Lupus nephritis in first year of SLE predicts 'absolute worst' for patient
DESTIN, Fla. — Patients who develop lupus nephritis within their first year of being diagnosed with systemic lupus erythematosus have a 23.2% risk of renal failure within 20 years, according to findings presented at the 2018 Congress of Clinical Rheumatology.
“I was really shocked by this longitudinal study from my cohort – if someone gets lupus nephritis in the first year of their disease, that is the absolute worst,” Michelle Petri, MD, MPH, of the Johns Hopkins University School of Medicine, told the attendees. “About one-fourth of those patients will end up on dialysis within the next 20 years. Just think about this: You are 25 years old, and you develop lupus nephritis, we already know what is going to happen by age 45. However, I’m planning on my patients living beyond age 45.”
Petri added that the risks are higher among men and black patients, as well as those diagnosed at a young age and those with immunologic markers, such as low complement anti-double stranded DNA.
According to Petri, the “gold standard” for measuring renal disease activity remains the kidney biopsy. However, the glomerulocentric view of renal biopsy is about to change, she said, in favor of a focus on tubulointerstitial inflammation, which has proved “crucially important” in predicting negative outcomes.
“Kidney biopsies are glomerulocentric, so our ISN classes are telling us what is happening at the glomerular level, but the NIH has activity and chronicity indices that include the tubulointerstitium,” Petri said. “NIH deserves credit for teaching all of us that what is happening in the tubulointerstitium is crucially important in prognostication for poor outcomes later. Why is everything going to change? Because glomerulocentric was wrong. The focus in nephrology is what is happening at the tubulointerstitial level.”
Petri stressed that a patient’s first episode of lupus nephritis may lead to a one-third loss of nephrons, and once lost, they are gone forever. In addition, the magnitude of nephron loss is often hidden due to the hypertrophy of the remaining nephrons. This, combined with the expected gradual loss of podocytes and nephrons with aging means that most patients with lupus nephritis will be on dialysis by the time they reach 70 years.
For this reason, Petri said the goal of lupus nephritis treatment should be to never allow the patient to have a flare. This means checking urine protein-creatinine ratios and drug adherence during every visit, she added. In addition, physicians should avoid putting remaining nephrons at risk, and avoid NSAIDS, CT with contrast dye and kidney toxins, she said.
Petri also cautioned against placing “blind trust” in the urine protein-creatinine ratio, noting that a protocol kidney biopsy can be a useful tool for telling when a treatment approach should change, due to its ability to detect a very active disease, delayed kidney repair, the discovery of another kidney disease and renal scarring.
“There is a lot of work to do, but I think lupus nephritis is finally becoming something fascinating, and something where we might be much more effective,” Petri said. “We don’t have to do things the old way anymore.” – by Jason Laday
Petri M. Update in lupus nephritis. Presented at: Congress of Clinical Rheumatology; May 17-20, 2018; Destin, Fla.
Disclosure: Petri reports consulting fees from GSK, Merck EMD Serono, Eli Lilly, Janssen, Amgen, Novartis, Quintiles, Exagen, Inova Diagnostics and AstraZeneca.