Severity of systemic lupus erythematosus with diffuse proliferative glomerulonephritis and the ineffectiveness of standard pulse intravenous cyclophosphamide therapy in Jamaican patients

Abstract

The majority of patients seen at the renal clinic of the University Hospital of the West Indies (UHWI) are of African descent. The case notes of patients with systemic lupus erythematosus (SLE) with class 4 nephritis and who were given standard pulse intravenous cyclophosphamide therapy during the period 1990-2000 were retrospectively reviewed. Primary outcomes were doubling of serum creatinine and development of end stage renal disease (ESRD). Secondary outcomes were return of proteinuria to normal and renal remission. A total of 117 patients had a renal biopsy for SLE nephritis at the UHWI between 1990 and 2000. Of the patients, 34 (29%) had diffuse proliferative glomerulonephritis (WHO class 4), of which 29 were reviewed. Twenty-two patients of 24 in whom it was measured (92%) had significant proteinuria at presentation. The 24-hour proteinuria was measured at final review in 16 patients and in 10 patients it went into complete remission. At the beginning of therapy, 24 patients (83%) had renal impairment. Of the 18 who had final creatinine values, the renal function returned to normal in eight patients (44%) and an additional six patients showed a significant improvement in renal function at final review. Six patients developed end stage renal disease (ESRD). The risk (95% confidence interval) of developing ESRD at one year was 16.2% (CI, 6.4-37.6) and at two years was 23.2% (CI, 10.0-48.5). There were three deaths, two from sepsis and one from heart failure. The one-year mortality (95% CI) was 8% (CI, 2.0-28.5), the two-year mortality was 15.6% (CI, 4.9-43.5) and the five-year mortality was also 15.6% (CI, 4.9-43.5). Intravenous pulse cyclophosphamide for Jamaican patients with SLE and diffuse proliferative glomerulonephritis is an ineffective form of treatment.

Lupus organ damage: what is damaged in Asian patients?

“…Asian patients were also reported to have predominantly proliferative glomerulonephritis on renal biopsy, leading to an increased risk of end-stage renal disease. 40,41 As discussed previously, Chinese patients from Hong Kong and Singapore had a higher prevalence of premature gonadal failure, attributable to the use of CYC for the treatment of severe lupus nephritis. 33 In contrast, azathioprine was used as the standard treatment for nephritis in the Toronto cohort, resulting in a low incidence of premature gonadal failure (1%).…”

Male systemic lupus erythematosus in a Latin-American inception cohort of 1214 patients

“…This data emphasizes the concept of severity associated with male sex, with a proven higher risk of developing chronic renal failure and lower survival of the patients. 21,22 It is important to point out that four out of the five dead male patients of the GLADEL cohort suffered from acute nephropathy and two of them required hemodialysis. In accordance with this data, a 1996 Chilean publication stressed the aggressive course of nephropathy in Chile compared with developed countries.…”

A comparative study of two intensified pulse cyclophosphamide remission-inducing regimens for diffuse proliferative lupus nephritis: an Egyptian experience

“…Differences in genetic factors between the Egyptian patients included in our study and the Jamaican patients who have African descent in that study [26] might be the explanation. It was previously hypothesized that SLE has an important genetic background [27], and it can be assumed that difference in the genetics of different populations may be responsible for the difference in clinical presentation and response to different therapeutic modalities.…”