Evolución al año de la nefritis lúpica con proliferación extra capilar focal / Progression of focal lupus nephritis with extracapillary proliferation after one year

INTRODUCCIÓN: La nefritis lúpica proliferativa (NPL) con proliferación extra capilar focal (PECF) es una entidad frecuente en las biopsias renales, pero poco se conoce acerca de su evolución. Este estudio se realizó para investigar la correlación clínica, histológica y de laboratorio en la evolución de estos pacientes. OBJETIVO: Analizar las biopsias de nefritis lúpicas proliferativas focales o difusas (clases III y IV de la OMS), y su evolución de acuerdo al grado de proliferación extracapilar en un período de 10 años, en el Hospital de Clínicas "José de San Martín". MATERIAL Y MÉTODOS: Estudio observacional retrospectivo, se incluyeron 147 pacientes con GN clase III o IV, estudiados en un período de 10 años. Se subdividieron en base al compromiso extracapilar en: grupo 1 (5- <25% de semilunas, n=33), grupo 2 (25- 50% semilunas, n=34) y grupo 3 (>50% semilunas, n= 20) o proliferación extracapilar difusa (PECD). Los pacientes con nefritis lúpica III y IV, sin compromiso extra capilar, se denominó grupo control (n=60); las características clínicas, laboratorios y evolución en cuanto alcanzar remisión completa al año fueron comparadas entre los subgrupos y el grupo de control. Remisión completa se definió según normas KDIGO 2012. Se realizó un análisis univariado y posteriormente un multivariado, ambos con regresión logística. RESULTADOS: Hubo 124 mujeres (84,35%) y 23 hombres (15,65%) con una edad media de 35±10 años. Edad media en el grupo control, 32±10 años. El univariado mostro mayor remisión completa en el grupo control con odds ratio 0.05 (0.02.-0.12) p=0.001, y menor remisión completa en los 3 subgrupos con proliferación extra capilar, inclusive el grupo I con un odds ratio 7.61 (2,42-23.9) y valor de p=0.001 en dicho grupo. El análisis multivariado evidenció que la persistencia de la proteinuria a los 6 meses tenía significación estadística para no alcanzar la remisión completa, con un odd ratio 2.81 (1.58-5.0), valor de p=0.001. CONCLUSIÓN: La presencia de distintos grados de semilunas en la histología de las NL proliferativas (NPL), clase III y IV, y la persistencia de la proteinuria a los 6 meses, son marcadores independiente para no alcanzar la remisión completa al año

IINTRODUCTION: Although focal lupus nephritis (FLN) with extracapillary proliferation (ECP) is usually found in renal biopsies, little is known about its course. This study was carried out to investigate the correlation of clinical, histological and laboratory findings in these patients' progress. OBJECTIVE: To analyze focal or diffuse proliferative lupus nephritis biopsies (class III and IV, according to WHO) and their development regarding the level of extracapillary proliferation throughout a period of 10 years at Hospital de Clínicas 'José de San Martín'. METHODS: In this retrospective observational study, 147 patients with class III or IV GN were observed for 10 years. According to the degree of extracapillary proliferation, they were divided into the following groups: group 1 (5% <25% of crescents, n=33), group 2 (25% 50% of crescents, n=34) and group 3 [>50% of crescents, i.e. diffuse proliferative nephritis (DPN), n=20]. Patients suffering from class III and IV lupus nephritis with no extracapillary proliferation formed the control group (n=60). After one year, clinical and laboratory findings as well as the development of the condition among the four groups were compared to assess their level of remission. Complete remission was considered as defined in KDIGO 2012 Guideline. A univariate logistic regression analysis and a subsequent multivariate one were performed. RESULTS: There were 124 women (84.35%) and 23 men (15.65%) with an average age of 35±10. The average age in the control group was 32±10. The univariate analysis showed a greater number of patients who achieved complete remission in the control group with an odds ratio of 0.05 (0.02 0.12) p=0.001, whereas in the 3 groups with extracapillary proliferation fewer patients reached this state, even in group 1, which had an odds ratio of 7.61 (2.42 23.9) and p=0.001. The multivariate analysis revealed that the persistent protein in the urine after 6 months was statistically significant for not achieving complete remission, the odds ratio being 2.81 (1.58 5.0) and p=0.001. CONCLUSION: The presence of various degrees of crescent formation in class III and IV proliferative lupus nephritis (PLN) shown in the histological findings and the persistent protein in the urine at 6 months constitute independent factors for not achieving complete remission after one year

Meta-analysis of mycophenolate mofetil versus cyclophosphamide for diffuse proliferative lupus nephritis / 国际儿科学杂志

ObjectiveTo estimate the application of mycophenolate mofetil (MMF) and cyclophosphamide(CTX) intravenous pulse therapy on diffuse proliferative lupus nephritis (DPLN).MethodPubMed,Medline,EMBASE and CNKI were searched from the establishment of the database.Meta-analysis of 14 comparative studies on MMF and CTX in treatment of DPLN was performed,taking the remission,the relapse,the death of MMF and CTX for DPLN as primary efficacy variable,mean while taking the herpes zoster as safety evaluating indicator.ResultsMMF was better than CTX in remission rate ( P ＜ 0.05 ).There was no difference between in incidence rate of the relapse,the death and the herpes zoste MMF and CTX for DPLN ( P ＞ 0.05 ).ConclusionMMF was better than CTX on the efficacy and safety in DPLN.

Clinical Outcome and Prognostic Factors of Biopsy-proven Diffuse Proliferative Lupus Nephritis / 대한신장학회잡지

Lupus nephritis is a major cause of morbidity and mortality arising from systemic lupus erythematous. It is generally acknowledged that the presence of diffuse proliferative lupus nephritis(DPLN) is highly predictive of a poor prognosis in terms of renal and patient out- come on survival. The objective of this study was to evaluate the clinicopathologic characteristics, renal out- come according to therapeutic regimen, and prognostic factors of biopsy-proven diffuse proliferative lupus nephritis. Among the biopsy-proven lupus nephritis patients who were admitted to Yonsei University Medical Center from January 1986 to June 1997, 36 patents who were diagnosed DPLN by renal biopsy and treated for at least 6 months and regularly followed-up for at least 12 months were included. We retrospec-tively reviewed the medical recorders. Patients were treated with steroid regimen with or without cyclo-phosphamide. According to the therapeutic response, patients were divided into two groups : a therapeutic response group(n=24), and a therapeutic non-response group

The Efficacy of Intravenous Cycophosphamide Pulse Therapy in Proliferative Lupus Nephritis with Normal Serum Creatinine / 대한류마티스학회지

OBJECTIVE: To evaluate the efficacy of intravenous cyclophosphamide pulse therapy (IVC) in proliferative lupus nephritis (PLN) with normal serum creatinine. METHODS: We retrospectively reviewed 53 PLN patients treated with IVC more than 6 times from 1992 to 1997. The patients were classified into the alternative and the initial. In the former, IVC was started after failed remission with steroid or steroid and oral immunosuppressive drug; in the latter, IVC was started as initial treatment. Remmission was endpoint of study and defined as all of the followings should be maintained for more than 6 months, 1) 24-hour urine protein less than 1g, 2) normal serum creatinine, 3) less than 5 RBC in high power field microscopy and no granular and RBC cast in urine. We compared remission rate and frequency of complications associated with IVC between the initial and alternative by chi-square test and analyzed the variables of remission including methodological; initial or alternative, clinical; age, onset age of systemic lupus erythematous (SLE) and lupus nephritis (LN), duration of SLE and LN, laboratory; serum concentration of creatinine, C3, C4, albumin, anti ds-DNA Ab. titers and 24 hour urine proteins and pathological; activity and chronicity index, multivariatly. RESULTS: All 53 patients (22 initial, 31 alternative) had normal serum creatinine at start of IVC, treated with 9.7 +/-2.3 times of IVC and followed up during 37.2 +/-15.4 months. Thirty-four patients (64%) had remission (18 of the initial and 16 of the alternative). The remission rate of the initial was higher (82% vs 52%, p=0.04 by chi-square test) than the alternative, but frequency of complications was not different. In multivariate analysis, any other variables; including methodological, clinical, laboratory and pathological, did not influenced on remmission significantly. CONCLUSIONS: IVC is effective in PLN with normal serum creatinine as initial treatments and our results suggest that IVC may be chosen as an alternative therapy in PLN patients who failed remission with steroid or steroid and oral immunosuppressive drug.

Prognostic Factors of Diffuse Proliferative Lupus Nephritis / 대한신장학회잡지

Diffuse proliferative lupus nephritis(DPLN) is the most severe form in lupus nephritis. We retrospectively analyzed 90 DPLN patients who were confirmed by kidney biopsy and treated at least for 12 months to compare the effectiveness of treatment modalities and to investigate the prognostic factors of DPLN. The patients were categorized as intravenous cyclophosphamide pulse(CY) group and oral corticosteroid(with or without cytotoxic drug; PO) group. When CY group(69pts) and PO group(21pts) were compared, there was no differences between two groups in sex, age, follow-up months, chronicity index(CI, 4.55 vs 3.76; CY vs PO, respectively), complications of treatment, mortality rate(4.3% vs 0%), remission rate of nephritis(at 3 year; 59.1% vs 75.5%) and renal survival rate(at 5 years; 88.0% vs 91.7%), b ut significant differences in frequency of nephrotic syndrome(66.7% vs 33.3%) and azotemia (30.4% vs 0%), activity index(7.14 vs 4.33) and relapse rate(2.9% vs 42.9%). When remission group (49pts) and nonremission group(41pts) were compared, the CI, initial azotemia, tubular atrophy, glomerular sclerosis, sex and duration of nephritis were prognostic factors for remission in univariate analysis, and CI(OR, 9.89) and sex(OR, 10.99) in multivariate analysis. When remission group(35pts) and nonremission(34pts) group were compared in CY group, the CI, initial azotemia and tubular atrophy were the prognostic factors in univariate analysis, and CI(OR, 7.69) in multivariate analysis. The initial azotemia was the only prognostic factor for renal survival. We concluded that the CI, sex and initial azotemia were the prognostic factors for renal remission and survival, but the treatment modality was not in DPLN. Therefore it is necessary to evaluate the prognostic factors before decision of treatment modality.