Abstract
Introduction/objectives
Acute kidney injury (AKI) with the requirement of kidney replacement therapy (KRT) portends a poor prognosis for kidney function in lupus nephritis (LN). This study evaluated the kidney function recovery rates, the rates of reinitiation of KRT, and factors associated with these outcomes in LN.
Method
All consecutive patients hospitalized for LN with KRT requirement between 2000 and 2020 were included. Their clinical and histopathologic characteristics were retrospectively registered. The outcomes and associated factors were evaluated by multivariable Cox regression analysis.
Results
Among 140 patients, 75 (54%) recovered kidney function, with recovery rates of 50.9% and 54.2% by 6 and 12 months of therapy. The factors associated with a lower probability of recovery included a previous history of LN flares, worse eGFR and higher proteinuria at presentation, immunosuppression with azathioprine, and hospitalizations within 6 months of therapy initiation. There was no difference in the kidney function recovery rates between mycophenolate and cyclophosphamide treatment schemes. Out of 75 patients who recovered kidney function, 37 (49%) reinitiated KRT, with KRT reinitiation rates of 27.2% and 46.5% by 3 and 5 years. Seventy-three (52%) patients had at least one hospitalization within 6 months of initial therapy, 52 (72%) of them secondary to infectious events.
Conclusions
Approximately 50% of patients with LN and KRT requirement recover kidney function within 6 months. The risk-to-benefit ratio decisions may be aided by clinical and histological factors. These patients require close follow-up as ≈50% of those who recover kidney function will reinitiate dialysis in the long term.
Key Points • Approximately 50% of patients with severe acute lupus nephritis with the need for kidney replacement therapy requirement recover their kidney function. • The factors associated with a lower probability of recovery of kidney function include a previous history of LN flares, worse eGFR and higher proteinuria at presentation, immunosuppression with azathioprine, and hospitalizations within 6 months of therapy initiation. • Patients who recover kidney function will require close follow-up as around 50% of them will eventually reinitiate kidney replacement therapy. |
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Data availability
The data supporting this study is available upon reasonable request to the corresponding author.
References
Mejia-Vilet JM, Rovin BH (2019) Chapter 59. Epidemiology and management of lupus nephritis. In: Wallace D, Hahn B (eds) Dubois Systemic Lupus Erythematosus and Related Syndromes, 9th edn. Elsevier, Philadelphia, PA, pp 727–744
Zhu D, Qu Z, Tan Y, Yu F, Zhao M (2011) Acute kidney injury in Chinese patients with lupus nephritis: a large cohort study from a single center. Lupus 20(14):1557–1565. https://doi.org/10.1177/0961203311417035
Moroni G, Vercelloni PG, Quaglini S, Gatto M, Gianfreda D, Sacchi L et al (2018) Changing patterns in clinical–histological presentation and renal outcome over the last five decades in a cohort of 499 patients with lupus nephritis. Ann Rheum Dis 77(9):1318–1325. https://doi.org/10.1136/annrheumdis-2017-212732
Chen T, Ding X, Chen B (2009) Value of the RIFLE classification for acute kidney injury in diffuse proliferative lupus nephritis. Nephrol Dial Transplant 24(10):3115–3120. https://doi.org/10.1093/ndt/gfp235
Yu F, Tan Y, Liu G, Wang S, Zou W, Zhao M (2009) Clinicopathological characteristics and outcomes of patients with crescentic lupus nephritis. Kidney Int 76(3):307–317. https://doi.org/10.1038/ki.2009.136
Teh CL, Phui VE, Ling GR, Ngu LS, Wan SA, Tan CHH (2018) Causes and predictors of mortality in biopsy-proven lupus nephritis: the Sarawak experience. Clin Kidney J 11(1):56–61. https://doi.org/10.1093/ckj/sfx063
Furie R, Rovin BH, Houssiau F, Malvar A, Teng OYK, Contreras G et al (2020) Two-year, randomized, controlled trial of belimumab in lupus nephritis. N Engl J Med 383(12):1117–1128. https://doi.org/10.1056/NEJMoa2001180
Rovin BH, Teng YKO, Ginzler EM, Arriens C, Caster DJ, Romero-Diaz J et al (2021) Efficacy and safety of voclosporin versus placebo for lupus nephritis (AURORA 1): a double-blind, randomised, multicentre, placebo-controlled, phase 3 trial. Lancet 397(10289):2070–2080. https://doi.org/10.1016/s0140-6736(21)00578-x
Walsh M, Solomons N, Lisk L, Jayne DRW (2013) Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis with poor kidney function: a subgroup analysis of the Aspreva Lupus Management Study. Am J Kidney Dis 61(5):710–715. https://doi.org/10.1053/j.ajkd.2012.11.042
Sun F, Wang H, Zhang D, Han F, Ye S (2022) One-year renal outcome in lupus nephritis patients with acute kidney injury: a nomogram model. Rheumatology 61(7):2886–2893. https://doi.org/10.1093/rheumatology/keab818
Stotter BR, Cody E, Gu H, Daga A, Greenbaum LA, Duong MD et al (2023) Acute kidney injury requiring kidney replacement therapy in childhood lupus nephritis: a cohort study of the Pediatric Nephrology Research Consortium and Childhood Arthritis and Rheumatology Research Alliance. Pediatr Nephrol 38(5):1653–1665. https://doi.org/10.1007/s00467-022-05775-z
Fanouriakis A, Kostopoulou M, Cheema K, Anders HJ, Aringer M, Bajema I et al (2020) 2019 Update of the Joint European League against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis. Ann Rheum Dis 79(6):S713–S723. https://doi.org/10.1136/annrheumdis-2020-216924
Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM et al (2021) KDIGO 2021 clinical practice guideline for the management of glomerular diseases. Kidney Int 100(4S):S1–S276. https://doi.org/10.1016/j.kint.2021.05.021
Singh JA, Hossain A, Kotb A, Wells G (2016) Risk of serious infections with immunosuppressive drugs and glucocorticoids for lupus nephritis: a systematic review and network meta-analysis. BMC Med 14(1):137. https://doi.org/10.1186/s12916-016-0673-8
Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M, Ramsey-Goldman R et al (2019) 2019 European League Against Rheumatism/American College of Rheumatology classification criteria for systemic lupus erythematosus. Ann Rheum Dis 78(9):1151–1159. https://doi.org/10.1136/annrheumdis-2018-214819
Weening JJ, D’Agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB et al (2004) The classification of glomerulonephritis in systemic lupus erythematosus revisited. Kidney Int 65(2):521–530. https://doi.org/10.1111/j.1523-1755.2004.00443.x
Bajema IM, Wilhelmus S, Alpers CE, Bruijn JA, Colvin RB, Cook HT et al (2018) Revision of the International Society of Nephrology/Renal Pathology Society classification for lupus nephritis: clarification of definitions, and modified National Institutes of Health activity and chronicity indices. Kidney Int 93(4):789–796. https://doi.org/10.1016/j.kint.2017.11.023
Inker LA, Eneanya ND, Coresh J, Tighiouart H, Wang D, Sang Y et al (2021) New creatinine- and cystatin C–based equations to estimate GFR without race. N Engl J Med 385(19):1737–1749. https://doi.org/10.1056/NEJMoa2102953
Jin SY, Huang DL, Dang XQ, Yi ZW (2017) Lupus glomerulonephritis in 788 Chinese children: a multi-centre clinical and histopathological analysis based on 549 renal biopsies. Paediatr Int Child Health 37(4):286–291. https://doi.org/10.1080/20469047.2017.1309337
Benseler SM, Bargman JM, Feldman BM, Tyrrell PN, Harvey E, Hebert D, Silverman ED (2009) Acute renal failure in paediatric systemic lupus erythematosus: treatment and outcome. Rheumatology (Oxford) 48(2):176–182. https://doi.org/10.1093/rheumatology/ken445
Ishimori S, Kaito H, Shima Y, Kamioka I, Hamahira K, Nozu K et al (2019) Clinicopathological characteristics and renal outcomes of childhood-onset lupus nephritis with acute kidney injury: a multicenter study. Mod Rheumatol 29(6):970–976. https://doi.org/10.1080/14397595.2018.1532861
Chen T, Zhou Y, Zhang J, Chen C, Pan J (2020) Long-term predictive value of acute kidney injury classification in diffuse proliferative lupus nephritis with acute kidney injury. BMC Nephrol 21(1):13. https://doi.org/10.1186/s12882-019-1676-4
Mohan S, Huff E, Wish J, Lilly M, Chen SC, McClellan WM (2013) Recovery of renal function among ESRD patients in the US Medicare program. PLoS One 8(12):e83447. https://doi.org/10.1371/journal.pone.0083447
Sekkarie MA, Port FK, Wolfe RA, Guire K, Humphrys R, Amburg GV, Ferguson CW (1990) Recovery from end-stage renal disease. Am J Kidney Dis 15(1):61–65. https://doi.org/10.1016/S0272-6386(12)80593-2
Ku E, Hsu RK, Johansen KL, McCulloch CE, Mitsnefes M, Grimes BA, Liu KD (2021) Recovery of kidney function after dialysis initiation in children and adults in the US: a retrospective study of United States Renal Data System data. PLOS Med 18(2):e1003546. https://doi.org/10.1371/journal.pmed.1003546
Kwong YD, Liu KD, Hsu RK, Johansen KL, McCulloch CE, Seth D et al (2021) Recovery of kidney function among patients with glomerular disease starting maintenance dialysis. Am J Kidney Dis 77(2):303–305. https://doi.org/10.1053/j.ajkd.2020.06.012
Ku E, Hsu RK, McCulloch CE, Lo L, Copeland T, Siyahian S, Grimes B, Johansen KL (2022) Incidence and risk factors for dialysis reinitiation among patients with a history of dialysis dependency. Clin J Am Soc Nephrol 17(9):1346–1352. https://doi.org/10.2215/CJN.01870222
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This work was performed with local resources from the Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán.
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Márquez-Macedo, S.E., Perez-Arias, A.A., Pena-Vizcarra, Ó.R. et al. Predictors of treatment outcomes in lupus nephritis with severe acute kidney injury and requirement of dialytic support. Clin Rheumatol 42, 2115–2123 (2023). https://doi.org/10.1007/s10067-023-06629-1
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DOI: https://doi.org/10.1007/s10067-023-06629-1