Value of a Complete or Partial Remission in Severe Lupus Nephritis

Abstract

Background and objectives: The value of a complete remission in severe lupus nephritis is well known but little is known about the impact of a partial remission in this patient population. The purpose of this study was to evaluate the long-term prognosis of achieving a complete or partial remission in a well-defined group of patients with severe lupus nephritis.Design, setting, participants, & measurements: In this study, 86 patients with diffuse lupus glomerulonephritis were reviewed for assessment of the value of a partial remission (50% reduction in baseline proteinuria to <1.5 g/d and <25% increase in baseline creatinine) and complete remission (proteinuria <0.33 g/d and serum creatinine <1.4 mg/dl) on outcomes compared with patients who did not attain a remission. These well-characterized patients were entered into a prospective therapeutic trial conducted by the Collaborative Study Group and were followed for more than 10 yr.Results: All biopsies showed diffuse lupus nephritis. A complete remission was attained in 37 (43%) patients, a partial remission in 21 (24%) patients, and no remission in 28 (32%) patients. Baseline clinical and serologic features were similar among the groups, but patients with a complete remission had a lower serum creatinine and chronicity index compared with patients with partial or no remission. The patient survival at 10 yr was 95% for complete remission, 76% for partial remission, and 46% for no remission. The renal survival at 10 yr was 94% for complete remission, 45% for partial remission, and 19% for no remission, and the patient survival without end-stage renal disease at 10 yr was 92% for complete remission, 43% for partial remission, and 13% for no remission.Conclusion: Even a partial remission in lupus nephritis is associated with a significantly better patient and renal survival compared with no remission.

Immunosuppressive Treatment for Lupus Nephritis: Long-Term Results in 178 Patients

“…IT overall efficacy (CR plus PR) turned to be 84.8%, with the rate of CR 35.3%, which is similar to Chen et al data [15] and higher than the ALMS study [17], probably because our study group included not only patients with LN lass III–V but also milder cases. Under ST, the rate of flares turned to be 19.2% during median follow-up of 12 [1; 236] months, similar to the data from the long-term follow-up of the MAINTAIN Nephritis Trial [18].…”

“…In patients who achieved PR, patient and kidney survival were 65% and 58%, respectively, and in nonresponders they were 35% and 0%, respectively. These differences confirm the positive prognostic value of complete and even partial LN response [15, 16], associated with significantly better outcomes compared to NR, and stress that failure to achieve renal response to immunosuppression negatively influences not only kidney but also patient survival.…”

“…Although the definitions of remission for LN were controversial for more than two decades [14, 15], and the impact of decrease of proteinuria versus hematuria is not completely clear so far [16], KDIGO, based on the evaluation of published clinical trials, provides definitions for the response to therapy in LN as follows: complete response (CR)—return of serum creatinine (SCr) to previous baseline plus decline in urine protein/creatinine ratio (uPCR) to <50 mg/mmol; partial response (PR)—stabilisation or improvement of SCr but not to normal range, plus ≥50% decrease in uPCR and uPCR ≤300 mg/mmol [7]. EULAR/ERA-EDTA recommendations also point that immunosuppressive treatment targets are complete renal response (proteinuria <0.5 g/24-hr with normal or near-normal renal function) or at least partial renal response (≥50% reduction in proteinuria with decrease to subnephrotic levels and normal or near-normal GFR), which should be achieved preferably by 6 months and no later than 12 months following treatment initiation [4].…”

Clinical Features and Outcomes of IgA Nephropathy with Nephrotic Syndrome

“…In these patients, the risk reduction for the primary outcome was much greater than those in the NR group. The importance of PR has been suggested for various glomerulopathies (1,21,22). In particular, Reich et al indicated that patients with IgAN who initially presented with proteinuria .3 g/d and achieved PR (,1 g/d) had similar outcomes to patients with persistent proteinuria of ,1 g/d during follow-up and also had superior prognoses to patients who never achieved remission (1).…”

Multitarget Therapy of Lupus Nephritis

“…This may be important because the longer term outcome of treatment of lupus nephritis, measured as patient or renal survival, is significantly affected by the extent of the initial remission. 12 Partial as well as complete remissions have a salutary effect on long-term outcome of lupus nephritis. 12 The most consequential aspect of the trial by Bao et al is the short-term nature of the observations.…”