FLARES, INFECTIONS AND PREDICTORS OF MAJOR ADVERSE KIDNEY EVENTS IN INDIAN CHILDREN WITH LUPUS NEPHRITIS: A COHORT STUDY

Introduction:

Children with lupus nephritis experience recurrent disease flares and heightened infection risk. Limited data exists on impact of these on refractory illness and kidney outcomes from Low- and middle-income countries (LMIC)

Methods:

Children aged 1-18 years with biopsy-proven LN followed from January 2010-February 2024 in a tertiary-care center were enrolled and their clinical data, infections, flares, histological characteristics, major adverse kidney events (MAKE) (defined as eGFR<60 mL/min/1.73m2, refractory illness or death) were collected and analysed for predictive factors.

Results:

Seventy-six children (79% girls) with median (IQR) age at diagnosis being 11 (9,13) years were studied. The clinical presentations were nephritic syndrome, mixed nephritic-nephrotic features, rapidly progressive glomerulonephritis (RPGN), and nephrotic syndrome in 24 (31.6%), 15 (19.7%), 11 (14.5%), 5 (6.6%) patients respectively. Proliferative lupus nephritis was the major histological subtype. Infections occurred in 33 (43.4%), with incidence rate of 0.43 episodes per person-year; with pneumonia, sepsis and tropical infections being most common. Thirty-two (42.1%) children experienced kidney flares. There were total of 79 kidney flares (22.4% nephritic) with an incidence rate of 0.37 flares per person-year. At median last follow-up of 2.3 (1.3, 5.5) years with 93.4% kidney-survival rate, 41(51.9%), 22 (27.8%) and 13 (16.5%) were in complete-remission (CR), partial-remission (PR), and no-remission (NR) respectively (Fig 1). Proliferative lupus nephritis and those in PR or NR were at a significantly higher risk of having kidney flares and infections. Kidney flares and progression to chronic kidney disease stage 2-3 were significantly higher in PR vs. CR group. MAKE was observed in 11 (14.5%). Failure to achieve remission by 6-months and severe infections predicted MAKE. Consistent with previous LMIC cohorts, infections were predominantly bacterial (pneumonia, sepsis, UTI) and clustered in the first year, likely due to higher disease activity and immunosuppression (Fig. 2). The less common infections including herpes zoster, disseminated varicella, and measles mirrored the pattern observed in standard of care treatment arm of adult LN trials, from developed countries, such as BLISS LN, TULIP and LUNAR

Figure 1:

Figure 2:

Conclusions:

Severe infections and failure to achieve remission by 6-months significantly impact the kidney outcomes in children with Lupus nephritis, highlighting the need for preventive strategies for infections and effective treatment strategies for better outcomes. 

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.