Session Title: Systemic Lupus Erythematosus: Clinical Aspects
Session Type: Abstract Submissions (ACR)
To study the presentation and outcome of membranous nephropathy in SLE in comparison with proliferative lupus glomerulonephritis.
Patients with biopsy firmed active lupus nephritis who were recruited in our randomized comparative trial of mycophenolate mofetil (MMF) vs tacrolimus (Tac) were studied. Participants were divided into 3 groups: group 1 (pure membranous lupus Gn: RPS/ISN class V); group 2 (mixed membranous and proliferative Gn: class V+III or IVS/IVG) and group 3 (proliferative lupus Gn: IVS/IVG). The clinical presentation, treatment response, outcome and complications were compared.
141 patients were studied (92% women; age 35.2±12.8 years; SLE duration 49.3±62 months at renal biopsy). There were 25 patients (18%), 31 patients (22%) and 85 patients (60%) in group 1, 2 and 3, respectively. At presentation, group 1/2 patients had significantly higher hemoglobin level (11.3±1.8 vs 9.9±1.7g/dL), creatinine clearance (CrCl) (90.0±31 vs 69.7±27ml/min), complement C3 level (0.62±0.27 vs 0.42±0.16g/L) but lower serum Cr (70.8±25 vs 91.5±33umol/L) and anti-dsDNA titer (166±116 vs 234±89IU/ml;p<0.001) than that of group 3 patients (p<0.001 in all). 18 (32%) patients in group 1/2 had normal range C3 or anti-dsDNA, compared to 3 (4%) patients in group 3 (p<0.001). Nephrotic syndrome was more common in group 1/2 than group 3 (46% vs 32%; p=0.08). Blood pressure and serum albumin level was similar among the 3 groups. SLE disease activity index (SLEDAI) score was significantly lower in group 1/2 than group 3 patients (13.5±4.9 vs 18.0±5.3 points; p<0.001). Extra-renal activity was less common in group 1/2 than group 3 patients, but the difference was only statistically significant for arthritis (25% vs 42%; p=0.04). All patients were treated with high-dose prednisolone and either MMF (N=72) or Tac (N=69), followed by low-dose prednisolone and azathioprine for maintenance. Complete response to induction treatment at 6 months, defined as urine P/Cr of <1.0, resolution of active urine sediments, improvement in lupus serology and stabilization of CrCl, was less common with group 1/2 than group 3 patients (45% vs 62%; p=0.10). After a mean of 48.5±21 months, the cumulative risk of loss in 30% of CrCl compared to baseline was 4.6% at year 1, 6.3% at year 3 and 18% at year 5. Group 1/2 patients did not differ significantly from group 3 patients in terms of decline in CrCl (HR 0.46[0.15-1.46];p=0.19, adjusted for age, sex, SLE duration, initial CrCl and treatment arms). There were 4 arterial events (2 acute coronary syndrome; 2 cerebrovascular accidents) and 1 venous event (deep vein thrombosis) - all occurred in group 1/2 patients (compared with group 3; p=0.01). Infections (major and minor) were numerically more common in group 1/2 than group 3 patients.
The presence of histological membranous component in lupus nephritis is associated with heavier proteinuria, better renal function but less active lupus serology or extra-renal activity such as arthritis. One-third of patients have either normal complements or anti-dsDNA. Renal function decline in membranous lupus nephropathy is no different from proliferative lupus nephritis at 5 years, but thrombotic complications are more frequent.
C. C. Mok,
L. Y. Ho,
K. L. Yu,
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ACR Meeting Abstracts - http://acrabstracts.org/abstract/clinical-presentation-treatment-and-outcome-of-membranous-nephropathy-in-sle-a-comparison-with-proliferative-lupus-glomerulonephritis-in-141-patients/