Restricted accessResearch articleFirst published online 2025-4
Prognostic value of the modified National Institute of health activity and chronicity scoring system in predicting end-stage kidney disease in Latin American lupus nephritis patients
To assess the effectiveness of the modified National Institute of Health (mNIH) activity and chronicity scoring system in predicting the progression to end-stage kidney disease (ESKD) in Latin American lupus nephritis (LN) patients.
Methods
We retrospectively analyzed 412 patients with biopsy-proven LN. ESKD was defined as an estimated glomerular filtration rate (eGFR) < 15 mL/min/1.73 m2 for ≥3 months, dialysis for >3 months, or kidney transplant. Univariable and multivariable Cox proportional hazards regression analyses were performed to evaluate the predictive value of the mNIH activity and chronicity indices for ESKD.
Results
84 patients (20.4%) progressed to ESKD at a median of 3.0 months after biopsy. The mNIH activity and chronicity indices were significantly higher in patients who progressed to ESKD compared to those who did not [7 (5-10) versus 4 (1-7), p < .001; and 3 (1-5) versus 0 (0-2), p < .001, respectively]. Multivariable Cox regression analysis revealed that the mNIH activity index (HR 1.17, 95% CI 1.05-1.29), and the mNIH chronicity index (HR 1.21, 95% CI 1.05-1.40) were independently associated with a higher risk of ESKD, adjusting for age, sex, ethnicity, and eGFR. Furthermore, fibrinoid necrosis (HR 4.09, 95% CI 1.54-10.86) and fibrous crescents (HR 2.36; 95% CI 1.06-5.27), components of the activity and chronicity indices, respectively, were also associated with a shorter time to ESKD.
Conclusions
In Latin American LN patients, the mNIH activity and chronicity indices are associated with an increased risk of ESKD. Among the components of these indices, shorter time to ESKD was mainly driven by fibrinoid necrosis and fibrous crescents.
AndersHJSaxenaRZhaoMH, et al.Lupus nephritis. Nat Rev Dis Primers2020; 6(1): 7.
2.
CerveraRKhamashtaMAFontJ, et al.Morbidity and mortality in systemic lupus erythematosus during a 10-year period: a comparison of early and late manifestations in a cohort of 1,000 patients. Medicine (Baltim)2003; 82(5): 299–308.
3.
ParikhSVAlmaaniSBrodskyS, et al.Update on lupus nephritis: core curriculum 2020. Am J Kidney Dis2020; 76(2): 265–281.
4.
MahajanAAmelioJGairyK, et al.Systemic lupus erythematosus, lupus nephritis and end-stage renal disease: a pragmatic review mapping disease severity and progression. Lupus2020; 29(9): 1011–1020.
5.
TektonidouMGDasguptaAWardMM. Risk of end-stage renal disease in patients with lupus nephritis, 1971-2015: a systematic review and bayesian meta-analysis. Arthritis Rheumatol2016; 68(6): 1432–1441.
AustinHAMuenzLRJoyceKM, et al.Prognostic factors in lupus nephritis. Contribution of renal histologic data. Am J Med1983; 75(3): 382–391.
8.
AustinHAMuenzLRJoyceKM, et al.Diffuse proliferative lupus nephritis: identification of specific pathologic features affecting renal outcome. Kidney Int1984; 25(4): 689–695.
9.
AustinHABoumpasDTVaughanEM, et al.Predicting renal outcomes in severe lupus nephritis: contributions of clinical and histologic data. Kidney Int1994; 45(2): 544–550.
10.
ContrerasGPardoVCelyC, et al.Factors associated with poor outcomes in patients with lupus nephritis. Lupus2005; 14(11): 890–895.
11.
TangYQinWPengW, et al.Development and validation of a prediction score system in lupus nephritis. Medicine (Baltim)2017; 96(37): e8024.
12.
MoroniGPorataGRaffiottaF, et al.Beyond ISN/RPS lupus nephritis classification: adding chronicity index to clinical variables predicts kidney survival. Kidney2021; 3(1): 122–132.
13.
EsdaileJMAbrahamowiczMMacKenzieT, et al.The time-dependence of long-term prediction in lupus nephritis. Arthritis Rheum1994; 37(3): 359–368.
14.
Arce-SalinasCAVillaARMartínez-RuedaJO, et al.Factors associated with chronic renal failure in 121 patients with diffuse proliferative lupus nephritis: a case-control study. Lupus1995; 4(3): 197–203.
15.
RavinalRCCostaRSCoimbraTM, et al.Classes, activity and chronicity indices, and alpha-smooth muscle actin expression as prognostic parameters in lupus nephritis outcome. Lupus2002; 11(2): 82–87.
16.
HurtadoAAsatoCEscuderoE, et al.Clinicopathologic correlations in lupus nephritis in Lima, Peru. Nephron1999; 83(4): 323–330.
17.
SchwartzMMLanSPBernsteinJ, et al.Role of pathology indices in the management of severe lupus glomerulonephritis. Lupus Nephritis Collaborative Study Group. Kidney Int1992; 42(3): 743–748.
18.
WuLHYuFTanY, et al.Inclusion of renal vascular lesions in the 2003 ISN/RPS system for classifying lupus nephritis improves renal outcome predictions. Kidney Int2013; 83(4): 715–723.
19.
HsiehCChangABrandtD, et al.Predicting outcomes of lupus nephritis with tubulointerstitial inflammation and scarring. Arthritis Care Res2011; 63(6): 865–874.
20.
WeeningJJD'AgatiVDSchwartzMM, et al.The classification of glomerulonephritis in systemic lupus erythematosus revisited. Kidney Int2004; 65(2): 521–530.
21.
WeeningJJD'AgatiVDSchwartzMM, et al.The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol2004; 15(2): 241–250.
22.
RodeloJAguirreLOrtegónK, et al.Predicting kidney outcomes among Latin American patients with lupus nephritis: the prognostic value of interstitial fibrosis and tubular atrophy and tubulointerstitial inflammation. Lupus2023; 32(3): 411–423.
23.
WilsonPCKashgarianMMoeckelG. Interstitial inflammation and interstitial fibrosis and tubular atrophy predict renal survival in lupus nephritis. Clin Kidney J2018; 11(2): 207–218.
24.
Mejía-ViletJMCórdova-SánchezBMUribe-UribeNO, et al.Prognostic significance of renal vascular pathology in lupus nephritis. Lupus2017; 26(10): 1042–1050.
25.
LeatherwoodCSpeyerCBFeldmanCH, et al.Clinical characteristics and renal prognosis associated with interstitial fibrosis and tubular atrophy (IFTA) and vascular injury in lupus nephritis biopsies. Semin Arthritis Rheum2019; 49(3): 396–404.
26.
BajemaIMWilhelmusSAlpersCE, et al.Revision of the International Society of Nephrology/Renal Pathology Society classification for lupus nephritis: clarification of definitions, and modified National Institutes of Health activity and chronicity indices. Kidney Int2018; 93(4): 789–796.
27.
UmedaROgataSHaraS, et al.Comparison of the 2018 and 2003 International Society of Nephrology/Renal Pathology Society classification in terms of renal prognosis in patients of lupus nephritis: a retrospective cohort study. Arthritis Res Ther2020; 22(1): 260.
28.
TaoJWangHYuXJ, et al.A validation of the 2018 revision of international society of nephrology/renal pathology society classification for lupus nephritis: a cohort study from China. Am J Nephrol2020; 51(6): 483–492.
29.
NakagawaSToyamaTIwataY, et al.The relationship between the modified National Institute of Health activity and chronicity scoring system, and the long-term prognosis for lupus nephritis: a retrospective single-center study. Lupus2021; 30(11): 1739–1746.
30.
SinghSSreenidhiHC. Prognostic value of modified National Institute of Health activity and chronicity scoring in determining complete renal response in newly diagnosed lupus nephritis: a retrospective single centre study. Int Urol Nephrol2022; 54(8): 2075–2082.
31.
Zavala-MirandaMFPerez-AriasAAMárquez-MacedoSE, et al.Characteristics and outcomes of a Hispanic lupus nephritis cohort from Mexico. Rheumatology2023; 62(3): 1136–1144.
32.
PetriMOrbaiAMAlarcónGS, et al.Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum2012; 64(8): 2677–2686.
33.
BombardierCGladmanDDUrowitzMB, et al.Derivation of the SLEDAI. A disease activity index for lupus patients. The Committee on Prognosis Studies in SLE. Arthritis Rheum1992; 35: 630–640.
34.
LeveyASStevensLASchmidCH, et al.A new equation to estimate glomerular filtration rate. Ann Intern Med2009; 150: 604–612.
35.
Kidney Disease Improving Global Outcomes KDIGO Lupus Nephritis Work Group. KDIGO 2024 clinical practice guideline for the management of LUPUS NEPHRITIS. Kidney Int2024; 105(1S): S1–S69.
36.
YokoyamaHWadaTHaraA, et al.The outcome and a new ISN/RPS 2003 classification of lupus nephritis in Japanese. Kidney Int2004; 66(6): 2382–2388.
37.
HiramatsuNKuroiwaTIkeuchiH, et al.Revised classification of lupus nephritis is valuable in predicting renal outcome with an indication of the proportion of glomeruli affected by chronic lesions. Rheumatology2008; 47(5): 702–707.
38.
Duque de Sá Carneiro FilhoEJJorgeLBTestagrossaL, et al.Worse renal outcome of subclass IV-G lupus nephritis patients over IV-S. Lupus2018; 27(4): 584–590.
39.
OliveiraCMarizHFernandesG, et al.Lupus nephritis class IV-global is associated with a higher risk of end-stage renal disease than class IV-segmental. Nephron2020; 144(3): 118–125.
40.
RijninkECTengYKOWilhelmusS, et al.Clinical and histopathologic characteristics associated with renal outcomes in lupus nephritis. Clin J Am Soc Nephrol2017; 12(5): 734–743.
41.
ZhangWYuanMHongL, et al.Clinical outcomes of lupus nephritis patients with different proportions of crescents. Lupus2016; 25(14): 1532–1541.
42.
ParodisITamirouFHoussiauFA. Prediction of prognosis and renal outcome in lupus nephritis. Lupus Sci Med2020; 7(1): e000389.
43.
MoroniGRaffiottaFPonticelliC. Remission and withdrawal of therapy in lupus nephritis. J Nephrol2016; 29(4): 559–565.
44.
IlleiGGTakadaKParkinD, 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 Rheum2002; 46(4): 995–1002.
45.
GinzlerEMDooleyMAAranowC, et al.Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. N Engl J Med2005; 353(21): 2219–2228.
46.
ChenYEKorbetSMKatzRS, et al.Value of a complete or partial remission in severe lupus nephritis. Clin J Am Soc Nephrol2008; 3(1): 46–53.
47.
Pinto PeñarandaLFCastro MercadoILDuque CaballeroV, et al.Predictive risk factors for failure to induction therapy of lupus nephritis in a cohort of Colombian patients. Reumatol Clínica2014; 10(3): 147–151.
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