Lupus Nephritis Affects One Third of Patients With Lupus

Beth Skwarecki

September 22, 2015

Data from an international cohort study of patients with lupus confirm that lupus nephritis is a common complication of the disease, occurring in 38.3% of the patients, researchers report in an article published online September 5 in Rheumatology. Patients with lupus nephritis had high rates of end-stage renal disease and death, and were more likely than other patients with lupus to be younger, male, and of nonwhite ethnicity.

"One thing this study should emphasize is that people with lupus should be checked for lupus nephritis, and make sure they have regular follow-up if they do have lupus nephritis. It's very important to treat early and aggressively. I don't necessarily mean to give more medicine, but better follow-up," especially for minority patients, Kyriakos Kirou, MD, from the Hospital for Special Surgery, told Medscape Medical News. Dr Kirou was not involved in the study.

For the current study, John G. Hanly, MD, from the Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada, and colleagues analyzed data from 1827 patients newly diagnosed with lupus and enrolled in the Systemic Lupus International Collaborating Clinics (SLICC) study. The patients, from the United States, Europe, Canada, Mexico, and Asia, were receiving standard care.

The patients, recruited between 1999 and 2012, had an average age of 35.1 years at baseline, and 89% were female. The average follow-up for this analysis was 4.6 years, with data gathered annually, including estimated glomerular filtration rate, proteinuria, end-stage renal disease, and health-related quality of life. The authors note, however, that the study was not originally designed to assess renal outcomes, so some of this information came from retrospective chart reviews.

Overall, 700 patients had lupus nephritis, with 566 (80.9%) of those having the condition when they enrolled in the study. Lupus nephritis was diagnosed according to American College of Rheumatologists criteria or using renal biopsy when possible. Although current guidelines recommend biopsy for all patients with suspected kidney disease, only 56.4% of the patients with lupus nephritis had had a biopsy.

Compared with other patients with lupus, those with lupus nephritis had a higher frequency of hypertension, serositis, neurological disorders, and immunological disorders, but they were less likely to have mucocutaneous disease, arthritis, and antinuclear antibodies.

Corticosteroid and immunosuppressant use was more common among patients with lupus nephritis, but antimalarial use was less frequent: only 49.1% of the patients with lupus nephritis were taking them at enrollment, increasing to 72% over the course of the study. Patients with the most severe nephritis had the lowest health-related quality-of-life scores.

The 10-year incidence of end-stage renal disease was 10.1% (95% confidence interval [CI], 6.6% - 13.6%) of patients with lupus nephritis compared with 4.3% (95% CI, 2.8% - 5.8%) of patients with lupus overall. Patients with nephritis also had a higher risk for death (hazard ratio, 2.98; 95% CI, 1.48 - 5.99; P = .002). In addition, those taking antimalarials at the time of enrollment were no less likely to develop end-stage renal disease, but they did survive longer (hazard ratio for death, 0.34; 95% CI, 0.15 - 0.63; P = .001).

"These numbers are better than what we had a few decades ago, but we still have a long way to go to improve the outcome of these patients," says Dr Kirou.

"Notably, early and liberal use of [the antimalarial hydroxychloroquine], increase in the renal biopsy rate and prospective evaluation of the [health related quality of life] for lupus patients are essential, not only for improving survival but also for enhancing holistic care in our patients with [systemic lupus erythematosus]," Anselm Mak, MD, and Sen Hee Tay, MD, from the Division of Rheumatology at the Yong Loo Lin School of Medicine in Singapore, write in an accompanying editorial.

Because patients were treated at academic centers, their care may have been more aggressive than that of patients with lupus treated in the community, the authors note. Because patients were enrolled soon after diagnosis (on average, 6 months later), they are younger and have shorter disease duration than the total population of patients with lupus. Dr Kirou also notes that the ethnic makeup of the study population includes a high proportion of white patients, and because this group tends to have better outcomes, mortality and disease rates may have been lower in the study than in the general population.

One coauthor holds grants from UCB, Sanofi/Genzyme, Roche, and Glaxo Smith Kline and honoraria/speakers bureaus from UCB, Glaxo Smith Kline, Roche, Pfizer, and Medimmune outside of the submitted work. Another coauthor has received research support and grants from AbbVie, BMS, GSK, Pfizer, Roche, UCB and has received consultancy honoraria from AbbVie, Biotest, BMS, Crescendo, GSK, Janssen, Lilly, Merck, Pfizer, Roche, UCB, and Vertex. Another coauthor has participated on Lupus Advisory Boards for Eli Lilly, AbbVie and GSK. Another coauthor has received clinical trial grant support from GlaxoSmithKline and Aurinia Pharmaceuticals. All other authors and the editorialists have disclosed no relevant financial relationships. Dr Kirou reports receiving funds from BMS to conduct a clinical trial in lupus nephritis as one of the trial sites.

Rheumatology. Published online September 5, 2015. Article abstract, Editorial full text

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