Lupus nephritis is an important complication in SLE. There have been impressive gains in outcome with current immunosuppressive regimens in developed countries. However, there is sparse data on the long-term outcome from developing countries including India. This study looked at outcome in Asian-Indians.
Retrospective study of SLE patients (fulfilling ACR 1997) with nephritis (unexplained proteinuria >=500mg with or without active sediments) seen at single Indian center over 20 years. They were treated as per standard regimens. Treatment response assessed by remission at 1 year (proteinuria<=2g/day with at least 50% reduction from baseline, no active sediments and serum creatinine<=1.5mg/dl). Primary outcome was development of chronic renal failure (CRF, serum creatinine>1.5mg/dl) or death. Secondary outcome was end-stage renal disease or death. Survival analysis was done using Kaplan-Meier and differences in survival by log rank test. Risk factors for poor outcome were assessed by cox-proportional hazards.
The study included 188 patients of lupus nephritis, female: male ratio 11:1, mean age 23.6±10.5 years. Of these 136 patients had renal biopsy. Renal histology was: class II in 22, class III in 36, class IV in 61, class V in 16 and class VI in 1. Intravenous cyclophosphamide pulses (NIH) used as induction in most cases of proliferative nephritis: class III (85.3%), class IV (94.8%) and non-biopsied (71.1%). Most with non-proliferative nephritis received steroids with or without azathioprine: class II (73.7%) and class V (80%). The 1-year remission rate was 84.6%, with no statistical difference by class of nephritis. Median duration of follow up was 6 years (IQR 3-9). Survival with normal renal function was 84, 69 and 57% at 5, 10 and 15 years as shown in the figure (N= numbers at risk).
Survival curves were not different for various histological classes, however non-biopsied patients had lower survival compared to class II and class III or IV (p<0.05). Risk factors and hazard ratio (95% CI) for primary outcome on univariate analysis was number of infections 1.5 (1.1-2.0), initial serum creatinine 1.8 (1.4-2.2), hypertension 2.3 (1.0-5.1), hematuria 2.8 (1.3-6.1), low C3 3.0 (1.1-7.6) and absence of remission 13.8 (5.2-36.7). Only hematuria and absence of remission were significant on multivariate analysis. Renal survival at 5, 10 and 15 years was 91, 81 and 76%. Of 130 patients analyzed for complications, 45 (34.6%) had at least one serious infection, including tuberculosis in 17 (13.1%). There were 16 deaths, half due to infections (half of these were due to TB).
Outcome of lupus nephritis in Asian-Indians on standard treatment is comparable to developed nations. Lack of remission at 1 year and hematuria were risk factors for poor outcome. There was a high rate of infections especially tuberculosis; these were also a major cause of death.
Disclosure: V. Dhir, None; A. Aggarwal, None; A. Lawrence, None; V. Agarwal, None; R. Misra, None.