Factors associated with renal relapse in lupus nephritis after remission: a systematic review and meta-analysis

High relapse rates in lupus nephritis (LN) remain clinically challenging and may contribute to progression toward end-stage renal disease. This study synthesized observational evidence on factors associated with renal relapse after LN remission.

PubMed, Embase, Web of Science, the Cochrane Library, CNKI, CBM andWanfang were searched from inception to 10 October 2025. Study quality was assessed using the Newcastle-Ottawa Scale. Remission and relapse definitions were extracted, and unadjusted odds ratios, mean differences, and adjusted hazard ratios were interpreted separately.

Thirteen cohort studies involving 2269 patients were included. Definitions of complete remission, partial remission, proteinuric relapse, and nephritic relapse varied across studies. In pooled adjusted analyses, younger age and anti-dsDNA positivity were associated with relapse, although anti-dsDNA was based on two studies. Pooled unadjusted analyses suggested associations for poor adherence, hematuria, elevated serum creatinine, uric acid, reduced albumin, low C3, anti-SSB positivity, and Class IV or mixed Class V + IV pathology. Class V showed a lower observed relapse likelihood, while Class II was borderline and heterogeneous. BUN, ESR, C1q, anti-Sm antibodies, antiphospholipid antibodies, lupus anticoagulant, and SLEDAI were supported mainly by single-study evidence.

Several variables were associated with post-remission renal relapse in LN, but evidence strength and outcome definitions differed across studies. These findings should be interpreted as observational associations and candidate monitoring markers rather than validated independent prognostic markers. Prospective studies with standardized remission and relapse definitions and adjustment strategies are needed.