Factors associated with poor outcomes in patients with lupus nephritis

Abstract

The objective of this study was to identify the factors associated with important clinical outcomes in a case-control study of 213 patients with lupus nephritis. Included were 47% Hispanics, 44% African Americans and 9% Caucasians with a mean age of 28 years. Fifty-four (25%) patients reached the primary composite outcome of doubling serum creatinine, end-stage renal disease or death during a mean follow-up of 37 months. Thirty-four percent African Americans, 20% Hispanics and 10% Caucasians reached the primary composite outcome (P < 0.05). Patients reaching the composite outcome had predominantly proliferative lupus nephritis (WHO classes: 30% III, 32% IV, 18% V and 5% II, P < 0.025) with higher activity index score (7 +/- 6 versus 5 +/- 5, P < 0.05), chronicity index (CI) score (4 +/- 3 versus 2 +/- 2 unit, P < 0.025), higher baseline mean arterial pressure (MAP) (111 +/- 21 versus 102 +/- 14 mmHg, P < 0.025) and serum creatinine (1.9 +/- 1.3 versus 1.3 +/- 1.0 mg/dL, P < 0.025), but lower baseline hematocrit (29 +/- 6 versus 31 + 5%, P < 0.025) and complement C3 (54 +/- 26 versus 65 + 33 mg/dL, P < 0.025) compared to controls. More patients reaching the composite outcome had nephrotic range proteinuria compared to controls (74% versus 56%, P < 0.025). By multivariate analysis, CI (hazard ratio [95% CI] 1.18 [1.07-1.30] per point), MAP (HR 1.02 [1.00-1.03] per mmHg), and baseline serum creatinine (HR 1.26 [1.04-1.54] per mg/dL) were independently associated with the composite outcome. We concluded that hypertension and elevated serum creatinine at the time of the kidney biopsy as well as a high CI are associated with an increased the risk for chronic renal failure or death in patients with lupus nephritis.

Outcome of reclassification of World Health Organization (WHO) class III under International Society of Nephrology-Renal Pathology Society (ISN-RPS) classification: retrospective observational study

“…The reclassified class IV LN had higher activity index on initial biopsy, poorer renal response after 1 year of treatment and inferior renal outcome during total followup period. The fact that the reclassified class IV LN group showed higher activity index but not chronicity index is inconsistent with previous reports that suggested poor outcomes associated with the presence of chronic lesions [8,13,14]. A possible explanation is that the initial renal biopsy was performed in very early stage of disease process in our institution.…”

Long‐term outcome of lupus nephritis in Asian Indians

“…This is contrary to the traditional view of a worse prognosis for proliferative nephritis, with an increasing risk from class I to class VI, with the exception of class V (28,29). Indeed, many studies have found proliferative lesions on biopsy or class IV to have a worse prognosis (2,8,10,30,31). However, there have been some studies that also did not find any differences in outcomes by class of nephritis (11,21,32).…”

Non-invasive imaging to monitor lupus nephritis and neuropsychiatric systemic lupus erythematosus

“…More than 50% of patients with SLE develop renal involvement during their lives 17 . SLE patients with LN have a higher mortality than those without renal involvement 18, 19 , but the prognosis among patients with LN varies widely 20 . Several histologic findings predict those patients whose disease is most likely to progress to renal failure 17 , and this has led to the development of histologic scoring systems.…”

“…The prognostic value of these systems has been validated, and the ISN/RPS system is now widely employed 21, 22 . Several clinical and laboratory findings are also of prognostic importance (such as hypertension, an elevated serum creatinine, and a low serum C3 level) 20 , but a renal biopsy is still considered essential for deciding whether a patient requires treatment 23 .…”