Risk of End‐Stage Renal Disease in Patients With Lupus Nephritis, 1971–2015: A Systematic Review and Bayesian Meta‐Analysis

Abstract

Objective End-stage renal disease (ESRD) is a major consequence of lupus nephritis, but how this risk has changed over time is unknown. We conducted this systematic review to examine changes in ESRD among adults with lupus nephritis from 1971 to 2015 and to estimate risks of ESRD among contemporary patients. Methods We searched PubMed, Embase, and the Cochrane Database of Systematic Reviews for cohort studies and clinical trials on ESRD in adults with lupus nephritis. We analyzed studies from developed and developing countries separately. The outcome was probability of ESRD at 5, 10, and 15 years of lupus nephritis. Results We included 187 articles that reported on 18,309 patients. In developed countries, the 5-year risk of ESRD decreased from 16% (95% confidence interval [95% CI] 14–17%) in 1970–1979 to 11% (95% CI 10–12%) in the mid-1990s and then plateaued. ESRD risks at 10 years and 15 years showed steeper declines in the 1970s and 1980s but also plateaued in 1993–1997, with a notable increase in the late 2000s. The decrease in risk after 1980 coincided with increased use of cyclophosphamide. The 15-year ESRD risk was higher in developing countries than in developed countries. Patients with class IV lupus nephritis had the greatest risk of ESRD, with a 15-year risk of 44% during the 2000s. Conclusion Risks of ESRD in lupus nephritis improved between the 1970s and the mid-1990s and then plateaued, with an increase in the late 2000s. This pattern suggests limitations in the effectiveness of, or access to, current treatments.

Update on Lupus Nephritis

“…The risk of ESRD is higher in certain subsets of LN. For example, in class 4 LN the risk may be as high as 44% over 15 years (27). Patients with LN also have a higher standardized mortality ratio (6-6.8 versus 2.4) and die earlier than SLE patients without LN (28)(29)(30)(31).…”

“…The increased exposure of LN patients to MMF has raised some concerns as to whether it is equivalent to cyclophosphamide induction with respect to longterm kidney outcomes (77). A recent meta-analysis showed that between the 1970s and the 1990s the risk of ESRD from LN declined and plateaued, and this was coincident with cyclophosphamide treatment becoming routine (27). In the 2000s, as MMF was becoming a dominant induction drug for LN, the risk of ESRD increased, and was highest at 44% over 15 years in patients with diffuse proliferative LN.…”

Childhood lupus nephritis: 12 years of experience from a developing country’s perspective

“…Renal involvement remains one of the important factors influencing management and long-term prognosis of pSLE (6)(7)(8)(9). There is some evidence that the prognosis of lupus nephritis in developing countries is worse than that in developed countries (10). Some studies from other parts of India have highlighted the long-term outcome in children with lupus nephritis (11,12), but there has been no detailed report from Eastern India.…”

The immune cell landscape in kidneys of lupus nephritis patients

“…Current immunosuppressive therapies for LN are both toxic and insufficiently effective, and a substantial number of patients progress to end stage renal disease and death 2,3 . Despite the rapid pace of immunologic discovery, most clinical trials of rationally designed therapies have failed in both general SLE and LN, and only one new drug has been approved for the treatment of SLE in the last 5 decades 2,4 .…”