Original Investigation
Factors predictive of outcome in severe lupus nephritis

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Abstract

In 1992, we published the results of a prospective, controlled trial of aggressive therapy (high-dose prednisone plus oral cyclophosphamide alone or with plasmapheresis) in 86 patients with severe lupus nephritis. During this study, remission (serum creatinine ≤1.4 mg/dL [≤123 μmol/L] and proteinuria ≤330 mg/d of protein) in renal disease occurred in 37 patients (43%). To assess the long-term effect of remission on patient and renal survival, we now report the results of our extended follow-up of these patients. After an average of 10 years of follow-up in the 86 patients, patient survival rates at both 5 and 10 years were 95% in the group that had a remission and 69% at 5 years and 60% at 10 years in the no-remission group (P < 0.001). Renal survival rates were 94% at both 5 and 10 years in the remission group compared with 46% at 5 years and 31% at 10 years in the no-remission group (P < 0.0001). Features predictive of remission included stable renal function after 4 weeks on therapy, category IV lesion, lower chronicity index, white race, lower urine protein excretion level at baseline, and lower baseline serum creatinine level. The features predictive of end-stage renal disease were higher baseline serum creatinine level, presence of anti-Ro antibodies, and failure to attain a remission. Thus, in patients with the most severe forms of lupus nephritis, a remission of clinical renal abnormalities is associated with dramatic improvement in long-term patient and renal survival.

Section snippets

Patients

The 86 adult patients participating in the prospective controlled trial of plasmapheresis in severe lupus nephritis conducted from April 1981 to December 1988 comprise the study group. In this retrospective study, we extended the mean follow-up to 120 months. Because there were no significant differences between the two treatment groups during the therapeutic trial, patient data are pooled for the purpose of this follow-up study.

Entry criteria, therapeutic and medical management protocols, and

Clinical renal remission

Clinical remission occurred in 37 of the 86 patients (43%) with severe lupus nephritis during the initial 5 years of the study. The average time to remission was 16 ± 14 months (median, 10.5 months). Baseline features of the 86 patients and comparisons based on remission status are listed in Tables 1 through 3, and features were similar between the two groups with respect to age, sex, and level of proteinuria (Table 1).

. Baseline Clinical Characteristics

Empty CellAllRemissionNo RemissionP *
No. of

Discussion

Our experience shows that the induction of clinical remission of renal dysfunction is predictive of improved long-term prognosis in patient and renal survival, even for patients with the most severe forms of lupus nephritis. These findings agree with retrospective analyses by Appel et al17, 18 and Fraenkel et al,2 who also found that marked regression or remission of clinical renal disease predicted a favorable long-term prognosis in patients with lupus nephritis.

Evidence for the likelihood of

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    Received August 31, 1999; accepted in revised form December 3, 1999.

    Address reprint requests to Stephen M. Korbet, MD, Section of Nephrology, Rush-Presbyterian–St Lukes Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612.

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