The clinical course of the proliferative and membranous forms of lupus nephritis

The Prognostic Value of Histopathologic Lesions in Native Kidney Biopsy Specimens: Results from the Boston Kidney Biopsy Cohort Study

Background Few studies have evaluated whether histopathologic lesions on kidney biopsy provide prognostic information beyond clinical and laboratory data.Methods We enrolled 676 individuals undergoing native kidney biopsy at three tertiary care hospitals into a prospective, observational cohort study. Biopsy specimens were adjudicated for semiquantitative scores in 13 categories of histopathology by two experienced renal pathologists. Proportional hazards models tested the association between histopathologic lesions and risk of kidney disease progression (≥40% eGFR decline or RRT).Results Mean baseline eGFR was 57.5±36.0 ml/min per 1.73 m² During follow-up (median, 34.3 months), 199 individuals suffered kidney disease progression. After adjustment for demographics, clinicopathologic diagnosis, and laboratory values, the following lesions (hazard ratio; 95% confidence interval) were independently associated with progression: inflammation in nonfibrosed interstitium (0.52; 0.32 to 0.83), moderate and severe versus minimal interstitial fibrosis/tubular atrophy (2.14; 1.24 to 3.69 and 3.42; 1.99 to 5.87, respectively), moderate and severe versus minimal global glomerulosclerosis (2.17; 1.36 to 3.45 and 3.31; 2.04 to 5.38, respectively), moderate and severe versus minimal arterial sclerosis (1.78; 1.15 to 2.74 and 1.64; 1.04 to 2.60, respectively), and moderate and severe versus minimal arteriolar sclerosis (1.63; 1.08 to 2.46 and 2.33; 1.42 to 3.83, respectively). An 11-point chronicity score derived from semiquantitative assessments of chronic lesions independently associated with higher risk of kidney disease progression (hazard ratio per one-point increase, 1.19; 95% confidence interval, 1.12 to 1.27).Conclusions Across a diverse group of kidney diseases, histopathologic lesions on kidney biopsy provide prognostic information, even after adjustment for proteinuria and eGFR.

The lupus patient with positive rheumatoid factor

Background Patients with systemic lupus erythematosus (SLE) may form clusters with clinical manifestations and autoantibodies. Objective The objective of this report is to study whether SLE patients with positive rheumatoid factor (RF) have a special clinical and/or serological profile. Methods A retrospective study of 467 SLE patients seen at a single rheumatology unit was conducted. Epidemiological data (age, gender, age at disease onset, ethnic background and tobacco use), clinical data (malar rash, photosensitivity, oral ulcers, discoid lesions, serositis, glomerulonephritis, convulsions, psychosis, hemolytic anemia, leukopenia, lymphocytopenia, arthritis and hypothyroidism) and serological profile (anti-dsDNA, anti-Ro/SS-A, anti-La/SS-B, anti-RNP, anti-Sm, IgG aCL, IgM aCL, lupus anticoagulant, direct Coombs and RF) were collected. Patients with positive and negative RF were compared. Results RF was found in 24.9% of the sample. In univariate analysis, RF was positively associated with butterfly rash ( p = 0.04), anti-Ro ( p = 0.03), anti-Sm antibodies ( p = 0.01) and hypothyroidism ( p = 0.01) and negatively associated with glomerulonephritis ( p = 0.003). Logistic regression showed that only glomerulonephritis ( p = 0.03; OR = 0.45; 95% CI = 0.21-0.93) and anti-Ro ( p = 0.009; OR = 2.3; 95% CI = 1.24-4.57) were independent associations. Conclusion In our sample RF was associated with protection from glomerulonephritis and with higher prevalence of anti-Ro antibodies.

Remission of refractory lupus nephritis with a protocol including rituximab

Immunosuppression with corticosteroids and cyclophosphamide is the standard of care for lupus nephritis. We report a 19-year old woman with lupus nephritis and nephrotic syndrome who had not achieved complete remission after treatment with 15.7g cyclophosphamideand 13.7g prednisone.We planned a consolidation phase with: 1) cyclophosphamide 20mg/kg i.v. every 28 days for three cycles; 2) anti-CD20 chimeric monoclonal antibody (rituximab) 375mg/m2i.v. weekly for four weeks; and 3) slow tapering of prednisone p.o., q.o.d., after a reinduction dose during rituximab administration. At the end of this phase the patient achieved complete remission. An indefinite maintenance treatment with methotrexate, cyclosporin and low-dose prednisone was then started. Twenty-four months later the patient remains in remission. In the immunosuppressive treatment of lupusnephritisthe insertionof a consolidationphasewith rituximab combinedwith cyclophosphamide achieves a therapeutically important and lasting deletion of the lymphocyte clone responsible for autoimmunity.

Comparison of Outcomes between Individuals with Pure and Mixed Lupus Nephritis: A Retrospective Study

INTRODUCTION

Lupus nephritis (LN) is a serious organ manifestation of systemic lupus erythematosus. Histologic overlap is relatively common in the six pathologic classes (I to VI) of LN. For example, mixed proliferative LN (MPLN) often includes features of classes III & V or classes IV & V combined. We performed a comparative evaluation of renal outcomes in patients with MPLN to patients with pure proliferative LN (PPLN) against pre-specified renal outcomes, and we also identified predictor of clinical outcomes among those with PPLN and MPLN.

HYPOTHESIS

Individuals with MPLN will have worse short-term renal outcomes compared to those with PPLN.

METHODS

We retrospectively reviewed 278 adult LN patients (≥18 years old) identified from an Emory University Hospital registry of native renal biopsies performed between January 2000 and December 2011. The final analytic sample consisted of individuals with a diagnosis of PPLN (n = 60) and MPLN (n = 96). We analyzed differences in clinical and laboratory characteristics at baseline. We also assessed associations between LN category and renal outcomes (complete remission and time to ESRD) with logistic and Cox proportional hazards models within two years of baseline.

RESULTS

The study population was predominantly female (83.97%) and African American (71.8%) with a mean age of 33.4 years at baseline. Over a median follow up of 1.02 years, we did not find any statistically significant associations between MPLN and the development of ESRD or remission when compared to patients with PPLN (adjusted HR = 0.30, 95% CI = 0.07, 1.26).

CONCLUSION

There was no association between mixed or pure histopathologic features of LN at presentation and rate of complete or partial remission but higher baseline eGFR was associated with a lower probability of complete remission among patients with lupus nephritis.

The Revisited Classification of GN in SLE at 10 Years: Time to Re-Evaluate Histopathologic Lesions

Over 10 years have passed since the latest revision of the histopathologic classification of lupus nephritis. This revision was a significant improvement compared with the previous version, mainly because of clearer and more concise definitions and the elimination of mixed subclasses. Despite these improvements, there are still some difficulties in the classification for lupus nephritis, many of which are in the definitions provided. In this review, we focus on the difficulties surrounding the evaluation of classes III and IV lesions, particularly the definitions of endocapillary and extracapillary proliferation, the use of the terms endocapillary proliferation and hypercellularity, the clinical relevance of segmental and global subdivision in class IV, and the value of distinguishing lesions that indicate activity and chronicity. Vascular and tubulointerstitial lesions are also discussed. Furthermore, we give an overview of the history of the classification to provide background on the origin and development of the definitions in lupus nephritis. The issues raised in this review as well as the suggestions for improvements may assist with a revision of the lupus nephritis classification in the near future.

Healthcare cost and loss of productivity in a Canadian population of patients with and without lupus nephritis

OBJECTIVE

To compare the healthcare cost and loss of productivity in patients with systemic lupus erythematosus (SLE) with (LN) and without lupus nephritis (lupus nephritis-negative, LNN).

METHOD

Patients were classified into those with active (ALN and ALNN) and inactive disease (ILN and ILNN). Patients reported on visits to healthcare professionals and use of diagnostic tests, medications, assistive devices, alternative treatments, hospital emergency visits, surgical procedures, and hospitalizations as well as loss of productivity in the 4 weeks preceding enrollment.

RESULTS

Enrollment was 141 patients, 79 with LN and 62 LNN. Patients with LN were more likely to visit rheumatologists and nephrologists, undergo diagnostic tests, and had higher costs for medications than patients who were LNN. The annual healthcare cost averaged $CAN 12,597 ± 9946 for patients with LN and $10,585 ± 13,149 for patients who were LNN, a difference of $2012 (95% CI -$2075, $6100). Patients with ALN had more diagnostic tests and surgical procedures, contributing to a significantly higher annual direct cost ($14,224 ± 10,265) compared to patients with ILN ($9142 ± 8419) and a difference of $5082 (95% CI $591, $9573). The healthcare cost was not different between patients with ALNN and patients with ILNN. In patients with LN and patients who were LNN, < 50% were employed and on average missed 6.5-9 days of work per month. The loss of productivity was significantly higher for caregivers of patients with LN than caregivers of patients who were LNN.

CONCLUSION

Healthcare cost and loss of productivity were similar between patients with LN and patients who were LNN; the loss of productivity for caregivers is higher for patients with LN; and the healthcare cost is greater in ALN than in ILN.

Practice pattern variation in oral glucocorticoid therapy after the induction of response in proliferative lupus nephritis

Glucocorticoids are standard therapy for induction of response in proliferative lupus nephritis. However, the optimal duration of glucocorticoid therapy is uncertain. We surveyed physicians who treat lupus nephritis regarding their use of glucocorticoids in proliferative lupus nephritis after induction of response and regarding factors associated with different practice patterns. We administered a questionnaire of standardized cases assessing glucocorticoid use after induction of response to specialists with expertise in proliferative lupus nephritis. We examined the association between continuation of glucocorticoids and patient and physician characteristics. Of 90 invited participants, 72 (80%) responded. A total of 24 (33%) respondents attempted to discontinue glucocorticoids in all scenarios, 21 (29%) continued glucocorticoids in all scenarios, and 27 (38%) attempted to discontinue in some scenarios but not others. Responses varied according to the physician group (p < 0.001) and by years in practice (p < 0.001). Of those who discontinued glucocorticoids in selected scenarios, 15/27 (55%) were influenced by the characteristics of the induction of response, 16/27 (59%) by past lupus history, and 9/27 (33%) by the tolerance and use of immunosuppression. We conclude that glucocorticoid therapy after induction of response in proliferative lupus nephritis is varied. This variability likely represents clinical equipoise. A randomized trial evaluating the effect of glucocorticoid use after induction of response is warranted.

[Atypical presentation and clinical course in mesangial lupus nephritis]

Mesangial lupus nephritis (type II according to the WHO classification) is usually considered a benign variant. Its clinical manifestations are minimal: hematuria and proteinuria, normal sediment, and normal renal function. To evaluate the clinical manifestations and course in mesangial nephritis, we studied 20 patients with a histological diagnosis of type II lupus nephritis who attended our clinic. We found that clinical presentation was atypical in a significant proportion of these patients. Data from the two groups of patients were compared: those with classical presentation and those with atypical presentation. The results were analyzed with descriptive and inferential statistics. Twenty patients (19 women and 1 man) were included. The mean age at nephritis onset was 33.9 years and the mean length of follow-up was 4.2 years. Clinical presentation was atypical in 17 patients, with active urinary sediment in 12, urine protein>1 g/24 h in 7, and reduction in creatinine clearance in 14. Clinical remission was achieved with treatment in 16 patients, with subsequent flares in 8. All flares responded well to treatment. Biopsies in 5 patients with flares showed progression to type III and IV nephritis. At the end of the follow-up period, 4 patients had chronic renal failure. Some of our patients with mesangial lupus nephritis did not have the benign course that is usually described. Despite a good initial response, 20% of the patients progressed to chronic renal failure. Initial hyperlipidemia and proteinuria seem to correlate with a more aggressive course.

Nephrotic syndrome in mesangial proliferative lupus nephritis

Renal involvement is a major complication of systemic lupus erythematosus (SLE) and occurs in 30-70% of patients with SLE. Lupus nephritis is classified into six classes (I-VI) by the International Society of Nephrology and Renal Pathology Society (ISN/RPS). Although nephrotic syndrome is commonly associated with diffuse (ISN/RPS class IV) or membranous (ISN/RPS class V) lupus nephritis, several reports have described nephrotic syndrome in adult patients with minimal mesangial lupus nephritis (ISN/RPS class I) or mesangial proliferative lupus nephritis (ISN/RPS class II). However, nephrotic syndrome in mesangial proliferative lupus nephritis has rarely been reported in children. Although the pathogenesis of nephrotic syndrome with mesangial lupus nephritis is incompletely understood, three potential mechanisms have been postulated including lupus nephritis itself, non-steroidal anti inflammatory drug (NSAID)-induced minimal change nephrotic syndrome (MCNS) and coincidental occurrence of MCNS. We describe here a child with mesangial proliferative lupus nephritis who developed MCNS.

Systemic lupus erythematosus in men: a retrospective analysis in a Veterans Administration Healthcare System population

Systemic lupus erythematosus (SLE), a connective tissue disease of unknown etiology, is generally considered to occur in women of child-bearing age and to be uncommon among men . Because of the female predominance in most studies, less is known about the disease in men. To begin to better understand lupus in men, we retrospectively analyzed all the SLE patients from all the hospitals in the Department of Veterans Affairs (VA) system, a population that is predominantly male. Between 1987 and 1996, 2614 SLE patients were retrieved from the VA databank; 2144 were male, making this the largest group of male patients with SLE reported in United States of America. Age, racial and geographic distribution, comorbidities, and mortality of the SLE patients are reported. This study suggests that SLE men in this population are older at onset of disease, have different comorbidities, and have a higher mortality at 1 year than women with SLE. These findings suggest that men with SLE have a more complex clinical course than women, although the data do not illuminate whether the comorbidities are due to or coincident with SLE. On the basis of these data, practitioners are reminded to consider SLE in the differential diagnosis for older men and be attentive to the frequent presence of comorbidities such as cardiac ischemia and neoplasms. Because of the identified regional variations in demographics, comorbidities, and mortality, this study suggests the need for future SLE studies to include data from multiple geographic areas.

Prognostic Value of Renal Hemodynamic Characteristics in Patients with Proliferative Lupus Nephritis

BACKGROUND/AIM

Previous studies showed that renal hemodynamic parameters, especially the filtration fraction (FF), are decreased in patients with active lupus nephritis (LN). In this study, we evaluate the prognostic value of renal hemodynamic function tests on the renal outcome in patients with proliferative LN.

METHODS

We performed a retrospective cohort study of our patients with proliferative LN from 1986 to 2005. Glomerular filtration rate (GFR) and FF before treatment were measured. Treatment failure was defined as a renal relapse or development of end-stage renal disease.

RESULTS

Thirty-seven patients were included. The median follow-up period was 8 years. Creatinine clearance, GFR, and FF before treatment correlated with the creatinine clearance at the end of follow-up (p = 0.001, p = 0.006, and p = 0.04, respectively). The FF was decreased in 92% of our patients, but FF and GFR did not have a prognostic value with regard to treatment failure.

CONCLUSIONS

Most patients with proliferative LN had a low FF. Low GFR and FF at baseline were correlated with a worse renal function at the end of follow-up, but this had no prognostic value in individual patients.

The pathology of lupus nephritis

An international working group of clinicians and pathologists met in 2003 under the auspices of the International Society of Nephrology (ISN) and the Renal Pathology Society (RPS) to revise and update the 1982 and 1995 World Health Organization classification of lupus glomerulonephritis. This article compares and contrasts the ISN/RPS classification and the antecedent World Health Organization classifications. Although systemic lupus erythematosus is the prototypical systemic immune-complex disease, several non-immune-complex mechanisms of glomerular injury and dysfunction have been proposed, and this article summarizes the evidence supporting the pathogenic mechanisms of lupus vasculitis, glomerular capillary thrombosis, and lupus podocytopathy. The most significant and controversial feature of the ISN/RPS classification is the separation of diffuse glomerulonephritis into separate classes with either segmental (class IV-S) or global (class IV-G) lesions. Several groups have tested the prognostic significance of this separation, and this article discusses the implications of these studies for the ISN/RPS classification.

Treatment with cyclophosphamide delays the progression of chronic lesions more effectively than does treatment with azathioprine plus methylprednisolone in patients with proliferative lupus nephritis

OBJECTIVE

To analyze the effect of treatment with either pulse cyclophosphamide (CYC) or azathioprine (AZA) combined with methylprednisolone (MP), on serial biopsy results in patients with proliferative lupus nephritis, and to evaluate the predictive value of various histopathologic and clinical parameters with regard to disease outcome.

METHODS

Biopsy specimens from patients with proliferative lupus nephritis, obtained at study entry and after 2 years of therapy, were scored according to a standardized method, and results assessed in relation to disease outcome.

RESULTS

Of the 87 patients originally enrolled, 39 underwent repeat biopsy. These patients were representative of the overall group, both at entry and at 2-year followup. The median activity index changed from 8.0 to 2.7 (no differences between the treatment groups). In the group treated with AZA plus MP (AZA group), the increase in the median chronicity index (from 2.7 to 3.8) was larger than that in the CYC group (from 2.7 to 3.0) (P = 0.050). In multivariate analyses, renal function at enrollment and after 2 years was the best predictor of renal function at the last visit, while none of the histopathologic variables (either at entry or at 2 years) added to this prediction. Comparing patients whose disease transitioned to class II with those who had persistent proliferative lupus nephritis revealed no differences between the treatment groups at either time point, and no clinical differences at 2 years. However, a higher serum creatinine level at entry and greater proteinuria at last visit were characteristic of patients who still had proliferative lupus nephritis at 2 years.

CONCLUSION

These results indicate that, although both CYC and AZA are effective in reducing active lesions in lupus nephritis, progression of chronic lesions is more effectively halted by CYC. Variables assessed by repeat biopsy do not predict clinical outcome.

Membranous lupus nephritis

Membranous lupus nephritis (MLN) represents about 20% of clinically significant renal disease in lupus. Few studies have addressed directly the pathogenesis of MLN. Our assumptions about the underlying mechanisms are based on the combination of extrapolations from idiopathic membranous nephritis (mainly from animal models) and proliferative lupus nephritis. Natural history studies of MLN suggest a relatively low rate of progression to end-stage renal disease but a high rate of significant comorbidities. Historical changes in the criteria for pathologic diagnosis and classification of membranous lupus nephropathy have precluded definitive descriptions of the natural history, prognosis and treatment of this disorder. Patients with membranous lupus nephropathy should be treated early with angiotensin antagonists to minimize proteinuria, as well as lifestyle changes and appropriate drugs to reduce attendant cardiovascular risk factors. In patients with protracted nephrotic syndrome, consideration should be given to immunosuppressive therapies, including corticosteroids, cyclosporine, mycophenolate and cyclophosphamide. Prospective controlled trials are clearly needed in order to establish solid clinical practice guidelines for use of these drugs and other experimental therapies currently under study in membranous lupus nephropathy.

Pathology of lupus nephritis

The glomerular pathology of lupus nephritis is the result of diverse immune insults which are probably of independent pathogenetic origins. Although lupus nephritis is looked upon as a classic example of immune complex-induced microvascular injury resulting from circulating DNA double stranded polynucleotide antigens/anti-DNA antibody complexes, other mechanisms, including in situ reactivity of free antibody with fixed antigens and the role of sensitized T-cells, are probably an important part of the picture. This complexity makes categorization of glomerular pathology into a clinically relevant classification an important goal so that our experiences can be reliably compared. This review describes the various glomerular lesions commonly encountered in lupus nephritis and, based upon data derived from experimental models, emphasizes the importance of understanding the clinical relevance of the reported morphology. We point out that the severity of glomerular damage is not merely the accrued result of immune complex induced injury to individual capillaries, but involves capillary necrosis and thrombosis, neither of which may have anything to do with immune complexes or immune aggregates. In fact, the segmental lesions of glomerular capillary necrosis and thrombosis may have a great deal to do with the response to therapy and the ultimate outcome of the patient. While discrete morphologic lesions such as mesangiopathy, acute inflammation, necrosis, thrombosis, epimembranous lesions and podocytopathy are readily described, it is important to note that any given case can represent any combination of these insults. In this context, the new proposed International Society of Nephrology Classification is presented and its strengths and weaknesses discussed.

The classification of glomerulonephritis in systemic lupus erythematosus revisited

The currently used classification reflects our understanding of the pathogenesis of the various forms of lupus nephritis, but clinicopathologic studies have revealed the need for improved categorization and terminology. Based on the 1982 classification published under the auspices of the World Health Organization (WHO) and subsequent clinicopathologic data, we propose that class I and II be used for purely mesangial involvement (I, mesangial immune deposits without mesangial hypercellularity; II, mesangial immune deposits with mesangial hypercellularity); class III for focal glomerulonephritis (involving <50% of total number of glomeruli) with subdivisions for active and sclerotic lesions; class IV for diffuse glomerulonephritis (involving > or =50% of total number of glomeruli) either with segmental (class IV-S) or global (class IV-G) involvement, and also with subdivisions for active and sclerotic lesions; class V for membranous lupus nephritis; and class VI for advanced sclerosing lesions. Combinations of membranous and proliferative glomerulonephritis (i.e., class III and V or class IV and V) should be reported individually in the diagnostic line. The diagnosis should also include entries for any concomitant vascular or tubulointerstitial lesions. One of the main advantages of the current revised classification is that it provides a clear and unequivocal description of the various lesions and classes of lupus nephritis, allowing a better standardization and lending a basis for further clinicopathologic studies. We hope that this revision, which evolved under the auspices of the International Society of Nephrology and the Renal Pathology Society, will contribute to further advancement of the WHO classification.

Gender differences in systemic lupus erythematosus

BACKGROUND

Systemic lupus erythematosus (SLE) is known to be much more prevalent in females than in males, but the cause of this sexual predilection is not established. In addition, much controversy surrounds the differences in manifestations of SLE in both sexes.

OBJECTIVE

This article reviews the possible etiologies of the greater prevalence of SLE in females, as well as the differences in the clinical presentation of the disease in both sexes.

METHODS

Relevant studies were identified through a PubMed search for articles published between 1960 and 2001; no language restrictions were applied. Search terms included lupus, SLE, and gender differences. Books and online resources were also consulted.

RESULTS

Potential causes of the female predilection for SLE included the effects of estrogen and its hydroxylation, decreased androgen levels, hyperprolactinemia, and differences in gonadotropin-releasing hormone (GnRH) signaling. Clinical manifestations of SLE included females having more frequent relapses, but the incidence of severe relapses was the same in both sexes. Raynaud phenomenon, arthritis, and leukopenia were more common in women, whereas skin manifestations, serositis, and renal involvement were more common in men. For neurologic manifestations, females with SLE experienced more psychiatric symptoms and headaches, whereas males with SLE experienced more seizures and peripheral neuropathy. Males with SLE also tended to have more severe renal disease and cardiorespiratory involvement.

CONCLUSIONS

The increased frequency of SLE among women may be attributed to differences in the metabolism of sex hormones and/or GnRH. Though less common in men, when it does occur SLE tends to run a more severe course-an important consideration in the diagnosis and follow-up of male patients with SLE.

Significance of histologic patterns of glomerular injury upon long-term prognosis in severe lupus glomerulonephritis

BACKGROUND

Patients with systemic lupus erythematosus have a spectrum of glomerular disease, but the different patterns of glomerular injury identified within the general category of "severe" lupus glomerulonephritis are responsible for much of the morbidity and mortality in this disease. The glomerular injury patterns seen with severe lupus glomerulonephritis have been separated into distinct histopathologic groups to determine whether they can predict long-term patient outcome.

METHODS

We analyzed the clinical follow-up of 85 patients participating in a controlled prospective therapeutic trial for the treatment of severe lupus glomerulonephritis conducted from April 1981 to December 1988, with an average follow-up of 10 years. Patients were classified according to the 1982 World Health Organization classification for lupus glomerulonephritis.

RESULTS

During the course of follow-up [120 +/- 65 (SD) months], 60% of patients with category IV (diffuse proliferative glomerulonephritis) lesions entered a remission compared with only 38% of patients with category III (> or =50%, focal and segmental glomerulonephritis) lesions and 27% of patients with category Vc (> or =50%) and Vd (P < 0.05). Renal survival at 10 years was 75% for those with category IV lesions, 47% for patients with category Vc (> or =50%) and Vd, and 52% for patients with category III (> or =50%) lesions (P < 0.05). Based on multivariate analysis, patients with category III (> or =50%) or Vc (> or =50%) and Vd lesions had a relative risk of progression to end-stage renal disease 2.9 times that of category IV patients (P < 0.01), while the likelihood of entering a remission was 8.2 times greater for category IV patients (P = 0.0001).

CONCLUSION

The histopathologic categorization among patients with severe lupus glomerulonephritis provides information relevant to their long-term outcome.

Cyclosporine for lupus membranous nephritis: experience with ten patients and review of the literature

OBJECTIVES

The treatment of lupus membranous nephritis (LMN), a lupus subset that carries a high morbidity, is unsatisfactory. We report our experience in treating LMN with the immunosuppressive drug cyclosporine (CYS).

METHODS

We treated 10 patients with systemic lupus erythematosus fulfilling ACR criteria with CYS for at least 12 months and followed renal function, serologic activity and SLEDAI scores.

PATIENT CHARACTERISTICS

8 females, 2 males, 50% Caucasian, mean age 37.3 y (range 22-48), disease duration 108.7 months (range 16-216), nephritis duration 35.5 months (range 12-59), date of biopsy to date of starting treatment 10.7 months (range 0-90). The patients were started on CYS with a mean dose of 3.8 mg/kg (range 2.2-6) and followed for a mean duration of 24.8 months (range 12-59). A Medline search identified all patients with lupus who were given CYS or had LMN in articles from 1966-1999.

RESULTS

Proteinuria improved from a baseline mean of 5,588mg/24h (range 2,712-11,055) to 1,404 mg/24 h (range < 150-2,652). Serum albumin increased from a baseline mean of 2.8 g/100 ml (range 1.31-3.8) to a mean of 3.9 g/100 ml (range 3-4.5) at last follow-up. There was no significant change in lupus activity as measured by SLEDAI. Nephrotoxicity was common as evidenced by an increase in serum creatinine but it returned to baseline with adjustment of the dose of CYS (20% decrease in the dose of CYS for a 20% increase in serum creatinine). More antihypertensive medications were required to control the blood pressure in these ten patients at the end of the study compared to the onset (total number= 13 versus 6).

CONCLUSION

Proteinuria and serum albumin improved in all patients on CYS. A literature review is consistent with this. Controlled studies of the use of CYS for membranous lupus nephritis would be useful.

Class specific rheumatoid factors and antiphospholipid syndrome in systemic lupus erythematosus

The relationship of rheumatoid factors (RF) with antiphospholipid syndrome (aPLS) and anticardiolipin antibodies (aCL) has rarely been investigated in systemic lupus erythematosus (SLE). We found IgM-RF, IgG-RF, IgA-RF, IgM-aCL, IgG-aCL, IgA-aCL, respectively, in 35.4%, 35.4%, 33.8%, 23.1%, 23.1%, 20.0% of 65 SLE patients. Class specific RFs were negatively associated (P<0.05) with IgG-aCL. The frequency of definite or probable aPLS according to Alarcon-Segovia classification criteria was significantly (P<0.05) different (8.7% vs 30.9%) in patients with or without IgG-RF. Among the other clinical features of SLE, we found that patients with IgG-RF, compared to patients lacking this autoantibody, showed a lower frequency (P<0.05) of serositis (21.7% vs 52.4%) and hematologic (52. 2% vs 80.9%) disorders. The levels of IgG-RF and IgM-RF negatively correlated with the number of ARA criteria (P<0.05) but not with the indices of diseases activity or damage. Our study shows that in SLE the presence of RFs are not markers of severity of the disease, but the negative association between IgG-RF and IgG-aCL suggests a distinct role of these autoantibodies in the pathology of SLE, whereas the presence of IgG isotype may identify a subset of SLE patients having a lower risk to develop some clinical manifestations such as aPLS.

Treatment of membranous lupus nephritis with nephrotic syndrome by sequential immunosuppression

The optimal therapy for pure membranous lupus nephritis (MLN) with nephrotic syndrome remains controversial. While the risk of progressive renal deterioration may be small, persistent heavy proteinuria leads to the complications of oedema, hypoalbuminaemia, hyperlipidaemia, hypercoagulability, and venous thrombosis. We examined prospectively the efficacy and tolerability of a sequential immunosuppressive regimen in a cohort of 20 patients with nephrotic syndrome due to pure MLN (WHO Class Va and Vb). Initial therapy comprised prednisolone (0.8 mg/kg/d p.o.) and cyclophosphamide (2-2. 5 mg/kg/d p.o.). Prednisolone dosage was gradually tapered to 10 mg/d at 6 months, when cyclophosphamide was replaced by azathioprine (2 mg/kg/d p.o.) as maintenance therapy. Within 12 months of therapy 11(55%) patients had complete remission (CR), 7(35%) patients achieved partial remission (PR) (proteinuria reduced from 6.2+/-4.0 to 2.0+/-1.7 g/24 h, P<0.01), and 2 patients failed to respond. Improvements in proteinuria and serum albumin level were observed after 3-6 months of treatment. Non-responders had lower baseline serum albumin compared to complete responders. Renal function remained stable during follow-up for 73.5+/-48.9 months. 8 patients had disease relapse at 47+/-15 months. Early complications (</=12 months) included herpes zoster (40%), minor respiratory or urinary tract infections (25%), mild leukopenia (15%), and transient amenorrhea (14.3%). 4 of the 20 patients developed pulmonary tuberculosis during follow-up, at 35+/-24 months after the diagnosis of MLN. 8 patients had hyperlipidaemia. Haemorrhagic cystitis, permanent amenorrhea, vascular complications, and mortality were not observed. We conclude that this sequential immunosuppressive regimen is effective in 90% of patients with MLN and heavy proteinuria. Prudent consideration of the benefits and potential side-effects is required to determine the optimal management for individual patients.

Spatial arrangement of subepithelial deposits in lupus and nonlupus membranous nephropathy

Subepithelial deposits are a common feature of idiopathic membranous glomerulonephritis (MGN) and lupus membranous glomerulopathy (LMGN). We investigated the spatial arrangement of immunoglobulin G (IgG) and C3c fraction of complement (C3c) in the immune deposits of MGN and LMGN with confocal laser scanning microscopy to correlate specific patterns of IgG-C3 interactions with different diseases. Ten patients with MGN and 8 patients with LMGN (World Health Organization class VB) were selected. A determination of the spatial arrangement of the two fluorochromes and the glomerular area occupied by each fluorochrome was performed for each case. Our results showed MGN specimens have an orderly distribution of IgG and C3c, with each deposit showing an outer ring of sole IgG. IgG was always more abundant than C3c (1,619 +/- 271 v 790 +/- 105 micrometer(2), P = 0.002). In LMGN, IgG and C3c were haphazardly arranged, with deposits made of C3c only and an outer ring of IgG only rarely present. Also, the relative amounts of the two antigens were variable, and two groups could be identified (group 1: IgG, 5,515 +/- 1,179 micrometer(2) v C3c, 4,810 +/- 1,174 micrometer(2); P = 0.02; group 2: IgG, 3,358 +/- 658 micrometer(2) v C3c, 4,047 +/- 740 micrometer(2); P = 0.03). Our data show that diffuse IgG capping of the subepithelial immune deposits is diagnostic of MGN. The absence of an orderly three-dimensional arrangement in LMGN deposits (ie, outer ring of IgG) is likely to render active complement components more readily available to inflammatory activities.

Clinical characteristics and outcome of southern Chinese males with systemic lupus erythematosus

The aims were to study the gender differences in clinical manifestations, disease course and organ damage in systemic lupus erythematosus (SLE). Clinical manifestations, autoantibody profile, relapses and damage scores were obtained from 51 Chinese males with SLE and compared with 201 consecutive female SLE controls. Fifty-one males were identified among 630 SLE patients who attended our clinics, giving a male prevalence of 8% and a female to male ratio of 11.4-1. Both the male SLE patients and the female controls had similar age and SLEDAI score at disease onset. Male SLE patients had less alopecia (P = 0.03), Raynaud's phenomenon (P = 0.01) and anti-Ro (P = 0.049) during the course of the disease but none of the differences were statistically significant after correction for multiple observations. The prevalence of major organ involvement in either sex was not different. Both groups of patients had a comparable mean duration of follow-up (104 vs. 102 months, P = 0.87). Males had a significantly lower rate of relapses (total No. of flares/patient-year: 0.23 in men vs. 0.33 in women, P = 0.04), but the frequency of severe flares (No. of severe flares/patient-year in men 0.08 vs. 0.12 in women, P = 0.16) was not significantly different from the females. Male patients with positive anti-Ro had significantly less overall flares than their female counterparts who were anti-Ro positive (0.16 vs. 0.34, P = 0.006). However, the use of immunosuppressive agents for disease control in patients of both sexes was similar. 22 (43%) of the males and 78 (39%) of the females had organ damage. A higher percentage of male patients had impairment of renal function (P = 0.006) but the proportion of patients who required dialysis was not different (4% in men vs. 2% in females. P = 0.92). There was also a trend of more cardiovascular damage in the males but the difference was not statistically significant (P = 0.09). The mean SLICC/ACR scores were not significantly higher in the males than the females (0.71 vs. 0.60, P = 0.47). Males tend to differ from females in clinical manifestations, immunological profile and disease course in SLE. However, there was no gender difference in the involvement of major organs/systems. Males had less overall disease flares than the females but the rate of severe flares was not significantly lower. For patients who were anti-Ro positive, males had significantly less total number of flares/patient-year than their female counterparts. More renal impairment and cardiovascular damage was present in our male lupus patients but the overall damage scores were not significantly higher.

Renal involvement in systemic lupus erythematosus. A study of 180 patients from a single center

Charts of 180 patients (147 women, 33 men) with systemic lupus erythematosus (SLE) complicated by renal involvement were retrospectively analyzed from a series of 436 patients. Mean age at renal disease onset was 27 years. Thirty-six percent of the patients had renal involvement after diagnosis of lupus, for 30.7% of that group it was more than 5 years later. Renal involvement occurred more frequently in young male patients of non-French non-white origin. Patients with renal involvement suffered more commonly from malar rash, psychosis, myocarditis, pericarditis, lymphadenopathy, and hypertension. Anemia, low serum complement, and raised anti-dsDNA antibodies were more frequent. According to the 1982 World Health Organization classification, histologic examination of initial renal biopsy specimen in 158 patients showed normal kidney in 1.5% of cases, mesangial in 22%, focal proliferative in 22%, diffuse proliferative in 27%, membranous in 20%, chronic sclerosing glomerulonephritis in 1%, and other forms of nephritis in 6.5%. Distribution of initial glomerulonephritis patterns was similar whether renal involvement occurred before or after the diagnosis of lupus. Transformation from 1 histologic pattern to another was observed in more than half of the analyzable patients (those who underwent at least 2 renal biopsies). Nephritis evolved toward end-stage renal disease in 14 patients despite the combined use of steroids and cyclophosphamide in 12. Initial elevated serum creatinine levels, initial hypertension, non-French non-white origin, and proliferative lesions on the initial renal biopsy were indicators of poor renal outcome. Twenty-four patients died after a mean follow-up of 109 months from SLE diagnosis. Among our 436 patients, the 10-year survival rate was not significantly affected by the presence or absence of renal involvement at diagnosis (89% and 92%, respectively).

Intraglomerular monocyte infiltration and immune deposits in diffuse lupus glomerulonephritis

Previous studies have suggested that separately, glomerular monocyte (MO) infiltration and persistent glomerular immune deposits have opposite prognostic implications in lupus nephritis (LN). To see whether these pathological variables are inversely related, 37 renal biopsy specimens from 37 patients with diffuse proliferative LN were assessed histologically for activity index, chronicity index, and mean glomerular deposit score per biopsy (deposit index [DI]); the latter was determined semiquantitatively on a scale of 0 to 4.0. Frozen sections were double immunolabeled for immunoglobulin G (IgG) and CD68, a marker for MOs. For each glomerulus in each biopsy specimen, the number of CD68+ cells was counted and the amount of IgG scored semiquantitatively on a scale of 0 to 4.0. For each biopsy specimen, the mean number of MOs per glomerular cross-section (MO index [MOI]) was calculated. Linear regression analysis showed a moderately strong inverse correlation between individual glomerular IgG deposit score and individual glomerular MO count (r = -0.447; P < 0.0001), a weaker but significant inverse correlation between DI and MOI (r = -0.350; P = 0.0389), and a positive correlation between the DI determined histologically in each case and the corresponding DI scored on the immunolabeled sections (r = 0.534; P = 0.0105). The results indicate that the amount of glomerular deposit and the extent of glomerular MO infiltration are inversely related in LN.

Persistent lupus activity in end-stage renal disease

Clinical and serological activity of systemic lupus erythematosus (SLE) has been reported to dramatically improve in patients who develop end-stage renal disease (ESRD). At Tulane University Medical Center, most patients with SLE and ESRD continue to have evidence of disease activity. A retrospective study of lupus activity was therefore performed in 19 patients with SLE, who were either undergoing dialysis or had undergone transplantation between 1988 and 1994, to determine disease activity before and a mean follow-up of 3 years after ESRD. There were seven hemodialysis patients, five peritoneal dialysis patients, and seven transplant recipients in the study population. Clinical events recorded to evaluate disease activity as indicators of serological activity were malar rash, ulcers, alopecia, arthritis, myositis, pleuritis, pericarditis, fever, cerebritis, and vasculitis. The following studies were recorded as measures of serological activity: leukocyte count, platelet count, serum complement 3 level, and anti-double-stranded DNA level. Disease activity was measured by using the SLE Disease Activity Index and the requirement for immunosuppressive medications. Clinical event rates for alopecia, arthritis, myositis, pleuritis, pericarditis, fever, and vasculitis were greater after ESRD but not to statistical significance. Serological studies showed little change in the dialysis patients before and after ESRD; however, there was a tendency for lupus serological results to improve after transplantation. When all event rates were combined, there was a statistically significant greater incidence of lupus activity after both hemodialysis and peritoneal dialysis (P < 0.01) but not after renal transplantation. Fifty-eight percent of the patients undergoing dialysis died, either during the study period or within a 5-year follow-up, all of whom had clinically active lupus. This study therefore shows that lupus activity may persist in patients with ESRD. It is speculated that the study population, 84% of whom were black women, may represent a subgroup of patients with lupus in whom the disease remains active, even after they have developed ESRD.

The significance of arterial hypertension at the onset of clinical lupus nephritis

The prognostic importance of hypertension at the onset of clinical lupus nephritis is not well established. We studied retrospectively 44 patients with lupus nephritis in order to ascertain the prevalence of hypertension at presentation and to investigate a possible association between hypertension and renal functional impairment. A correlation was also sought between hypertension and histological class of lupus nephritis. Hypertension was graded as mild (diastolic 95-99 mmHg), moderate (100-114) or severe (> 115). Impaired renal function (creatinine > 120 mumol/l) was graded as mild (120-200 mumol/l), moderate (200-350 mumol/l), or severe (> 350 mumol/l). Histological class and the presence of hypertensive renal vascular lesions was recorded. The prevalence of hypertension was 38%. There were 17 hypertensives and 27 normotensives. The incidence of renal impairment was greater in the hypertensives, 47% vs 18.5% (p = 0.04). Mean serum creatinine was also higher higher in this group (p = 0.02). The presence of hypertensive renal vascular lesions identified a high-risk subgroup who had a higher incidence of renal functional impairment and worse renal function than the hypertensive group as a whole. Even at an early stage, hypertension and hypertensive renal vascular lesions correlated well with renal functional impairment. Aggressive treatment of hypertension is therefore essential in early lupus nephritis in order to prevent further deterioration of renal function as the disease evolves.

Treatment with dsDNA-anti-dsDNA antibody complexes extends survival, decreases anti-dsDNA antibody production and reduces severity of nephritis in MRLlpr mice

Lupus nephritis results from the deposition on the glomerular basement membrane of antibodies cross-reacting with dsDNA. In an attempt to suppress the production of such antibodies in the MRLlpr mouse strain, mice were treated by injections of dsDNA-anti-dsDNA antibody complexes formed in an excess of syngeneic polyclonal antibodies to increase the immunogenicity of idiotypes. A first group of mice was treated after the onset of high-affinity anti-dsDNA IgG antibodies (3 months). We show here that fortnightly injections of dsDNA-anti-dsDNA antibody complexes significantly extend mouse survival over that of two control groups treated with either the carrier buffer or with sham complexes. Treated mice produced 5-fold less anti-dsDNA antibodies than control mice and presented a reduced nephritis activity index at the age of 7 months. Specific anti-idiotypic antibody levels were not modified in the treated group, while showing a sharp decrease in the control group between months 6 and 7. Mice of a second group were started on injections of dsDNA-anti-dsDNA complexes at the age of 4 months when nephritis was already ongoing, and were followed until death while receiving fortnightly injections. Forty percent of the treated mice were still alive after one year, while none of the control mice survived. dsDNA-anti-dsDNA complexes have therefore the potential of reducing the production of anti-dsDNA antibody production and the severity of nephritis in MRLlpr mice. These findings could be relevant for the treatment of human lupus.

Predictors of renal outcome in diffuse proliferative glomerulonephritis in systemic lupus erythematosus

The occurrence of nephritis is considered to be the most important factor influencing the prognosis in systemic lupus erythematosus (SLE). Despite the apparent histological similarity of the lesions, however, patients with diffuse proliferative glomerulonephritis (DPGN) may exhibit different outcomes. A retrospective study was carried out on 81 SLE patients with DPGN to evaluate the prognostic significance of different clinical, serological and histological variables; in particular, 95 renal biopsies were re-evaluated and the activity and chronicity indices for the patients were determined. A positive correlation was observed between the presence of chronic lesions on renal biopsy and a poor renal outcome (< 0.001). Moreover, in the repeat biopsies the patients with a poor outcome showed a higher degree of chronic lesions. Active lesions and other clinical and serological parameters did not correlate with the outcome.

The role of the kidney biopsy in the treatment of lupus nephritis

The renal biopsy plays an important role in the clinical evaluation of patients with lupus erythematosus. From numerous studies of renal biopsies in lupus nephritis, it has become clear that although the renal lesions are quite varied, the pattern of renal involvement correlates with the clinical outcome. The broad spectrum of lesions seen in lupus nephritis has been attributed to individual differences in the immune response in different patients or in the same patient during the course of disease. Classification of lupus nephritis authorized by the World Health Organization has provided a standardized approach to the findings on renal biopsy. This classification combines all of the morphologic modalities of biopsy interpretation including light, immuno-fluorescence, and electron microscopy as well as providing a semiquantitative assessment of activity and chronicity. The clinical correlations utilizing this histologic classifications have demonstrated that the specific nature of the renal histopathology can predict both the acute and long-term outcome of the renal disease in patients with lupus erythematosus and can be useful in determining the management of individual patients.

Outcome of silent lupus nephritis

To analyze the long-term outcome in patients with silent lupus nephritis, we retrospectively studied 20 patients with systemic lupus erythematosus without clinical renal involvement who had renal biopsies in our unit between 1978 and 1986 and reviewed 193 cases reported between 1957 and 1995. Two patients of the current series were lost to follow-up. Mean follow-up in the other 18 was 13 +/- 3 years (range, 2 to 17). On kidney biopsy, nine had class I, six class II, one class IV, and two class V disease (WHO classification). Three patients with prior normal renal function died of nonrenal causes. During the study, the remaining 15 patients had normal renal function and urinalysis. Most patients from the literature had "mild" histologic lesions, but 30 had diffuse proliferative glomerulonephritis. Over an average of 46 months of follow-up from biopsy, renal survival rate and patient survival rate were 98% and 91%, respectively. Three patients died of end-stage renal failure. In conclusion, end-stage renal failure in patients with silent lupus nephritis is rare regardless of the histopathological renal lesions. Patients survival depends on nonrenal causes.

Systemic lupus erythematosus in males. A study of 107 Latin American patients

Clinical and laboratory features were analyzed in 107 Latin American male patients with systemic lupus erythematosus (SLE) who were compared with a group of 1,209 Latin American female patients with SLE to determine the presence of gender-associated differences. Males had an increased prevalence of renal disease, vascular thrombosis, and the presence of anti-dsDNA antibodies, as well as the use of moderate to high doses of corticosteroids, compared with female SLE patients. Although there was no difference in mortality from all causes, SLE-related mortality was higher in the male group. All these findings are consistent with a more severe disease in Latin American males than in female patients from the same region.

Mortality in the rheumatic diseases

OBJECTIVE

To review mortality data in published studies of various rheumatic diseases.

METHODS

A MEDLINE search of the literature on the rheumatic diseases, including osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, scleroderma, polymyositis, and vasculitis.

RESULTS

Mortality rates higher than expected have been reported in most rheumatic conditions, considerably higher for inflammatory rheumatic diseases. The mortality rates in patients with systemic lupus erythematosus, scleroderma, polymyositis, and vasculitis are often comparable to mortality rates seen in patients with neoplastic or cardiovascular diseases, although the causes of death often are not identified as the rheumatic disease.

CONCLUSION

Mortality has been found to be predicted in most instances by more severe clinical status, and therefore death should not be considered as "unrelated" to the rheumatic disease. These observations may have important implications for clinical care and health policies regarding patients with rheumatic diseases.

Factors associated with chronic renal failure in 121 patients with diffuse proliferative lupus nephritis: a case-control study

Lupus nephritis remains an important problem in patients with systemic lupus erythematosus (SLE). Some patients with diffuse proliferative lupus nephritis (DPLN) develop chronic renal failure (CRF). A case-control study was designed to determine the variables associated with CRF in patients with DPLN. We studied 121 patients with biopsy-proven DPLN seen in our institution from 1970 to 1988. There were 34 patients who developed CRF, the remaining were their controls. Clinical charts were reviewed and a pathologist re-scored blindly both activity and chronicity indices. The mean of age at SLE onset was 24.1 +/- 7.9 years; the mean disease duration was 9.2 +/- 6.1 years for controls and 6.1 +/- 5 years for patients. The main variables associated with CRF were male sex. HR (hazard ratio): 12.6 (95% CI 1.6-98.2); activity index, HR 2.59 (1.07-6.3); severe infections, HR 2.9 (1.2-7.3): number of antihypertensive drugs, HR 2.5 (1.4-4.7); cellular crescents, HR 1.6 (1.2-2): and interstitial inflammation, HR 2.7 (1.5-5.1). A protective effect was observed with longer use of < or = 20 mg of prednisone, HR 0.53 (95% CI 0.34-08): azathioprine, HR 0.6 (0.4-0.8); and length of formal education. HR 0.3 (0.09-0.94). Our results indicate that maleness, activity index, extracapillary proliferation and interstitial inflammation, as well as hypertension and severe infections associate with CRF in patients with DPLN, and treatment and higher education, perhaps through better therapeutic compliance, may be protective.

Systemic lupus erythematosus in Saudi patients

Eighty-seven patients with systemic lupus erythematosus (SLE) were retrospectively studied in King Khalid University Hospital, Riyadh. There were 78 females and 9 males (F:M ratio of 9:1). The mean age (+/- SD) at onset and at diagnosis were 25.3 +/- 10.5 and 28.5 +/- 10.9 years, respectively, with peak incidence in the 20-30 year age group. Musculoskeletal (91%), constitutional (76%), cutaneous (72%) and renal (63%) manifestations occurred most frequently, while neuropsychiatric manifestations (26%), photosensitivity (26%) and oral ulcers (16%) were relatively less frequent. The most common laboratory abnormalities included ANA (98%), anti-DNA (93%), LE cells (66%) and lymphopenia (70%). There were seven deaths during the study period and most of them were related to renal failure and complications from infections. Overall, the pattern of SLE observed in the series was comparable to that observed in other series among Caucasians.

IgG subclass deposits in glomeruli of lupus and nonlupus membranous nephropathies

Membranous nephropathy (MN) accounts for approximately 10% of all renal lesions of systemic lupus erythematosus (SLE). These membranous lesions often have a clinical presentation similar to that of idiopathic MN and may present before SLE is apparent clinically. However, unlike proliferative lesions of lupus nephritis (LN), membranous LN often does not show a "full-house" pattern of glomerular immunoglobulin and complement (C) deposits by immunofluorescence (IF); only nine of 14 such lesions that we examined stained for all of the following: IgG, IgA, IgM, C3, and C1q. Iskandar et al reported in 1992 that most cases of diffuse proliferative LN showed IgG3 as the major IgG subclass present in glomerular deposits; by contrast, IgG4 predominated in six of seven cases of MN of unspecified etiology. If IgG subclass deposition is similar in membranous and proliferative lesions of LN, then IF staining for IgG3 and IgG4 may be helpful in distinguishing lupus from nonlupus lesions in patients with MN who are lacking a firm diagnosis of SLE. We therefore stained cryostat sections of renal biopsies from 14 patients with SLE and MN (without a proliferative component; World Health Organization [WHO] classes Va and Vb) and 28 non-SLE patients with MN for IgG subclasses by direct IF; the observer was blind to the diagnosis for each case until all were read. The intensity of glomerular staining was graded on a 0 to 4+ scale with increments of 0.5+.(ABSTRACT TRUNCATED AT 250 WORDS)

Injections of complexes made of dsDNA and specific polyclonal antibodies extend MRL lpr mouse survival: a pilot study

Antibodies towards double-strain (ds) DNA are responsible for the development of lupus nephritis both in human and animal models. A method by which one would suppress the production of pathogenic idiotypes could therefore prevent the development of nephritis. To this end, we prepared polyclonal anti-dsDNA antibodies by immunoaffinity from a serum pool of MRL/MpJ-lpr mice, a strain that develops an early form of nephritis identical to its human counterpart. Antigen-antibody complexes were prepared by addition of dsDNA. Such complexes have the potential of altering the anti-DNA antibody response and boosting the production of specific anti-idiotypic antibodies. Two groups of 14 MRL lpr mice were treated by regular intraperitoneal injections of 10 micrograms dsDNA-anti-dsDNA complexes or carrier buffer, starting at the age of 4 weeks, namely, prior to the appearance of nephritogenic anti-dsDNA IgG antibodies. We show here that such a treatment significantly extended the survival of treated mice compared with the control group. Five treated mice were still alive at month 11 compared with two in the control group. In addition, microscopic kidney examination at the time of death showed less lesions in the treated group compared with controls. This study indicates that complexes made of dsDNA and anti-dsDNA can delay the development of nephritis in the MRL lpr mouse strain.

Immunosuppressive drug therapy in lupus nephritis

During the past two decades, the immunosuppressive drugs azathioprine and cyclophosphamide have been widely used in the treatment of patients with lupus nephritis. Their toxicities are well known and are mostly dose- and time-dependent. Complications that arise from these therapies stem from their immunosuppressive (susceptibility for infection) or pharmacologic (hemorrhagic cystitis, bladder cancer, and fibrosis from the alkylating agents) effects, or both. Uncontrolled studies reporting good results in treating patients with various combinations of corticosteroids and azathioprine and, especially, cyclophosphamide cannot be conclusively confirmed by the few controlled clinical trials that are available for review. Part of the problem of inconclusiveness has to do with timing treatment to different phases of the disease and the vast heterogeneity of lupus nephritis. Although these immunosuppressive agents may have favorable effects on the overall activity of systemic lupus erythematosus, their long-term effects per se on renal disease are in question and could be attributed to lower prednisone dosage and better medical management of hypertension, hyperlipidemia, infection, and other metabolic consequences of the disease.

Role of pathology indices in the management of severe lupus glomerulonephritis. Lupus Nephritis Collaborative Study Group

The principal value of the renal biopsy in patients with SLE is as a therapeutic guide. Although semiquantitative indices of nephron loss (chronicity = CI) and acute potentially reversible inflammation (activity = AI) are reported by some to have separate values from traditional classifications of glomerular pathology as predictors of outcome and therapeutic guides, this point remains controversial. We have tested the predictive value of the AI and CI in a large group of patients with severe lupus glomerulonephritis (SLE GN) and a mean follow-up of 281 weeks +/- 116 (mean +/- SD). A total of 86 patients entered into the study of plasmapheresis in severe SLE GN by the Lupus Nephritis Collaborative Study Group, and long-term follow-up was available in 83. The predictive value of the AI and the CI was described over the entire range of cut-off points by the method of receiver operator characteristics (ROC). ROC analysis demonstrated that there was no level of either AI or CI that predicted the outcome of death or renal failure with sufficient sensitivity and specificity to be useful in the individual patient. The CI signifies renal damage and nephron loss, whereas the AI describes potentially reversible pathology. Neither the CI nor the AI taken by itself predicts individual outcomes of renal failure or death in patients with aggressively treated SLE GN. Since the indices fail to identify the patient whose disease will progress to renal failure, they are both insufficient as therapeutic guides and add little to the management of the patient with severe SLE GN.