Lupus nephritis: Efficient treatment may reduce the risk of kidney disease advancement

Progressing to advanced or end-stage chronic kidney disease (CKD) is not so rare in patients with systemic lupus erythematosus and lupus nephritis. The risk for these outcomes rises more than 2-fold in case of late or no remission after diagnosis of lupus nephritis or flares.

“Lupus nephritis affects up to 40% of patients with systemic lupus erythematosus and leads to end-stage CKD in about 17–33% of patients after 10 years. The prevalence of stage IV CKD is not known. However, these patients will develop end-stage CKD in about 2/3 of the cases after 6 years on average,” Prof. Konstantinos Tselios (McMaster University, Canada) laid the land on the background of his research [1].

The presented study investigated the potential influence of the timespan to remission as well as the occurrence of flares on the onset of advanced CKD. The study included 418 patients with confirmed lupus nephritis that were followed for at least 5 years.

After lupus nephritis diagnosis, remission was achieved by 50% within the first year and by 24.4% in the second and third years. Furthermore, 8.9% never reached remission, and 16.7% only did after 3 years. After a mean of 9.5 years, advanced CKD (eGFR ≤29 ml/min/1.73 m²) developed in 15.8% of patients. Baseline variables that were significantly different in patients who developed advanced CKD were: higher Systemic Lupus International Collaborating Clinics (SLICC) Damage Index, lower eGFR, higher prevalence of hypertension and proliferative nephritis, as well as more treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.

“With regards to the variables of concern, patients who later developed advanced CKD needed more time from lupus nephritis to achieve complete remission, had significantly more flares within the first 5 years of disease, and received fewer immunosuppressive drugs compared with patients who had good outcomes,” Prof. Tselios stated.

A multivariate analysis identified circumstances that modified the risk of developing advanced CKD. Overall, results were best for patients who attained remission in the first year. In comparison with patients who achieved remission within 1 year, the risk of advanced CKD was significantly increased in those who had complete remission after 1-3 years (HR 2.48; 95% CI 1.2–5.4), no remission, or remission after 3 years (HR 2.99; 95% CI 1.4–6.3). Stratification according to <3 years or ≥3 years of immunosuppression was in favour of a longer time of therapy (P=0.0005). The occurrence of 1 flare was associated with a 2.7-fold increased risk for advanced CKD.

“In total, our findings emphasise the importance of early remission, as well as flare prevention with prolonged immunosuppressive treatment in order to maximise renal survival in lupus nephritis,” Prof. Tselios underlined.

1. Tselios K, et al. Impact of time to remission, flares, and exposure to immunosuppressives on the development of advanced chronic kidney disease (stage IV or worse) in lupus nephritis. POS0740, EULAR 2022 Congress, Copenhagen, 1–4 June, Copenhagen, Denmark.

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Posted on 21 July 202217 May 2024