follow-up visit. Logistic and Cox-regression models were applied. Results: After induction treatment (69% received cyclophosphamide (CYC) and 27% mycophenolic acid (MPA)), partial (PR) or complete (CR) response was achieved in 59% (26% CR, 33% PR) and 67% (43% CR, 24% PR) of patients at 3 and 6 months, respectively; median time to PR was 3 months (IQR 5) and median time to CR was 6 months (IQR 9). Baseline proteinuria <1.5 g/day correlated with a shorter time to CR (HR 1.77) and with CR at 3, 6, and 9 months (OR 9.4, OR 5.3 and OR 3.7, respectively). During 100-month median follow-up, 33% of patients had ≥1 renal flares (median time: 38 months). Proteinuria >0.8 g/day at 12 months was associated with a higher risk of flares (OR 4.12), while MPA and mixed classes with lower risk (OR 0.14 and OR 0.13, respectively). Baseline proteinuria >2 g/day and 12-month proteinuria >0.8 g/day correlated with a shorter time to flare (HR 2.56 and HR 2.57, respectively). At the end of follow-up, 10% developed stage 3–4 chronic kidney disease (CKD), and 12% end-stage renal disease (ESRD). Twelve-month proteinuria >0.8 g/day (OR 10.8) and interstitial fibrosis/tubular atrophy >25% (OR 7.7) predicted CKD or ESRD at last visit. Conclusions: Baseline proteinuria <1.5 g/day predicted time to CR. Twelve-month proteinuria >0.8 g/day correlated with flares (ever) and time to flare and, along with baseline interstitial fibrosis/tubular atrophy >25%, predicted CKD or ESRD at the last visit.
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Affiliation(s)
- Eleni Kapsia
- Department of Nephrology and Renal Transplantation, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Smaragdi Marinaki
- Department of Nephrology and Renal Transplantation, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Ioannis Michelakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - George Liapis
- Department of Pathology, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Petros P. Sfikakis
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - John Boletis
- Department of Nephrology and Renal Transplantation, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Maria G. Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Joint Academic Rheumatology Program, Laiko Hospital, Medical School, National & Kapodistrian University of Athens, 11527 Athens, Greece
- Correspondence: ; Tel.: +30-2107462710
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Renal response and its predictive factors of lupus nephritis: a 2-year real-world study of 56 hospital-based patients. Clin Rheumatol 2022; 41:3363-3371. [PMID: 35854166 DOI: 10.1007/s10067-022-06258-0] [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: 11/29/2021] [Revised: 06/13/2022] [Accepted: 06/19/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Our aim was to evaluate the renal response rate of patients with lupus nephritis (LN) undergoing standard treatment during a 2-year follow-up and to investigate its predictive factors. METHODS A prospective cohort study that enrolled 56 clinically diagnosed LN patients with urinary protein positivity was carried out. All patients underwent standard treatment. All patients were followed up at 6-month intervals for 2 years. Data on renal response and clinical characteristics were collected and analyzed. RESULTS Among 56 patients, 27 (48.2%) and 13 (23.2%) patients achieved complete renal response (CR) and partial renal response (PR) at 6 months after induction therapy, respectively, and 42 (75.0%) and 4 (7.1%) patients developed CR and PR at 2 years. Among patients who achieved PR at 6 months, 90.0% achieved CR at 24 months, while only 37.5% of the patients who were unresponsive at 6 months achieved CR. In the multivariable Cox proportional-hazards model, female (OR 6.51, 95% CI 1.23-34.52, p = 0.028), disease duration (OR 0.84, 95% CI 0.73-0.98, p = 0.021), achieving PR within 6 months (OR 8.09, 95% CI 2.06-31.73, p = 0.003), and urine protein/creatinine ratio (UPCR) (OR 0.998, 95% CI 0.996-1.000, p = 0.025) were found to be predictive factors of CR. CONCLUSION A total of 48.2% of patients achieved CR at 6 months of induction therapy, and the response rates gradually increased to 60.7%, 64.3%, and 75.0% at 12, 18, and 24 months. Besides, female, disease duration, partial response within 6 months, and UPCR were predictive factors for a complete renal response. Key Points • We evaluate the renal response rates in Chinese patients with lupus nephritis in the real world for 2 years. • A total of 48.2% and 75.0% of patients achieved a complete response after standard treatment for 6 months and 2 years. • Female, disease duration, partial response within 6 months, and UPCR are predictors of complete renal response.
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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.
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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
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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.
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Klumb EM, Scheinberg M, de Souza VA, Xavier RM, Azevedo VF, McElwee E, Restrepo MR, Monticielo OA. The landscape of systemic lupus erythematosus in Brazil: An expert panel review and recommendations. Lupus 2021; 30:1684-1695. [PMID: 34255586 PMCID: PMC8489682 DOI: 10.1177/09612033211030008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE The objective of this review is to address the barriers limiting access to diagnosis and treatment of systemic lupus erythematosus (SLE) and lupus nephritis (LN) in Brazil, specifically for patients in the public healthcare system, arguably those with the least access to innovation. DESIGN A selected panel of Brazilian experts in SLE/LN were provided with a series of relevant questions to address in a multi-day conference. During the conference, responses were discussed and edited by the entire group through numerous drafts and rounds of discussion until a consensus was achieved. RESULTS The authors propose specific and realistic recommendations for implementing access to innovative diagnostic tools and treatment alternatives for SLE/LN in Brazil. Moreover, in creating these recommendations, the authors strived to address barriers and impediments for technology adoption. The multidisciplinary care required for SLE/LN necessitates the collective participation of all involved stakeholders. CONCLUSION A great need exists to expand the adoption of innovative diagnostic tools and treatments for SLE/LN not only in Brazil but also in most countries, as access issues remain an urgent demand. The recommendations presented in this article can serve as a strategy for new technology adoption in other countries in a similar situation.
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Affiliation(s)
- Evandro Mendes Klumb
- Rheumatology Department, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
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