Outcome of lupus nephritis in Iranian children: prognostic significance of certain features

European evidence-based recommendations for the diagnosis and treatment of childhood-onset lupus nephritis: the SHARE initiative

Lupus nephritis (LN) occurs in 50%-60% of patients with childhood-onset systemic lupus erythematosus (cSLE), leading to significant morbidity. Timely recognition of renal involvement and appropriate treatment are essential to prevent renal damage. The Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) initiative aimed to generate diagnostic and management regimens for children and adolescents with rheumatic diseases including cSLE. Here, we provide evidence-based recommendations for diagnosis and treatment of childhood LN. Recommendations were developed using the European League Against Rheumatism standard operating procedures. A European-wide expert committee including paediatric nephrology representation formulated recommendations using a nominal group technique. Six recommendations regarding diagnosis and 20 recommendations covering treatment choices and goals were accepted, including each class of LN, described in the International Society of Nephrology/Renal Pathology Society 2003 classification system. Treatment goal should be complete renal response. Treatment of class I LN should mainly be guided by other symptoms. Class II LN should be treated initially with low-dose prednisone, only adding a disease-modifying antirheumatic drug after 3 months of persistent proteinuria or prednisone dependency. Induction treatment of class III/IV LN should be mycophenolate mofetil (MMF) or intravenous cyclophosphamide combined with corticosteroids; maintenance treatment should be MMF or azathioprine for at least 3 years. In pure class V LN, MMF with low-dose prednisone can be used as induction and MMF as maintenance treatment. The SHARE recommendations for diagnosis and treatment of LN have been generated to support uniform and high-quality care for all children with SLE.

International validation of a urinary biomarker panel for identification of active lupus nephritis in children

BACKGROUND

Conventional markers of juvenile-onset systemic lupus erythematosus (JSLE) disease activity fail to adequately identify lupus nephritis (LN). While individual novel urine biomarkers are good at detecting LN flares, biomarker panels may improve diagnostic accuracy. The aim of this study was to assess the performance of a biomarker panel to identify active LN in two international JSLE cohorts.

METHODS

Novel urinary biomarkers, namely vascular cell adhesion molecule-1 (VCAM-1), monocyte chemoattractant protein 1 (MCP-1), lipocalin-like prostaglandin D synthase (LPGDS), transferrin (TF), ceruloplasmin, alpha-1-acid glycoprotein (AGP) and neutrophil gelatinase-associated lipocalin (NGAL), were quantified in a cross-sectional study that included participants of the UK JSLE Cohort Study (Cohort 1) and validated within the Einstein Lupus Cohort (Cohort 2). Binary logistic regression modelling and receiver operating characteristic curve analysis [area under the curve (AUC)] were used to identify and assess combinations of biomarkers for diagnostic accuracy.

RESULTS

A total of 91 JSLE patients were recruited across both cohorts, of whom 31 (34 %) had active LN and 60 (66 %) had no LN. Urinary AGP, ceruloplasmin, VCAM-1, MCP-1 and LPGDS levels were significantly higher in those patients with active LN than in non-LN patients [all corrected p values (p _c) < 0.05] across both cohorts. Urinary TF also differed between patient groups in Cohort 2 (p _c = 0.001). Within Cohort 1, the optimal biomarker panel included AGP, ceruloplasmin, LPGDS and TF (AUC 0.920 for active LN identification). These results were validated in Cohort 2, with the same markers resulting in the optimal urine biomarker panel (AUC 0.991).

CONCLUSION

In two international JSLE cohorts, urinary AGP, ceruloplasmin, LPGDS and TF demonstrate an 'excellent' ability for accurately identifying active LN in children.

Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years

INTRODUCTION

Childhood SLE (cSLE) has a higher prevalence of lupus nephritis (LN), and there are ethnic variations in response to treatment as well as outcome of LN. There are limited data on long-term outcome of LN in cSLE from the Indian subcontinent.

METHODS

Retrospective analysis of case records of patients with cSLE (satisfying revised American College of Rheumatology (ACR) 1997 criteria for diagnosis) and age of onset <18 years was conducted from 1989 to 2013. Data on clinical features, renal involvement and biopsy findings, treatment, renal outcome, damage accrual and mortality were collected. End-stage renal disease (ESRD) was defined as the need for renal replacement therapy. Actuarial ESRD-free survival was studied as the primary outcome measure using Kaplan-Meier analysis.

RESULTS

Among 205 children with cSLE, 134 (121 girls) had evidence of LN. The mean age at disease onset was 13.7 ± 3.5 years and the mean disease duration at presentation was 1.9 ± 2.5 years. Kidney biopsy was available for 92 patients, and histology included: 13 (14.2%) Class II, 24 (26%) Class III, 43 (46.7%) Class IV and 12 (13.1%) Class V LN. The mean follow-up period was 6.75 ± 5.7 years. At last visit, 81 (60.4%) children were in complete remission, 28 (20.9%) were in partial remission, 15 (11.2%) still had active nephritis and 10 (7.4%) had progressed to ESRD. Almost two-thirds (62.9%) of patients experienced lupus flares, and mean flare rate was 0.09 flares/patient follow-up year. Fifty-six (43.8%) children accrued damage and the mean Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage score was 0.79 ± 1.13. Actuarial ESRD-free survival at five, 10 and 15 years was 91.1%, 79% and 76.2%, and five-, 10- and 15-year renal survival was 93.8%, 87.1% and 84%, respectively. Although multiple factors individually predicted poor outcome (death/ESRD), only raised serum creatinine at onset (R square = 0.65, p ≤ 0.0001) and damage accrual (R square = 0.62, p ≤ 0.0001) remained significant on multivariate analysis. Eleven (8.2%) children died during the follow-up period, and infections were the leading cause of mortality.

CONCLUSIONS

Long-term outcome of LN in cSLE in our cohort was better than previous reports from India. However, a high rate of major infection still remains the leading cause of mortality.

Early predictors of outcomes in pediatric lupus nephritis: focus on proliferative lesions

OBJECTIVES

Studies regarding the clinical features and outcomes of pediatric lupus nephritis are limited, and risk factors of poor outcome in the more severe form of renal involvement, proliferative lupus nephritis (PLN), are poorly understood. This study analyzed the data from a large prospective cohort of childhood systemic lupus erythematosus to determine such risk factors.

METHODS

Subjects younger than 18 years at onset with biopsy-proven lupus nephritis were enrolled. Data on baseline presentations and laboratory values, response to treatment, and outcomes were collected. Primary outcome measures were death or end-stage renal disease (ESRD). Survival analysis was done and predictors were approached.

RESULTS

One hundred four patients with mean age of 12.4 ± 2.5 years (range, 4.0-17.2 years) and the female-to-male ratio of 5.94:1 were included. Among them, 81 patients had PLN and 23 had non-proliferative lupus nephritis. Those with PLN had significantly lower GFR, more proteinuria, more urine sediment, more hypertension, and poor early response to treatment (within 6 months). There was no significant difference in extra-renal manifestations. All poor outcomes happened in the PLN group. The prognostic factors were high baseline SLEDAI-2k >20 (HR, 6.76; p = 0.002), baseline GFR <60ml/min/m² (HR, 3.88; p = 0.022), and early responder (HR, 0.19; p = 0.013).

CONCLUSIONS

Patients with pediatric lupus nephritis and high risk factor can be identified early by concomitantly considering their baseline features and early response, which provides a novel hint in decision for management decisions.

Survival of Mexican patients with paediatric-onset systemic lupus erythematosus and abnormal electroencephalogram

BACKGROUND

Over the past three decades, there has been a remarkable improvement in the outcome of children diagnosed with systemic lupus erythematosus (SLE). In general, paediatric-onset SLE has been associated with higher mortality rates and more disease damage than adults with SLE. The objective was to determinate the impact of clinical, laboratory, and electroencephalographic findings on survival amongst patients with paediatric-onset SLE.

METHODS

Charts of Mexican patients with paediatric-onset SLE diagnosed between 1970 and 2001 were analysed retrospectively; univariate and multivariate analyses were used for analysing associations between clinical and laboratory features and death; Kaplan-Meier tests were used to estimate survival curves.

RESULTS

159 patients were included, 105 were female, with a median age of 12.7 years at diagnosis and a median duration of symptoms prior to diagnosis of 8.4 months. Univariate analysis showed that haematuria, leukocyturia, proteinuria, presence of urine cast, <60% glomerular filtration rate, haemolytic anaemia, and abnormal electroencephalogram, were all poor prognostic factors (p<0.05). Multivariate analysis showed that the presence of proteinuria and abnormal electroencephalograms (p<0.05) were independent factors associated with death. The overall survival rate was 82.9% at five years and 77.4% at ten years upon follow-up. Infection and high disease activity were the most common causes of death.

CONCLUSIONS

Survival of paediatric-onset SLE patients was lower compared to that reported for patients in wealthier countries. Amongst the patients who died, the presence of proteinuria and abnormal electroencephalograms were found to be determinant for survival. Infection and activity were the most common causes of death.

Taxonomy for systemic lupus erythematosus with onset before adulthood

OBJECTIVE

To propose a common nomenclature to refer to individuals who fulfill the American College of Rheumatology classification criteria for systemic lupus erythematosus (SLE) during childhood or adolescence.

METHODS

The medical literature was reviewed for studies conducted in the target population between 1960 and December 2011 to obtain information about the terms used to refer to such children and adolescents. We reviewed the threshold ages used and disease features considered to discriminate these individuals from patients with onset of SLE during adulthood. Furthermore, the nomenclature used in other chronic diseases with onset during both childhood and adulthood was assessed.

RESULTS

There was an astonishing variability in the age cutoffs used to define SLE onset prior to adulthood, ranging from 14-21 years, but most studies used age 18 years. The principal synonyms in the medical literature were SLE without reference to the age at onset of disease, childhood-onset SLE, juvenile SLE, and pediatric (or paediatric) SLE.

CONCLUSION

Based on the definition of childhood, in analogy with other complex chronic diseases commencing prior to adulthood, and given the current absence of definite genetic variations that discriminate adults from children, the term childhood-onset SLE is proposed when referring to individuals with onset of SLE prior to age 18 years.

Juvenile systemic lupus erythematosus onset patterns in Vietnamese children: a descriptive study of 45 children

BACKGROUND

Incidence and disease pattern of childhood-onset SLE is reported to differ among ethnic groups.

METHODS

To describe disease pattern and 6 month follow-up in a referral based cohort of 45 Vietnamese children with SLE. Forty-five children who were subsequently diagnosed to have systemic lupus erythematosus (f/m = 4/1) were referred to the Ho Chi Minh City Children's Hospital No.1 during a 12-month period in 2009.

RESULTS

The mean age at diagnosis was 12.8 years (SD = 2.5). Thirty-seven (82%) fulfilled criteria for lupus nephritis (LN). At diagnosis, impressively high SLEDAI and ECLAM scores were recorded (mean and SD), 23.8 (11.6) and 6 (2.3), respectively. The mean renal SLEDAI score was 8.2. The mean haemoglobin (g/dL, SD) was 8.5 (2.1). The Coombs test was positive in 30 of 36 children (83%). The mean plasma creatinine was 0.98 (SD 1.2) and mean Westergren sedimentation rate was 83.6 (SD 37.4). The patient age at diagnosis was positively correlated to the SLEDAI (p = 0.034) and ECLAM (p = 0.022). At 6 month follow-up of the 45 children, 15 patients were in complete remission, 5 were in partial remission, 6 had stable disease, 3 had relapsed, 3 had evolving disease, 2 had ongoing resistant disease and 4 had died. Seven patients were lost to follow-up. A second renal biopsy showed an improved ISN class in 13 of 15; in 2 cases the ISN class remained unchanged.

CONCLUSIONS

Forty-five Vietnamese children with SLE were referred to Ho Chi Minh Children's Hospital No. 1 during a16 month period from 2008-2009. These patients had a strikingly high prevalence of Coombs positive anaemia, a high prevalence of lupus nephritis, and very high SLEDAI and ECLAM scores at the time of diagnosis. While there may be referral biases, our Vietnamese SLE patients appear to have severe disease upon presentation but do reasonably well in the short-term.

Minimal mesangial lupus nephritis: a systematic review

OBJECTIVES

To summarize the clinical presentation, histological features, treatment, and outcome of minimal change nephropathy (MCN) in patients with systemic lupus erythematosus (SLE).

METHODS

We performed a systematic review of cases of MCN in SLE patients reported in the English literature from January 1985 to May 2009 by a Medline search.

RESULTS

The estimated prevalence of MCN in biopsy-proven lupus nephritis is 2.3% in childhood and 1.1% in adults. There are 13 individual cases (12 women, one man) of SLE-related MCN reported in the literature. The mean age of nephritis onset was 32.7 years. In six (46%) patients, MCN was the initial manifestation of SLE. All patients presented with nephrotic syndrome and two (15%) had active urinary sediments. Renal function was impaired in eight (62%) patients and six (46%) patients had active lupus serology. All patients responded promptly to high-dose glucocorticoids but four (31%) had relapse of proteinuria during their course of SLE. None of the patients developed thromboembolic or infective complications.

CONCLUSIONS

MCN is an uncommon histological class of lupus nephritis. Typically, patients present with heavy proteinuria, and transient renal dysfunction is common. The prognosis of MCN in SLE appears to be good because of its rapid response to glucocorticoids. Relapses of proteinuria may be reduced by the use of maintenance immunosuppression. Alkylating agents, calcineurin inhibitors, mycophenolate mofetil, and rituximab can be considered in glucocorticoid-dependent or refractory cases of SLE-related MCN.

[Long-term outcome of paediatric lupus nephritis]

INTRODUCTION

Kidney is frequently affected in patients with systemic lupus erythematosus (SLE). It has been recently suggested that the renal outcome in this disease has improved with an earlier diagnosis and intensive specific treatment. Quite often, articles with paediatric patients lack a prolonged follow-up which could help to predict long term outcome.

METHODS

This is a retrospective descriptive study based on the review of clinical records from patients with a diagnosis of lupus nephritis in a Paediatric Nephrology unit of a tertiary care centre, between 1987 and 2009. Patients were included with an age up to 18 at diagnosis. They were excluded if follow-up period was shorter than 3 months or if data lacked about it. It includes descriptive evolution of clinical parameters, kidney function, lupus activity as well as pathology and treatment. Several variables were tested for association with chronic kidney disease (CKD) in the last checkpoint.

RESULTS

Data were obtained from 16 patients, 3 men and 13 women. Age at the beginning of SLE was 10.6 + or - 2.9 years and 12.6 + or - 3.5 years at debut of lupus nephritis. Biopsy was obtained in 14 of them, in 11 cases (78.6 %), 3 or less months following diagnosis. In 9 cases (64.3 per cent), biopsy showed WHO class IV, 3 cases, class III and 2 cases, class II. In the last control (10.7 + or - 6.7 years of follow-up), 7/16 (43.8 %) had developed CKD: 5 cases with proteinuria (one in nephrotic range), one in stage 2 and one patient in haemodialysis after renal graft loss. Among those with a follow-up longer than 10 years, 4/9 (44.4 %) of them showed some sign of renal disease: 3/9 with proteinuria, and the one needing haemodialysis. Most of the patients (15/16) received treatment with intravenous cyclophosphamide boluses in a variable number after diagnosis. Only a more intense proteinuria at 3 months, 1 year and 3 years of evolution was related to CKD in the last visit.

CONCLUSIONS

We consider the long term evolution of our patients to have been very satisfactory. Although 44.4 % of them developed renal anomalies after 10 or more years, only one (11.1%) reached an end-stage renal disease. These patients presented a higher grade of proteinuria from the first visits.