Recognition of information in renal biopsies of patients with lupus nephritis

Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis

OBJECTIVES

To develop recommendations for the management of adult and paediatric lupus nephritis (LN).

METHODS

The available evidence was systematically reviewed using the PubMed database. A modified Delphi method was used to compile questions, elicit expert opinions and reach consensus.

RESULTS

Immunosuppressive treatment should be guided by renal biopsy, and aiming for complete renal response (proteinuria <0.5 g/24 h with normal or near-normal renal function). Hydroxychloroquine is recommended for all patients with LN. Because of a more favourable efficacy/toxicity ratio, as initial treatment for patients with class III-IV(A) or (A/C) (±V) LN according to the International Society of Nephrology/Renal Pathology Society 2003 classification, mycophenolic acid (MPA) or low-dose intravenous cyclophosphamide (CY) in combination with glucocorticoids is recommended. In patients with adverse clinical or histological features, CY can be prescribed at higher doses, while azathioprine is an alternative for milder cases. For pure class V LN with nephrotic-range proteinuria, MPA in combination with oral glucocorticoids is recommended as initial treatment. In patients improving after initial treatment, subsequent immunosuppression with MPA or azathioprine is recommended for at least 3 years; in such cases, initial treatment with MPA should be followed by MPA. For MPA or CY failures, switching to the other agent, or to rituximab, is the suggested course of action. In anticipation of pregnancy, patients should be switched to appropriate medications without reducing the intensity of treatment. There is no evidence to suggest that management of LN should differ in children versus adults.

CONCLUSIONS

Recommendations for the management of LN were developed using an evidence-based approach followed by expert consensus.

Lupus Nephritis Outcome With and Without Renal Biopsy

BACKGROUND

: Renal biopsy is an important tool in devising an adequate treatment plan for lupus nephritis. However, it is not always possible to perform a biopsy, and in many cases, treatment must rely exclusively on clinical data.

OBJECTIVE

: The aim of this study was to compare the 5-year course of patients treated without a biopsy with another group with histologic evidence of diffuse proliferative glomerulonephritis (DPGN).

METHODS

: The no-biopsy group consisted of 30 patients with lupus with strong clinical and laboratory suspicion of proliferative glomerulonephritis in whom a renal biopsy was unavailable either because of medical contraindication or the patient's refusal. The biopsy group included 30 patients undergoing biopsy and a histologic diagnosis of DPGN. Patients were followed from the onset of nephritis and at 18, 36, and 60 months.

RESULTS

: At onset, the no-biopsy group showed lower C3 levels and higher proteinuria, although both groups showed evident deterioration of the renal function. No significant differences were found in treatment, outcome, survival, renal function tests, or in the development of kidney failure.

CONCLUSIONS

: Proliferative glomerulonephritis deserves prompt diagnosis and treatment. This study demonstrates that experience in the management of lupus nephropathy, together with clinical and laboratory data, are often enough information to adequately treat proliferative glomerulonephritis even in the absence of a renal biopsy.

Judgment analysis in clinical nephrology

To ameliorate the clinical performance of nephrologists, improving their clinical judgment is crucial. No methodology for judgment analysis in nephrology is currently available. Therefore, we designed a trial to assess the intraphysician consistency of the judgment of typical non-end-stage renal disease (ESRD) patients by 24 board-certified nephrologists. The participants were asked to analyze cases to determine the interobserver variability with respect to diagnosis, therapy, prognosis, and strategy of follow-up. They were unaware that every patient was presented on 2 occasions separated by a period of 6 months. Of the 1,288 questionnaires that were completed, 28 cases belonged to 1 of the following 3 groups: (A) patients once with, once without renal histology, (B) patients twice without histology, and (C) patients twice with histology. Only cases of group (A) differed at the 2 occasions of assessment with respect to knowledge of histology. The results from the first and second assessment were compared and analyzed. The median (95% confidence interval) percentages of changed diagnoses were 64% (59% to 68%), 50% (44% to 62%), and 33% (26% to 47%) in groups A, B, and C, respectively, indicating large intraobserver variability. The frequency of changes in diagnoses declined with the degree of confidence in the first diagnosis in all 3 groups. The subjective desire to know the histology was without impact on the frequency of changes in diagnoses. However, a knowledge of the histology enhanced the degree of confidence in the diagnoses. Interestingly, the enormous variability in changing diagnoses from one analysis to the other was not reflected by corresponding changes in the judgment of prognosis, therapy to be prescribed, or strategy of follow-up. The individual judgment with respect to diagnosis of clinical cases is inconsistent and highly dependent on the subjective degree of confidence in the diagnosis. The practical relevant consequences traditionally derived from a diagnosis (therapy, prognosis, and strategy of follow-up) are only marginally, if at all, affected by changing the diagnosis. Thus, the utility of "diagnosis" for judgment analysis in clinical nephrology should be reconsidered.

Lupus nephritis in Southern Chinese patients: clinicopathologic findings and long-term outcome

Despite the improvement in survival of patients with systemic lupus erythematosus (SLE) and associated nephritis in the past 20 years, few studies of the long-term outcome of large cohorts of patients with well-defined histological classes of lupus nephropathy are available. We examined the long-term outcome of 183 patients with lupus nephritis (LN) followed up by the Division of Rheumatology at Queen Mary Hospital (Hong Kong) between 1976 and 1997. Their renal biopsies were classified according to World Health Organization (WHO) criteria. There were 27 men and 156 women. Initial renal biopsy showed the following WHO classes of LN: 2 patients (1%), class I; 9 patients (5%), class II; 46 patients (25%), class III; 101 patients (55%), class IV; and 25 patients (14%), class V. The mean duration of follow-up from the renal biopsy was 130.7 +/- 5.9 months (range, 13 to 260 months). The overall 5-, 10-, and 15-year survival and renal survival (survival without dialysis) rates were 98.9%, 94.4%, and 94.4% and 92.1%, 81.2%, and 75.2%, respectively. Univariate analysis showed class IV nephritis, hypertension, impaired renal function (glomerular filtration rate < 50 mL/min), nephrotic syndrome at time of renal biopsy, and failure of complete remission in the first year of treatment were unfavorable predictors for renal survival. Multivariate analysis using the Cox regression model also showed persistent hypertension, class IV nephritis, and incomplete renal remission in the first year were independent risk factors for renal failure. Our results showed the renal survival rate of our patients from South China with LN was similar to that of most reported series of white patients. Prospective randomized studies with well-defined treatment protocols are needed to delineate the optimal treatment strategy for LN.

Renal involvement in systemic lupus erythematosus. A study of 180 patients from a single center

Charts of 180 patients (147 women, 33 men) with systemic lupus erythematosus (SLE) complicated by renal involvement were retrospectively analyzed from a series of 436 patients. Mean age at renal disease onset was 27 years. Thirty-six percent of the patients had renal involvement after diagnosis of lupus, for 30.7% of that group it was more than 5 years later. Renal involvement occurred more frequently in young male patients of non-French non-white origin. Patients with renal involvement suffered more commonly from malar rash, psychosis, myocarditis, pericarditis, lymphadenopathy, and hypertension. Anemia, low serum complement, and raised anti-dsDNA antibodies were more frequent. According to the 1982 World Health Organization classification, histologic examination of initial renal biopsy specimen in 158 patients showed normal kidney in 1.5% of cases, mesangial in 22%, focal proliferative in 22%, diffuse proliferative in 27%, membranous in 20%, chronic sclerosing glomerulonephritis in 1%, and other forms of nephritis in 6.5%. Distribution of initial glomerulonephritis patterns was similar whether renal involvement occurred before or after the diagnosis of lupus. Transformation from 1 histologic pattern to another was observed in more than half of the analyzable patients (those who underwent at least 2 renal biopsies). Nephritis evolved toward end-stage renal disease in 14 patients despite the combined use of steroids and cyclophosphamide in 12. Initial elevated serum creatinine levels, initial hypertension, non-French non-white origin, and proliferative lesions on the initial renal biopsy were indicators of poor renal outcome. Twenty-four patients died after a mean follow-up of 109 months from SLE diagnosis. Among our 436 patients, the 10-year survival rate was not significantly affected by the presence or absence of renal involvement at diagnosis (89% and 92%, respectively).

Current role of renal biopsy in patients with SLE

All aspects of the role of renal biopsy in systemic lupus erythematosus may not be defined and accepted, but there is increasing agreement as to the information that can be obtained from biopsy. Awareness of the importance of clinical (non-biopsy) predictors has permitted a clearer understanding of the ability of renal biopsy to confirm and to add information to a determination of prognosis based on clinical data. New techniques for scoring the patterns of injury detectable on renal biopsy have provided important insights into prognosis, pathogenesis and treatment of lupus nephritis. Watchful waiting is often an unwise course for the management of lupus nephritis. Thus, renal biopsy is increasingly seen as an important tool in the timely determination of prognosis.

Outcome of silent lupus nephritis

To analyze the long-term outcome in patients with silent lupus nephritis, we retrospectively studied 20 patients with systemic lupus erythematosus without clinical renal involvement who had renal biopsies in our unit between 1978 and 1986 and reviewed 193 cases reported between 1957 and 1995. Two patients of the current series were lost to follow-up. Mean follow-up in the other 18 was 13 +/- 3 years (range, 2 to 17). On kidney biopsy, nine had class I, six class II, one class IV, and two class V disease (WHO classification). Three patients with prior normal renal function died of nonrenal causes. During the study, the remaining 15 patients had normal renal function and urinalysis. Most patients from the literature had "mild" histologic lesions, but 30 had diffuse proliferative glomerulonephritis. Over an average of 46 months of follow-up from biopsy, renal survival rate and patient survival rate were 98% and 91%, respectively. Three patients died of end-stage renal failure. In conclusion, end-stage renal failure in patients with silent lupus nephritis is rare regardless of the histopathological renal lesions. Patients survival depends on nonrenal causes.

Lupus nephritis in childhood and adolescence

Lupus nephritis in childhood usually presents after the age of 10 years, and presentation under 5 years is very rare. More males (F:M ratio 4.5:1) are affected than in adult-onset cases, but the ratio is the same in prepubertal and pubertal children. The incidence of clinically evident renal disease is greater at onset than in adults (82%), the usual presentation being with proteinuria, 50% having a nephrotic syndrome. Half the children show World Health Organisation class IV nephritis in renal biopsies. Neuropsychiatric lupus is present at onset in 30%, may complicate 50% at some point and remains a major problem. Prognosis has improved greatly over the past 30 years, at least in part the result of immunosuppressive treatment. Treatment of the initial phase may be guided by the severity of the renal biopsy appearances, more aggressive treatment including cytotoxic agents, i.v. methylprednisolone and perhaps plasma exchange, although the value of exchange is not established. Controversy persists as to the most effective cytotoxic treatment in the acute phase, both oral and i.v. cyclophosphamide and azathioprine being used in different units. In the chronic maintenance phase it seems established both clinically and histologically that addition of a cytotoxic agent improves outcome, but again the drug and route of administration are contentious. Azathioprine has the advantage of being safe for pregnancy and not gonadotoxic, whilst i.v. cyclophosphamide has been demonstrated to improve results over prednisolone alone in controlled trials and has advantages in non-compliant patients. No trial comparing the two regimes has been carried out, and one is needed. Today children much less commonly go into renal failure, and the main causes of actual death (15% of patients over 10 years) are now infections and extra-renal manifestations of lupus, principally neurological. Morbidity of the disease and the treatment remain a major problem, especially when treatment exacerbates complications of the disease itself, such as infections, osteonecrosis, thrombosis, vascular disease and possibly neoplasia.

Can experienced clinicians predict the outcome of lupus nephritis?

The ability of four experienced clinicians to predict short-term outcome (serum creatinine level at 1 year) and long-term outcome (renal insufficiency) was evaluated in 87 patients with lupus nephritis. The correlational agreement and the accuracy of their predictions were contrasted with the actual outcomes observed and with statistically generated prognostic regression models. In contrast to previously published data, all four clinicians predicted both short-term outcomes (P < 0.001) and long-term outcomes (P < 0.02) well. The clinicians' predictions approximated that of a statistically generated computer model for both agreement and accuracy for renal function at 1 year. The four clinicians identified nearly identical clinical variables as important in determining prognosis. Provision of biopsy data to the clinicians improved short-term and long-term prediction slightly. The value of the statistical models was 'validated' by demonstrating that three of the four clinical variables identified by the models, but not by the clinicians, could enhance clinical prediction (P < 0.05). In addition, the extent of tubulo-interstitial involvement on biopsy, a predictor that has recently received increased attention, could improve the long-term clinical predictions of all four clinicians (P < 0.05).

Kidney biopsy in systemic lupus erythematosus. II. Survival analyses according to biopsy results

Renal biopsy specimens from 123 patients with systemic lupus erythematosus (SLE) seen between 1970 and 1984 were assessed according to the World Health Organization classification and according to the presence of proliferative, active, or chronic renal lesions. Survival analysis was used to study the determinants of mortality. Survival rates were higher for patients with minimal lesions, intermediate for patients with focal or diffuse proliferative nephritis, and low for patients with glomerular sclerosis. The presence of proliferative and chronic lesions was associated with a higher risk of dying. Renal biopsy results are helpful in predicting prognosis for all-cause mortality in patients with SLE.

Contribution of renal biopsy data in predicting outcome in lupus nephritis. Analysis of 116 patients

We reassessed renal biopsy specimens from 116 patients with systemic lupus erythematosus and clinical manifestations of lupus nephritis to determine the contributions of the World Health Organization classification system, the activity and chronicity indexes of the National Institutes of Health scoring system, and various clinical parameters at the time of biopsy to predicting disease outcome. Multivariate analysis showed that only a chronicity index greater than 3 was predictive for decreased renal survival, while age greater than 31 years at biopsy and a chronicity index greater than 3 were associated with decreased patient survival. Clinical tests of renal function were not reliable in discriminating between active lesions and chronic renal damage.

Long-term follow-up of patients with lupus nephritis. A study based on the classification of the World Health Organization

The long-term course of 56 patients with systemic lupus erythematosus who had precisely defined renal histology and carefully assessed clinical status at the time of their initial renal biopsy prior to 1976 was evaluated and analyzed by life-table analysis. The average length of follow-up has now been greater than 10 years since initial biopsy. Patients with mesangial lesions (World Health Organization [WHO] classes IIA and IIB) had a more favorable renal and patient survival at five and 10 years than did patients in the other WHO classes (III, IV, and V). Individual renal histologic features of activity and chronicity when combined into an activity index and a chronicity index did not significantly predict renal survival in this population, nor did the presence of hypertension or renal dysfunction at the time of the initial renal biopsy significantly influence renal or patient survival. Patients with the nephrotic syndrome at initial biopsy had a poorer renal survival than did patients without the nephrotic syndrome. However, patients who experienced a remission of the nephrotic syndrome fared better in terms of both renal and patient survival than did those patients without a remission. By life-table analysis, patient survival was significantly better for patients in whom biopsy was performed after 1973 than for those in whom biopsy was performed prior to that time despite similar clinical features and WHO histology in each group interval. Our data suggest that improved survival for patients in recent studies may relate to better supportive care and more selective use of immunosuppressive therapy in patients with milder forms of lupus nephritis.

The prognosis of segmental glomerulonephritis in systemic lupus erythematosus

Severe segmental glomerulonephritis (Seg GN) (greater than or equal to 50% involvement) in systemic lupus erythematosus (SLE) is classified as diffuse GN (DPGN) in the WHO classification. We tested the validity of the assumption that severe Seg GN and DPGN have the same prognosis by determining the proportion of glomeruli involved by active segmental inflammation in a series of 127 patients and by comparing the prognosis in various categories of Seg GN with patients with DPGN. In Seg GN we found mild involvement (1 to 19%) in 19 patients, moderate involvement (20 to 49%) in 9 patients and severe involvement (greater than or equal to 50%) in 17 patients. There were 28 cases of DPGN. The actuarial five-year survival of patients with mild and moderate Seg GN was 82%. The survival of patients with severe Seg GN and DPGN were 59 and 53%, respectively. The incidence of adverse outcomes, including death, end-stage kidney disease, and deterioration of renal function was similar in patients with severe Seg GN and DPGN, and greater than in patients with mild and moderate Seg GN. Although there was a trend associating increasing glomerular involvement with elevated urinary protein excretion and serum creatinine and decreased serum C3 and C4, the differences were not significant. Cumulative prednisone dose and prednisone given in the first and second years following biopsy were not different in the various categories of Seg GN and DPGN, suggesting that differences in outcome were not related to the amount of prednisone therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Systemic lupus erythematosus

Systemic lupus erythematosus is a multisystem inflammatory disease characterized by autoantibody production. Recent investigations are providing insights into the immunoregulatory disturbances underlying this disease, and are clarifying the approach to diagnosis and treatment.

Monocyte procoagulant activity in glomerulonephritis associated with systemic lupus erythematosus

Monocyte infiltration and activation of the coagulation system have been implicated in the pathophysiology of glomerulonephritis. In this study, spontaneous procoagulant activity (PCA) was measured in circulating mononuclear cells to determine whether elevated PCA correlated with the presence of proliferative glomerulonephritis in patients with systemic lupus erythematosus (SLE). No increase in PCA was found in 20 patients with end-stage renal failure, 8 patients with glomerulonephritis without SLE, and 10 patients undergoing abdominal surgical or orthopedic procedures as compared with 20 normal controls. In eight patients with SLE but with no apparent active renal disease, PCA was not elevated above normal basal levels. Seven additional patients with SLE who had only mesangial proliferation on biopsy also had no increase in PCA. In contrast, eight patients with focal or diffuse proliferative lupus nephritis, and one patient with membranous nephritis who ultimately developed a proliferative lesion, had a marked increase in PCA with greater than 100 times the base-line levels. The activity was shown to originate in the monocyte fraction of the mononuclear cells and was shown to be capable of cleaving prothrombin directly. The prothrombinase activity was not Factor Xa, because it was not neutralized by anti-Factor X serum and was not inhibited by an established panel of Factor Xa inhibitors. Monocyte plasminogen activator determinations did not correlate with renal disease activity. We conclude that monocyte procoagulant activity, a direct prothrombinase, seems to correlate with endocapillary proliferation in lupus nephritis and could be a mediator of tissue injury.