Characteristics of lupus nephritis in Saudi lupus patients: A retrospective observational study

Abstract

Objectives Systemic lupus erythematosus (SLE) is a chronic autoimmune multi-systemic disorder of the connective tissue, characterized mainly by involvement of the skin, joints, kidneys, and serosal membranes. It affects females particularly at childbearing age more commonly than males. Lupus nephritis affects around half of patients with SLE. Data about SLE and lupus nephritis in Saudi Arabia are still scarce. In this study, we aimed to evaluate the prevalence, clinical and laboratory findings of SLE and different histological types of lupus nephritis among Saudi patients at King Fahad Medical City. Methods This is a retrospective study for adult patients who have been evaluated at king Fahad medical city between 2014 and 2019 and fulfilled the Systemic Lupus International Collaborating Clinics classification criteria (SLICC). Results 112 patients, 103 (92%) females and 9 (8%) males, with confirmed diagnoses of SLE were reviewed. Skin rash (69.6%), photosensitivity (61.6%), mucosal ulcerations (45.9%), arthralgia and/or arthritis (44.6%) are the most common clinical features. Ninety seven (86.6%) out of 112 patients had a recorded first visit 24 hour urine protein level, out of those only 26 (23.2) patients presented with significant proteinuria of more than 0.5grams per day. Forty four (39.2%) have undergone kidney biopsy. Class IV and III lupus nephritis are the most common reported biopsy results (43.18% and 27.28% respectively). During the study period, three patients (2.7%) developed end-stage kidney disease requiring dialysis and five (4.5%) had renal transplant. Conclusion Our study provided insight on the demographics, characteristics and presentation of SLE patients and the outcome of lupus nephritis in Saudi Arabia.

Literature review of lupus nephritis From the Arabian Gulf region

“…Three separate Saudi Arabian studies showed that more patients were prescribed MMF (47%–75%) than CYC (18%–43%) as induction therapy. 40 – 42 The use of hydroxychloroquine was referenced in one of these studies, and was prescribed to all patients in the study population; this is consistent with current APLAR treatment recommendations. 13 , 40 Another study identified that 20% of patients who received induction therapy were prescribed a higher dose of CYC (NIH protocol) versus approximately 12% on a lower dose (Euro Lupus protocol).…”

“… 40 – 42 The use of hydroxychloroquine was referenced in one of these studies, and was prescribed to all patients in the study population; this is consistent with current APLAR treatment recommendations. 13 , 40 Another study identified that 20% of patients who received induction therapy were prescribed a higher dose of CYC (NIH protocol) versus approximately 12% on a lower dose (Euro Lupus protocol). 42 Separately, findings from a randomised clinical trial (RCT) in Saudi Arabia showed that the use of induction therapy of low-dose CYC (5 mg/kg) was as effective as a higher dose (10 mg/kg), resulting in similar rates of remission and fewer side effects in a Saudi Arabian patient population with Class IV LN.…”

“…Additionally, TAC has been used alone, and in combination with MMF and steroids, among 2.3% and 6.8% of patients as induction therapy, respectively. 40 Among patients from a Saudi Arabian hospital with Class II LN, 92% of patients were able to achieve complete remission with corticosteroids alone; however, the authors of this study recommend that more aggressive immunosuppressant treatment should be administered to patients with Class II LN with acute kidney injury. 44 …”

“… 35 , 38 , 39 , 48 , 50 , 51 However, MMF was prescribed most frequently in Saudi Arabia. 40 – 42 Use of hydroxychloroquine was rarely mentioned as a frequently prescribed medication in the studies referenced here. These practices are similar to those observed in Iran, where several studies have shown that most patients are prescribed CYC alone, 57 – 59 or in combination with MMF.…”

Lupus-related vasculitis in a cohort of systemic lupus erythematosus patients

“…[ 1 ] Although the pathogenesis of SLE has not been fully understood, loss of self-tolerance and activation of autoreactive T and B cells occurs, leading to the production of pathogenic autoantibodies and tissue injury that characterize the disease. [ 2 ] Vasculitis is inflammation of blood vessel wall,[ 3 ] characterized by infiltration of inflammatory cells and subsequent necrosis of vessel walls. [ 4 ] The term secondary vasculitis is used to describe inflammation of blood vessels occurring as a complication of underlying disease process (mainly systemic autoimmune diseases as SLE) or triggered by exogenous factors such as infection, drugs, or malignancy.…”