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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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Ornella S, García L, Cosentino M, Taylor MF, Ciappa M, García MA. Results and prognosis of kidney transplantation in lupus nephritis: Experience of an Argentine center. Lupus 2024; 33:762-768. [PMID: 38569651 DOI: 10.1177/09612033241244508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
INTRODUCTION Although RT has improved the survival of the population with ESRD due to all causes, renal outcomes in SLE are controversial. The objective of this study is to describe the characteristics and evolution of the patients and the kidney transplant in LN, and compare it with patients transplanted for other causes. MATERIALS AND METHODS Retrospective, observational, analytical, single-center study in which records of patients undergoing nephrotransplantation for LN were analyzed. They were compared with a group of patients transplanted at the same center for other causes of ESRD. RESULTS 41 patients with kidney transplant due to SLE and 89 transplanted due to other causes of ESRD were registered. Graft loss occurred in 12 (29.26%) patients with LN and 34 (38.2%) patients in the comparison group (p = .428). Only one case (4.8%) presented reactivation of the LN in the graft, without graft loss. Median graft survival was 73.1 months in the LN group and 66.3 months in the comparison group (p = .221). A total of 8 (19.5%) patients with LN and 11 (12.4%) without LN died (p = .42), with infections being the main cause in both groups. There were no statistically significant differences between groups in graft and patient survival. In a sub-analysis of 28 patients with LN with aPL study, 4 thrombotic events were observed, in 3 different patients, in the aPL-positive group. There were no statistically significant differences in terms of causes of graft loss and graft survival (positive aFL 75.7 months vs negative aFL 72.7 months, p= .96). There were also no differences in mortality between the groups (p = .61). CONCLUSION Patients transplanted for LN did not differ from the control population in terms of graft and patient survival. Infections were the main cause of death, so prophylaxis and vaccination continue to be a fundamental pillar in the prevention of infections in immunocompromised patients.
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Affiliation(s)
- Sofía Ornella
- Servicio de Reumatologia, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Lucila García
- Servicio de Reumatologia, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Máximo Cosentino
- Servicio de Reumatologia, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Marcelo F Taylor
- Unidad de Trasplante Renal del Centro Regional de Ablación e Implante (CRAI SUR), Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Martín Ciappa
- Unidad de Trasplante Renal del Centro Regional de Ablación e Implante (CRAI SUR), Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
| | - Mercedes A García
- Servicio de Reumatologia, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
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Siegel CH, Sammaritano LR. Systemic Lupus Erythematosus: A Review. JAMA 2024; 331:1480-1491. [PMID: 38587826 DOI: 10.1001/jama.2024.2315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Importance Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by inflammation and immune-mediated injury to multiple organ systems, including the mucocutaneous, musculoskeletal, hematologic, and kidney systems. Approximately 3.4 million people worldwide have received a diagnosis of SLE. Observations Approximately 90% of people with SLE are female. Although there are no uniformly accepted diagnostic criteria for SLE, the 2019 European Alliance of Associations for Rheumatology (formerly the European League Against Rheumatism)/American College of Rheumatology classification criteria developed for scientific study are an estimated 96.1% sensitive and 93.4% specific for SLE. These classification criteria include both clinical factors, such as fever, cytopenia, rash, arthritis, and proteinuria, which may be indicative of lupus nephritis; and immunologic measures, such as SLE-specific autoantibodies and low complement levels. Approximately 40% of people with SLE develop lupus nephritis, and an estimated 10% of people with lupus nephritis develop end-stage kidney disease after 10 years. The primary goal of treatment is to achieve disease remission or quiescence, defined by minimal symptoms, low levels of autoimmune inflammatory markers, and minimal systemic glucocorticoid requirement while the patient is treated with maintenance doses of immunomodulatory or immunosuppressive medications. Treatment goals include reducing disease exacerbations, hospitalizations, and organ damage due to the disease or treatment toxicity. Hydroxychloroquine is standard of care for SLE and has been associated with a significant reduction in mortality. Treatments in addition to hydroxychloroquine are individualized, with immunosuppressive agents, such as azathioprine, mycophenolate mofetil, and cyclophosphamide, typically used for treating moderate to severe disease. Three SLE medications were recently approved by the Food and Drug Administration: belimumab (for active SLE in 2011 and for lupus nephritis in 2020), voclosporin (for lupus nephritis), and anifrolumab (for active SLE). Conclusions and Relevance Systemic lupus erythematosus is associated with immune-mediated damage to multiple organs and increased mortality. Hydroxychloroquine is first-line therapy and reduces disease activity, morbidity, and mortality. When needed, additional immunosuppressive and biologic therapies include azathioprine, mycophenolate mofetil, cyclophosphamide, belimumab, voclosporin, and anifrolumab.
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Affiliation(s)
- Caroline H Siegel
- Division of Rheumatology, Hospital for Special Surgery, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Lisa R Sammaritano
- Division of Rheumatology, Hospital for Special Surgery, New York, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
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Robert JT, Rajaram A, Fiset PO, Bernard C, Samanta R, Sandal S. Class V lupus nephritis recurrence with histologic resolution in a kidney transplant recipient on a pregnancy-adapted immunosuppression protocol: a lesson for the clinical nephrologist. J Nephrol 2024; 37:811-814. [PMID: 38530604 DOI: 10.1007/s40620-024-01920-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/01/2024] [Indexed: 03/28/2024]
Affiliation(s)
- Jorane-Tiana Robert
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Ajay Rajaram
- Department of Pathology, McGill University Health Centre, Montreal, QC, Canada
| | - Pierre O Fiset
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Pathology, McGill University Health Centre, Montreal, QC, Canada
| | - Chantal Bernard
- Department of Pathology, McGill University Health Centre, Montreal, QC, Canada
| | - Ratna Samanta
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital- Glen Site D05-7160, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada
| | - Shaifali Sandal
- Research Institute of the McGill University Health Centre, Montreal, QC, Canada.
- Division of Nephrology, Department of Medicine, McGill University Health Centre, Royal Victoria Hospital- Glen Site D05-7160, 1001 Decarie Boulevard, Montreal, QC, H4A 3J1, Canada.
- Division of Experimental Medicine, Department of Medicine, McGill University Health Centre, Montreal, QC, Canada.
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Liu T, Yang YL, Zhou Y, Jiang YM. Noninvasive biomarkers for lupus nephritis. Lab Med 2024:lmae015. [PMID: 38493322 DOI: 10.1093/labmed/lmae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2024] Open
Abstract
Lupus nephritis (LN) is one of the most severe clinical manifestations of systemic lupus erythematosus (SLE). Notably, the clinical manifestations of LN are not always consistent with the histopathological findings. Therefore, the diagnosis and activity monitoring of this disease are challenging and largely depend on invasive renal biopsy. Renal biopsy has side effects and is associated with the risk of bleeding and infection. There is a growing interest in the development of novel noninvasive biomarkers for LN. In this review, we summarize most of the LN biomarkers discovered so far by correlating current knowledge with future perspectives. These biomarkers fundamentally reflect the biological processes of kidney damage and repair during disease. Furthermore, this review highlights the role of urinary cell phenotype detection in the diagnosis, monitoring, and treatment of LN and summarizes the limitations and countermeasures of this test.
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Affiliation(s)
- Ting Liu
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), West China Second University Hospital, Sichuan University, Chengdu, China
- State Key Laboratory of Biotherapy and Cancer Center/National Collaborative Innovation Center for Biotherapy, Sichuan University, Chengdu, China
| | - Yun-Long Yang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yan Zhou
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yong-Mei Jiang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Ministry of Education), West China Second University Hospital, Sichuan University, Chengdu, China
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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McPherson L, Plantinga LC, Howards PP, Kramer M, Pastan SO, Patzer RE. Referral and evaluation for kidney transplantation among patients with lupus nephritis-related end-stage kidney disease. Lupus 2024; 33:48-57. [PMID: 38019182 PMCID: PMC10842868 DOI: 10.1177/09612033231219739] [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] [Indexed: 11/30/2023]
Abstract
OBJECTIVE For the majority of patients with lupus nephritis-related end-stage kidney disease (LN-ESKD), kidney transplant is associated with better outcomes than dialysis. Access to kidney transplant requires an initial referral to a transplant center and medical evaluation prior to waitlisting. The study's objective was to examine access to these early steps in the kidney transplant process among patients with LN-ESKD. METHODS Adults who began treatment for ESKD in the Southeast, Northeast, New York, or Ohio River Valley U.S. regions from 1/1/2012 to 12/31/2019, followed through 6/30/2021, were identified from the United States Renal Data System. Referral and evaluation start data were collected from 28 of 48 transplant centers across these regions. The exposure was primary cause of ESKD (LN-ESKD vs other-ESKD). The outcomes were referral and evaluation start at a transplant center. Cox models quantified the association between LN-ESKD (vs other-ESKD) and referral and evaluation start. RESULTS Among 192,318 patients initiating treatment for ESKD, 0.4% had LN-ESKD. Over half (58%) of LN-ESKD patients were referred before study end, and among those referred, 66% started the evaluation. In adjusted analyses, patients with LN-ESKD were referred (HR: 1.09, 95% CI: 0.99, 1.19) and started the transplant evaluation (HR: 1.13, 95% CI: 1.00, 1.28) at a higher rate than patients with other-ESKD. Among referred patients with LN-ESKD, the median time from ESKD start to referral was 2.9 months (IQR: <1 to 11.7 months), which is similar to patients with other-ESKD (median 2.6 months, IQR: <1 to 8.8 months). CONCLUSIONS Among incident patients with ESKD, having a primary diagnosis of LN-ESKD versus other-ESKD is associated with higher rates of early transplant access outcomes. Despite this, patients with LN-ESKD (vs other-ESKD) are less likely to be preemptively referred (i.e., referred prior to ESKD start) for kidney transplant. While providers may no longer be delaying the early steps in the kidney transplantation process among this patient population, there is still room for improvement in the rates of preemptive referral. Access to kidney transplant referral prior to ESKD could result in increased transplant rates and better transplant outcomes for patients with LN-ESKD.
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Affiliation(s)
- Laura McPherson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Laura C. Plantinga
- Divisions of Rheumatology and Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Penelope P. Howards
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Michael Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Stephen O. Pastan
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rachel E. Patzer
- Division of Transplantation, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
- Regenstrief Institute, Indianapolis, IN
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Milhès J, Marion O, Puissant B, Carlé C, Bouthemy C, Del Bello A, Kamar N, Renaudineau Y, Congy-Jolivet N. Impact of imlifidase treatment on immunoglobulins in an HLA-hypersensitized lupus nephritis patient with anti-SSA/SSB antibodies after kidney transplantation: A case report. J Transl Autoimmun 2023; 7:100223. [PMID: 38162455 PMCID: PMC10755536 DOI: 10.1016/j.jtauto.2023.100223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/28/2023] [Indexed: 01/03/2024] Open
Abstract
Bacterial recombinant cysteine protease Ides (imlifidase, Idefirix®, Hansa Biopharma) is used to prevent humoral transplant rejection in highly HLA-sensitized recipients, and to control IgG-mediated autoimmune diseases. We report the case of a 51 years old woman suffering from lupus nephritis with end stage kidney disease, grafted for the second time and pre-treated with imlifidase. The patient was HLA-hypersensitized (calculated Panel Reactive Antibodies [Abs], cPRA>99 %) and has three preformed Donor Specific Antibodies (DSA). Circulating immunoglobulins were monitored at initiation (0, 6, 36, 72 and 96 h), and at Ab recovery one and two months following imlifidase injection. From baseline, the higher depletion was reported after 36h for total IgG (-75 %) and IgG subclasses (-87 % for IgG1, IgG2 and IgG3, -78 % for IgG4), while no significant impact on IgA and IgM was observed. Anti-SSA 60 kDa and anti-SSB auto-Abs quickly decreased after imlifidase injection (-96 % for both after 36 h) as well as post-vaccinal specific IgG (-95 % for tetanus toxoid, -97 % for pneumococcus and -91 % for Haemophilus influenzae Abs after 36 h). At the Ab recovery phase, total IgG and anti-SSA60/SSB Abs reached their initial level at two months. Regarding alloreactive Abs, anti-HLA Abs including the three DSA showed a dramatic decrease after injection with 100 % depletion from baseline after 36 h as assessed by multiplex single bead antigen assay, leading to negative crossmatches using both lymphocytotoxicity (LCT) and flow cell techniques. DSA rebound at recovery was absent and remained under the positivity threshold (MFI = 1000) after 6 months. The findings from this case report are that imlifidase exerts an early depleting effect on all circulating IgG, while IgG recovery may depend in part from imlifidase's capacity to target memory B cells.
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Affiliation(s)
- Jean Milhès
- Immunology Laboratory Department, Institut Fédératif de Biologie, Purpan, Toulouse University Hospital Center, Toulouse, France
| | - Olivier Marion
- Nephrology and Organ Transplantation Department, Rangueil Toulouse University Hospital, Toulouse, France
| | - Benedicte Puissant
- Immunology Laboratory Department, Institut Fédératif de Biologie, Purpan, Toulouse University Hospital Center, Toulouse, France
- INSERM UMR 1291 - CNRS UMR 5051, Toulouse Institute for Infectious and Inflammatory Diseases (INFINITy), University Toulouse III, Toulouse, France
| | - Caroline Carlé
- Immunology Laboratory Department, Institut Fédératif de Biologie, Purpan, Toulouse University Hospital Center, Toulouse, France
- INSERM UMR 1291 - CNRS UMR 5051, Toulouse Institute for Infectious and Inflammatory Diseases (INFINITy), University Toulouse III, Toulouse, France
| | - Charlène Bouthemy
- Immunology Laboratory Department, Institut Fédératif de Biologie, Purpan, Toulouse University Hospital Center, Toulouse, France
| | - Arnaud Del Bello
- Nephrology and Organ Transplantation Department, Rangueil Toulouse University Hospital, Toulouse, France
| | - Nassim Kamar
- Nephrology and Organ Transplantation Department, Rangueil Toulouse University Hospital, Toulouse, France
| | - Yves Renaudineau
- Immunology Laboratory Department, Institut Fédératif de Biologie, Purpan, Toulouse University Hospital Center, Toulouse, France
- INSERM UMR 1291 - CNRS UMR 5051, Toulouse Institute for Infectious and Inflammatory Diseases (INFINITy), University Toulouse III, Toulouse, France
| | - Nicolas Congy-Jolivet
- Immunology Laboratory Department, Institut Fédératif de Biologie, Purpan, Toulouse University Hospital Center, Toulouse, France
- UMR 1037 INSERM Team 20 / Université Toulouse III Paul Sabatier, Toulouse Cancerology Research Center (CRCT), Toulouse, France
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9
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Dioscin ameliorates silica-aggravated systemic lupus erythematosus via suppressing apoptosis and improving LC3-associated phagocytosis in MRL/lpr mice. Int Immunopharmacol 2023; 116:109814. [PMID: 36773568 DOI: 10.1016/j.intimp.2023.109814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/14/2023] [Accepted: 01/28/2023] [Indexed: 02/11/2023]
Abstract
Inhalation of silica not only directly leads to silicosis locally, but also results in various types of autoimmune diseases systemically, most commonly systemic lupus erythematosus (SLE). Little is known about the etiopathogenesis of silica-aggravated SLE to date, however, abnormal apoptosis and impaired apoptotic clearance have been reported to be closely related to the occurrence of SLE. LC3-associated phagocytosis (LAP) is a non-canonical form of autophagy, which plays a crucial role in mediating the clearance of apoptotic cells. Here we showed that the excessive accumulation of apoptotic debris in MRL/lpr mice exposed to silica might be due to the increased cell apoptosis and defective LAP caused by silica, thus accelerating the occurrence and progression of silica-aggravated SLE. Dioscin is an active ingredient in the family of Dioscoreaceae and is reported to possess multiple pharmacological activities, including anti-inflammatory, anti-apoptotic and autophagy-promoting properties. However, its role in SLE aggravated by silica exposure has not been investigated. In our study, we confirmed that dioscin decreased the accumulation of apoptotic debris by suppressing the excessive cell apoptosis and improving the LAP of immune cells in lung and spleen, leading to subsequent dramatically ameliorated lupus-like symptoms in silica-exposed MRL/lpr mice.
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10
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Rojas-Rivera JE, García-Carro C, Ávila AI, Espino M, Espinosa M, Fernández-Juárez G, Fulladosa X, Goicoechea M, Macía M, Morales E, Porras LFQ, Praga M. Consensus document of the Spanish Group for the Study of the Glomerular Diseases (GLOSEN) for the diagnosis and treatment of lupus nephritis. Nefrologia 2023; 43:6-47. [PMID: 37211521 DOI: 10.1016/j.nefroe.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/17/2022] [Indexed: 05/23/2023] Open
Abstract
A significant number of patients with systemic lupus erythematosus (between 20% and 60% according to different reported series) develop lupus nephritis in the course of its evolution, which directly influences their quality of life and vital prognosis. In recent years, the greater knowledge about the pathogenesis of systemic lupus and lupus nephritis has allowed relevant advances in the diagnostic approach and treatment of these patients, achieving the development of drugs specifically aimed at blocking key pathogenic pathways of the disease. Encouragingly, these immunomodulatory agents have shown in well-powered, randomized clinical trials good clinical efficacy in the medium-term, defined as proteinuria remission and preservation of kidney function, with an acceptable safety profile and good patient tolerability. All this has made it possible to reduce the use of corticosteroids and other potentially more toxic therapies, as well as to increase the use of combined therapies. The present consensus document carried out by the Glomerular Diseases Working Group of the Spanish Society of Nephrology (GLOSEN), collects in a practical and summarized, but rigorous way, the best currently available evidence about the diagnosis, treatment, and follow-up of lupus nephritis patients, including cases of special situations, with the main objective of providing updated information and well-founded clinical recommendations to treating physicians, to improve the diagnostic and therapeutic approach to our patients.
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Affiliation(s)
- Jorge E Rojas-Rivera
- Hospital Universitario Fundación Jiménez Díaz, Servicio de Nefrología e Hipertensión, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Servicio de Nefrología, Madrid, Spain.
| | - Clara García-Carro
- Hospital Universitario Clínico San Carlos, Servicio de Nefrología. Madrid, Spain.
| | - Ana I Ávila
- Hospital Dr. Peset, Servicio de Nefrología, Valencia, Spain
| | - Mar Espino
- Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain
| | - Mario Espinosa
- Hospital Universitario Reina Sofía, Servicio de Nefrología, Cordoba, Spain
| | | | - Xavier Fulladosa
- Hospital Universitario de Bellvitge, L'Hospitalet de Llobregat, Servicio de Nefrología, Barcelona, Spain
| | - Marian Goicoechea
- Hospital Universitario Gregorio Marañón, Servicio de Nefrología, Madrid, Spain
| | - Manuel Macía
- Hospital Universitario Nuestra Señora de la Candelaria, Servicio de Nefrología, Tenerife, Spain
| | - Enrique Morales
- Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Instituto de Investigación Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Departamento de Medicina, Universidad Complutense, Servicio de Nefrología, Madrid, Spain
| | - Luis F Quintana Porras
- Hospital Clínic de Barcelona, Servicio de Nefrología, Barcelona, Spain; Departamento de Medicina, Universidad de Barcelona, IDIBAPS, Servicio de Nefrología, Barcelona, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital Universitario 12 de Octubre, Servicio de Nefrología, Madrid, Spain; Departamento de Medicina, Universidad Complutense, Servicio de Nefrología, Madrid, Spain
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11
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Christenson ES, Lee V, Wang H, Yarchoan M, De Jesus-Acosta A, Azad N, Gurakar A, Lin MT, Le DT, Brennan DC, Jaffee EM, Bever K. Solid Organ Transplantation Is Associated with an Increased Rate of Mismatch Repair Deficiency and PIK3CA Mutations in Colorectal Cancer. Curr Oncol 2022; 30:75-84. [PMID: 36661655 PMCID: PMC9858144 DOI: 10.3390/curroncol30010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 11/17/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Solid organ transplants are associated with a modestly increased risk of colorectal cancers (CRC). However, the molecular profile of these cancers has not been described. We hypothesized that transplant-related immunosuppression may promote development of more immunogenic tumors as suggested by a high tumor mutation burden or mismatch repair deficiency. We performed an electronic medical record search for patients seen in the Johns Hopkins University Health System (JHHS) between 2017 and 2022 who developed CRC following solid organ transplantation. A comparator cohort of patients treated for CRC at JHHS with molecular profiling data was also identified. In this case, 29 patients were identified that developed post-transplant CRC (renal transplant, n = 18; liver transplant, n = 8; kidney-liver transplantation, n = 3). Compared to the JHHS general population CRC cohort, patients who developed post-transplant CRC had a higher rate of mismatch repair deficiency (41% versus 12%, p-value = 0.0038), and elevated tumor mutation burden (median of 22 mut/Mb versus 3.5 mut/Mb, p-value = 0.033) (range 3.52-53.65). Post-transplant tumors were enriched for PIK3CA mutations (43% versus 24%, p-value = 0.042). Post-Transplant CRCs are associated with clinical and molecular features of immune sensitivity, supporting a potential role for impaired immune surveillance in shaping the landscape of CRCs. These results may help inform the management of patients with post-transplant CRC.
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Affiliation(s)
- Eric S. Christenson
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Valerie Lee
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Hao Wang
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Mark Yarchoan
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Ana De Jesus-Acosta
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Nilo Azad
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Ahmet Gurakar
- Division of Gastroenterology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Ming-Tseh Lin
- Department of Pathology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Dung T. Le
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Daniel C. Brennan
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Elizabeth M. Jaffee
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Katherine Bever
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Department of Oncology, Johns Hopkins University, Baltimore, MD 21287, USA
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12
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Jorge A, Fu X, Cook C, Lu N, Zhang Y, Choi HK, Wallace ZS. Kidney Transplantation and Cardiovascular Events Among Patients With End-Stage Renal Disease Due to Lupus Nephritis: A Nationwide Cohort Study. Arthritis Care Res (Hoboken) 2022; 74:1829-1834. [PMID: 34121367 PMCID: PMC8666461 DOI: 10.1002/acr.24725] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/13/2021] [Accepted: 06/03/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess the potential impact of kidney transplantation on cardiovascular (CV) events among patients with end-stage renal disease (ESRD) due to lupus nephritis (LN). METHODS In a nationwide cohort study, we identified all patients with LN-ESRD enrolled in the US Renal Data System who were waitlisted for a kidney transplant and enrolled in Medicare between January, 2000 and December, 2016. The primary outcome was incident CV events, including myocardial infarction (MI) and ischemic cerebrovascular accident (CVA). We used time-dependent Cox regression to estimate the hazard ratios (HRs) of these outcomes associated with kidney transplant as a time-varying exposure, adjusting for sex, age, race, ethnicity, geographic region, year of ESRD onset, first ESRD treatment modality (e.g., hemodialysis or peritoneal dialysis), Charlson Comorbidity Index score, and history of prior organ transplants. RESULTS Of 5,963 waitlisted patients with LN-ESRD, 3,209 (54%) had a kidney transplant during the study period. The majority were female (82%), and African American patients represented 48% of waitlisted patients and 43% of transplanted patients. Kidney transplantation was associated with a lower risk of incident CV events (adjusted HR 0.31 [95% confidence interval (95% CI) 0.18-0.53]) as well as lower risks of MI and CVA (adjusted HRs 0.13 [95% CI 0.08-0.34] and 0.30 [95% CI 0.16-0.54], respectively). CONCLUSION Kidney transplantation was associated with a reduced risk of CV events, including MI and CVA, in patients with LN-ESRD. Our findings highlight the importance of identifying barriers to transplantation in this population, as improved access could reduce CV morbidity.
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Affiliation(s)
- April Jorge
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Claire Cook
- Arthritis Research Canada, Richmond, BC, Canada
| | - Na Lu
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Arthritis Research Canada, Richmond, BC, Canada
| | - Yuqing Zhang
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hyon K. Choi
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zachary S. Wallace
- Clinical Epidemiology Program, Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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13
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Documento de consenso del Grupo de Estudio de Enfermedades Glomerulares de la Sociedad Española de Nefrología (GLOSEN) para el diagnóstico y tratamiento de la nefritis lúpica. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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14
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Prada SI, Pérez AM, Nieto-Aristizábal I, Tobón GJ. Increase in direct costs for health systems due to lupus nephritis: the case of Colombia. EINSTEIN-SAO PAULO 2022; 20:eAO6553. [PMID: 35476081 PMCID: PMC9018061 DOI: 10.31744/einstein_journal/2022ao6553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/22/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Lupus nephritis is one of the most severe complications of systemic lupus erythematosus and it has been estimated that can occur in up to 60% of patients. Direct costs of lupus nephritis have not been studied in developing countries. This study aimed to describe lupus nephritis direct costs in Colombia. Methods Administrative data from two Colombian health maintenance organizations for 2014 and 2015 was obtained. An algorithm based on the International Statistical Classification of Diseases and Related Health Problems 10th revision codes was developed to identify patients with lupus nephritis and lupus nephritis under study. Results The average annual per-patient, all-claims, all-cause direct cost for lupus nephritis was US$ 12,624, 7.5 times higher than the average lupus patient without lupus nephritis. For lupus nephritis cases under study, estimated direct cost was US$ 3,664, 2 times higher than average lupus patient in Colombia. Difference in lupus nephritis patients is mainly accounted for the cost and frequency of procedures, exceeding by a factor of 5 the cost for durable medical equipment and the cost for drugs, respectively. Conclusion Lupus patients who progress to lupus nephritis stage increased seven-fold the average annual per-patient, all-claims, and all-cause direct cost for the Colombian health system.
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Abstract
PURPOSE OF REVIEW Systemic lupus erythematosus is a lifelong, multisystemic disease. Around a fifth of patients present during childhood. Children are recognized to have a more active disease course with more renal involvement (lupus nephritis) when compared with adults. This review article summarizes the current literature surrounding the management of paediatric lupus nephritis. RECENT FINDINGS International recommendations agree that active, proliferative forms of lupus nephritis are treated with a period of intense induction therapy aimed at inducing remission followed by maintenance immunosuppressive therapy for at least 3 years. Complete response rates in lupus nephritis remain inadequate, in the region of 40-60%, and disease flares are common. Revised histological classification have been proposed but they are yet to be adopted in clinical practice. Lupus nephritis progresses to chronic kidney disease (CKD) stage 5 (kidney failure) in more than 10% of patients within 10 years however the rates of CKD stages 1-4 remain largely unknown. Current trials are focused on the use of biologic agents as adjuncts to current therapy. SUMMARY There is an urgent need for better outcomes in paediatric lupus nephritis. The use of biomarkers to monitor lupus nephritis and scientific studies to improve our understanding of the pathogenesis offer hope of improved outcomes.
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Affiliation(s)
- Thomas Dowsett
- Department of Paediatric Nephrology, Royal Manchester Children's NHS Trust Hospital, Manchester
| | - Louise Oni
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust Hospital
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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16
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Rovin BH. Kidney Failure in Systemic Lupus Erythematosus: A Fraught Complication in a Fraught Disease. Am J Kidney Dis 2022; 79:617-619. [PMID: 35125262 DOI: 10.1053/j.ajkd.2021.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/15/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Brad H Rovin
- Department of Internal Medicine, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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17
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Chapa JJ, Ilonze OJ, Guglin ME, Rao RA. Heart transplantation in systemic lupus erythematosus: A case report and meta-analysis. Heart Lung 2022; 52:174-181. [DOI: 10.1016/j.hrtlng.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 01/20/2023]
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18
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Pattanaik D, Green J, Talwar M, Molnar M. Relapse and Outcome of Lupus Nephritis After Renal Transplantation in the Modern Immunosuppressive Era. Cureus 2022; 14:e20863. [PMID: 35145770 PMCID: PMC8803130 DOI: 10.7759/cureus.20863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 11/05/2022] Open
Abstract
Background Recurrence of lupus nephritis in the graft is a concern in lupus patients with end-stage renal disease undergoing renal transplantation. The recurrence of lupus nephritis has been variable among different studies depending on the patient characteristics, immunosuppressive regimen, and indications of renal biopsy. Therefore, we investigated the recurrence of lupus nephritis among our patients to see if the new post-transplant regimen has impacted the recurrence. Methods We collected data on all recipients with end-stage renal disease secondary to lupus nephritis, who received renal transplants between 2006-2017 in our center. Patient demographics, transplant, and dialysis-related information have been recorded including kidney biopsy, graft loss, and survival were recorded. An association between recurrent lupus nephritis with survival and/or graft loss was examined using survival models. Results The overall mean±SD age at baseline was 42±13 years; 89% were female; 89% were African American; the previous time on dialysis was a median of 4 years (IQR: 2-8 years), 81% received hemodialysis and 31% received living donor transplantation in the cohort. Our patients received the standard immunosuppressive regimen consisting of prednisone, tacrolimus, and mycophenolate mofetil. Four (10.5%) of the 38 patients had biopsy-proven lupus nephritis recurrence. A total of 10 patients (26%) had graft loss or died during the median follow-up time of 1,230 days (IQR: 460-2,227 days). Recurrence of lupus nephritis showed a trend for increased risk of graft loss or patient death (Hazard Ratio: 3.14, 95%Confidence Interval: 0.65-15.24) compared to the recipient without recurrence in our unadjusted proportional Cox regression model. Conclusion The recurrence rate of lupus nephritis in our patient population is much lower compared to past studies from different immunosuppressive eras. Patients with recurrent lupus nephritis showed an increased risk of graft loss or death.
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19
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Abstract
Cardiovascular disease remains a leading cause of death and morbidity in kidney transplant recipients and a common reason for post-transplant hospitalization. Several traditional and nontraditional cardiovascular risk factors exist, and many of them present pretransplant and worsened, in part, due to the addition of immunosuppression post-transplant. We discuss optimal strategies for identification and treatment of these risk factors, including the emerging role of sodium-glucose cotransporter 2 inhibitors in post-transplant diabetes and cardiovascular disease. We present common types of cardiovascular disease observed after kidney transplant, including coronary artery disease, heart failure, pulmonary hypertension, arrhythmia, and valvular disease. We also discuss screening, treatment, and prevention of post-transplant cardiac disease. We highlight areas of future research, including the need for goals and best medications for risk factors, the role of biomarkers, and the role of screening and intervention.
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Affiliation(s)
- Kelly A. Birdwell
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meyeon Park
- Division of Nephrology, Department of Medicine, University of California, San Francisco, California
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20
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Cook C, Jorge A, Fu X, Niles J, Jeyabalan A, Zonozi R, Stone JH, Zhang Y, Choi HK, Wallace ZS. Association of renal transplantation with reduced risk of myocardial infarction and ischemic stroke in ANCA-associated vasculitis: An observational cohort study. Semin Arthritis Rheum 2021; 51:1180-1185. [PMID: 34600217 PMCID: PMC8784187 DOI: 10.1016/j.semarthrit.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Myocardial infarction and ischemic stroke are leading causes of cardiovascular (CV) morbidity and mortality in ANCA-associated vasculitis (AAV), especially for the 20% with end-stage renal disease (ESRD). We assessed the impact of renal transplantation on the risk of myocardial infarction and stroke among patients with ESRD due to AAV. METHODS We identified patients from the United States Renal Data System with ESRD due to AAV between 2000 and 2016. We examined the association between renal transplantation and the risk of non-fatal and fatal myocardial infarction or ischemic stroke among waitlisted patients using Medicare claims and death data through 2017. We used time-varying Cox proportional hazards models with age as the time scale to estimate hazard ratios (HR) and 95% confidence intervals (CIs) for myocardial infarction and ischemic stroke events among patients who received a renal transplant compared to those who remained on the waitlist. RESULTS Of 1029 waitlisted patients, 593 (58%) were transplanted over a mean of 5.7 years. There were 17 events (4.6/1,000 person-years) in the transplanted group and 40 events (13.7/1,000 person-years) in the group that remained waitlisted. A renal transplant was associated with a 78% lower risk of myocardial infarction or ischemic stroke (HR=0.22, 95% CI 0.11 to 0.47). These findings persisted across sex and age groups and when censoring patients after living donor transplantation. CONCLUSIONS Among AAV patients with ESRD, renal transplantation can substantially reduce the risk of myocardial infarction and ischemic stroke. Improving access to transplantation for this population may further improve outcomes.
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Affiliation(s)
- Claire Cook
- Clinical Epidemiology Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - April Jorge
- Clinical Epidemiology Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Xiaoqing Fu
- Clinical Epidemiology Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - John Niles
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Anushya Jeyabalan
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Reza Zonozi
- Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Nephrology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - John H. Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Yuqing Zhang
- Clinical Epidemiology Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Hyon K. Choi
- Clinical Epidemiology Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Zachary S. Wallace
- Clinical Epidemiology Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Mongan Institute, Massachusetts General Hospital and Harvard Medical School, Boston, MA,Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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21
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Nguyen VT, Engleton M, Davison M, Ravaud P, Porcher R, Boutron I. Risk of bias in observational studies using routinely collected data of comparative effectiveness research: a meta-research study. BMC Med 2021; 19:279. [PMID: 34809637 PMCID: PMC8608432 DOI: 10.1186/s12916-021-02151-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/04/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND To assess the completeness of reporting, research transparency practices, and risk of selection and immortal bias in observational studies using routinely collected data for comparative effectiveness research. METHOD We performed a meta-research study by searching PubMed for comparative effectiveness observational studies evaluating therapeutic interventions using routinely collected data published in high impact factor journals from 01/06/2018 to 30/06/2020. We assessed the reporting of the study design (i.e., eligibility, treatment assignment, and the start of follow-up). The risk of selection bias and immortal time bias was determined by assessing if the time of eligibility, the treatment assignment, and the start of follow-up were synchronized to mimic the randomization following the target trial emulation framework. RESULT Seventy-seven articles were identified. Most studies evaluated pharmacological treatments (69%) with a median sample size of 24,000 individuals. In total, 20% of articles inadequately reported essential information of the study design. One-third of the articles (n = 25, 33%) raised some concerns because of unclear reporting (n = 6, 8%) or were at high risk of selection bias and/or immortal time bias (n = 19, 25%). Only five articles (25%) described a solution to mitigate these biases. Six articles (31%) discussed these biases in the limitations section. CONCLUSION Reporting of essential information of study design in observational studies remained suboptimal. Selection bias and immortal time bias were common methodological issues that researchers and physicians should be aware of when interpreting the results of observational studies using routinely collected data.
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Affiliation(s)
- Van Thu Nguyen
- Centre of Research Epidemiology and Statistics (CRESS), Inserm, Université de Paris, F-75004, Paris, France. .,Meta-Research Innovation Centre at Stanford (METRICS), Stanford University, 1265 Welch Rd, Stanford, CA, 94305, USA.
| | - Mishelle Engleton
- Centre of Research Epidemiology and Statistics (CRESS), Inserm, Université de Paris, F-75004, Paris, France
| | - Mauricia Davison
- Centre of Research Epidemiology and Statistics (CRESS), Inserm, Université de Paris, F-75004, Paris, France.,Cochrane France, AP-HP, 75004, Paris, France
| | - Philippe Ravaud
- Centre of Research Epidemiology and Statistics (CRESS), Inserm, Université de Paris, F-75004, Paris, France.,Cochrane France, AP-HP, 75004, Paris, France.,Centre d'Epidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique des Hôpitaux de Paris (APHP), F-75004, Paris, France
| | - Raphael Porcher
- Centre of Research Epidemiology and Statistics (CRESS), Inserm, Université de Paris, F-75004, Paris, France.,Cochrane France, AP-HP, 75004, Paris, France.,Centre d'Epidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique des Hôpitaux de Paris (APHP), F-75004, Paris, France
| | - Isabelle Boutron
- Centre of Research Epidemiology and Statistics (CRESS), Inserm, Université de Paris, F-75004, Paris, France.,Cochrane France, AP-HP, 75004, Paris, France.,Centre d'Epidémiologie Clinique, Hôpital Hôtel Dieu, Assistance Publique des Hôpitaux de Paris (APHP), F-75004, Paris, France
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22
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Derner O, Kramer A, Hruskova Z, Arici M, Collart F, Finne P, Fuentes Sánchez L, Harambat J, Hemmelder MH, Hommel K, Kerschbaum J, De Meester J, Palsson R, Segelmark M, Skrunes R, Traynor JP, Zurriaga O, Massy ZA, Jager KJ, Stel VS, Tesar V. Incidence of Kidney Replacement Therapy and Subsequent Outcomes Among Patients With Systemic Lupus Erythematosus: Findings From the ERA Registry. Am J Kidney Dis 2021; 79:635-645. [PMID: 34752912 DOI: 10.1053/j.ajkd.2021.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 09/18/2021] [Indexed: 01/10/2023]
Abstract
RATIONALE AND OBJECTIVE There is a dearth of data characterizing patients requiring kidney replacement therapy (KRT) for kidney failure due to systemic lupus erythematosus (SLE) and their clinical outcomes. The aim of this study was to describe trends in incidence and prevalence of KRT among these patients as well as to compare their outcomes to patients treated with KRT for diseases other than SLE. STUDY DESIGN Retrospective cohort study based on kidney registry data. SETTING & PARTICIPANTS Patients recorded in 14 registries of patients receiving kidney replacement therapy that provided data to the European Renal Association (ERA) Registry between 1992 and 2016. PREDICTOR SLE as cause of kidney failure. OUTCOMES Incidence and prevalence of KRT, patient survival while receiving KRT, patient and graft survival after kidney transplantation, and specific causes of death. ANALYTICAL APPROACH Kaplan-Meier methods and Cox regression models were fit to compare patient survival between the SLE and non-SLE groups, overall KRT, dialysis and patient and graft survival after kidney transplantation. RESULTS In total, 1826 patients commenced KRT for kidney failure due to SLE, representing an incidence of 0.80 per million population (pmp) per year. The incidence remained stable during the study period (annual percent change=0.1 [95%CI: -0.6 ; 0.8]). Patient survival among patients with SLE receiving KRT was similar to survival within the comparator group (HR=1.11 [95%CI: 0.99-1.23]). After kidney transplantation, the risk of death was greater among patients with SLE than among patients within the comparator group (HR=1.25 [95%CI: 1.02-1.53]), while the risk of all-cause graft failure was similar (HR=1.09 [95%CI: 0.95-1.27]). Ten-year patient overall survival on KRT, and patient and graft survival after kidney transplantation improved over the study period (HR=0.71 [95%CI: 0.56-0.91], 0.43 [0.27-0.69] and 0.60 [0.43-0.84], respectively). Patients with SLE receiving KRT were significantly more likely to die from infections (24.8%) than patients in the comparator group (16.9%, p<0.001). LIMITATIONS No data were available on extrarenal manifestations of SLE, drug treatments, comorbidities, kidney transplant characteristics, or relapses of SLE. CONCLUSION The prognosis of patients with SLE receiving KRT has improved over time. Survival of patients with SLE requiring KRT was similar when compared to patients requiring KRT due to other causes of kidney failure. Survival following kidney transplantation was worse among patients with SLE.
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Affiliation(s)
- Ondrej Derner
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Anneke Kramer
- ERA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, the Netherlands.
| | - Zdenka Hruskova
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
| | - Mustafa Arici
- Department of Nephrology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | | | - Patrik Finne
- Abdominal Center Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Finnish Registry for Kidney Diseases, Helsinki, Finland
| | | | - Jérôme Harambat
- Université de Bordeaux, Inserm U1219, Unité de Néphrologie, Service de Pédiatrie, CHU de Bordeaux, Bordeaux, France
| | - Marc H Hemmelder
- Dutch Renal Registry Renine, Nefrovisie foundation, Utrecht, the Netherlands; Department of internal medicine, Division of nephrology, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Julia Kerschbaum
- Austrian Dialysis and Transplant Registry, Department of Internal Medicine IV - Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - Johan De Meester
- Department of Nephrology, Dialysis and Hypertension, Dutch-speaking Belgian Renal Registry (NBVN), Sint-Niklaas, Belgium
| | - Runolfur Palsson
- Division of Nephrology, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland; Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Mårten Segelmark
- Department of Clinical Sciences, Division of Nephrology, Lund University and Skane University Hospital, Lund, Sweden
| | - Rannveig Skrunes
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jamie P Traynor
- Scottish Renal Registry, Meridian Court, ISD Scotland, Glasgow G2 6QE, United Kingdom
| | - Oscar Zurriaga
- Valencia Region Renal Registry. Direccio General de Salut Publica i Adiccions, Valencia, Spain; Department of Preventive Medicine and Public Health. Universitat de Valencia, Valencia, Spain; Rare Diseases Joint Research Unit Universitat de Valencia-Foundation for the Promotion of Health and Biomedical Research in the Valencian Region, FISABIO, Valencia, Spain; Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Ziad A Massy
- Division of Nephrology, Ambroise Paré University Hospital, APHP, Boulogne-Billancourt, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM) Unit 1018 team5, Research Centre in Epidemiology and Population Health (CESP), University of Paris Ouest-Versailles-St Quentin-en-Yveline, Villejuif, France
| | - Kitty J Jager
- ERA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, the Netherlands
| | - Vianda S Stel
- ERA Registry, Amsterdam UMC, University of Amsterdam, Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam, the Netherlands
| | - Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital in Prague, Czech Republic
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Yang JX, Williamson KA, Duarte-García A. 75-Year-Old Man With Fever and Malaise. Mayo Clin Proc 2021; 96:2905-2910. [PMID: 34736613 DOI: 10.1016/j.mayocp.2021.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 11/21/2022]
Affiliation(s)
- Jeffrey X Yang
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Katrina A Williamson
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Alí Duarte-García
- Advisor to residents and Consultant in Rheumatology, Mayo Clinic, Rochester, MN.
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24
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 673] [Impact Index Per Article: 224.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Wasik H, Chadha V, Galbiati S, Warady B, Atkinson M. Dialysis Outcomes for Children With Lupus Nephritis Compared to Children With Other Forms of Nephritis: A Retrospective Cohort Study. Am J Kidney Dis 2021; 79:626-634. [PMID: 34461164 DOI: 10.1053/j.ajkd.2021.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 07/16/2021] [Indexed: 01/12/2023]
Abstract
RATIONALE & OBJECTIVE Children with lupus nephritis (LN) are at high risk of developing kidney failure requiring initiation of kidney replacement therapy. This study compared outcomes among children with LN on dialysis with children with non-lupus glomerular disease and investigated risk factors for adverse outcomes among children with LN on dialysis. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Children and adolescents aged 6-20 years with LN (n = 231) and non-lupus glomerular disease (n = 1,726) who initiated maintenance dialysis 1991-2018 and were enrolled in the North American Pediatric Renal Trials and Collaborative Studies (NAPRTCS) registry. EXPOSURE Lupus nephritis. OUTCOME Hospitalization, mortality, and time to transplant. ANALYTICAL APPROACH Contingency tables were used to compare hospitalizations, and multivariable cause-specific hazards models were used to compare rates of death and transplantation in children with LN compared with those with non-lupus glomerular disease. Using data from children with LN, multivariable logistic regression models were fit to evaluate the risk factors for hospitalization, and multivariable Cox regression models were fit to evaluate factors associated with kidney transplantation. RESULTS Children with LN were more likely to be hospitalized in the first year after dialysis initiation (63.3% vs 48.6%, P < 0.001) and were less likely to receive a kidney transplant in the first 3 years after dialysis initiation (year 0-1: adjusted hazard ratio [AHR], 0.36 [95% CI, 0.23-0.57], P < 0.001; year 1-3: AHR, 0.73 [95% CI, 0.54-0.98], P = 0.04). Anemia was associated with hospitalization after dialysis initiation (adjusted OR, 4.44 [95% CI, 1.44-13.66], P = 0.01). Non-White race was associated with a lower rate of kidney transplantation (AHR, 0.47 [95% CI, 0.27-0.82], P = 0.01). LN was not associated with death while on dialysis (AHR, 1.21 [95% CI, 0.47-3.11], P = 0.7). LIMITATIONS The NAPRTCS registry does not collect information on lupus disease activity or medication doses and has limited data on medication use. CONCLUSIONS Children and adolescents with LN on dialysis are at higher risk for adverse outcomes including hospitalization and lower rates of kidney transplantation compared with children with non-lupus glomerular disease receiving maintenance dialysis.
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Affiliation(s)
- Heather Wasik
- Division of Pediatric Nephrology, SUNY Upstate Medical University, Syracuse, New York.
| | - Vimal Chadha
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | | | - Bradley Warady
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Meredith Atkinson
- Division of Pediatric Nephrology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
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26
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Rodelo J, González LA, Ustáriz J, Matera S, Pérez K, Ramírez Z, Arias LF, García Á, Arbeláez M, Henao J. Kidney transplantation outcomes in lupus nephritis: A 37-year single-center experience from Latin America. Lupus 2021; 30:1644-1659. [PMID: 34225520 DOI: 10.1177/09612033211028663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE We assessed patient and graft outcomes and prognostic factors in kidney transplantation in patients with end-stage kidney disease (ESKD) secondary to lupus nephritis (LN) undergoing kidney transplantation from August 1977 to December 2014 in a Latin American single center. METHODS The primary endpoint was patient survival, and the secondary endpoints were death-censored graft survival for the first renal transplant and the rate of recurrent LN (RLN). Kaplan-Meier method was used for survival analysis. Factors predicting patient and death-censored graft survivals were examined by Cox proportional-hazards regression analyses. RESULTS 185 patients were retrospectively evaluated. Patient survival rates were 88% at one year, 82% at three years, 78% at five years, and 67% at ten years. Death-censored graft survival for the first renal transplant was 93% at one year, 89% at three years, 87% at five years, and 80% at ten years. RLN was diagnosed in 2 patients (1.08%), but no graft was lost because of RLN. Thirty-nine (21.1%) patients died, and 65 (35.1%) patients experienced graft loss during the follow-up. By multivariable analyses, older recipient age and 1-month posttransplantation eGFR <45 ml/min/1.73m2 were associated with lower patient survival and an increased risk of graft loss, while induction immunosuppressive therapy exerted a protective effect on patients' survival. In the subgroup of patients in whom disease activity was measured at the time of transplantation, a higher SLEDAI score was also associated with lower patient survival and an increased risk of graft loss. CONCLUSION In a mostly Mestizo population, kidney transplantation is an excellent therapeutic alternative in LN patients with ESKD. Older recipient age, an eGFR <45 ml/min/1.73m2 at one month posttransplantation, and disease activity at the time of transplantation are predictive of a lower patient and death-censored graft survival, while induction immunosuppressive therapy has a protective effect on patient survival. RLN is rare and does not influence the risk of graft loss.
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Affiliation(s)
- Joaquín Rodelo
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Luis Alonso González
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - José Ustáriz
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Silvia Matera
- Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Keylis Pérez
- Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Zoraida Ramírez
- Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Luis Fernando Arias
- Department of Pathology, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Álvaro García
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Division of Nephrology, Nefron Sas, Medellín, Colombia
| | - Mario Arbeláez
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Division of Nephrology, Nefron Sas, Medellín, Colombia
| | - Jorge Henao
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Universidad de Antioquia, 27983Universidad de Antioquia, Hospital Universitario San Vicente Fundación, Medellín, Colombia.,Division of Nephrology, Nefron Sas, Medellín, Colombia
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Kostopoulou M, Fanouriakis A, Cheema K, Boletis J, Bertsias G, Jayne D, Boumpas DT. Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations. RMD Open 2021; 6:rmdopen-2020-001263. [PMID: 32699043 PMCID: PMC7425195 DOI: 10.1136/rmdopen-2020-001263] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/08/2020] [Accepted: 05/22/2020] [Indexed: 01/24/2023] Open
Abstract
Objectives To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations. Methods According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012. Results We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500–700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b). Conclusions There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.
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Affiliation(s)
- Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece .,Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, Athens, Greece, and Medical School, University of Cyprus, Nicosia, Cyprus
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28
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Yafasova A, Fosbøl EL, Schou M, Baslund B, Faurschou M, Docherty KF, Jhund PS, McMurray JJV, Sun G, Kristensen SL, Torp-Pedersen C, Køber L, Butt JH. Long-Term Cardiovascular Outcomes in Systemic Lupus Erythematosus. J Am Coll Cardiol 2021; 77:1717-1727. [PMID: 33832598 DOI: 10.1016/j.jacc.2021.02.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Data on long-term cardiovascular outcomes in systemic lupus erythematosus (SLE) are sparse. OBJECTIVES This study sought to examine the long-term risk and prognosis associated with cardiovascular outcomes, including heart failure (HF), in patients with SLE. METHODS Using Danish administrative registries, risks of outcomes were compared between SLE patients (diagnosed 1996 to 2018, no history of cardiovascular disease) and age-, sex-, and comorbidity-matched control subjects from the background population (matched 1:4). Furthermore, mortality following HF diagnosis was compared between SLE patients developing HF and age- and sex-matched non-SLE control subjects with HF (matched 1:4). RESULTS A total of 3,411 SLE patients (median age: 44.6 years [25th to 75th percentile: 31.9 to 57.0 years]; 14.1% men) were matched with 13,644 control subjects. The median follow-up was 8.5 years (25th to 75th percentile: 4.0 to 14.4 years). Absolute 10-year risks of outcomes were: HF, 3.71% (95% confidence interval [CI]: 3.02% to 4.51%) for SLE patients, 1.94% (95% CI: 1.68% to 2.24%) for control subjects; atrial fibrillation, 4.35% (95% CI: 3.61% to 5.18%) for SLE patients, 2.82% (95% CI: 2.50% to 3.16%) for control subjects; ischemic stroke, 3.75% (95% CI: 3.06% to 4.54%) for SLE patients, 1.92% (95% CI: 1.66% to 2.20%) for control subjects; myocardial infarction, 2.17% (95% CI: 1.66% to 2.80%) for SLE patients, 1.49% (95% CI: 1.26% to 1.75%) for control subjects; venous thromboembolism, 6.03% (95% CI: 5.17% to 6.98%) for SLE patients, 1.68% (95% CI: 1.44% to 1.95%) for control subjects; and the composite of implantable cardioverter-defibrillator implantation/ventricular arrhythmias/cardiac arrest, 0.89% (95% CI: 0.58% to 1.31%) for SLE patients, 0.30% (95% CI: 0.20% to 0.43%) for control subjects. SLE with subsequent HF was associated with higher mortality compared with HF without SLE (adjusted hazard ratio: 1.50; 95% CI: 1.08 to 2.08). CONCLUSIONS SLE patients had a higher associated risk of HF and other cardiovascular outcomes compared with matched control subjects. Among patients developing HF, a history of SLE was associated with higher mortality.
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Affiliation(s)
- Adelina Yafasova
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Bo Baslund
- Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mikkel Faurschou
- Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Guoli Sun
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Søren L Kristensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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29
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Bae S, Johnson M, Massie AB, Luo X, Haywood C, Lanzkron SM, Grams ME, Segev DL, Purnell TS. Mortality and Access to Kidney Transplantation in Patients with Sickle Cell Disease-Associated Kidney Failure. Clin J Am Soc Nephrol 2021; 16:407-414. [PMID: 33632759 PMCID: PMC8011008 DOI: 10.2215/cjn.02720320] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 01/21/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients with sickle cell disease-associated kidney failure have high mortality, which might be lowered by kidney transplantation. However, because they show higher post-transplant mortality compared with patients with other kidney failure etiologies, kidney transplantation remains controversial in this population, potentially limiting their chance of receiving transplantation. We aimed to quantify the decrease in mortality associated with transplantation in this population and determine the chance of receiving transplantation with sickle cell disease as the cause of kidney failure as compared with other etiologies of kidney failure. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Using a national registry, we studied all adults with kidney failure who began maintenance dialysis or were added to the kidney transplant waiting list in 1998-2017. To quantify the decrease in mortality associated with transplantation, we measured the absolute risk difference and hazard ratio for mortality in matched pairs of transplant recipients versus waitlisted candidates in the sickle cell and control groups. To compare the chance of receiving transplantation, we estimated hazard ratios for receiving transplantation in the sickle cell and control groups, treating death as a competing risk. RESULTS Compared with their matched waitlisted candidates, 189 transplant recipients with sickle cell disease and 220,251 control recipients showed significantly lower mortality. The absolute risk difference at 10 years post-transplant was 20.3 (98.75% confidence interval, 0.9 to 39.8) and 19.8 (98.75% confidence interval, 19.2 to 20.4) percentage points in the sickle cell and control groups, respectively. The hazard ratio was also similar in the sickle cell (0.57; 95% confidence interval, 0.36 to 0.91) and control (0.54; 95% confidence interval, 0.53 to 0.55) groups (interaction P=0.8). Nonetheless, the sickle cell group was less likely to receive transplantation than the controls (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.61 to 0.87). Similar disparities were found among waitlisted candidates (subdistribution hazard ratio, 0.62; 95% confidence interval, 0.53 to 0.72). CONCLUSIONS Patients with sickle cell disease-associated kidney failure exhibited similar decreases in mortality associated with kidney transplantation as compared with those with other kidney failure etiologies. Nonetheless, the sickle cell population was less likely to receive transplantation, even after waitlist registration.
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Affiliation(s)
- Sunjae Bae
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Morgan Johnson
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland,Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
| | - Allan B. Massie
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Xun Luo
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Carlton Haywood
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland,Sickle Cell Center for Adults, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sophie M. Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland,Sickle Cell Center for Adults, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Morgan E. Grams
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dorry L. Segev
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Tanjala S. Purnell
- Division of Transplantation, Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland,Johns Hopkins Center for Health Equity, Johns Hopkins University, Baltimore, Maryland
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Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with extreme heterogeneity and potentially involvement of any organ or system. Numerous unanswered questions and challenges in SLE always prompt further exploration. In 2019, great progress in various aspects of SLE emerged. Both the classification criteria and management recommendation for SLE were updated. New promising medications have been widely developed and tested, although subsequent clinical studies are warranted. As an emerging number of most notable studies in SLE were published in both clinical area and basic research in 2019, we aim to summarize the highest quality data on SLE regarding novel insights of pathogenesis, updated recommendations, hot-spot issues on clinical manifestations, new understanding of disease prognosis, and most importantly, the therapeutic advances in SLE in this review.
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Affiliation(s)
- Yong Fan
- Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing 100034, China
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31
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Abstract
PURPOSE OF REVIEW The management of lupus nephritis remains unsatisfactory due to insufficiently effective treatment regimens and the dearth of reliable predictors of disease onset or progression to guide individualized therapeutic decisions. This review summarizes new findings related to lupus nephritis over the last 18 months and discusses clinical needs that should be considered to advance trials of mechanism-based therapeutic strategies. RECENT FINDINGS Collaborative teams are addressing how to improve disease definitions and are developing predictive models for disease onset, disease response and risk of flare in individual patients. More attention is being paid to clinical trial design. Advanced technologic approaches are allowing the analysis of small amounts of human tissue and urine in unprecedented detail so as to discover new pathogenic mechanisms and identify disease biomarkers. Novel therapies continue to be tested in disease models and include new strategies to protect renal tissue from cell damage and fibrosis. SUMMARY The collaborative efforts of patients, clinical and translational researchers, the pharmaceutical industry and funding sources are needed to advance therapies for lupus nephritis. Specialized clinical centers can then deliver optimal and more personalized patient care that will improve patient outcomes.
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32
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Abstract
PURPOSE OF REVIEW Update on the diagnosis, treatment, and monitoring of lupus nephritis. RECENT FINDINGS The recent criteria enable the earlier classification of lupus nephritis based on kidney biopsy and compatible serology. Treatment of active nephritis includes low-dose intravenous cyclophosphamide or mycophenolate, followed by maintenance immunosuppression. Recent trials have suggested superiority of regimens combining mycophenolate with either calcineurin inhibitor or belimumab, although their long-term benefit/risk ratio has not been determined. Encouraging results with novel anti-CD20 antibodies confirm the effectiveness of B cell depletion. Achievement of low-grade proteinuria (< 700-800 mg/24 h) at 12-month post-induction is linked to favorable long-term outcomes and could be considered in a treat-to-target strategy. Also, repeat kidney biopsy can guide the duration of maintenance immunosuppression. Lupus nephritis has increased cardiovascular disease burden necessitating risk-reduction strategies. An expanding spectrum of therapies coupled with ongoing basic/translational research can lead to individualized medical care and improved outcomes in lupus nephritis.
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Affiliation(s)
- Myrto Kostopoulou
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Christina Adamichou
- 4th Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, 71008 Voutes-Stavrakia, Heraklion, Greece
| | - George Bertsias
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, 71008 Voutes-Stavrakia, Heraklion, Greece.
- Laboratory of Rheumatology, Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology-FORTH, Heraklion, Greece.
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33
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Fanouriakis A, Kostopoulou M, Cheema K, Anders HJ, Aringer M, Bajema I, Boletis J, Frangou E, Houssiau FA, Hollis J, Karras A, Marchiori F, Marks SD, Moroni G, Mosca M, Parodis I, Praga M, Schneider M, Smolen JS, Tesar V, Trachana M, van Vollenhoven RF, Voskuyl AE, Teng YKO, van Leew B, Bertsias G, Jayne D, Boumpas DT. 2019 Update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis. Ann Rheum Dis 2020; 79:713-723. [PMID: 32220834 DOI: 10.1136/annrheumdis-2020-216924] [Citation(s) in RCA: 404] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN). METHODS Following the EULAR standardised operating procedures, a systematic literature review was performed. Members of a multidisciplinary Task Force voted independently on their level of agreeement with the formed statements. RESULTS The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNIs) and management of end-stage kidney disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7 g/24 hours with (near-)normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3 g/day or mycophenolic acid (MPA) at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500 mg × 6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5 mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1 g/24 hours despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations. Treatment of LN in children follows the same principles as adult disease. CONCLUSIONS We have updated the EULAR recommendations for the management of LN to facilitate homogenization of patient care.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital LMU Munich, Munich, Germany
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - John Boletis
- Nephrology Department and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Eleni Frangou
- Department of Nephrology, Limassol General Hospital, Limassol, Cyprus
| | - Frederic A Houssiau
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Jane Hollis
- Lupus nurse specialist, Addenbrooke's Hospital, Cambridge, UK
| | - Adexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Stephen D Marks
- University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Manuel Praga
- Nephrology Department, Research Institute Hospital Universitario 12 de Octubre (i+12), Department of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Duesseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Maria Trachana
- Pediatric Immunology and Rheumatology Referral Center, First Pediatric Clinic, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Y K Onno Teng
- Centre of expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece .,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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Romero Karam LA, Patel AM, Truong L, Gonzalez JM. A Case Report of Recurrent Lupus Nephritis 15 Days After Renal Transplantation. Transplant Proc 2020; 52:614-618. [PMID: 32057496 DOI: 10.1016/j.transproceed.2019.10.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/23/2019] [Accepted: 10/18/2019] [Indexed: 10/25/2022]
Abstract
Renal transplantation is an ever-growing therapeutic option for patients with end-stage renal disease due to lupus nephritis. Outcomes for these patients are comparable to those of patients receiving renal transplantation for other causes. A known complication for these patients is recurrence of lupus nephritis in the renal graft (recurrent lupus nephritis [RLN]). Although disease severity at the time of recurrence is usually milder, a small number of cases have been reported to progress to allograft failure. There is a trend toward preemptive renal transplantation in patients with lupus nephritis, as more favorable outcomes have been observed with this treatment modality. While clinicians usually seek clinical remission of lupus prior to proceeding with renal transplantation, no guidelines are established regarding how often to check for serologic activity of lupus in patients with end-stage renal disease due to lupus nephritis and whether these serologic markers should be taken into account when deciding on the timing of transplantation. We present a case of early RLN co-occurring with acute cellular rejection 15 days after renal transplantation. The patient had been in clinical remission for more than 5 months prior to transplantation but had a rise in anti-double-stranded DNA antibody titers and a decrease in complement C3 level at the time of surgery. Although additional studies are needed to establish the extent to which serologic markers of lupus correlate with renal graft dysfunction, this case suggests hypocomplementemia and high double-stranded DNA antibody titers may be a risk factor for early RLN.
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Affiliation(s)
| | - Amol M Patel
- Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Luan Truong
- Department of Anatomic, Clinical, and Laboratory Pathology, Houston Methodist Hospital, Houston, Texas
| | - Juan M Gonzalez
- Department of Nephrology, Transplant Nephrology, Houston Methodist Hospital, Houston, Texas
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Carrión-Barberà I, Fajardo M, Danias G, Tsapepas D, Gartshteyn Y, Fernandez H, Askanase A. Belatacept in kidney transplant patients with systemic lupus erythematosus. Lupus Sci Med 2019; 6:e000355. [PMID: 31908816 PMCID: PMC6928461 DOI: 10.1136/lupus-2019-000355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/31/2019] [Accepted: 12/07/2019] [Indexed: 11/04/2022]
Abstract
Objectives Lupus nephritis (LN) requires renal replacement therapy in 10%-30% of patients. About 30% of these patients receive a kidney transplant. Belatacept is a second-generation, selective, T-cell co-stimulator blocker (inhibits cytotoxic, T-lymphocyte antigen 4, CTLA-4) used as an alternative to calcineurin inhibitors (CNI) for maintenance regimens after kidney transplantation. The pathogenic relevance of CTLA-4 inhibition and the favourable cardiovascular profile of belatacept make it an attractive therapeutic option in systemic lupus erythematosus (SLE). Intravenous administration of belatacept ensures therapeutic adherence. Methods This retrospective, single-centre study evaluates the outcomes of LN kidney transplant recipients treated with belatacept for reasons not related to SLE at the Columbia University Lupus and Renal Transplant Cohort. Results Belatacept was started in six patients on CNI regimens at 15.5±17.1 months following transplantation for LN. In five patients, creatinine levels stabilised 6 months after belatacept, one returned to haemodialysis due to CNI toxicity and pyelonephritis and one relisted for a kidney transplant following acute cellular rejection and cortical necrosis. Five patients are followed for extrarenal lupus; no extrarenal manifestations were documented in the other two patients. Data on SLE disease activity pre-belatacept and post-belatacept were available and scored in three patients using the SLE Disease Activity Index Glucocorticosteroid Index (SLEDAI-2KG), which accounts for clinical and laboratory manifestations, as well as steroid dose. Mean SLEDAI-2KG decreased from 13 to 7.6. Conclusion Belatacept in LN kidney transplant recipients may decrease extrarenal manifestations, attenuate CNI toxicity and stabilise allograft function, providing a better alternative to CNI regimens. Furthermore, these data suggest that belatacept, although initiated for reasons not related to SLE, might have a beneficial effect in SLE.
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Affiliation(s)
| | - Melissa Fajardo
- Department of Nephrology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - George Danias
- Department of Rheumatology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Demetra Tsapepas
- Department of Nephrology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Yevgeniya Gartshteyn
- Department of Rheumatology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Hilda Fernandez
- Department of Nephrology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
| | - Anca Askanase
- Department of Rheumatology, NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, New York, USA
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36
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Barete S. Quoi de neuf en médecine interne ? Ann Dermatol Venereol 2019; 146:12S24-12S31. [DOI: 10.1016/s0151-9638(20)30103-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Falasinnu T, O'Shaughnessy MM, Troxell ML, Charu V, Weisman MH, Simard JF. A review of non-immune mediated kidney disease in systemic lupus erythematosus: A hypothetical model of putative risk factors. Semin Arthritis Rheum 2019; 50:463-472. [PMID: 31866044 DOI: 10.1016/j.semarthrit.2019.10.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/08/2019] [Accepted: 10/30/2019] [Indexed: 12/13/2022]
Abstract
About half of patients with systemic lupus erythematosus (SLE) are diagnosed with lupus nephritis (LN). Patients with SLE are also at increased risk for diabetes, hypertension and obesity, which together account for >70% of end-stage renal disease in the general population. The frequencies of non-LN related causes of kidney disease, and their contribution to kidney disease development and progression among patients with SLE have been inadequately studied. We hypothesize that a substantial, and increasing proportion of kidney pathology in patients with SLE might not directly relate to LN but instead might be explained by non-immune mediated factors such as diabetes, hypertension, and obesity. The goal of the manuscript is to draw attention to hypertension, diabetes and obesity as potential alternative causes of kidney damage in patients with SLE. Further, we suggest that misclassification of kidney disease etiology in patients with SLE might have important ramifications for clinical trial recruitment, epidemiologic investigation, and clinical care. Future studies aiming to elucidate and distinguish discrete causes of kidney disease - both clinically and histologically - among patients with SLE are desperately needed as improved understanding of disease mechanisms is paramount to advancing therapeutic discovery. Collaboration among rheumatologists, pathologists, nephrologists, and endocrinologists, and the availability of dedicated research funding, will be critical to the success of such efforts.
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Affiliation(s)
- Titilola Falasinnu
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane Stanford, Palo Alto, CA 94305, United States
| | | | - Megan L Troxell
- Department of Pathology, Stanford University Medical Center, Palo Alto, CA. United States
| | - Vivek Charu
- Department of Pathology, Stanford University Medical Center, Palo Alto, CA. United States
| | - Michael H Weisman
- Division of Rheumatology, Cedars-Sinai Medical Center, David Geffen School of Medicine, UCLA, United States
| | - Julia F Simard
- Department of Health Research and Policy, Stanford University School of Medicine, 150 Governor's Lane Stanford, Palo Alto, CA 94305, United States; Division of Immunology and Rheumatology, Stanford University, Palo Alto, CA, United States.
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Tanaka A, Kono H, Leung PSC, Gershwin ME. Recurrence of disease following organ transplantation in autoimmune liver disease and systemic lupus erythematosus. Cell Immunol 2019; 347:104021. [PMID: 31767117 DOI: 10.1016/j.cellimm.2019.104021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/15/2022]
Abstract
Disease recurrence after organ transplantation associated with graft failure is a major clinical challenge in autoimmune diseases. Primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC) and autoimmune Hepatitis (AIH) are the three most common (autoimmune liver diseases) ALD for which liver transplantation (LT) is the most effective treatment option for patients with end-stage diseases. Although the 5- and 10-year survival rates of post-LT patients are remarkable (80-84% and 71-79% in PBC, 73-87% and 58-83% in PSC, 76-79% and 67-77% respectively in AIH patients), post-LT disease recurrence is not uncommon. Here, we summarize literature findings on disease recurrence of these ALD with emphasis on the incidence, risk factors and impact on long-term outcome. We noted that the incidence of disease recurrence varies between studies, which ranges from 53% to 10.9% in PBC, 8.2% to 44.7% in PSC and 7% to 42% in AIH. The variations are likely due to differences in study design, such as sample size, duration of studies and follow up time. This is further compounded by the lack of precise clinical diagnosis criteria and biomarkers of disease recurrence in these ALD, variation in post-LT treatment protocols to prevent disease recurrence and a multitude of risk factors associated with these ALD. While recurrence of PBC and AIH does not significantly impact long term outcome including overall survival, recurrent PSC patients often require another LT. Renal transplantation, like LT, is the treatment of choice in patients with end-stage lupus nephritis. While calcineurin inhibitor (CNI) and immunosuppressive drugs have improved the survival rate, post-transplant recurrence of lupus nephritis from surveillance-biopsy proven lupus nephritis range from 30% to 44%. On the other hand, recurrence of post-transplant lupus nephritis from registry survey analysis were only 1.1% to 2.4%. In general, risk factors associated with an increased frequency of post-transplant recurrence of autoimmune diseases are not clearly defined. Large scale multi-center studies are needed to further define guidelines for the diagnosis and clinical management to minimize disease recurrence and improve outcomes of post-transplant patients.
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Affiliation(s)
- Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Hajime Kono
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Patrick S C Leung
- Division of Rheumatology Allergy and Clinical Immunology, University of California School of Medicine, Davis, CA, United States
| | - M Eric Gershwin
- Division of Rheumatology Allergy and Clinical Immunology, University of California School of Medicine, Davis, CA, United States.
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39
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Lee IJ, Parikh SV. Lupus Nephritis: How Far Have We Come, and Where Are We Headed? Adv Chronic Kidney Dis 2019; 26:311-312. [PMID: 31733714 DOI: 10.1053/j.ackd.2019.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/17/2019] [Indexed: 11/11/2022]
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40
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Avasare RS, Yee J. Lupus Nephritis: Breaking the Lull. Adv Chronic Kidney Dis 2019; 26:307-310. [PMID: 31733713 DOI: 10.1053/j.ackd.2019.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 11/11/2022]
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Wong T, Goral S. Lupus Nephritis and Kidney Transplantation: Where Are We Today? Adv Chronic Kidney Dis 2019; 26:313-322. [PMID: 31733715 DOI: 10.1053/j.ackd.2019.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 06/03/2019] [Accepted: 08/09/2019] [Indexed: 12/12/2022]
Abstract
Lupus nephritis (LN) is the cause of end-stage kidney disease (ESKD) for 1.9% of the ESKD population in the United States. Although the incidence rates of ESKD from LN stopped rising in recent years, racial disparities in waiting time, pre-emptive kidney transplant, and transplant outcomes still exist. Patients with LN who progress to ESKD tend to be female, of African ancestry, and young. Kidney transplantation is safe in this population and associated with a substantial survival benefit, primarily due to reduced deaths from cardiovascular disease and infection. Transplant outcomes for patients with ESKD due to LN are similar to those without LN.
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Goyal N, Weiner DE, Levey AS. Kidney Transplantation in Lupus Nephritis: Can We Do Even Better? Ann Intern Med 2019; 170:266-267. [PMID: 30665233 DOI: 10.7326/m18-3721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Nitender Goyal
- Tufts Medical Center, Boston, Massachusetts (N.G., D.E.W., A.S.L.)
| | - Daniel E Weiner
- Tufts Medical Center, Boston, Massachusetts (N.G., D.E.W., A.S.L.)
| | - Andrew S Levey
- Tufts Medical Center, Boston, Massachusetts (N.G., D.E.W., A.S.L.)
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