Outcome of the acute glomerular injury in proliferative lupus nephritis.

Treatment with total lymphoid irradiation (TLI) and corticosteroids markedly reduced activity of systemic lupus erythematosis in 10 patients with diffuse proliferative lupus nephritis (DPLN) complicated by a nephrotic syndrome. Physiologic and morphometric techniques were used serially before, and 12 and 36 mo post-TLI to characterize the course of glomerular injury. Judged by a progressive reduction in the density of glomerular cells and immune deposits, glomerular inflammation subsided. A sustained reduction in the fractional clearance of albumin, IgG and uncharged dextrans of radius greater than 50 A, pointed to a parallel improvement in glomerular barrier size-selectivity. Corresponding changes in GFR were modest, however. A trend towards higher GFR at 12 mo was associated with a marked increase in the fraction of glomerular tuft area occupied by patent capillary loops as inflammatory changes receded. A late trend toward declining GFR beyond 12 mo was associated with progressive glomerulosclerosis, which affected 57% of all glomeruli globally by 36 mo post-TLI. Judged by a parallel increase in volume by 59%, remaining, patent glomeruli had undergone a process of adaptive enlargement. We propose that an increasing fraction of glomeruli continues to undergo progressive sclerosis after DPLN has become quiescent, and that the prevailing GFR depends on the extent to which hypertrophied remnant glomeruli can compensate for the ensuing loss of filtration surface area.

Treatment of murine lupus nephritis with cyclophosphamide or total lymphoid irradiation.

Untreated 9 to 11 month-old, female NZB/W F1 mice all died within six weeks (wks) after the occurrence of nephrotic range proteinuria (greater than or equal to 3 g/liter). Significant prolonged survival could be obtained in similar groups of animals either by weekly i.v. pulses of cyclophosphamide (CY, 25 mg/kg, 40% survival 20 wks after start of treatment) or by administering total lymphoid irradiation (TLI, 17 daily fractions of 2 Gy, 70% survival at 20 wks). All surviving animals in both groups showed remission of the nephrotic range proteinuria. In all treated mice, light microscopy examination of the kidneys revealed a decrease of inflammation and a stabilization of proliferation and sclerosis, yet immunofluorescence for IgM, IgG and C3 was not significantly altered. The better survival of the TLI- as compared to the CY-treated mice (P less than 0.001) was due to a lower incidence of lymphomas or viral infections. IgG anti-DNA auto-antibodies were significantly lowered by CY but not by TLI treatment. It is concluded that CY pulse therapy and TLI are both efficient treatment modalities for high grade lupus like NZB/W disease. In this model TLI is safer than CY when used in a dose regimen of 25 mg/kg/wk and interferes with the course of the disease without lowering the IgG anti-DNA antibodies.

Long-term followup of patients treated with total lymphoid irradiation for lupus nephritis.

OBJECTIVE: To describe the long-term survival, renal condition, and morbidity outcomes in patients who received total lymphoid irradiation (TLI) for the treatment of lupus nephritis. METHODS: Twenty-one patients with biopsy-proven, diffuse membranoproliferative glomerulonephritis and significant proteinuria of >2.5 grams/day received TLI from 1980 to 1987 at Stanford University Medical Center. All patients had previously failed to respond to treatment with high-dose corticosteroids or therapy with corticosteroids plus immunosuppressive agents (azathioprine, cyclophosphamide, or chlorambucil). RESULTS: The mean duration of followup since TLI was 10.7 years. Fifteen of 21 patients (71%) remained alive at the time of this assessment. Nine of the 21 patients (43%) survived without developing end-stage renal disease (ESRD). The probability of long-term survival without ESRD and without need for additional immunosuppressive agents after TLI was 19% (4 of 21). Factors predicting renal failure at the time of TLI included elevated creatinine levels, increased interstitial fibrosis on renal biopsy, and increased fractional excretion of immunoglobulin and albumin. Malignancies were found in 4 patients, and opportunistic infections occurred in 7 patients. CONCLUSION: Overall, patients with lupus nephritis treated with TLI do not appear to have better 10-year survival with lower incidence of ESRD compared with patients in published series treated with conventional immunosuppressive therapies. However, in this series of patients, treatment with conventional immunosuppressive therapies had been unsuccessful and given the limited number of adverse events and the efficacy seen in some patients, TLI appears to be a reasonable therapeutic option for the treatment of severe lupus nephritis among patients who fail to respond under standard cytotoxic regimens.

Treatment of lupus nephritis with total lymphoid irradiation. Observations during a 12-79-month followup.

Seventeen patients with intractable lupus nephritis and nephrotic syndrome were treated with total lymphoid irradiation. Statistically significant improvement in mean renal disease and serologic activity parameters occurred within 3 months and persisted for at least 3 years. Although there was a marked reduction of T helper cell numbers and function after total lymphoid irradiation, recovery of these parameters was not associated with a return of disease activity. Risks of sterility, severe infections, and hematologic malignancy appeared to be lower than with alkylating agents.