Background/Purpose: Lupus Nephritis (LN) is a severe SLE manifestation, leading to a six-fold increased risk of death. This study aims to assess the outcome of patients with LN and the effect of change in management guidelines on outcome.

Methods: Retrospective analysis of all SLE patients with LN followed at the Tel Aviv Medical Center over a period of 20 years. Data included: sex, age at SLE diagnosis, age at LN diagnosis, number and timing of LN flares (rise in proteinuria to > 500 mg/d) and remissions (proteinuria < 500 mg/d and normal creatinine or < 10% of normal if baseline abnormal), creatinine, C3, C4 and anti-dsDNA at LN diagnosis, induction and maintenance therapy. Renal biopsy findings were obtained from pathology records. Patients with non-lupus related renal disease were excluded.

Results: LN was diagnosed in 90 patients (28% of the SLE cohort), F-76, M-14. The majority were Caucasian (n=81). Median follow up was 11.5 years, age at SLE diagnosis was 30.3+12years, mean time to first LN episode was 3.3+5.6 years. LN was present at SLE diagnosis in 47 patients. Mean serum creatinine at diagnosis was >1.1 mg/dl in 35% and > 2mg/dl in 10% of patients. At first episode mean proteinuria was 3230+2402 mg/d, C3 was 67.5+23.6 mg/dl, C4 was 13.1+9 mg/dl. Anti-dsDNA was positive in 80% of patients. Renal biopsies available for review (n=79) demonstrated: class III -19%, class IV – 48.1%, class V – 21.5%, class III+V- 5.1%, class IV+V – 3.8%, isolated antiphospholipid nephropathy- 2.5%. For induction treatment 95% received oral prednisone, 21% received additional IV pulse methylprednisolone, 43% – IV cyclophosphamide (CYC), 42% – mycophenolate mofetil (MMF), 19% – azathioprine, 9% – prednisone alone, 4% – rituximab, 11% – other (tacrolimus, cyclosporine, rituximab+CYC, azathioprine+cyclosporine). The regime of IV CYC (low / high dose) varied mainly depending on year of treatment (before / after 2009). Eighty-five percent received hydroxychloroquine (HCQ). Out of 7 patients who stopped HCQ, 5 had a LN flare. Maintenance therapy included MMF -50%, azathioprine-27%, high dose IV CYC -10%, prednisone alone -9%, other – cyclosporine, tacrolimus -4%. Remission was achieved in 79.9% of the patients. Among patients treated before 2009, 85.9% achieved remission, while in those treated since 2009, when use of MMF was more prevalent, 75% achieved remission. The mean time from LN presentation to remission was 2.7+2.9 years. Among patients who achieved remission, 29.6% experienced a flare after the induction phase: 81% flared once, 19% flared twice. The median time from remission to first flare was 4 years, and from second remission to second flare 3.5 years. Eleven patients (12.2%) developed ESRD, 6 were diagnosed before 2009. Six patients (6.7%) died (ESRD-1; infection-3; severe thrombotic event -1; brain hemorrhage-1), 5 of whom had been diagnosed > 10 years ago, 4 received high dose CYC induction therapy.

Conclusion: In this cohort of LN patients, a high percentage achieved remission (79.9%), however rates of remission and ESRD did not improve when comparing patients treated before or after 2009, suggesting that changes in treatment strategies during this period have not significantly changed the outcome of LN.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/assessment-of-outcome-in-lupus-nephritis-patients-a-retrospective-analysis-of-a-single-center-cohort-over-20-years/