Lupus Nephritis with Crescents: Clinicopathological Profile and Predictors of Poor Outcomes

Lupus nephritis occurs in 10-40% of patients with systemic lupus erythematosus. Although crescents involving >50% of the glomeruli portend a poor prognosis, little is known about outcomes with fewer crescents. We compared the clinicopathological profiles of different percentages of crescents, treatment outcomes, the type of immunosuppression used, the characteristics of anti-neutrophil cytoplasmic antibody-positive cases, and predictors of poor outcomes in cases of lupus nephritis with crescents. This was a 14-year retrospective single-center cohort study of patients with lupus nephritis who had cellular and/or fibrocellular crescents. In total, 8515 native biopsies were evaluated. Lupus nephritis was observed in 457 patients, and crescents were found in 110 patients. The patients were predominantly young females with nephritic syndrome. The remission rate was higher in those with ≤25% of crescentic glomeruli (Cr1) [complete remission (CR): 33.3%, partial remission (PR):17.6%] and those with 25-50% (Cr2) (CR: 24.1%, PR: 10.3%) than in those with >50% (Cr3) (CR: 13.0% PR: 3.3%). Chronic kidney disease (CKD) and end-stage renal disease (ESRD) rates were higher in Cr3 (CKD: 43.3%; ESRD: 10.0%) than in Cr1 (CKD: 21.5%; ESRD: 6.8%) and Cr2 (CKD: 34.4%; ESRD: 13.8%). Serum creatinine at biopsy, estimated glomerular filtration rate at the time of biopsy, rapidly progressive glomerulonephritis clinical presentation, the percentage of global glomerulosclerosis, the percentage of tubular atrophy, and >50% crescents predicted poor outcomes. Lupus nephritis with a higher proportion of crescents has an aggressive clinical presentation, the progression of the disease is rapid, and it has a poor response to treatment, warranting intensive immunosuppression.