PROSPECTIVE STUDY OF OUTCOMES IN LUPUS NEPHRITIS AMONGST ASIAN INDIANS: FIRST REPORT OF VNA:GNR LUPUS REGISTRY

Introduction:

Prospective data on long-term outcomes in patients with lupus nephritis (LN) is scarce from developing countries. We evaluated the predictors of patients and kidney outcomes in the Indian Dr Vidya Acharya Glomerulonephritis (VNA:GNR) registry. 

Methods:

This prospective study included patients enrolled in the VNA:GNR registry from western India from January 2019 to August 2024. This registry is based at Seth GSMC and KEM Hospital, Mumbai. Consecutive patients with biopsy-proven lupus nephritis having at least six months of follow-up were included. Patients who reached the primary endpoint (Mortality + End-stage kidney disease-ESKD) within six months were also included. All patients received treatment as per KDIGO recommendations. Predictors of primary outcome and treatment response were analyzed using multivariate analysis. 

Results:

Demographics: We included 151 patients with a mean age at presentation of 28.9 ± 10.3 years; 133 [88.1%] were females. Median[IQR] follow-up duration was 39 [17-64 ] months. The most common presentation was nephrotic syndrome (40%). At presentation, 60 (39.7%) had HTN, 74 (49%) had AKI (mean serum creatinine of 1.97 ± 1.39 mg/dL), and 15 (9.9%) required dialysis. The most common was Class IV LN in 46(30.5%) patients [Table 1].

Patient and kidney survival: At the last follow-up, 27 [17.9%] patients had eGFR <45 ml/min/1.73m2; 14 [9.3%] reached ESKD. Seventeen (11.3%) patients died, out of which 5/17 [29%] developed ESKD. Infection was the most common cause of mortality seen in 59% of patients. Six (35%) deaths happened in the first year. Patients with the composite outcome (Death + ESKD) were more likely to have education below secondary (p 0.028), delayed medical consultation (p 0.002), at the onset - HTN (p 0.007), higher creatinine (p  0.003), lower Hb (p 0.002), higher chronicity index (p 0.00), No response at 1year (p = 0.00), and more infective episodes (p 0.00). After multivariate adjustment, higher creatinine, lower Hb, no response at 1 yr, and more infective episodes remained significant predictors of death + ESKD.

Therapy and response: Details of induction and maintenance therapy are in Table 2. At the end of one year, 66/134(49%) achieved CR, and 43/134(32%) had PR. At 3 years, 38/69(55%) had CR, 25/69(36%). At five years, 22/43(51%) had CR, 17/43 (39%) had PR. There was no difference in induction with cyclophosphamide vs MMF. After adjustment, higher presentation creatinine and drug non-adherence independently predicted a lack of CR+PR at one year. 

Maintenance therapy and relapses:  Two or more nephrotic relapses were seen in 21(14%), and 28(18.5%) had one or more nephritic relapses. There was no difference in relapses between AZA and MMF. Drug non-adherence was seen in 60 (39.7%) of patients.

Infections: Eighty-five major infective episodes were seen in 64 (42.3%) patients. Respiratory tract infections were the most common. 19(12.6%) patients had tuberculosis while being treated for lupus nephritis.

Conclusions:

Patient and kidney outcomes at one and were better than previously reported, they were independently predicted by higher creatinineand lower Hb at presentation, no response at 1 yr, and major infective episodes.  Drug non-compliance was common and caused lack of response to therapy. Majority of deaths were secondary to infections. 

I have no potential conflict of interest to disclose.

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