Session Type: ACR Poster Session C
Session Time: 9:00AM-11:00AM
Background/Purpose: Using light microscopy (LM) or immunofluorescence (IF), combined proliferative and membranous lupus nephritis (LN) is defined as an active proliferative class III/IV lesion and diffusely distributed membranous lesion (involving >50% tuft of >50% glomeruli) in ISN/RPS 2003. A mixed-type LN was reported to show poor prognosis1,2; however, an interesting case report on corticosteroid-free treatment regimen of rituximab and mycophenolate mofetil is recently published3. We examined the renal outcome of mixed-type LN based on renal remission, end-stage renal disease (ESRD), and death.
Methods: We retrospectively evaluated 66 cases constituting class III and IV lesions, including 22 showing mixed-type LN on renal biopsy, during 2005–2014. Mixed-type LN were divided into 2 groups; membranous findings on LM + IF (LM group; n = 18) and those on IF only (IF group; n = 4). Renal remission was defined as a spot urine protein/creatinine ratio <0.5 g/g Cr and normal or near-normal eGFR (within 10% of normal eGFR) in EULAR/ERA-EDTA recommendations and KDIGO guidelines.
Results: Clinical findings were mean age 40.6 ± 15.8 years (male:female = 6:16), disease duration 5.2 ± 5.2 years, and observation period 2.2 ± 2.0 years and concentration of urine protein 3.5 ± 2.9 g/day, serum creatinine 0.93 ± 0.49 mg/dl, dsDNA 225.2 ± 745.6 IU/ml, C3 57.6 ± 24.0 mg/dl, and C4 9.9 ± 7.0 mg/dl. Pathological findings were activity index 6.0 ± 3.1, chronicity index 2.4 ± 2.6, cellular crescents 54.6%, fibrinoid necrosis 22.7%, and chronicity of glomeruli 72.7%. Twenty of 22 cases were class IV + V and 2 cases were class III + V. Most cases received a high dose of corticosteroids (0.6–1.0 mg/kg/day) and various immunosuppressants such as cyclophosphamide, tacrolimus, azathioprine, cyclosporine, and mizoribine for remission induction and maintenance therapy. IF group cases had a tendency toward shorter disease duration than LM group cases; there were no chronic lesions. The IF group cases achieved renal remission at the last observation and no ESRD or death. The LM group cases had a statistically significant lower remission rate of 27.8%; two cases developed ESRD and death.
Conclusion: This retrospective clinico–pathological study shows that mixed-type LN, defined as per findings of LM + IF, has a poor prognosis. However, mixed-type LN determined by IF only has an unexpectedly high remission rate, probably because of early detection of membranous lesions without morphological alterations.
1. Najafi CC, Korbet SM, Lewis EJ, Schwartz MM, Reichlin M, Evans J. Significance of histologic patterns of glomerular injury upon long-term prognosis in severe lupus glomerulonephritis. Kidney Int. 2001;59(6):2156–63.
2. Sloan RP, Schwartz MM, Korbet SM, Borok RZ, Lupus Nephritis Collaborative Study Group. Long-term outcome in systemic lupus erythematosus membranous glomerulonephritis. J Am Soc Nephrol. 1996;7(2):299–305.
3. Tedeschi B, Arnaud L, Hie M, Mathian A, Amoura Z. Successful treatment of combined proliferative and membranous lupus nephritis using a full corticosteroid-free regimen. Ann Rheum Dis. 2014;73(2):474–5.
To cite this abstract in AMA style:Sakai R, Shibata A, Chino K, Kikuchi J, Kondo T, Okuyama A, Takei H, Amano K. Combined Proliferative and Membranous Lupus Nephritis: Is the Prognosis Really Poor? [abstract]. Arthritis Rheumatol. 2015; 67 (suppl 10). https://acrabstracts.org/abstract/combined-proliferative-and-membranous-lupus-nephritis-is-the-prognosis-really-poor/. Accessed October 16, 2021.
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