Chronic kidney disease trajectories in lupus nephritis: Is progression unavoidable?

Case 1: 35-year-old patient with lupus nephritis presents with anasarca, hypertension and renal insufficiency at her 18th week of pregnancyLiz Lightstone, and Sandra NavarraClinical presentationA 35-year-old female was diagnosed lupus...

ObjectiveTo investigate second kidney biopsy as predictor of end-stage kidney disease (ESKD) in active lupus nephritis (LN).MethodsPatients with biopsy-proven LN (International Society of Nephrology/Renal Pathology Society 2003) who had undergone...

Immunohistochemical Expression of Activated Caspase-3 as a Marker of Apoptosis in Glomeruli of Human Lupus Nephritis

PurposeTo investigate second kidney biopsy as predictor of end-stage kidney disease (ESKD) in active lupus nephritis (LN).MethodsPatients with biopsy-proven LN (ISN/RPS 2003) who had undergone a second kidney biopsy between...

FRI0165 RISK OF CKD IN MEMBRANOUS AND PROLIFERATIVE LUPUS NEPHRITIS - ANALYSIS OF A NATIONWIDE MULTICENTRE COHORT

The Use of Serological Tests in the Care of Patients with Lupus Nephritis.

Blood Pressure Goals: How Low Is Safe in CKD?

Do Children With Acute Kidney Injury Require Long-term Evaluation for CKD?

ObjectiveTo assess the effectiveness of the modified National Institute of Health (mNIH) activity and chronicity scoring system in predicting the progression to end-stage kidney disease (ESKD) in Latin American lupus nephritis (LN) patients.MethodsWe retrospectively analyzed 412 patients with biopsy-proven LN. ESKD was defined as an estimated glomerular filtration rate (eGFR) < 15mL/min/1.73m2 for ≥3months, dialysis for >3months, or kidney transplant. Univariable and multivariable Cox proportional hazards regression analyses were performed to evaluate the predictive value of the mNIH activity and chronicity indices for ESKD.Results84 patients (20.4%) progressed to ESKD at a median of 3.0 months after biopsy. The mNIH activity and chronicity indices were significantly higher in patients who progressed to ESKD compared to those who did not [7 (5-10) versus 4 (1-7), p < .001; and 3 (1-5) versus 0 (0-2), p < .001, respectively]. Multivariable Cox regression analysis revealed that the mNIH activity index (HR 1.17, 95% CI 1.05-1.29), and the mNIH chronicity index (HR 1.21, 95% CI 1.05-1.40) were independently associated with a higher risk of ESKD, adjusting for age, sex, ethnicity, and eGFR. Furthermore, fibrinoid necrosis (HR 4.09, 95% CI 1.54-10.86) and fibrous crescents (HR 2.36; 95% CI 1.06-5.27), components of the activity and chronicity indices, respectively, were also associated with a shorter time to ESKD.ConclusionsIn Latin American LN patients, the mNIH activity and chronicity indices are associated with an increased risk of ESKD. Among the components of these indices, shorter time to ESKD was mainly driven by fibrinoid necrosis and fibrous crescents.

Advanced chronic kidney disease (CKD) carries an increased risk for progression to endstage renal disease (ESRD). We aimed to determine the rate of progression and the factors that drive the decline of renal function in lupus nephritis (LN). Patients with advanced LN-related CKD were identified from our longterm longitudinal cohort. Advanced CKD was defined as stage 3b [estimated glomerular filtration rate (eGFR) = 30-44 ml/min/1.73 m2] and stage 4 (eGFR = 15-29 ml/min/1.73 m2). All individuals were followed until progression to ESRD or the last visit and were divided into "progressors" and "non- progressors." Demographic, clinical, immunological, and therapeutic variables were compared at baseline. Multivariable Cox regression analysis (both time-dependent and independent) was performed to identify predictors for progression. One hundred eighteen patients (74 CKD 3b and 44 CKD 4) were included. Forty-five patients progressed (29 to ESRD and 16 from CKD 3b to CKD 4) after 6 years on average. No significant decline in the renal function was observed in 73 patients ("non-progressors") after 10 years on average. Active serology (high anti-dsDNA titers and low complements C3/C4) at the time of CKD diagnosis and any increase of the daily prednisone dose after baseline were strongly associated with progression. Treatment with renin angiotensin system (RAS) blockers was associated with less risk for progression. Dialysis is not inevitable in LN-related advanced CKD because 62% of our patients did not progress over 10 years of followup on average. Certain predictors were identified to affect progression to ESRD.

Background:Systemic Lupus Erythematosus (SLE) renal involvement occurs in approximately 40-50% of adult patients. Compared to adult-onset SLE cases, pediatric-onset SLE nephritis is reported to be more prevalent and often results...

Background:Up to 20% of lupus nephritis diagnosed within 1 year of lupus diagnosis ends up in end-stage kidney disease (ESKD). Increasing evidence suggests that findings from a second biopsy provide...

Among adults in the United States, 1 in 4 has hypertension and 1 in 8 has chronic kidney disease (CKD). Although the relationship between hypertension and CKD has been recognized for several hundred years, the prevalence of CKD among patients with normal blood pressure has not been assessed in randomly sampled populations. Crews et al1 in this issue of Hypertension are the first to report such estimates: 13.4% of people who have normal blood pressure have CKD. Among those with prehypertension, the prevalence is 17.3%; among those with undiagnosed hypertension, the prevalence is 22.0%; and among those with diagnosed hypertension, the prevalence is 27.4%. The magnitude of these CKD prevalence estimates is astounding and may even be misleading unless placed in appropriate context. The awareness of CKD diagnosis was dismal: <10% of people were aware of CKD regardless of hypertension category. A thorough analysis of the definition of CKD is necessary to understand how the varying definitions of CKD may have influenced both the prevalence and awareness estimates. The prevalence estimates may be inflated because of CKD that is so mild that it may not be considered a disease at all. For example, examination of the Figure (derived from Table 3 of the article) shows that if one considers the prevalence of more severe CKD defined as macroalbuminuria or estimated glomerular filtration rate (GFR) <45 mL/min per 1.73 m2, then the prevalence estimates fall dramatically. These stricter definitions of CKD yield the following prevalence estimates of CKD: normal blood pressure 0.5%; prehypertension 1.0%; undiagnosed hypertension 2.0%; and <5.0% prevalence of CKD among those with diagnosed hypertension. These prevalence estimates are much lower than those obtained with the more sensitive definition that is typically used to define CKD. Thus, the prevalence estimates of CKD may be driven up …

Childhood-onset lupus nephritis (cLN) is an aggressive disease. Although histological class has historically guided its treatment, its prognostic value remains limited. Although the National Institutes of Health (NIH)-modified activity index (AI) and chronicity index (CI) incorporate glomerular and tubulointerstitial changes and may provide better prognostic insight, their utility in cLN is not well established. Here we aimed to assess the utility of the NIH-modified-modified AI and CI for predicting kidney outcomes and identify histopathological features and treatment-related factors associated with the development of kidney function impairment in cLN. We retrospectively analyzed 60 children with biopsy-proven proliferative lupus nephritis. Their baseline clinical and histological features, treatments, and outcomes were assessed. The association between AI and CI scores, along with individual histological components, and kidney function impairment, defined as an estimated glomerular filtration rate < 90 mL/min/1.73 m² sustained for ≥3 months, was evaluated. Over a median follow-up of 55.5 months, 30% of patients developed kidney function impairment. AI scores and glomerular lesions did not differ significantly between patients with and without kidney function impairment. However, the CI scores were significantly higher in patients who developed kidney function impairment, with tubular atrophy and interstitial fibrosis being the most predictive components. On a multivariate analysis, tubular atrophy was an independent predictor of kidney function impairment (hazard ratio [HR], 17.74; 95% confidence interval [CI], 1.94-162.5; P=0.01). Use of mycophenolate mofetil (MMF) as maintenance therapy was associated with a reduced risk of kidney function impairment (HR, 0.09; 95% CI, 0.02-0.47; P=0.003). Chronic tubulointerstitial changes, particularly tubular atrophy, are a stronger predictor of longterm kidney function than glomerular findings or AI scores. These findings highlight the prognostic value of NIH-modified CI and the importance of MMF in maintenance therapy. The early identification of chronic lesions on biopsy may guide therapeutic decisions aimed at preserving kidney function and improving long-term outcomes in patients with cLN.

A renewed interest for activity and chronicity indices as predictors of lupus nephritis (LN) outcome has emerged. Revised National Institutes of Health activity and chronicity indices have been proposed to classify LN lesions, but they should be validated by future studies. The aims of this study were (1) to detect the histologic features associated with the development of kidney function impairment (KFI), and (2) to identify the best clinical-histologic model to predict KFI at time of kidney biopsy. Patients with LN who had more than ten glomeruli per kidney biopsy specimen were admitted to the study. Univariate and multivariate logistic regression and Cox proportional hazards models were used to investigate whether activity and chronicity indices could predict KFI development. Among 203 participants with LN followed for 14 years, correlations were found between the activity index, and its components, and clinical-laboratory signs of active LN at baseline. The chronicity index was correlated with serum creatinine. Thus, serum creatinine was significantly and directly correlated with both activity and chronicity indices. In the multivariate analysis, glomerulosclerosis (OR, 3.05; 95% CI, 1.17 to 7.91; P=0.02) and fibrous crescents (OR, 6.84; 95% CI, 3.22 to 14.52; P<0.001) associated with either moderate/severe tubular atrophy (OR, 3.17; 95% CI, 1.04 to 9.64; P=0.04), or with interstitial fibrosis (OR, 2.36; 95% CI, 1.05 to 5.32; P=0.04), predicted KFI. Considering both clinical and histologic features, serum creatinine (OR, 1.68; 95% CI, 1.31 to 2.15; P<0.001), arterial hypertension (OR, 4.64; 95% CI, 1.90 to 11.32; P<0.001), glomerulosclerosis (OR, 2.12; 95% CI, 1.00 to 4.50; P=0.05), and fibrous crescents (OR, 5.18; 95% CI, 2.43 to 11.04; P<0.001) independently predicted KFI. Older age (P<0.001) and longer delay between clinical onset of LN and kidney biopsy (P<0.001) were significantly correlated with baseline chronicity index. The chronicity index and its components, but not the activity index, were significantly associated with an impairment of kidney function. The Cox model showed that serum creatinine, arterial hypertension, chronic glomerular lesions, and delay in kidney biopsy predicted KFI. These data reinforce the importance of timely kidney biopsy in LN.