Background/Purpose:

End-stage renal disease (ESRD) is the most important complication of lupus nephritis (LN) and greatly affects mortality. Its incidence has been estimated at 11% at 5 years and 17% at 10 years after LN diagnosis. The identification of certain predictive factors is of importance for risk stratification and proper management. The aim of the present study was to define the factors associated with ESRD development in a defined cohort of LN patients.

Methods:

Patients with LN (class II-V according to the International Society of Nephrology/Renal Pathology Society classification) were recruited from our long-term longitudinal cohort. Individuals with ESRD (estimated glomerular filtration rate, eGFR≤15 ml/min/1.73m²) at the first two clinic visits after enrolment were excluded. Patients were followed until the occurrence of ESRD (defined as two consecutive visits with an eGFR≤15 ml/min/1.73m² or initiation of dialysis) or last visit. They were divided in two groups (ESRD or not) and compared as per the demographic, histopathological, clinical and therapeutic variables. Statistical analysis was performed with SAS 9.0; p<0.05 was considered significant. Time-dependent Cox regression analysis was performed for the identification of predictors.

Results:

LN was diagnosed in 560 patients, 43 of whom developed ESRD (7.7%) after 7.5±6.4 years of follow up. There were no differences in demographic variables at baseline. Concerning the histopathologic class, diffuse proliferative LN (class IV) was more frequent in the ESRD patients (51.2% vs. 28.4%, p=0.033). Baseline serum creatinine was higher in the ESRD patients (152±94 vs. 85±41mmol/L, p<0.001); consequently eGFR was lower (61±37 vs. 93±37ml/min/1.73m² respectively, p<0.001). Hypertension was more frequent in the ESRD patients (58.1 vs. 38.3%, p=0.015). Concerning laboratory values, initial proteinuria was more severe in the ESRD patients (3.2±2.5 vs. 1.9±2.8g/day, p=0.027) whereas hemoglobin was lower (113±18 vs. 120±20g/L, p=0.02). There were no differences in therapeutic variables (dose of glucocorticosteroids, type and dose of immunosuppressives and antimalarials). Patients with ESRD were using angiotensin converting enzyme inhibitors or angiotensin receptor blockers more frequently (34.9 vs. 21.3%, p=0.04). Multivariable Cox regression analysis revealed that hypertension (HR=10.1, 95%CI=4.34-23.8, p<0.001), baseline serum creatinine (HR=1.009, 85%CI=1.008-1.01, p<0.001) and initial prednisone dose (HR=1.016, 95%CI=1.001-1.031, p=0.03) were associated with a higher probability for ESRD development. On the contrary, normal hemoglobin at baseline was protective (HR=0.97, 95%CI=0.95-0.99, p<0.001).

Conclusion:

Initial serum creatinine and hypertension were the most important predictors for the development of ESRD in patients with LN. These findings reinforce the importance of regular monitoring of serum creatinine even in asymptomatic patients as well as the need for strict control of hypertension in LN.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/predictors-of-end-stage-renal-disease-in-lupus-nephritis/