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Long-term outcome in systemic lupus erythematosus membranous glomerulonephritis. Lupus Nephritis Collaborative Study
R P Sloan1, M M Schwartz, S M Korbet
1Department of Medicine, Rush Medical College, Chicago, IL, USA.
Abstract:
The pathology of membranous glomerulonephritis (MGN) in patients with systemic lupus erythematosus (SLE) may be complicated by superimposed glomerular inflammation and/or necrosis. This retrospective study examined whether various histologic patterns of glomerulonephritis (GN) seen on renal biopsy impact upon the prognosis of these patients. Clinical parameters at the time of biopsy were also studied, to determine which might serve as risk factors associated with renal and patient outcome. On the basis of renal biopsy findings, patients were stratified into three pathological study groups by using the World Health Organization (WHO) classification (11). Thirty-six patients had "pure' SLE MGN without (WHO Va) or with (WHO Vb) mesangial hypercellularity. Fifteen patients had SLE MGN with segmental endocapillary proliferation and/or necrosis in < 50% of glomeruli (WHO Vc < 50%). Twenty-eight patients had SLE MGN with endocapillary proliferation and/or necrosis in > or = 50% of glomeruli (MGN with segmental proliferation and/or necrosis in > 50%, WHO Vc > or = 50%, or MGN with superimposed diffuse endocapillary proliferation, WHO Vd). There were no significant differences in sex, age, or race among patients in the three study groups. There was a trend for increasing serum creatinine concentration, urine protein excretion, and diastolic blood pressure, and decreasing the third component of serum complement (C3) to be associated with increasing glomerular inflammation, and these differences were significant when Vc > or = 50% and Vd was compared with Va and Vb (P < 0.05). The 5- and 10-yr actuarial survival rates without reaching the study outcomes of death or renal replacement therapy for the three study groups were 86, 72, and 49% and 72, 48, and 20% respectively, and the differences between Va and Vb and Vc > 50% and Vd were significant (P < 0.05). SLE MGN has a heterogeneous course and outcome, and this variability is related to the extent and degree of glomerulonephritis seen on renal biopsy. The only clinical factor with an independent risk of reaching a study outcome was elevation of the initial serum creatinine concentration (Cox regression analysis). This predictive value appears to apply only to patients with the most severe forms of glomerulonephritis, suggesting that they may have a different natural history and/or a response to therapy than SLE MGN with less widespread glomerular inflammation and/or necrosis.
Insights
Histologic patterns of lupus nephritis (SLE MGN) significantly impact patient prognosis and survival. Higher degrees of glomerular inflammation and necrosis correlate with poorer outcomes, with elevated creatinine being a key risk factor.
Area of Science:
- Nephrology
- Immunology
- Pathology
Background:
- Membranous glomerulonephritis (MGN) in systemic lupus erythematosus (SLE) can present with superimposed inflammation or necrosis.
- Renal biopsy findings are crucial for understanding disease heterogeneity and patient outcomes.
Purpose of the Study:
- To investigate the impact of various glomerulonephritis (GN) histologic patterns on the prognosis of patients with SLE MGN.
- To identify clinical parameters that serve as risk factors for renal and patient outcomes.
Main Methods:
- Retrospective study stratifying patients into three groups based on World Health Organization (WHO) classification of SLE MGN.
- Analysis of clinical parameters including serum creatinine, urine protein, diastolic blood pressure, and serum complement C3.
- Actuarial survival rates and Cox regression analysis were used to assess outcomes.
Main Results:
- Patients with more severe GN (WHO Vc ≥ 50% and Vd) showed significant trends towards higher serum creatinine, urine protein, and blood pressure, and lower C3 levels compared to less severe forms (WHO Va and Vb).
- Five- and 10-year survival rates without death or renal replacement therapy were significantly lower in the more severe GN groups (49% and 20% at 10 years) compared to less severe groups (86% and 72% at 5 years).
- Elevated initial serum creatinine was the only independent clinical risk factor for adverse outcomes.
Conclusions:
- The course and outcome of SLE MGN are heterogeneous and strongly related to the extent of glomerulonephritis observed on renal biopsy.
- Patients with severe forms of SLE MGN may have a distinct natural history and response to therapy.
- Initial serum creatinine level is a critical predictor of outcome, particularly in severe cases of lupus nephritis.