Successful Treatment of Class V+IV Lupus Nephritis with Multitarget Therapy

Objectives Anti-ribosomal P protein autoantibodies (anti-P) specifically develop in patients with systemic lupus erythematosus. Associations of anti-P with lupus nephritis (LN) histological subclass and renal outcome remain inconclusive. We sought to determine the association of anti-P and anti-double-stranded DNA antibody (anti-dsDNA) with renal histology and prognosis in LN patients. Methods Thirty-four patients with LN, having undergone kidney biopsy, were included. The 2018 revised ISN/RPS classification system was used for pathophysiological evaluation. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 for > 3 months. Results Six patients (17.6%) were positive for anti-P and 26 (76.5%) for anti-dsDNA. Among the six patients with anti-P, one did not have anti-dsDNA, but did have anti-Sm antibody, and showed a histological subtype of class V. This patient maintained good renal function for over 14 years. The remaining five patients, who had both anti-P and anti-dsDNA, exhibited proliferative nephritis and were associated with prolonged hypocomplementemia, and the incidence of CKD did not differ from patients without anti-P. Conclusion Although this study included a small number of patients, the results indicated that histology class and renal prognosis associated with anti-P depend on the coexistence of anti-dsDNA. Further studies with a large number of patients are required to confirm this conclusion.

Download Full-text

Transformation of Recurred Lupus Nephritis from Class IV to Class V

Journal of Rheumatic Diseases ◽

10.4078/jrd.2012.19.5.290 ◽

2012 ◽

Vol 19 (5) ◽

pp. 290

Author(s):

Jin-Ju Park ◽

Ji-Yeong Kwak ◽

Ju-Yang Jung ◽

Bo-Ram Koh ◽

Hyoun-Ah Kim ◽

...

Keyword(s):

Lupus Nephritis ◽

Class V ◽

Class Iv

Download Full-text

Multitarget Therapy for Maintenance Treatment of Lupus Nephritis

Journal of the American Society of Nephrology ◽

10.1681/asn.2017030263 ◽

2017 ◽

Vol 28 (12) ◽

pp. 3671-3678 ◽

Cited By ~ 43

Author(s):

Haitao Zhang ◽

Zhengzhao Liu ◽

Minlin Zhou ◽

Zhangsuo Liu ◽

Jianghua Chen ◽

...

Keyword(s):

Lupus Nephritis ◽

Maintenance Treatment ◽

Multitarget Therapy

Download Full-text

SAT0196 RENAL FLARE IN CLASS V LUPUS NEPHRITIS: INCREASED RISK IN PATIENTS WITH TUBULOINTERSTITIAL LESIONS

10.1136/annrheumdis-2019-eular.4683 ◽

2019 ◽

Author(s):

Oh Chan Kwon ◽

Wook Jang Seo ◽

Ji Seon Oh ◽

Min-Chan Park ◽

Seokchan Hong ◽

...

Keyword(s):

Lupus Nephritis ◽

Class V ◽

Renal Flare ◽

Increased Risk ◽

Tubulointerstitial Lesions

Download Full-text

Early-stage predictors for treatment responses in patients with active lupus nephritis

Lupus ◽

10.1177/0961203319826703 ◽

2019 ◽

Vol 28 (3) ◽

pp. 283-289 ◽

Cited By ~ 2

Author(s):

G Liu ◽

H Wang ◽

J Le ◽

L Lan ◽

Y Xu ◽

...

Keyword(s):

Lupus Nephritis ◽

Serum Albumin ◽

Immunosuppressive Therapy ◽

Early Stage ◽

Complement C3 ◽

Class Iii ◽

Class V ◽

Predictive Values ◽

Cutoff Value ◽

Active Lupus Nephritis

Objective We analyzed data of lupus nephritis (LN) patients to find parameters that can predict remission. Methods Sixty-four LN patients who were diagnosed with class III, IV, V or V + III/IV by renal biopsy and were followed up for more than six months in our center were enrolled retrospectively. Receiver operating characteristic curves were used to test the predictive values of urinary protein-to-creatinine ratio (UPCR), serum albumin and complement C3 at the first, second and third months as predictors for remission at the sixth month. Results The patients' renal pathologies were class III (five cases), class IV (33 cases), class V (nine cases) and class V + III/IV (17 cases). All patients received standard immunosuppressive therapy. Forty-six (71.9%) patients (grouped as the remission group) achieved remission at the end of the sixth month, including 23 complete remissions and 23 partial remissions. The other 18 patients were grouped as the no-remission group. There were no significant differences in clinical data, proportion of immunosuppressive therapy or renal pathological characteristics between the remission group and no-remission group at baseline, except the serum urea nitrogen of the remission group was lower than in the no-remission group. The UPCR were significantly lower in the remission group than in the no-remission group at months 1, 2, 3 and 6, respectively, while the serum albumin was significantly higher in the remission group than in the no-remission group at months 3 and 6, respectively. There were no significant differences in serum creatinine between the remission group and no-remission group, except at month 1. The C3 levels were higher in the remission group than in the no-remission group at months 1, 2 and 3, respectively. The areas under the curve (AUC) of the change percentage of UPCR at month 3 and the serum albumin at month 3 were the most significant (AUC 0.778, p = 0.002; AUC 0.773, p = 0.001, respectively). The cutoff value of the change percentage of UPCR at month 3 was 59%. The cutoff value of serum albumin at month 3 was 32.9g/l. Conclusion The change percentage of UPCR ≥59% and the serum albumin ≥32.9 g/l at the third month were valuable for predicting remission at the sixth month in LN. Because of the small-size and retrospective nature, this study needs to be validated.

Download Full-text

P0429OUTCOMES OF LUPUS NEPHRITIS OVER AN ERA OF EVOLVING IMMUNOSUPPRESSION

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa142.p0429 ◽

2020 ◽

Vol 35 (Supplement_3) ◽

Author(s):

Jason McMinn ◽

Colin C Geddes ◽

Emily McQuarrie

Keyword(s):

Lupus Nephritis ◽

Electronic Patient Record ◽

Immunosuppressive Treatment ◽

Complete Response ◽

Histopathological Diagnosis ◽

Class V ◽

Remission Rates ◽

Induction Regimen ◽

Before And After

Abstract Background and Aims The reported incidence of lupus nephritis (LN) is approximately 6.1 cases per million population per year in Scotland based on Scottish Renal Registry biopsy data. Despite immunosuppressive treatment, approximately 10-30% of patients will progress to established renal failure (ERF) within 15 years. In December 2007, our unit moved from a protocol of Cyclophosphamide/ steroid induction with Azathioprine/ Prednisolone maintenance to Mycophenolate/ steroid induction and maintenance. We undertook this study to compare remission rates before and after this change. Method A retrospective electronic patient record analysis was performed for all patients in our centre with a documented native renal biopsy showing a histopathological diagnosis of LN, between 1 July 1993 and 31 December 2017. Repeat biopsies were excluded. Baseline demographics, histopathological class and first and second line induction and maintenance therapies were recorded. Endpoints analysed were; partial and complete response (as defined in KDIGO Clinical Practice Guideline for Glomerulonephritis 2012), time to achieve this response, relapse, progression to ERF and death. Results 120 patients who underwent a biopsy during the 24.5-year period received a diagnosis of lupus nephritis. 82.5% of patients were Caucasian. Median duration of follow-up was 72 months. 15% of patients died and 5% developed ERF within the follow-up period, representing one death per 56 patient years and one incident case of ERF per 168 patient years. There were 40 patients in the pre-December 2007 group and 80 in the post-December 2007 group. Those in the earlier group were younger, with a mean age of 35.4 years versus 44.8 years in the later group (p=0.002). 23% had class V in the earlier group compared to 15% in the later group (p=0.31). Proportions of female patients were 80% and 75% in the early and late groups respectively (p=0.54). Median creatinine was 106µmol/L in the pre-December 2007 group and 89.5 µmol/L in the post-December 2007 group (p=0.96). Patients in the pre- and post- December 2007 groups had comparable rates of complete response, at 72% and 71% respectively. However, those diagnosed before December 2007 were slower to respond, with a median time to achieve complete response of 10.5 months, compared to 6 months in those diagnosed after 1 December 2007 (p=0.007). Conclusion Following a change in our immunosuppressive induction regimen from Cyclophosphamide/ steroids to Mycophenolate/ steroids, our response rates have remained similar, however speed of attaining remission has improved.

Download Full-text

Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations

RMD Open ◽

10.1136/rmdopen-2020-001263 ◽

2020 ◽

Vol 6 (2) ◽

pp. e001263 ◽

Cited By ~ 1

Author(s):

Myrto Kostopoulou ◽

Antonis Fanouriakis ◽

Kim Cheema ◽

John Boletis ◽

George Bertsias ◽

...

Keyword(s):

Lupus Nephritis ◽

Literature Review ◽

Systematic Literature Review ◽

Immunosuppressive Treatment ◽

Class Iii ◽

High Quality ◽

Class V ◽

High Quality Evidence ◽

Optimal Duration ◽

Quality Evidence

ObjectivesTo analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations.MethodsAccording to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012.ResultsWe identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500–700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b).ConclusionsThere is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.

Download Full-text

The correlation of urinary podocytes and podocalyxin with histological features of lupus nephritis

Lupus ◽

10.1177/0961203317734918 ◽

2017 ◽

Vol 27 (3) ◽

pp. 484-493 ◽

Cited By ~ 6

Author(s):

D Ikuma ◽

K Hiromura ◽

H Kajiyama ◽

J Suwa ◽

H Ikeuchi ◽

...

Keyword(s):

Lupus Nephritis ◽

Lupus Erythematosus ◽

Activity Index ◽

Sandwich Elisa ◽

Characteristic Analysis ◽

Crescent Formation ◽

Class V ◽

Histological Features ◽

Cellular Crescent ◽

Class Iv

Objectives The objective of this study was to test the correlation of urinary podocyte number (U-Pod) and urinary podocalyxin levels (U-PCX) with histology of lupus nephritis. Methods This was an observational, cross-sectional study. Sixty-four patients were enrolled: 40 with lupus nephritis and 24 without lupus nephritis (12 lupus nephritis patients in complete remission and 12 systemic lupus erythematosus patients without lupus nephritis). Urine samples were collected before initiating treatment. U-Pod was determined by counting podocalyxin-positive cells, and U-PCX was measured by sandwich ELISA, normalized to urinary creatinine levels (U-Pod/Cr, U-PCX/Cr). Results Lupus nephritis patients showed significantly higher U-Pod/Cr and U-PCX/Cr compared with patients without lupus nephritis. U-Pod/Cr was high in proliferative lupus nephritis (class III±V/IV±V), especially in pure class IV (4.57 (2.02–16.75)), but low in pure class V (0.30 (0.00–0.71)). U-Pod/Cr showed a positive correlation with activity index ( r=0.50, P=0.0012) and was independently associated with cellular crescent formation. In contrast, U-PCX/Cr was high in both proliferative and membranous lupus nephritis. Receiver operating characteristic analysis revealed significant correlation of U-Pod/Cr with pure class IV, class IV±V and cellular crescent formation, and the combined values of U-Pod/Cr and U-PCX/Cr were shown to be associated with pure class V. Conclusions U-Pod/Cr and U-PCX/Cr correlate with histological features of lupus nephritis.

Download Full-text

AJKD Atlas of Renal Pathology: Membranous Lupus Nephritis, ISN/RPS Class V

American Journal of Kidney Diseases ◽

10.1053/j.ajkd.2017.06.003 ◽

2017 ◽

Vol 70 (2) ◽

pp. e13-e15

Author(s):

Mark A. Lusco ◽

Agnes B. Fogo ◽

Behzad Najafian ◽

Charles E. Alpers

Keyword(s):

Lupus Nephritis ◽

Renal Pathology ◽

Class V ◽

Membranous Lupus Nephritis

Download Full-text