Sage Journals: Discover world-class research

Abstract

Background

Few data are available about the rate of short-term remission and its impact on the long-term outcomes of proliferative lupus nephritis in the Middle East.

Methods

An observational study was carried out involving 96 adult patients with biopsy-proven focal or diffuse proliferative lupus nephritis (PLN) from four different hospitals. Data on induction, remission and long-term outcomes were collected and analyzed.

Results

Among the 96 patients with biopsy-proven PLN (median age 27 (IQR: 21,34) years, 85% women and median duration of systemic lupus erythematosus (SLE) prior to diagnosis 27 (IQR: 11, 55) months), 67% developed remission at 6 months (proportion 0.67; 95% CI 0.57, 0.76). Mycophenolate mofetil (MMF) was used in 45/96 (47%), CYC in 41/95 (43%) and other agents in 10/96 (10%). The choice of MMF as induction agent has increased in recent years. Among baseline characteristics, only histologic activity was found to have a significant association with remission, with active lesions more likely to remit than active/chronic and chronic lesions (AOR 6.5, 95% CI 1.44–29.39, p = 0.015). Based on Kaplan–Meier analysis, the 5-year renal survival rate without doubling serum creatinine was 73.8%. Compared to patients with complete remission, lower long-term renal survival rates were observed in patients with no remission (89.7 versus 43%, p = 0.001) and partial remission (89.7 versus 77.6%, p = 0.256). The cumulative rate of doubling serum creatinine, dialysis, relapse and death was 23%, 11%, 10% and 5%, respectively, at 48-month median follow up.

Conclusion

Approximately two-thirds of patients with PLN develop remission in response to standard induction therapy. Remission was negatively associated with the presence of chronic changes in renal biopsy. Overall, MMF is the most commonly used agent to induce remission; however, with more severe disease CYC, is used more frequently. PLN is associated with significant long-term renal outcomes including a 26% cumulative rate of doubling of serum creatinine at 5 years. Initial remission predicts this long-term renal survival.

Keywords

Long-term renal survival lupus nephritis lupus remission proliferative lupus nephritis

Get full access to this article

View all access options for this article.

References

Korbet

Schwartz

Evans

Lewis

Group

. Severe lupus nephritis: racial differences in presentation and outcome. J Am Soc Nephrol 2007; 18(1): 244–254.

Burgos

McGwin

Pons-Estel

Reveille

Alarcón

Vilá

. US patients of Hispanic and African ancestry develop lupus nephritis early in the disease course: data from LUMINA, a multiethnic US cohort (LUMINA LXXIV). Ann Rheum Dis 2011; 70(2): 393–393.

Contreras

Lenz

Pardo

, et al. Outcomes in African Americans and Hispanics with lupus nephritis. Kidney Int 2006; 69(10): 1846–1851.

Feldman

Hiraki

Liu

, et al. Epidemiology and sociodemographics of systemic lupus erythematosus and lupus nephritis among US adults with Medicaid coverage, 2000–2004. Arthritis Rheumatol 2013; 65(3): 753–763.

Pons-Estel

Catoggio

Cardiel

, et al. Lupus in Latin-American patients: lessons from the GLADEL cohort. Lupus 2015; 24(6): 536–545.

Cervera

Font

Shoenfeld

. Erythematosus EWPoSL. European working party on systemic lupus erythematosus: a 15-year report. Autoimm Rev 2006; 5(8): 549–553.

Osio-Salido

Manapat-Reyes

. Epidemiology of systemic lupus erythematosus in Asia. Lupus 2010; 19(12): 1365–1373.

Abid

Khan

Otaibi

FHA

. Systemic lupus erythematosus (SLE) in the eastern region of Saudi Arabia. A comparative study. Lupus 2013; 22(14): 1529–1533.

Al Arfaj

Khalil

. Clinical and immunological manifestations in 624 SLE patients in Saudi Arabia. Lupus 2009; 18(5): 465–473.

10.

Al Arfaj

Khalil

Al Saleh

. Lupus nephritis among 624 cases of systemic lupus erythematosus in Riyadh, Saudi Arabia. Rheumatol Int 2009; 29(9): 1057–1067.

11.

Heller

Ahmed

Siddiqqi

Wallrauch

Bahlas

. Systemic lupus erythematosus in Saudi Arabia: morbidity and mortality in a multiethnic population. Lupus 2007; 16(11): 908–914.

12.

Qari

. Clinical pattern of systemic lupus erythematosus in Western Saudi Arabia. Saudi Med J 2002; 23(10): 1247–1250.

13.

Dhir

Aggarwal

Lawrence

Agarwal

Misra

. Long-term outcome of lupus nephritis in Asian Indians. Arthritis Care Res 2012; 64(5): 713–720.

14.

Seshan

Jennette

. Renal disease in systemic lupus erythematosus with emphasis on classification of lupus glomerulonephritis: advances and implications. Archiv Pathol Lab Med 2009; 133(2): 233–248.

15.

Weening

D'agati

Schwartz

, et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. Kidney Int 2004; 65(2): 521–530.

16.

Khan

Abid

Khawaja

. Clinical continuum of systemic lupus in Saudi Arabia. Lupus Open Access 2016; 1(113): 2–2.

17.

Chen

Korbet

Katz

Schwartz

Lewis

Group

. Value of a complete or partial remission in severe lupus nephritis. Clin J Am Soc Nephrol 2008; 3(1): 46–53.

18.

Moroni

Quaglini

Gallelli

Banfi

Messa

Ponticelli

. The long-term outcome of 93 patients with proliferative lupus nephritis. Nephrol Dial Transplant 2007; 22(9): 2531–2539.

19.

Boumpas

Balow

. Outcome criteria for lupus nephritis trials: a critical overview. Lupus 1998; 7(9): 622–629.

20.

Chan

Tse

Tang

Lai

. Long-term outcome of patients with diffuse proliferative lupus nephritis treated with prednisolone and oral cyclophosphamide followed by azathioprine. Lupus 2005; 14(4): 265–272.

21.

Cortés-Herández

Ordi-Ros

Labrador

, et al. Predictors of poor renal outcome in patients with lupus nephritis treated with combined pulses of cyclophosphamide and methylprednisolone. Lupus 2003; 12(4): 287–296.

22.

Fraenkel

MacKenzie

Joseph

Kashgarian

Hayslett

Esdaile

. Response to treatment as a predictor of longterm outcome in patients with lupus nephritis. J Rheumatol 1994; 21(11): 2052–2057.

23.

Houssiau

Vasconcelos

D'cruz

, et al. Early response to immunosuppressive therapy predicts good renal outcome in lupus nephritis: lessons from long-term followup of patients in the Euro-Lupus Nephritis Trial. Arthritis Rheum 2004; 50(12): 3934–3940.

24.

Illei

Takada

Parkin

, et al. Renal flares are common in patients with severe proliferative lupus nephritis treated with pulse immunosuppressive therapy: Long-term followup of a cohort of 145 patients participating in randomized controlled studies. Arthritis Rheum 2002; 46(4): 995–1002.

25.

Korbet

Lewis

Schwartz

Reichlin

Evans

Rohde

. Factors predictive of outcome in severe lupus nephritis. Am J Kidney Dis 2000; 35(5): 904–914.

26.

Mok

CTK

Chan

Lau

Wong

RWS

. Outcome and prognostic indicators of diffuse proliferative lupus glomerulonephritis treated with sequential oral cyclophosphamide and azathioprine. Arthritis Rheum 2002; 46(4): 1003–1013.

27.

Koo

Kim

Chin

. Remission of proteinuria indicates good prognosis in patients with diffuse proliferative lupus nephritis. Lupus 2016; 25(1): 3–11.

28.

Zakharova

Makarova

Zvonova

Anilina

Stolyarevich

. Immunosuppressive treatment for lupus nephritis: long-term results in 178 patients. BioMed Res Int 2016; 2016: 1–7.

29.

Appel

Contreras

Dooley

, et al. Mycophenolate mofetil versus cyclophosphamide for induction treatment of lupus nephritis. J Am Soc Nephrol 2009; 20(5): 1103–1112.

30.

Martins

Rocha

Rodrigues

, et al. Lupus nephritis: a retrospective review of 78 cases from a single center. Clin Nephrol 2002; 57(2): 114–119.

31.

Grootscholten

Ligtenberg

Hagen

, et al. Azathioprine/methylprednisolone versus cyclophosphamide in proliferative lupus nephritis. A randomized controlled trial. Kidney Int 2006; 70(4): 732–742.

32.

Singh

Saxena

Zhou

Ahn

. A retrospective analysis of clinical presentation of lupus nephritis. Am J Med Sci 2011; 342(6): 467–473.

33.

Ruiz Irastorza

Espinosa

Frutos

, et al. Diagnosis and treatment of lupus nephritis. Consensus document from the systemic auto-immune disease group (GEAS) of the Spanish Society of Internal Medicine (SEMI) and the Spanish Society of Nephrology (SEN). Nefrología (English Edition) 2012; 32: 1–35.

34.

Moroni

Quaglini

Maccario

Banfi

Ponticelli

. “Nephritic flares” are predictors of bad long-term renal outcome in lupus nephritis. Kidney Int 1996; 50(6): 2047–2053.

35.

AlMatham

AlFayez

AlHarthi

, et al. Glomerulonephritis disease pattern at Saudi tertiary care center. Saudi Med J 2017; 38(11): 1113–1113.

36.

Alsuwaida

Husain

Al Ghonaim

, et al. Glomerular necrotic lesions and long-term outcomes among patients with proliferative lupus nephritis. Int J Clin Exp Pathol 2015; 8(5): 5787–5787.

37.

Appel

Cohen

Pirani

Meltzer

Estes

. Long-term follow-up of patients with lupus nephritis: a study based on the classification of the World Health Organization. Am J Med 1987; 83(5): 877–885.

38.

Austin

III Boumpas

Vaughan

Balow

. Predicting renal outcomes in severe lupus nephritis: contributions of clinical and histologic data. Kidney Int 1994; 45(2): 544–550.

39.

Schwartz

Bernstein

Hill

Holley

Phillips

. Predictive value of renal pathology in diffuse proliferative lupus glomerulonephritis. Kidney Int 1989; 36(5): 891–896.

40.

Davidson

, et al. Renal remission status and longterm renal survival in patients with lupus nephritis: a retrospective cohort analysis. J Rheumatol 2018. jrheum. 161554.

41.

Durahim

Ghamdi

Seraya

Alkhiari

Sayyari

. Predictors of mortality and end stage renal disease in Saudi patients with lupus nephritis. Lupus 2011; 20(12): 1329–1335.

42.

Korbet

Lewis

. Complete remission in severe lupus nephritis: assessing the rate of loss in proteinuria. Nephrol Dial Transplant 2011; 27(7): 2813–2819.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.50 MB

Remission and long-term outcomes of proliferative lupus nephritis: retrospective study of 96 patients from Saudi Arabia

Abstract

Background

Methods

Results

Conclusion

Keywords

Get full access to this article

References

Supplementary Material