Background/Purpose:

Hypertension and persistent proteinuria are risk factors for renal disease progression and are associated with high salt intake, poor adherence to medication and smoking. In systemic lupus erythematosus (SLE), proteinuria levels <0.8 g/day at 12 months is predictor of better long-term renal outcome. The aim of this study was to evaluate the effect of a multidisciplinary tight control renoprotective protocol (TCRP) in SLE patients with persistent proteinuria. 

Methods:

All SLE patients (ACR criteria) followed at Lupus Outpatient Clinic were evaluated between September 2014 and May 2015. Twelve patients with persistent stable proteinuria >1g/24h (any time after 6-month induction and on regular maintenance therapy) were included in the TCRP (with a target of proteinuria <1g/24h and BP <130/80). The protocol consisted of visits every 2 weeks to assess: 1. Blood pressure (BP) control; 2. adherence to therapy; 3. dietary modifications.  No change in immunosuppressive drugs was allowed during the study period and glucocorticoid dose was lowered as indicated. Clinical, laboratory and treatment evaluation performed at baseline (T0) and after 3 months (T3) included: SLEDAI,  24h proteinuria, serum levels of creatinine, albumin, potassium, complement C3/C4, anti-dsDNA antibodies, change in glucocorticoid dose, renin angiotensin blockage intake. 

Results:

Patients had mean age of 38.17 ± 7.85 years and disease duration of 9.75 ± 7.14 years. At nephritis presentation, three (25%) patients had creatinine >1mg/dL, 9 (75%) had positive anti-dsDNA and 8 (67%) had biopsy (5 membranous and 3 proliferative). Induction therapy consisted of mycophenolate (58%) and cyclophosphamide (42%), and maintenance therapy of mycophelonate (92%) and azathioprine (8%). The majority (75%) were under hydroxychloroquine. Renin angiotensin blockage was indicated in all patients as antiproteinuric and/or for BP control. At study entry (T0), 50% had BP > 130/80 mmHg. At least one dose optimization of these regimens and alternative agents were required in all patients during visits. At T3, 10 (83%) patients were using an angiotensin converting enzyme inhibitor, 7 (58%) an angiotensin receptor blocker and 5 (42%) of these patients were under combined therapy. Stable BP target was achieved by 10 (83%) patients at T3 with a significant reduction in diastolic BP (p=0.029). Of note, 24h proteinuria (2.06 ± 0.75 vs 0.94 ± 0.51 g/24h, p<0.001) reduced significantly, with a mean decline of 47.1 ± 19.2%. All patients had a decline in 24h proteinuria values and more than half (58%) of patients achieved proteinuria < 1g/24h at T3. Serum levels of creatinine (0.76 ± 0.18 vs 0.76 ± 0.18 mg/dL), albumin (3.94 ± 0.36 vs 3.99 ± 0.28 g/dL) as well as potassium, complement C3 and C4, frequency of anti-dsDNA and mean SLEDAI scores were similar at T0 and T3 (p>0.05). At T3, a decrease in mean prednisone dose was observed (10.63 ± 6.93 vs 5.83 ± 5.03 mg/day, p=0.077).

Conclusion:

This study suggests that a multidisciplinary tight control renoprotective protocol has a remarkable impact in reducing persistent proteinuria providing a brief window of opportunity for achieving the best predictor of long-term outcome in lupus nephritis.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/effectiveness-of-renoprotective-approaches-in-lupus-nephritis-more-than-just-immunosuppression/