[Lupus nephritis in Senegal: study of 42 cases].
Dia DKa EfM CisséAbdoulaye PouyeNiang NmAlisa KaneDieng MtAbdou NiangKa MmB DioufB. NdiayeT Moréira-Diop
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Abstract:
Renal involvement determines the prognosis of systemic lupus erythematosus. The aims of this study were to precise clinical, laboratory, therapeutic and evolutive aspects of lupus nephritis in Senegal in order to improve its management.According to ACR criteria we included all patients presenting a systemic lupus erythematosus followed in internal medicine and in the dermatology services of university teaching hospital Aristide le Dantec of Dakar from January 1993 to December 2002. All the patients who didn't have a lupus nephritis defined by the existence of more than 0.5 g/24 h of proteinuria and or hematuria were excluded.The prevalence of lupus nephritis was 56.75% among 74 patients with systemic lupus erythematosus. Mean age was 29.6 years and sex ratio 0.13 (male to female). There was a nephritic syndrome in 45.23% of the cases and renal insufficiency in 37.71%. Renal biopsy performed in 52.38% of cases showed predominantly WHO classes IV and V. The key treatment was corticotherapy while immunosuppressive were used in 35.71%. The short term evolution was favourable but in the medium term, many patients were lost or followed up irregularly.To improve the management and the prognosis of lupus nephritis in Senegal it is necessary to make patients with a systemic lupus erythematosus sensitive to it and to make systematically urine tests aiming the screening for an early diagnosis of lupus nephritis. In addition we should have aggressive policies in order to lower the costs of immunosuppressive therapy and haemodialysis.Keywords:
Nephritic syndrome
Nephritis
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We report here an adult patient with lupus nephritis who had a good clinical course under long-term observation. Apoptotic bodies in the glomeruli were determined in serial renal biopsy specimens by the nick end labeling method. Apoptotic bodies in the proliferated glomerular cells were detected in the 3rd renal biopsy but not in the 2nd biopsy. The clinical activities of lupus nephritis fluctuated until the time of the 3rd renal biopsy. The 3rd renal biopsy was performed because of increased proteinuria and an increased amount of hyaline, granular and red blood cell casts, with impairment of renal function. The levels of proteinuria, creatinine clearance and serum complements were improved after the 3rd renal biopsy. It appears that apoptosis might control glomerular cell proliferation and also influence the clinical course of lupus nephritis.
Nephritis
Hyaline
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Relapses occur frequently in patients with lupus nephritis. Renal biopsy is the gold standard for assessing renal activity and hence guiding the treatment. Whether repeat renal biopsy is helpful during flares of lupus nephritis remains inconclusive. In the present study, we retrospectively reviewed the patients with lupus nephritis who had more than one renal biopsy with the hope to find the clinical value of repeat biopsy.Patients who had a diagnosis of lupus nephritis and two or more renal biopsies were selected from the database of the patient pathology registration at this renal division. Renal biopsy was evaluated according to the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification of lupus nephritis. The pathological patterns and treatment regimens were analyzed after a repeat biopsy.We identified 44 systemic lupus erythematosus patients with serial renal biopsies. In total, there were 94 renal biopsies. Overall, the pathological transition occurred in 64% instances according to the ISN/RPS class. When the transition was analyzed according to proliferative, membranous or mix lesions, it showed different profile: 35% in patients with proliferative lesion, 23.5% patients with mix lesions, 100% in patients with pure membranous lesion. The pathological transition could not be predicted by any clinical characteristics. After the repeat renal biopsy, 34% of patients had a change in their treatment regimens.The pathological conversion was very prevalent in patients with lupus nephritis. However, the transitions became less prevalent when they were analyzed according to pure membranous, proliferative, and mix lesion. Repeat biopsy might be helpful to avoid unnecessary increased immunosuppression therapy.
Renal pathology
Nephrology
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The natural course of systemic lupus erythematosus (SLE) is characterized by periods of disease activity and remissions. Prolonged disease activity results in cumulative organ damage. Lupus nephritis is one of the most common and devastating manifestations of SLE. In the era of changing therapy to less toxic regimens, some authors have stated that if mycophenolate mofetil can be used for the induction and maintenance treatment in all histological classes of lupus nephritis, renal biopsy can be omitted. This article aims to answer the question of what brings the bigger risk: renal biopsy or its abandonment.
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Renal pathology
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Despite the widespread use of renal biopsy to guide the treatment of lupus nephritis, the disease can usually be diagnosed and managed on the basis of its clinical presentation alone. We propose a conservative approach in which biopsy is used selectively and present three algorithms that allow for a simplified initial approach to managing lupus nephritis.Although the grading systems of the World Health Organization and the National Institutes of Health for renal biopsy results are commonly used to guide the treatment of lupus nephritis, there are limits to the utility of these systems. Physicians can distinguish clinically mild lupus nephritis, the nephrotic syndrome, or the nephritic syndrome on the basis of the urine sediment, urine protein excretion, serum albumin and creatinine concentrations, and creatinine clearance, and can initiate treatment on the basis of this information, rather than performing a renal biopsy. Corticosteroids are the cornerstone of therapy for lupus nephritis, but new therapies are emerging. The nephritic syndrome reflects active disease and requires more vigorous treatment. It may be prudent to reserve renal biopsy for situations that arise later in the course of lupus nephritis, such as failure to respond to therapy based on the initial clinical presentation.
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Objective To analyze the relationship between the clinical and pathological effects and long term prognosis in children with Henoch Schonlein nephritis. Methods Changes of clinical pathology were studied in 32 children with Henoch Schonlein nephritis and 19 cases of them were followed over an 8 to 14 year period. Results Acute nephritis ranked first (50%) and the nephritic syndrome ranked second (40%) in the clinical classification of Henoch Schonlein nephritis; the majority had pathological changes of Grade Ⅱ～Ⅲ. The rate of recovery of acute nephritis and the nephritic syndrome was 55.6% and 28.6% , respectively. The rate of recovery and deterioration of Grade Ⅰ～Ⅲ pathological changes was 43.8% and 12.5% , respectively. Of the patients with Grade Ⅳ～Ⅴ pathological changes, 66.7% deteriorated or died. Conclusions The prognosis of acute nephritis was better than that of the nephritic syndrome, and long term prognosis is closely associated with the clinical classification and pathology.
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Clinical pathology
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SUMMARY In order to assess the ability of various serologic assays to correlate with lupus nephritis, we analysed sera obtained from 60 patients with systemic lupus erythematosus (SLE), Patients were categorized as having active nephritis (group 1), active lupus without nephritis (group 2), inactive lupus with prior nephritis (group 3), or inactive lupus without prior nephritis (group 4), Three parameters were assessed including anti-dsDNA antibodies (Farr assay), immune complexes (C1q binding), and anti-C1q antibodies (salt-stable C1q binding). Additionally, glomerular binding activity (GBA) was measured using a new solid-phase immunoassay that detects immune elements by their ability to bind glomerular tissue. We found that patients with nephritis (group 1) exhibited higher mean values for each assay than patients in each of the other three groups (P= 0·001,0·009, 0·14, and 0·23 in the GBA, C1q, anti-dsDNA, and anti-C1q assays, respectively). The only assay which distinguished patients with nephritis (group 1) from patients having active disease without nephritis (group 2) was the GBA (mean 0·48 ± 0·09 versus 0·15 ± 0·04, (P 0·05), In terms of utility, all tests were specific for diagnosing nephritis among patients with lupus; however, only the GBA was reasonably sensitive. The information provided by the anti-dsDNA and C1q assays were not correlated with one another, nor additive to the GBA, Patients with false negative GBA tended to have received more intensive immunosuppression. The qualitative characteristics of GBA varied among patients with nephritis. These data suggest the pathogenesis of lupus nephritis is complex, and may be mediated by an array of immune elements. Moreover, the data indicate the potential utility for a broad tissue-based approach to detection of pathogenic immune elements over other, specific immunologic markers.
Nephritis
Anti-dsDNA antibodies
Immune complex
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The gold standard to diagnose the lupus nephritis is the renal biopsy. It provides information not only for diagnosis but also for the treatment plan and the prognosis. Laboratory studies, including the immunological profile, play an essential role in diagnosing and evaluating the lupus nephritis activity. The patient is unlikely to have the active lupus nephritis with the combination of anti-ds DNA, anti-C1q, C3 and C4 being within normal limits. In this case report, we present a patient with moderately active diffuse proliferative lupus glomerulonephritis (Class IV) confirmed by the renal biopsy, while her immunological profile is unusually normal.
Renal pathology
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Nephritis
Renal pathology
Presentation (obstetrics)
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To evaluate the usefulness of Bb, a split product of complement factor B, as a clinical marker for disease activity of lupus nephritis, we measured the Bb concentration of sera from 42 patients with lupus nephritis. Serum Bb levels were significantly higher in patients with active nephritis (active nephritis group, n=30) than in patients with nephritis in remission (remission group, n=12) (14.3±8.3 versus 7.4±5.9 μg/ml; p=0.012). In contrast, there was no significant difference in serum C3 levels between active nephritis group and remission group (42.5±20.9 versus 44.7±15.9 mg/dl; p=0.77). In the comparison of Bb levels between active nephritis group and remission group, the sensitivity was 66.6%, specificity was 83.3%, and the positive and negative likelihood ratios were 3.95% and 0.41%, respectively. The present results suggest that serum Bb level is a useful clinical marker for disease activity in lupus nephritis.
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Complement
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Objective To explore the significance of the urine microalbumin,transferrin,alpha 1-microglobulin,beta 2-microglobulin in SLE patients with early renal damage.Methods One hundred and eight patients with SLE,based on whether had the clinical manifestations of the kidney,were divided into two groups,obvious lupus nephritis group and silent lupus nephritis group,sixty-five healthy donors for normal control group.Immunol scatter turbidity test was used to assay microalbumin,transferrin,alpha 1-microglobulin,beta 2-microglobulin.The automatic biochemistry analyzer(Toshiba 120) was used to assay Serum BUN and Cr.Results The four kinds of microprotein in obvious lupus nephritis group were higher than that in silent lupus nephritis group and the control(P0.05).The four kinds of microprotein in silent lupus nephritis group were higher than those in the control group(P0.05).There were no statistical significance of four performance alone in obvious lupus nephritis group and in silent lupus nephritis group(P0.05).The four kinds of microprotein were jointly tested in Silent Lupus nephritis group.It's found that there was no statistical significance in positive frequency comparing to one index and two indexes,three indexes and four indexes(P 1,2;P3,40.05).However there was statistical difference in comparing one index and three indexes,one index and four indexes,two indexes and three indexes,two indexes and four indexes(P 1,3;P 1,2;P 2,3;P 2,40.05).The result in obvious lupus nephritis group was the same.There was no relationship between urine microalbumin,transferrin,alpha 1-micro globulin,beta 2-micro globulin and serum BUN.There was no statistics correlation between urine transferrin,alpha 1-micro globulin,beta 2-micro globulin and serum creatinine(P0.05).While there was positive relationship between urinary microalbumin and serum creatinine(r=0.737,P0.05).Conclusion The four index united detection can greatly improve the positive rate,indicating the significiance of dynamic monitoring the types and content of urine microprotein to early diagnosis of renal injury in SLE.
Nephritis
Beta-2 microglobulin
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