Response to therapy at 6 months predicts long-term renal outcome in lupus nephritis with poor kidney function

It is unclear whether aggressive treatment would benefit lupus nephritis (LN) with poor renal function, which has been excluded from most clinical trials. We aimed at demonstrating their clinicopathological features and prognosis.

From August 2012 to December 2018, patients with active LN with poor renal function (estimated glomerular filtration rate (eGFR) between 15 and 59 mL/min/1.73 m²) receiving induction therapy were included. Complete response (CR) was defined as proteinuria <0.5 g/24 hours, while partial response (PR) was defined as ≥50% proteinuria reduction to subnephrotic levels (<3.5 g/24 hours), with (near) normal eGFR. The primary outcome was end-stage renal disease (ESRD). The significant variables were selected via the least absolute shrinkage and selection operator method to construct prediction models for ESRD and treatment response.

A total of 107 patients were included. At 6 months, 18.7%, 38.3% and 43.0% of patients achieved CR, PR and no response (NR), respectively. During a median follow-up of 60 months, 40.2% ended up with reduced renal function (eGFR <60 mL/min/1.73 m²) and 14.0% progressed to ESRD. The proportions of NR at 6 months were significantly higher in these patients compared with those with recovered renal function (p<0.001). In multivariable analysis, baseline eGFR ≤33 mL/min/1.73 m² (HR 3.499, 95% CI 1.044 to 11.730), fibrous crescent (HR 3.439, 95% CI 1.029 to 11.490) and NR at 6 months (HR 17.070, 95% CI 2.155 to 135.240) independently predicted ESRD (C-index 0.911, 95% CI 0.866 to 0.956). Further, baseline hypertension (HR 2.517, 95% CI 0.820 to 8.580), SLE duration>3 months (2.517, 1.012-7.226) and chronicity index (HR 1.757, 95% CI 1.371 to 2.414) predicted NR at 6 months (C-index 0.833, 95% CI 0.756 to 0.910).

In patients with LN with poor renal function, no response at 6 months predicts a poor long-term renal outcome.