Incidence of Lupus Nephritis Flares After Complete Response in a Thai Population

Main Article Content

Amorn Sankhaanuruk, M.D. http://orcid.org/0000-0002-6819-0280 Nuntana Kasitanon, M.D. http://orcid.org/0000-0002-1150-6424 Worawit Louthrenoo, M.D.

Abstract

Background: Nowadays, we have standard treatment guidelines for lupus nephritis (LN), a substantial proportion of patients have LN flare. The aims here to determine the incidence of LN flare in patients who had renal complete remission (CR) after receiving induction therapy (IT) and to identify factors associated with renal flare after CR in clinical practice.


Methods: Retrospective analysis in a tertiary-level center for the clinical outcomes of patients who had first LN episode, achieved CR (24hr urine protein <0.5 gm/day with normal renal function) within 12 months after received IT and received the maintenance therapy (MT).


Results: Eighty-seven out of 548 patients (96.6% female with mean age 29.5±10.8 years) met the inclusion criteria. During 6.1±3.4 years of observation after CR, 42 (48.3%) patients had LN flare. The incidence ratio of LN flare was 10.9/100 patient-years. The mean time from CR to flare was 3.1 years. Using Cox-regression analysis, induction to remission therapy ≥6 months (OR=0.33, p=0.006), and using statins ≥9 months after reached CR (OR=0.44, p=0.032) had a lower incidence of LN flare, while age at onset of disease ≤20 years had a higher incidence of LN flare.


Conclusion: Despite achieving CR with standard treatment, almost half of the patients had an LN flare within a few years. Young SLE patients had an increased incidence of LN flare, the long period of induction therapy and using statins may retard a flare of the disease.

Article Details

How to Cite
SANKHAANURUK, Amorn; KASITANON, Nuntana; LOUTHRENOO, Worawit. Incidence of Lupus Nephritis Flares After Complete Response in a Thai Population. Medical Research Archives, [S.l.], v. 10, n. 5, june 2022. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/2831>. Date accessed: 30 june 2022. doi: https://doi.org/10.18103/mra.v10i5.2831.
Section
Research Articles

References

1. Jakes RW, Bae SC, Louthrenoo W, Mok CC, Navarra SV, Kwon N. Systematic review of the epidemiology of systemic lupus erythematosus in the Asia-Pacific region: prevalence, incidence, clinical features, and mortality. Arthritis Care Res (Hoboken). 2012;64(2):159-68.
2. Kasitanon N, Louthrenoo W, Sukitawut W, Vichainun R. Causes of death and prognostic factors in Thai patients with systemic lupus erythematosus. Asian Pac J Allergy Immunol. 2002;20(2):85-91.
3. Dooley MA, Hogan S, Jennette C, Falk R. Cyclophosphamide therapy for lupus nephritis: poor renal survival in black Americans. Glomerular Disease Collaborative Network. Kidney Int. 1997; 51(4):1188–1195.
4. Isenberg D, Appel GB, Contreras G, Dooley MA, Ginzler EM, Jayne D, Sanchez- Guerrero J, Wofsy D, Yu X, Solomons N. Influence of race/ethnicity on response to lupus nephritis treatment: the ALMS study. Rheumatology (Oxford). 2010; 49(1):128–140.
5. Kasitanon N, Intaniwet T, Wangkaew S, Pantana S, Sukitawut W, Louthrenoo W. The clinically quiescent phase in early-diagnosed SLE patients: inception cohort study. Rheumatology (Oxford). 2015;54(5):868-75.
6. Sidiropoulos PI, Kritikos HD, Boumpas DT. Lupus nephritis flares. Lupus. 2005;14(1):49-52.
7. Mejia-Vilet JM, Cordova-Sanchez BM, Arreola-Guerra JM, Morales-Buenrostro LE, Uribe-Uribe NO, Correa-Rotter R. Renal flare prediction and prognosis in lupus nephritis Hispanic patients. Lupus. 2016;25(3):315-24.
8. Momtaz M, Fayed A, Wadie M, et al. Retrospective analysis of nephritis response and renal outcome in a cohort of 928 Egyptian lupus nephritis patients: a university hospital experience. Lupus. 2017;26 (14):1564–1570.
9. Anders HJ, Saxena R, Zhao MH, et al. Lupus nephritis. Nat Rev Dis Primers. 2020;23;6(1):7.
10. Boumpas DT, Austin HA, 3rd, Vaughn EM, et al. Controlled trial of pulse methylprednisolone versus two regimens of pulse cyclophosphamide in severe lupus nephritis. Lancet. 1992;340(8822):741-5.
11. Fanouriakis A, Kostopoulou M, Cheema K, etal. 2019 Update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis. Ann Rheum Dis. 2020 Jun;79(6):713-723.
12. Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997;40(9):1725-34.
13. Uribe AG, Vila LM, McGwin GJ, Sanchez ML, Reveille JD, Alarcón GS. The Systemic Lupus Activity Measure-revised, the Mexican Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), and a modified SLEDAI-2K are adequate instruments to measure disease activity in systemic lupus erythematosus. J Rheumatol. 2004;31(10):1934-40.
14. Gladman DD, Urowitz MB, Goldsmith CH, et a. The reliability of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index in patients with systemic lupus erythematosus. Arthritis Rheum. 1997;40(5):809-13.
15. Tamirou F, D'Cruz D, Sangle S, et al. Long-term follow-up of the MAINTAIN Nephritis Trial, comparing azathioprine and mycophenolate mofetil as maintenance therapy of lupus nephritis. Ann Rheum Dis. 2016;75(3):526-31.
16. Parikh SV, Nagaraja HN, Hebert L, Rovin BH. Renal flare as a predictor of incident and progressive CKD in patients with lupus nephritis. Clin J Am Soc Nephrol. 2014;9(2):279-84.
17. Moroni G, Longhi S, Giglio E, Messa P, Ponticelli C. What happens after complete withdrawal of therapy in patients with lupus nephritis. Clin Exp Rheumatol. 2013;31(4 Suppl 78):S75–81.
18. Jin Deng, Huan Xie, Lin Zhu, Lei Luo, Hongping Xie. Maintenance therapy for lupus nephritis with mycophenolate mofetil or azathioprine. A meta-analysis. Clin Nephrol. 2019;91(3):172-179.
19. Fasano S, Margiotta DP, Navarini L, et al. Primary prevention of cardiovascular disease in patients with systemic lupus erythematosus: case series and literature review. Lupus. 2017;26(14):1463-72.
20. Lawman S, Mauri C, Jury EC, Cook HT, Ehrenstein MR. Atorvastatin inhibits autoreactive B cell activation and delays lupus development in New Zealand black/white F1 mice. J Immunol. 2004; 173(12):7641–46.
21. Abud-Mendoza C. Statins in systemic lupus erythematosus. Ann Rheum Dis. 2018 Sep;77(9):e60.
22. Sassi RH, Hendler JV, Piccoli GF, et al. Age of onset influences on clinical and laboratory profile of patients with systemic lupus erythematosus. Clin Rheumatol. 2017;36(1):89-95.
23. Amaral B, Murphy G, Ioannou Y, Isenberg DA. A comparison of the outcome of adolescent and adult-onset systemic lupus erythematosus. Rheumatology (Oxford). 2014;53(6):1130-5.
24. Sato VA, Marques ID, Goldenstein PT et al. Lupus nephritis is more severe in children and adolescents than in older adults. Lupus. 2012;21(9):978-83.
25. Boddaert J, Huong DL, Amoura Z et al. Late-onset systemic lupus erythematosus: a personal series of 47 patients and pooled analysis of 714 cases in the literature. Medicine (Baltimore). 2004;83(6):348-59.
26. Chen YM, Lin CH, Chen HH et al. Onset age affects mortality and renal outcome of female systemic lupus erythematosus patients: a nationwide population-based study in Taiwan. Rheumatology (Oxford). 2014;53(1):180-5.