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Lichtnekert J, Anders HJ. Lupus nephritis-related chronic kidney disease. Nat Rev Rheumatol 2024:10.1038/s41584-024-01158-w. [PMID: 39317803 DOI: 10.1038/s41584-024-01158-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2024] [Indexed: 09/26/2024]
Abstract
Lupus nephritis is a common complication of systemic lupus erythematosus (SLE) and a determinant of overall morbidity and mortality, as lupus nephritis-related chronic kidney disease (CKD) drives cardiovascular disease and secondary immunodeficiency. Two lines of action are required to prevent the progression of lupus nephritis-related CKD: suppression of autoimmune SLE activity, which is a risk factor for immunopathology-related irreversible kidney injury, and management of non-immune risk factors that contribute to CKD progression. As each episode or relapse of active lupus nephritis implicates CKD progression, preventing flares of lupus nephritis is a key treatment target. Non-immune risk factors of CKD mostly include causes of nephron hyperfiltration, such as obesity, hypertension, sodium- or protein-rich diets and type 2 diabetes mellitus, as well as pregnancy. Nephrotoxic agents and smoking also drive kidney cell loss. Intrinsic risk factors for CKD progression include poor nephron endowment because of prematurity at birth, nephropathic genetic variants, ageing, male sex and previous or concomitant kidney diseases. Care for lupus nephritis involves the control of all modifiable risk factors of CKD progression. In addition, remnant nephron overload can be reduced using early dual therapy with inhibitors of the renin-angiotensin system and sodium-glucose transporter-2, whereas further renoprotective drug interventions are underway. As patients with lupus nephritis are at risk of CKD progression, they would all benefit from interdisciplinary care to minimize the risk of kidney failure, cardiovascular disease and infections.
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Kim JW, Baek WY, Jung JY, Kim HA, Lee SW, Suh CH. Longitudinal assessment of urinary ALCAM, HPX, and PRDX6 in Korean patients with systemic lupus erythematosus: implications for disease activity monitoring and treatment response. Front Immunol 2024; 15:1369385. [PMID: 38915417 PMCID: PMC11194348 DOI: 10.3389/fimmu.2024.1369385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 05/22/2024] [Indexed: 06/26/2024] Open
Abstract
Introduction This study aimed to demonstrate the potential of activated leukocyte cell adhesion molecule (ALCAM), hemopexin (HPX), and peroxiredoxin 6 (PRDX6) as urine biomarkers for systemic lupus erythematosus (SLE). Methods Urine samples were collected from 138 Korean patients with SLE from the Ajou Lupus Cohort and 39 healthy controls (HC). The concentrations of urine biomarkers were analyzed using enzyme-linked immunosorbent assay kits specific for ALCAM, HPX, and PRDX6, respectively. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the diagnostic utility, and Pearson's correlation analysis was conducted to assess the relationships between the disease activity and urine biomarkers. Results Patients with SLE and patients with lupus nephritis (LN) showed significantly elevated ALCAM, HPX, and PRDX6 levels compared with HCs. ALCAM, HPX, and PRDX6 showed significant diagnostic values, especially for lupus nephritis (LN), with areas under the receiver operating characteristic curve for LN was 0.850 for ALCAM (95% CI, 0.778-0.921), 0.781 for HPX (95% CI, 0.695-0.867), and 0.714 for PRDX6 (95% CI, 0.617-0.812). Correlation analysis revealed that all proteins were significantly associated with anti-double stranded DNA antibody (ALCAM, r = 0.350, p < 0.001; HPX, r = 0.346, p < 0.001; PRDX6, r = 0.191, p = 0.026) and SLEDAI (ALCAM, r = 0.526, p < 0.001; HPX, r = 0.479, p < 0.001; PRDX6, r = 0.262, p = 0.002). Results from the follow-up of the three biomarker levels in these patients revealed a significant decrease, showing a positive correlation with changes in SLEDAI-2k scores (ALCAM, r = 0.502, p < 0.001; HPX, r = 0.475, p < 0.001; PRDX6, r = 0.245, p = 0.026), indicating their potential as indicators for tracking disease activity. Discussions Urinary ALCAM, HPX, and PRDX6 levels have diagnostic value and reflect disease activity in Korean patients with SLE, emphasizing their potential for non-invasive monitoring and treatment response evaluation.
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Affiliation(s)
- Ji-Won Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Wook-Young Baek
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Ju-Yang Jung
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Sang-Won Lee
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chang-Hee Suh
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Republic of Korea
- Department of Molecular Science and Technology, Ajou University, Suwon, Republic of Korea
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Parodis I, Moroni G, Calatroni M, Bellis E, Gatto M. Is per-protocol kidney biopsy required in lupus nephritis? Autoimmun Rev 2024; 23:103422. [PMID: 37633351 DOI: 10.1016/j.autrev.2023.103422] [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: 08/06/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023]
Abstract
Baseline kidney biopsy is recommended in lupus nephritis (LN). Biopsy allows to classify different forms of LN and differentiate other forms of renal involvement, such as tubulo-interstitial nephritis or thrombotic microangiopathy. The indications for repeat biopsy are more controversial. Some authors feel that good clinical monitoring is sufficient to assess prognosis and make therapeutic decisions. Based on the recently demonstrated discordance between clinical and histological response, some physicians recommend per-protocol biopsies either at 6 months in stable patients to verify the response to induction therapy, or after one-to-two years to assess treatment efficacy and tune the duration of maintenance therapy. Others recommend repeating kidney biopsy in case of incomplete response or to discriminate between active and chronic lesions. By definition, a per-protocol kidney biopsy differs from a repeat biopsy in that the former is foreseen at fixed timepoints, regardless of the clinical response. Although any decision should always consider the patient's overall clinical condition, there are no doubts that repeat kidney biopsy represents a useful tool in difficult cases to evaluate treatment response, modulate treatment intensity, and predict long-term renal outcome both in quiescent lupus and during flares. How to harmonize per-protocol biopsies in the LN course remains challenging.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Medical Unit of Gastroenterology, Dermatology, and Rheumatology, Karolinska University Hospital, Stockholm, Sweden; Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy.
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Elisa Bellis
- Unit of Rheumatology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Mariele Gatto
- Unit of Rheumatology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy; Unit of Rheumatology, Department of Medicine, University of Padua, Padua, Italy
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Anders HJ, Loutan J, Bruchfeld A, Fernández-Juárez GM, Floege J, Goumenos D, Turkmen K, van Kooten C, Frangou E, Stevens KI, Kronbichler A, Segelmark M, Tesar V. The management of lupus nephritis as proposed by EULAR/ERA 2019 versus KDIGO 2021. Nephrol Dial Transplant 2023; 38:551-561. [PMID: 34888694 DOI: 10.1093/ndt/gfab351] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Indexed: 11/12/2022] Open
Abstract
In 2019 and 2021, the European League for Rheumatism (EULAR) jointly with the European Renal Association (ERA) and the Kidney Disease: Improving Global Outcomes (KDIGO), respectively, released updated guidelines on the management of lupus nephritis (LN). The Immunology Working Group of the ERA reviewed and compared both updates. Recommendations were either consistent or differences were of negligible clinical relevance for: indication for kidney biopsy, kidney biopsy interpretation, treatment targets, hydroxychloroquine dosing, first-line initial immunosuppressive therapy for active class III, IV (±V) LN, pregnancy in LN, LN in paediatric patients and LN patients with kidney failure. Relevant differences in the recommended management relate to the recognition of lupus podocytopathies, uncertainties in steroid dosing, drug preferences in specific populations and maintenance therapy, treatment of pure class V LN, therapy of recurrent LN, evolving alternative drug options and diagnostic work-up of thrombotic microangiopathy. Altogether, both documents provide an excellent guidance to the growing complexity of LN management. This article endeavours to prevent confusion by identifying differences and clarifying discrepancies.
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Affiliation(s)
- Hans-Joachim Anders
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Munich, Germany
| | - Jerome Loutan
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Munich, Germany
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Division of Diagnostics and Specialist Medicine, Linköping University, Linköping, Sweden.,Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Gema M Fernández-Juárez
- Department of Nephrology, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Dimitrios Goumenos
- Department of Nephrology and Renal Transplantation, Patras University Hospital, Patras, Greece
| | - Kultigin Turkmen
- Department of Internal Medicine, Division of Nephrology, Necmettin Erbakan University, Konya, Turkey
| | - Cees van Kooten
- Division of Nephrology and Transplant Medicine, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleni Frangou
- Department of Nephrology, Limassol General Hospital, Limassol, Cyprus
| | - Kate I Stevens
- The Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Mårten Segelmark
- Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Sciences Lund, Division of Nephrology, Lund University and Skåne University Hospital, Lund, Sweden
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
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Obrișcă B, Vornicu A, Procop A, Herlea V, Terinte-Balcan G, Gherghiceanu M, Ismail G. A Histology-Guided Approach to the Management of Patients with Lupus Nephritis: Are We There Yet? Biomedicines 2022; 10:biomedicines10061409. [PMID: 35740431 PMCID: PMC9220241 DOI: 10.3390/biomedicines10061409] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/06/2022] [Accepted: 06/13/2022] [Indexed: 11/16/2022] Open
Abstract
Renal involvement is a frequent complication of systemic lupus erythematosus (SLE). It occurs in up to two-thirds of patients, often early during the disease course, and is the most important predictor of the morbidity and mortality of SLE patients. Despite tremendous improvements in the approach of the lupus nephritis (LN) therapy, including the recent approval of two new disease-modifying therapies, up to 50% of patients do not obtain a renal response and up to 25% will eventually progress to end-stage renal disease (ESRD) within 10 years of diagnosis. Given the lack of correlation between clinical features and histological lesions, there is an increasing need for a histology-guided approach to the management of patients with LN. Apart from the initial diagnosis of type and severity of renal injury in SLE, the concept of a repeat kidney biopsy (either in a for-cause or a per-protocol scenario) has begun to gain increasing popularity in the nephrology community. Herein, we will provide a comprehensive overview of the most important areas of utility of the kidney biopsy in patients with LN.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Alexandru Procop
- Department of Pathology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.P.); (V.H.)
| | - Vlad Herlea
- Department of Pathology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (A.P.); (V.H.)
| | - George Terinte-Balcan
- Ultrastructural Pathology, “Victor Babes” National Institute of Pathology, 050097 Bucharest, Romania; (G.T.-B.); (M.G.)
| | - Mihaela Gherghiceanu
- Ultrastructural Pathology, “Victor Babes” National Institute of Pathology, 050097 Bucharest, Romania; (G.T.-B.); (M.G.)
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (B.O.); (A.V.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence:
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Gatto M, Radice F, Saccon F, Calatroni M, Frontini G, Trezzi B, Zen M, Ghirardello A, Tamborini F, Binda V, L'Imperio V, Doria A, Vaglio A, Sinico RA, Moroni G, Iaccarino L. Clinical and histological findings at second but not at first kidney biopsy predict end-stage kidney disease in a large multicentric cohort of patients with active lupus nephritis. Lupus Sci Med 2022; 9:9/1/e000689. [PMID: 35568438 PMCID: PMC9109114 DOI: 10.1136/lupus-2022-000689] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/26/2022] [Indexed: 11/06/2022]
Abstract
Objective To investigate second kidney biopsy as predictor of end-stage kidney disease (ESKD) in active lupus nephritis (LN). Methods Patients with biopsy-proven LN (International Society of Nephrology/Renal Pathology Society 2003) who had undergone a second kidney biopsy between January 1990 and December 2018 were included. Clinical and histological findings at first and at second biopsy were analysed with Cox proportional hazard models to predict ESKD, defined as start of kidney replacement therapy. Survival curves were calculated with Kaplan-Meier method. Results Ninety-two patients with LN were included, 87% females, mean follow-up 17.9±10.1 years. Reasons for second kidney biopsy encompassed nephritic flares (n=28, 30.4%), proteinuric flares (n=46, 50%) or lack of renal response (n=18, 19.5%). Class switch from first biopsy occurred in 50.5% of cases, mainly from non-proliferative towards proliferative classes. Class IV remained stable in over 50% of cases. Twenty-five patients (27.2%) developed ESKD, mostly belonging to the nephritic flare group (17/28, 60.7%). Independent predictors of ESKD at second biopsy were activity index (AI; (HR 95% CI) 1.20 (1.03 to 1.41), p=0.022), chronicity index (CI; 1.41 (1.09 to 1.82), p=0.008) and 24h-proteinuria (1.22 (1.04 to 1.42), p=0.013). AI≥2 (log-rank p=0.031), CI >4 (log-rank p=0.001) or proteinuria ≥3.5 g/day (log-rank=0.009) identified thresholds for higher ESKD risk. In a subgroup analysis, glomerular activity and tubular chronicity mostly accounted for AI and CI association with ESKD. No histological or laboratory predictors emerged at first biopsy (95% CI): AI: 0.88 to 1.19; CI: 0.66 to 1.20; proteinuria 0.85 to 1.08. Conclusions Findings at second but not at first kidney biopsy in patients with persistently active or relapsing LN inform about ESKD development in a long-term follow-up.
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Affiliation(s)
- Mariele Gatto
- Unit of Rheumatology, Department of Medicine, DIMED, University of Padua, Padova, Italy
| | - Francesca Radice
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.,Nephrology Unit, ASST-Monza, Ospedale San Gerardo, Monza, Italy
| | - Francesca Saccon
- Unit of Rheumatology, Department of Medicine, DIMED, University of Padua, Padova, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Nephrology and Dialysis, IRCCS Humanitas Research Hospital, Rozzano, Lombardia, Italy
| | - Giulia Frontini
- Unit of Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Barbara Trezzi
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.,Nephrology Unit, ASST-Monza, Ospedale San Gerardo, Monza, Italy
| | - Margherita Zen
- Unit of Rheumatology, Department of Medicine, DIMED, University of Padua, Padova, Italy
| | - Anna Ghirardello
- Unit of Rheumatology, Department of Medicine, DIMED, University of Padua, Padova, Italy
| | - Francesco Tamborini
- Unit of Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Binda
- Unit of Nephrology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, Ospedale San Gerardo, Monza, Italy
| | - Andrea Doria
- Unit of Rheumatology, Department of Medicine, DIMED, University of Padua, Padova, Italy
| | - Augusto Vaglio
- Department of Biomedical Clinical and Experimental Sciences, Università degli Studi di Firenze, Firenze, Toscana, Italy
| | - Renato Alberto Sinico
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy.,Nephrology Unit, ASST-Monza, Ospedale San Gerardo, Monza, Italy
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Nephrology and Dialysis, IRCCS Humanitas Research Hospital, Rozzano, Lombardia, Italy
| | - Luca Iaccarino
- Unit of Rheumatology, Department of Medicine, DIMED, University of Padua, Padova, Italy
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Parodis I, Tamirou F, Houssiau FA. Treat-to-Target in Lupus Nephritis. What is the Role of the Repeat Kidney Biopsy? Arch Immunol Ther Exp (Warsz) 2022; 70:8. [PMID: 35147824 PMCID: PMC8837511 DOI: 10.1007/s00005-022-00646-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/12/2021] [Indexed: 01/14/2023]
Abstract
Kidney involvement, termed lupus nephritis (LN), develops in 35-60% of patients with systemic lupus erythematosus, often early during the disease course. When not treated promptly and efficiently, LN may lead to rapid and severe loss of kidney function, being the reason why it is considered one of the most severe lupus manifestations. Despite improved pharmacotherapy, 5-20% of LN patients develop end-stage kidney disease within ten years from the LN diagnosis. While the principal ground of LN therapy is prevention of renal function worsening, resembling a race against nephron loss, consensual agreement upon outcome measures and clinically meaningful short- and long-term targets of LN therapy have yet to be determined. Literature points to the importance of inclusion of tissue-based approaches in the determination of those targets, and evidence accumulates regarding the importance of per-protocol repeat kidney biopsies in the evaluation of the initial phase of therapy and prediction of long-term renal prognosis. The latter leads to the hypothesis that the information gleaned from repeat biopsies may contribute to optimised therapeutic decision making, and, therefore, increased probability to attain complete renal response in the short term, and a more favourable renal prognosis within a longer prospect. The multinational project ReBioLup was recently designed to serve as a key contributor to form evidence about the role of per-protocol repeat biopsies in a randomised fashion and aspires to unify the global LN community towards improved kidney and patient survival.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, 171 76, Stockholm, Sweden. .,Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Farah Tamirou
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Rheumatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Frédéric A Houssiau
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Rheumatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Parodis I, Adamichou C, Aydin S, Gomez A, Demoulin N, Weinmann-Menke J, Houssiau FA, Tamirou F. Per-protocol repeat kidney biopsy portends relapse and long-term outcome in incident cases of proliferative lupus nephritis. Rheumatology (Oxford) 2021; 59:3424-3434. [PMID: 32353879 DOI: 10.1093/rheumatology/keaa129] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/24/2020] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES In patients with LN, clinical and histological responses to treatment have been shown to be discordant. We investigated whether per-protocol repeat kidney biopsies are predictive of LN relapses and long-term renal function impairment. METHODS Forty-two patients with incident biopsy-proven active proliferative (class III/IV±V) LN from the database of the UCLouvain were included in this retrospective study. Per-protocol repeat biopsies were performed after a median [interquartile range (IQR)] time of 24.3 (21.3-26.2) months. The National Institutes of Health activity index (AI) and chronicity index (CI) scores were assessed in all biopsies. RESULTS Despite a moderate correlation between urinary protein/creatinine ratios (UPCR) and AI scores at repeat biopsy (r = 0.48; P = 0.001), 10 patients (23.8%) with UPCR < 1.0 g/g still had a high degree of histological activity (AI > 3). High AI scores (continuous) in repeat biopsies were associated with an increased probability and/or shorter time to renal relapse (n = 11) following the repeat biopsy [hazard ratio (HR) = 1.2, 95% CI: 1.1, 1.3; P = 0.007], independently of proteinuria levels. High CI scores (continuous) in repeat biopsies were associated with a sustained increase in serum creatinine levels corresponding to ≥120% of the baseline value (HR = 1.8, 95% CI: 1.1, 2.9; P = 0.016) through a median (IQR) follow-up time of 131.5 (73.8-178.2) months, being also the case for acute tubulointerstitial inflammation and interstitial fibrosis/tubular atrophy in repeat but not baseline biopsies. CONCLUSION Our results highlight the usefulness of per-protocol repeat biopsies, herein performed after a median time of 24 months from baseline, as an integral part of the treatment evaluation, also in patients showing adequate clinical response.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Christina Adamichou
- Rheumatology Department, Cliniques Universitaires Saint-Luc and Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain
| | - Selda Aydin
- Pathology Department, Cliniques Universitaires Saint-Luc
| | - Alvaro Gomez
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Nathalie Demoulin
- Division of Nephrology, Cliniques Universitaires Saint-Luc and Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Julia Weinmann-Menke
- Department of Nephrology, Rheumatology and Clinical Immunology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Frédéric A Houssiau
- Rheumatology Department, Cliniques Universitaires Saint-Luc and Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain
| | - Farah Tamirou
- Rheumatology Department, Cliniques Universitaires Saint-Luc and Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain
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Zhang L, Zhang M, Chen X, He Y, Chen R, Zhang J, Huang J, Ouyang C, Shi G. Identification of the tubulointerstitial infiltrating immune cell landscape and immune marker related molecular patterns in lupus nephritis using bioinformatics analysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 8:1596. [PMID: 33437795 PMCID: PMC7791250 DOI: 10.21037/atm-20-7507] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease that commonly affects the kidneys. Research into markers that can predict the prognosis of tubulointerstitial lupus nephritis (LN) has been impeded by the lack of well-designed studies. Methods In this study, we selected and merged 3 sets of renal biopsy tubulointerstitial data from GSE32591, GSE69438, and GSE127797, including 95 LN and 15 living healthy donors. CIBERSORTx was utilized for differentially infiltrating immune cell (DIIC) analysis. Weighted Gene Co-Expression network analysis (WGCNA) was employed to explore differentially expressed gene (DEG) related modules. Combined WGCNA hub genes and protein-protein interaction (PPI) validation was used for immune marker identification. Lastly, unsupervised clustering was carried out to validate the correlation between these markers and clinical characteristics. Results Our findings unveiled TYROBP, C1QB, LAPTM5, CTSS, PTPRC as the 5 immune markers, which were negatively correlated with glomerular filtration rate (GFR). Specifically, the expression levels of TYROBP and C1QB were significantly different between proliferative LN (PLN) and membranous LN (MLN). Unsupervised clustering could aggregate LN by these immune marker expression spectrums. Conclusions This study is the first to identify infiltrating immune cells and associated molecular patterns in the tubulointerstitium of LN by utilizing bioinformatics methods. These findings contribute to a better understanding of the mechanisms behind LN, and promote more precise diagnosis.
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Affiliation(s)
- Lu Zhang
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen, China.,The Fifth Hospital of Xiamen, Xiang'an Branch, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Mengqin Zhang
- Department of Rheumatology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Xing Chen
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen, China.,The Fifth Hospital of Xiamen, Xiang'an Branch, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Yan He
- Department of Rheumatology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Rongjuan Chen
- Department of Rheumatology, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jun Zhang
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen, China.,The Fifth Hospital of Xiamen, Xiang'an Branch, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jiyi Huang
- Department of Nephrology, The First Affiliated Hospital of Xiamen University, Xiamen, China.,The Fifth Hospital of Xiamen, Xiang'an Branch, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Chun Ouyang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guixiu Shi
- Department of Rheumatology, The First Affiliated Hospital of Xiamen University, Xiamen, China
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10
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Gasparotto M, Gatto M, Binda V, Doria A, Moroni G. Lupus nephritis: clinical presentations and outcomes in the 21st century. Rheumatology (Oxford) 2020; 59:v39-v51. [PMID: 33280015 PMCID: PMC7751166 DOI: 10.1093/rheumatology/keaa381] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/28/2020] [Indexed: 01/17/2023] Open
Abstract
Lupus nephritis (LN) is a frequent and severe manifestation of SLE. Along the decades, the epidemiology of LN and its clinical presentation have been changing. However, even though retrospective cohort studies report a decreased mortality rate and an improvement in the disease prognosis, the percentage of patients progressing into end stage renal disease (ESRD) keeps steady despite the improvements in therapeutic strategies. Current in-use medications have been available for decades now, yet over the years, regimens for optimizing their efficacy and minimizing toxicity have been developed. Therapeutic research is now moving towards the direction of precision medicine and several new drugs, targeting selectively different pathogenetic pathways, are currently under evaluation with promising results. In this review, we address the main changes and persistent unmet needs in LN management throughout the past decades, with a focus on prognosis and upcoming treatments.
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Affiliation(s)
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Valentina Binda
- Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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11
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Morales E, Trujillo H, Bada T, Alonso M, Gutiérrez E, Rodríguez E, Gutiérrez E, Galindo M, Praga M. What is the value of repeat kidney biopsies in patients with lupus nephritis? Lupus 2020; 30:25-34. [PMID: 33081588 DOI: 10.1177/0961203320965703] [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] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Recent studies with protocol biopsies have shown a mismatch between clinical and histological remission in lupus nephritis (LN). We aimed to evaluate histological changes in repeat kidney biopsies by clinical indication in patients with LN. METHODS We analyzed 107 patients with LN in which a kidney biopsy was performed between 2008 and 2018. Of those, we included 26 (24.2%) who had ≥2 kidney biopsies. Classification was done according to the International Society of Nephrology/Renal Pathology Society. RESULTS Mean time between biopsies was 71.5 ± 10.7 months. 73.1% of patients presented a change of class at repeat biopsy; 38.4% to a higher class and 34.6% to a lower class. A significant increase in glomerulosclerosis (% GS) (3.8% vs 18.7%, p = 0.006), interstitial fibrosis (3.8% vs 26.9%, p = 0.021), tubular atrophy (15.4% vs 57.7%, p = 0.001) and chronicity index (CI) (1 vs 3, p < 0.001) was observed at repeat biopsy. Subjects who developed chronic kidney disease progression had a lower rate of complete remission at 12 months (0% vs 37.5%, p = 0.02), higher % GS at first biopsy (7.9% vs 1.2%, p = 0.02) and higher CI (4 vs 2, p = 0.006), tubular atrophy (90% vs 37.6%, p = 0.008), interstitial fibrosis (50% vs 12.5%, p = 0.036) and vascular lesions (60% vs 18.8%, p = 0.031) at second biopsy. CONCLUSIONS Our major finding was that patients with LN showed a significant increase in % GS, interstitial fibrosis, tubular atrophy and vascular lesions in repeat biopsies performed by clinical indication. This suggest that a second kidney biopsy may provide valuable and useful information regarding kidney disease progression.
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Affiliation(s)
- Enrique Morales
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain.,Research Institute of University Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Hernando Trujillo
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain
| | - Teresa Bada
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain
| | - Marina Alonso
- Department of Pathology, University Hospital "12 de Octubre", Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain.,Research Institute of University Hospital "12 de Octubre" (imas12), Madrid, Spain
| | - Esther Rodríguez
- Department of Rheumatology, University Hospital "12 de Octubre", Madrid, Spain
| | - Elena Gutiérrez
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain
| | - María Galindo
- Research Institute of University Hospital "12 de Octubre" (imas12), Madrid, Spain.,Department of Rheumatology, University Hospital "12 de Octubre", Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, University Hospital "12 de Octubre", Madrid, Spain.,Research Institute of University Hospital "12 de Octubre" (imas12), Madrid, Spain
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12
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Selamet U, Hanna RM, Sisk A, Abdelnour L, Ghobry L, Kurtz I. Acute interstitial nephritis and drug-induced systemic lupus erythematosus due to chlorthalidone and amiodarone: A case report. SAGE Open Med Case Rep 2020; 8:2050313X20910029. [PMID: 32166031 PMCID: PMC7052449 DOI: 10.1177/2050313x20910029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 01/30/2020] [Indexed: 01/18/2023] Open
Abstract
Drug-induced lupus erythematosus has features distinct from primary systemic
lupus erythematosus. It can occur with a wide variety of agents that result in
the generation of anti-histone or other types of antibodies. Systemic
manifestations of drug-induced systemic lupus erythematosus may include renal
dysfunction due to circulating immune complexes or due to other immune reactions
to the culprit medication(s). Acute interstitial nephritis occurs due to
DNA–drug or protein–drug complexes that trigger an allergic immune response. We
report a patient who developed acute kidney injury, rash, and drug-induced
systemic lupus diagnosed by serologies after starting chlorthalidone and
amiodarone. A renal biopsy showed acute interstitial nephritis and not
lupus-induced glomerulonephritis. It is important to note that systemic lupus
erythematosus and acute interstitial nephritis can occur together, and this
report highlights the role of the kidney biopsy in ascertaining the pathological
diagnosis and outlining therapy in drug-induced lupus erythematosus.
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Affiliation(s)
- Umut Selamet
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ramy M Hanna
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Nephrology, Department of Medicine, UCI Medical Center, Orange, CA, USA
| | - Anthony Sisk
- Renal Pathology Division, Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lama Abdelnour
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Lena Ghobry
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ira Kurtz
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Brain Research Institute, University of California, Los Angeles, CA, USA
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13
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Parodis I, Tamirou F, Houssiau FA. Prediction of prognosis and renal outcome in lupus nephritis. Lupus Sci Med 2020; 7:e000389. [PMID: 32153796 PMCID: PMC7046967 DOI: 10.1136/lupus-2020-000389] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 02/06/2023]
Abstract
Lupus nephritis (LN) is a severe manifestation of SLE, characterised by subendothelial and/or subepithelial immune complex depositions in the afflicted kidney, resulting in extensive injury and nephron loss during the acute phase and eventually chronic irreversible damage and renal function impairment if not treated effectively. The therapeutic management of LN has improved during the last decades, but the imperative need for consensual outcome measures remains. In order to design trials with success potentiality, it is important to define clinically important short-term and long-term targets of therapeutic and non-therapeutic intervention. While it is known that early response to treatment is coupled with favourable renal outcomes, early predictors of renal function impairment are lacking. The information gleaned from kidney biopsies may provide important insights in this direction. Alas, baseline clinical and histopathological information has not been shown to be informative. By contrast, accumulating evidence of pronounced discrepancies between clinical and histopathological outcomes after the initial phase of immunosuppression has prompted investigations of the potential usefulness of per-protocol repeat kidney biopsies as an integral part of treatment evaluation, including patients showing adequate clinical response. This approach appears to have merit. Hopefully, clinical, molecular or genetic markers that reliably reflect kidney histopathology and portend the long-term prognosis will be identified. Novel non-invasive imaging methods and employment of the evolving artificial intelligence in pattern recognition may also be helpful towards these goals. The molecular and cellular characterisation of SLE and LN will hopefully result in novel therapeutic modalities, maybe new taxonomy perspectives, and ultimately personalised management.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Farah Tamirou
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
- Rheumatology Department, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Frédéric A Houssiau
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
- Rheumatology Department, Cliniques universitaires Saint-Luc, Brussels, Belgium
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