Remission and long-term outcomes of proliferative lupus nephritis: retrospective study of 96 patients from Saudi Arabia

Abstract

Background Few data are available about the rate of short-term remission and its impact on the long-term outcomes of proliferative lupus nephritis in the Middle East. Methods An observational study was carried out involving 96 adult patients with biopsy-proven focal or diffuse proliferative lupus nephritis (PLN) from four different hospitals. Data on induction, remission and long-term outcomes were collected and analyzed. Results Among the 96 patients with biopsy-proven PLN (median age 27 (IQR: 21,34) years, 85% women and median duration of systemic lupus erythematosus (SLE) prior to diagnosis 27 (IQR: 11, 55) months), 67% developed remission at 6 months (proportion 0.67; 95% CI 0.57, 0.76). Mycophenolate mofetil (MMF) was used in 45/96 (47%), CYC in 41/95 (43%) and other agents in 10/96 (10%). The choice of MMF as induction agent has increased in recent years. Among baseline characteristics, only histologic activity was found to have a significant association with remission, with active lesions more likely to remit than active/chronic and chronic lesions (AOR 6.5, 95% CI 1.44–29.39, p = 0.015). Based on Kaplan–Meier analysis, the 5-year renal survival rate without doubling serum creatinine was 73.8%. Compared to patients with complete remission, lower long-term renal survival rates were observed in patients with no remission (89.7 versus 43%, p = 0.001) and partial remission (89.7 versus 77.6%, p = 0.256). The cumulative rate of doubling serum creatinine, dialysis, relapse and death was 23%, 11%, 10% and 5%, respectively, at 48-month median follow up. Conclusion Approximately two-thirds of patients with PLN develop remission in response to standard induction therapy. Remission was negatively associated with the presence of chronic changes in renal biopsy. Overall, MMF is the most commonly used agent to induce remission; however, with more severe disease CYC, is used more frequently. PLN is associated with significant long-term renal outcomes including a 26% cumulative rate of doubling of serum creatinine at 5 years. Initial remission predicts this long-term renal survival.

Predictors of Early Response, Flares, and Long-Term Adverse Renal Outcomes in Proliferative Lupus Nephritis: A 100-Month Median Follow-Up of an Inception Cohort

“…In our study, response to treatment was achieved early after induction treatment; 59% of patients had a renal response at 3 months (26% CR, 33% PR), 67% at 6 months (43% CR, 24% PR), 88% at 12 months (69%CR, 19% PR) and 88% (71% CR, 17% PR) at 2 years. These results are encouraging compared to previous studies reporting 33–50% CR at 6 months, 49–68% CR at 12 months, and 63% CR at 2 years [ 9 , 14 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ], although our population was predominantly Caucasian. Response to treatment has been associated with better long-term renal outcomes [ 25 , 26 , 27 , 28 ], with some studies reporting better renal survival in patients with CR than those with PR only [ 19 , 27 ].…”

“…Response to treatment has been associated with better long-term renal outcomes [ 25 , 26 , 27 , 28 ], with some studies reporting better renal survival in patients with CR than those with PR only [ 19 , 27 ]. In contrast, others did not find any significant differences [ 9 ]. Baseline renal function, proteinuria, hypertension, histological activity and chronicity indexes have been previously suggested as predictors of renal response [ 9 , 18 , 19 , 24 , 29 , 30 , 31 ].…”

“…In contrast, others did not find any significant differences [ 9 ]. Baseline renal function, proteinuria, hypertension, histological activity and chronicity indexes have been previously suggested as predictors of renal response [ 9 , 18 , 19 , 24 , 29 , 30 , 31 ]. In our study, baseline proteinuria >1.5 g/day emerged as the most significant predictor of early (i.e., at 3, 6, 9 months) and late complete response (i.e., at 12, 18 and 24 months).…”

“…The main therapeutic goal in patients with LN is the long-term preservation of renal function, preventing and managing comorbidities, and improving disease-related quality of life [ 8 ]. These goals can be achieved by inducing and maintaining disease remission and by preventing and timely treating disease flares [ 9 , 10 ]. In this context, recognizing early predictors of renal response, flare and long-term renal survival is paramount in guiding the therapeutic management of LN patients.…”

Clinical characteristics and long-term outcomes in patients with mixed Class III/IV + V and pure proliferative lupus nephritis: A single-center experience

“…Patients with pure proliferative LN showed higher level of ds-DNA antibody; lower levels of complement, platelet, and hemoglobin; higher SLEDAI-2K score; and higher activity index on renal biopsy. Given that a higher activity index of proliferative LN has been associated with development of ESRD, 13,14 the higher incidence rate of ESRD in the pure proliferative LN group was likely more influenced by the activity of renal histology rather than the absence of membranous LN. Previous studies support the predictive role of the histologic activity index on the long-term renal outcome.…”