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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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Reis-Neto ETD, Seguro LPC, Sato EI, Borba EF, Klumb EM, Costallat LTL, Medeiros MMDC, Bonfá E, Araújo NC, Appenzeller S, Montandon ACDOES, Yuki EFN, Teixeira RCDA, Telles RW, Egypto DCSD, Ribeiro FM, Gasparin AA, Junior ASDA, Neiva CLS, Calderaro DC, Monticielo OA. II Brazilian Society of Rheumatology consensus for lupus nephritis diagnosis and treatment. Adv Rheumatol 2024; 64:48. [PMID: 38890752 DOI: 10.1186/s42358-024-00386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE To develop the second evidence-based Brazilian Society of Rheumatology consensus for diagnosis and treatment of lupus nephritis (LN). METHODS Two methodologists and 20 rheumatologists from Lupus Comittee of Brazilian Society of Rheumatology participate in the development of this guideline. Fourteen PICO questions were defined and a systematic review was performed. Eligible randomized controlled trials were analyzed regarding complete renal remission, partial renal remission, serum creatinine, proteinuria, serum creatinine doubling, progression to end-stage renal disease, renal relapse, and severe adverse events (infections and mortality). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to develop these recommendations. Recommendations required ≥82% of agreement among the voting members and were classified as strongly in favor, weakly in favor, conditional, weakly against or strongly against a particular intervention. Other aspects of LN management (diagnosis, general principles of treatment, treatment of comorbidities and refractory cases) were evaluated through literature review and expert opinion. RESULTS All SLE patients should undergo creatinine and urinalysis tests to assess renal involvement. Kidney biopsy is considered the gold standard for diagnosing LN but, if it is not available or there is a contraindication to the procedure, therapeutic decisions should be based on clinical and laboratory parameters. Fourteen recommendations were developed. Target Renal response (TRR) was defined as improvement or maintenance of renal function (±10% at baseline of treatment) combined with a decrease in 24-h proteinuria or 24-h UPCR of 25% at 3 months, a decrease of 50% at 6 months, and proteinuria < 0.8 g/24 h at 12 months. Hydroxychloroquine should be prescribed to all SLE patients, except in cases of contraindication. Glucocorticoids should be used at the lowest dose and for the minimal necessary period. In class III or IV (±V), mycophenolate (MMF), cyclophosphamide, MMF plus tacrolimus (TAC), MMF plus belimumab or TAC can be used as induction therapy. For maintenance therapy, MMF or azathioprine (AZA) are the first choice and TAC or cyclosporin or leflunomide can be used in patients who cannot use MMF or AZA. Rituximab can be prescribed in cases of refractory disease. In cases of failure in achieving TRR, it is important to assess adherence, immunosuppressant dosage, adjuvant therapy, comorbidities, and consider biopsy/rebiopsy. CONCLUSION This consensus provides evidence-based data to guide LN diagnosis and treatment, supporting the development of public and supplementary health policies in Brazil.
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Affiliation(s)
- Edgard Torres Dos Reis-Neto
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil.
| | - Luciana Parente Costa Seguro
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Emília Inoue Sato
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil
| | - Eduardo Ferreira Borba
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Evandro Mendes Klumb
- Department of Rheumatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lilian Tereza Lavras Costallat
- Division of Rheumatology, Department of Orthopedics, Rheumatology and Traumatology, Universidade Estadual de Campinas (Unicamp), Campinas, Brazil
| | | | - Eloisa Bonfá
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Nafice Costa Araújo
- Division of Rheumatology, Hospital do Servidor Público Estadual de São Paulo - Instituto de Assistência Médica ao Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Simone Appenzeller
- Division of Rheumatology, Department of Orthopedics, Rheumatology and Traumatology, Universidade Estadual de Campinas (Unicamp), Campinas, Brazil
| | | | - Emily Figueiredo Neves Yuki
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | | | - Rosa Weiss Telles
- Division of Rheumatology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | | | - Francinne Machado Ribeiro
- Department of Rheumatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andrese Aline Gasparin
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Antonio Silaide de Araujo Junior
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil
| | | | - Debora Cerqueira Calderaro
- Division of Rheumatology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Odirlei Andre Monticielo
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
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Koyama K, Ohgami A, Nawata T, Sato K, Fujinaka M, Shibuya M, Kitahara T, Yano M. Serial changes in anxiety levels related to corticosteroid use: A single-center prospective study. Medicine (Baltimore) 2024; 103:e38489. [PMID: 38847708 PMCID: PMC11155556 DOI: 10.1097/md.0000000000038489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/16/2024] [Indexed: 06/10/2024] Open
Abstract
Patients with autoimmune diseases treated with corticosteroids sometimes display feelings of anxiety regarding corticosteroid use. In this single-center prospective study, we aimed to evaluate the serial changes in anxiety levels related to corticosteroid use in 18 patients with autoimmune diseases. The degree of anxiety toward corticosteroid use was assessed using the visual analogue scale. Comprehension of drug characteristics and use was assessed using the Likert scale. To assess the patients' levels of depression and anxiety we used the State-Trait Anxiety Inventory. These surveys were conducted immediately before the initiation of corticosteroid therapy and just before discharge from the hospital. We observed a decrease in anxiety levels related to corticosteroid use and State-Trait Anxiety Inventory scores before discharge. However, we did not detect a correlation between these score changes. Additionally, we found that patients who had a poor understanding of the drugs showed little or no changes in their anxiety levels related to corticosteroid use at discharge. These results suggest that some aspects of anxiety related to corticosteroids might be groundless and substantiated by assumptions without a complete understanding of corticosteroid functioning. Patient education regarding corticosteroid use may lead to reductions in anxiety levels and improvement in quality of life of the patients.
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Affiliation(s)
| | - Ayaka Ohgami
- Department of Health Sciences, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Takashi Nawata
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Kana Sato
- Division of Nursing, Yamaguchi University Hospital, Ube, Japan
| | - Masafumi Fujinaka
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Masaki Shibuya
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | | | - Masafumi Yano
- Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
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Jeon H, Lee J, Moon SJ, Kwok SK, Ju JH, Kim WU, Park SH. Predictors of renal relapse in Koreans with lupus nephritis after achieving complete response: a 35-years of experience at a single center. Korean J Intern Med 2024; 39:347-359. [PMID: 38247126 PMCID: PMC10918382 DOI: 10.3904/kjim.2023.255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/18/2023] [Accepted: 09/01/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND/AIMS Renal relapse has known to be a poor prognostic factor in patients with lupus nephritis (LN), but there were few studies that identified the risk factors of renal relapse in real world. We conducted this study based on 35-years of experience at a single center to find out predictors of renal relapse in Korean patients with LN after achieving complete response (CR). METHODS We retrospectively analyzed the clinical, laboratory, pathologic and therapeutic parameters in 296 patients of LN who reached CR. The cumulative risk and the independent risk factors for renal relapse were examined by Kaplan-Meier methods and Cox proportional hazards regression analyses, respectively. RESULTS The median follow-up period from CR was 123 months. Renal relapse had occurred in 157 patients. Renal relapse occurred in 38.2%, 57.6% and 67.9% of patients within 5-, 10-, and 20-year, respectively. The age at diagnosis of SLE and LN were significantly younger, and the proportions of severe proteinuria and serum hypoalbuminemia were higher in patients with renal relapse. Interestingly, the proportion of receiving cytotoxic maintenance treatment was higher in patients with renal relapse. In Cox proportional hazards regression analyses, only young-age onset of LN (by 10 years, HR = 0.779, p = 0.007) was identified to independent predictor of renal relapse. CONCLUSION Young-age onset of LN was only independent predictor and the patients with severe proteinuria and serum hypoalbuminemia also tended to relapse more, despite of sufficient maintenance treatment. Studies on more effective maintenance treatment regimens and duration are needed to reduce renal relapse.
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Affiliation(s)
- Howook Jeon
- Division of Rheumatology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Jennifer Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Su-Jin Moon
- Division of Rheumatology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Seung-Ki Kwok
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Wan-Uk Kim
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul,
Korea
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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.
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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.
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Jourde-Chiche N, Bobot M, Burtey S, Chiche L, Daugas E. Weaning Maintenance Therapy in Lupus Nephritis: For Whom, When, and How? Kidney Int Rep 2023; 8:1481-1488. [PMID: 37547513 PMCID: PMC10403675 DOI: 10.1016/j.ekir.2023.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 08/08/2023] Open
Abstract
Lupus nephritis (LN) is one of the main determinants of the severity of systemic lupus erythematosus (SLE). LN flares can lead to organ damage with chronic kidney disease (CKD) or even end-stage kidney disease (ESKD) and impair patients' survival. The "treat-to-target" strategy, which aims at obtaining and maintaining remission or low disease activity of SLE to alleviate symptoms and prevent organ damage, also refers to the control of residual activity in the kidney. But damage in SLE can also come from treatments, and toxicities related to long-term use of treatments should be prevented. This may contribute to the frequent nonadherence in patients with SLE. The de-escalation or even weaning of treatments whenever possible, or "think-to-untreat" (T2U) strategy, is to be considered in patients with LN. This possibility of treatment weaning in LN was explored in retrospective cohorts, on the basis of long-term clinical remission. It was also proposed prospectively with a kidney-biopsy-based approach, combining clinical and pathologic remission to secure treatment weaning. The WIN-Lupus trial was the first randomized controlled trial comparing the continuation to the discontinuation of maintenance immunosuppressive therapy (IST) after 2 to 3 years in patients with LN in remission. It showed a higher risk of severe SLE flares in patients who discontinued treatment, but also a possibility of weaning without flare in some patients, who need to be better identified. We propose here a narrative review of the available literature on the weaning of treatment in LN and discuss how to secure a T2U strategy.
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Affiliation(s)
- Noémie Jourde-Chiche
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Mickaël Bobot
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
- Aix-Marseille Université, CERIMED, Marseille, France
| | - Stéphane Burtey
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Laurent Chiche
- Hôpital Européen de Marseille, Service de Médecine interne, Marseille, France
| | - Eric Daugas
- AP-HP, Service de Néphrologie, Hôpital Bichat, Paris, France
- Université Paris Cité, INSERM U1149, Paris, France
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Sun K, Eudy AM, Rogers JL, Criscione-Schreiber LG, Sadun RE, Doss J, Maheswaranathan M, Barr AC, Eder L, Corneli AL, Bosworth HB, Clowse ME. Pilot Intervention to Improve Medication Adherence Among Patients With Systemic Lupus Erythematosus Using Pharmacy Refill Data. Arthritis Care Res (Hoboken) 2023; 75:550-558. [PMID: 34739191 PMCID: PMC9068832 DOI: 10.1002/acr.24806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 09/07/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Despite high rates of medication nonadherence among patients with systemic lupus erythematosus (SLE), effective interventions to improve adherence in SLE are limited. We aimed to assess the feasibility of a pilot intervention and explore its effect on adherence. METHODS The intervention used pharmacy refill data to monitor nonadherence and prompt discussions surrounding SLE medications during clinic encounters. Over 12 weeks, the intervention was delivered through routine clinic visits by providers to patients with SLE who take SLE-specific medications. We measured acceptability, appropriateness, and feasibility using provider surveys. We also measured acceptability by patient surveys and feasibility by medical record documentation. We explored change in adherence by comparing percent of patients with medication possession ratio (MPR) ≥80% 3 months before and after the intervention visit using the McNemar's test. RESULTS Six rheumatologists participated; 130 patients were included in the analysis (median age 43, 95% female, and 59% racial and ethnic minorities). Implementation of the intervention was documented in 89% of clinic notes. Provider surveys showed high scores for feasibility (4.7/5), acceptability (4.4/5), and appropriateness (4.6/5). Among patient surveys, the most common reactions to the intervention visit were feeling determined (32%), empowered (32%), and proud (19%). Proportion of patients with MPR ≥80% increased from 48% to 58% (P = 0.03) after the intervention visit. CONCLUSION Our intervention showed feasibility, acceptability, and appropriateness and led to a statistically significant improvement in adherence. Future work should refine the intervention, assess its efficacy in a controlled setting, and adapt its use among other clinic settings.
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Affiliation(s)
- Kai Sun
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amanda M. Eudy
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jennifer L. Rogers
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Rebecca E. Sadun
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jayanth Doss
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Mithu Maheswaranathan
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ann Cameron Barr
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Lena Eder
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amy L. Corneli
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Hayden B. Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Megan E.B. Clowse
- Division of Rheumatology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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Perez-Arias AA, Márquez-Macedo SE, Pena-Vizcarra OR, Zavala-Miranda MF, Romero-Díaz J, Morales-Buenrostro LE, Mejía-Vilet JM. The influence of repeated flares in response to therapy and prognosis in lupus nephritis. Nephrol Dial Transplant 2022; 38:884-893. [PMID: 36318456 DOI: 10.1093/ndt/gfac304] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Indexed: 11/30/2022] Open
Abstract
ABSTRACT
Background
Repeated renal flares in lupus nephritis (LN) have been associated with worse long-term kidney function. This study aimed to assess the impact of repeated LN flares in response to therapy, kidney and patient prognosis.
Methods
All patients from a biopsy-proven LN cohort between 2008 and 2018 were segregated into three groups according to the number of LN flares when they entered our cohort: first LN flare, second LN flare or third LN flare. The following outcomes were evaluated by unadjusted and adjusted time-to-event analyses: complete and partial response, disease relapses, progression to decline of 30% of the estimated glomerular filtration rate (eGFR), doubling of serum creatinine, end-stage kidney disease and patient survival.
Results
A total of 441 patients were included: 257 (58%) in their first LN flare, 102 (23%) in their second LN flare and 82 (19%) in their third LN flare. There were significant differences in LN flare presentation in age, eGFR, serum albumin, pyuria and hematuria among groups. The National Institutes of Health chronicity indices and the percentage of patients with vascular lesions were higher in groups at progressive LN flares. In the adjusted analyses, complete and partial response rates decreased, as well as kidney and patient survival, at a progressive number of LN flares. No differences in the dynamic course of all surveillance laboratory parameters were observed in the first year after initial therapy among LN flare groups.
Conclusions
A progressive number of LN flares is associated with a lower response to therapy and an adverse prognosis for kidney function and patient survival.
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Affiliation(s)
- Abril A Perez-Arias
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Sofía E Márquez-Macedo
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Oscar R Pena-Vizcarra
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - María Fernanda Zavala-Miranda
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Juanita Romero-Díaz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Luis E Morales-Buenrostro
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Juan M Mejía-Vilet
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
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Awwad O, AlMuhaissen S, Al-Nashwan A, AbuRuz S. Translation and validation of the Arabic version of the Morisky, Green and Levine (MGL) adherence scale. PLoS One 2022; 17:e0275778. [PMID: 36206237 PMCID: PMC9543961 DOI: 10.1371/journal.pone.0275778] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/23/2022] [Indexed: 11/06/2022] Open
Abstract
The Morisky Green Levine (MGL) adherence scale is a 4-item tool used for the detection of medication nonadherence among patients with chronic health conditions. Despite being widely used in Arabic-speaking research contexts, it has never been validated in Arabic language. The aim of this study was to translate and validate the MGL tool into Arabic. A standard forward-backward process was used to translate the questionnaire. Cronbach’s alpha coefficient was measured to assess internal consistency of the scale. The test-retest reliability measured the consistency of participants’ responses over time. Construct validity was evaluated by Explanatory factor analysis (EFA); Kaiser-Meyer-Olkin value and Bartlett’s test of sphericity were determined. Convergent validity was assessed using a preexisting medications Arabic Adherence Assessment Tool (AAAT). The model fit was evaluated using confirmatory factor analysis (CFA). Associations between the MGL scale scores and the patient demographic/clinical characteristics were tested by linear regressions. A total of 201 participants were included into the study. The MGL scale categorization revealed that 20.9%, 59.2% and 19.9% of the participants had high, moderate and low levels of adherence respectively. Adequate internal consistency (alpha = 0.593) was observed. A significant strong ICC and Pearson’s correlations were generated between responses at time 1 and time 2. EFA results elucidated the suitability of the data for factor analysis. Pearson’s coefficient (r) revealed a significant strong correlation between MGL scale and AAAT. CFA results confirmed a good fit for the suggested model. Linear regression revealed higher number of medications, more frequent outpatient clinic visits and not experiencing medication adverse effect factors significantly associated with better adherence. The Arabic version of MLG scale is a reliable valid tool to assess adherence among Arabic-speaking communities. Implementing interventions targeting patients not compliant to regular clinic visits and those at higher risk of experiencing medication side effects can greatly enhance medication adherence.
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Affiliation(s)
- Oriana Awwad
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, University of Jordan, Amman, Jordan
- * E-mail:
| | - Suha AlMuhaissen
- Department of Pharmaceutics and Pharmaceutical Technology, School of Pharmacy, University of Jordan, Amman, Jordan
| | - Ayat Al-Nashwan
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, University of Jordan, Amman, Jordan
| | - Salahdein AbuRuz
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, University of Jordan, Amman, Jordan
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
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10
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Massicotte-Azarniouch D, Kotzen E, Todd S, Hu Y, Hogan SL, Jain K. Kidney thrombotic microangiopathy in lupus nephritis: Impact on treatment and prognosis. Lupus 2022; 31:1175-1185. [PMID: 35650019 PMCID: PMC9449430 DOI: 10.1177/09612033221106301] [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] [Indexed: 12/14/2022]
Abstract
Introduction Lupus nephritis (LN) may present with thrombotic microangiopathy (TMA) on
kidney biopsy, the impact of which on outcomes is unclear. This study
examined the prognostic importance of LN with TMA on kidney biopsy,
including response to therapy and long-term outcomes. Methods We conducted a single-center, retrospective study of all cases of LN with
concomitant TMA on kidney biopsy in the Glomerular Disease Collaborative
Network database. Controls were individuals with LN without TMA matched to
cases based on demographic and clinical variables. Outcomes were remission
at 6- and 12-months, end-stage kidney disease (ESKD) and death. Logistic
regression and Cox proportional hazards models were used to ascertain the
risks for outcomes, with adjustment for serum creatinine and
proteinuria. Results There were 17 cases and 28 controls. Cases had higher creatinine, higher
proteinuria and greater chronicity on biopsy at baseline compared to
controls. The rates of remission at 6-months and 12-months were similar
between cases and controls (6-months 53.9% vs 46.4%, adjusted OR 2.54, 95%
CI 0.48, 13.37; 12-months 53.9% vs 50.0%, adjusted OR 2.95, 95% CI 0.44,
19.78). Cases were at greater risk for ESKD in univariate analysis (HR 3.77;
95% CI 1.24, 11.41) but not when adjusting for serum creatinine and
proteinuria (HR 2.20; 95% CI 0.63, 7.71). There was no significant
difference in the risk of death between cases and controls. Conclusion Lupus nephritis with renal TMA likely responds to therapy similarly to those
without TMA; risk for ESKD is not significantly increased, although the
influence of renal function and proteinuria in larger samples is needed.
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Affiliation(s)
- David Massicotte-Azarniouch
- Division of Nephrology and Hypertension, Department of Medicine, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Elizabeth Kotzen
- Division of Nephrology and Hypertension, Department of Medicine, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah Todd
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yichun Hu
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Susan L Hogan
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Koyal Jain
- Department of Medicine and Pediatrics, 6797University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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