LONG TERM RENAL OUTCOMES OF PATIENTS WITH MEMBRANOUS LUPUS NEPHRITIS ATTENDING A TERTIARY CARE CENTER OF NORTH INDIA

Introduction:

Membranous lupus nephritis (MLN) comprises nearly 10-20% of total cases of lupus nephritis and is often associated with nephrotic syndrome. Steroids with Mycophenolate Mofetil (MMF) or Cyclophosphamide (CYC) are the two most common treatments, however, their long-term outcomes have not been studied extensively. This study outlines the long-term outcomes of MLN patients being treated at a tertiary care centre of North India. 

Methods:

A total of 133 biopsy proven MLN patients aged >10 were analyzed in this retrospective/prospective study after excluding patients with ESRD and drug-induced nephritis or those with incomplete records. All patients received HCQ, RAAS blockade and steroids. According to treatment, patients were divided into two groups, viz., those receiving MMF (Regimen A) and those receiving CYC (Regimen B). Follow-up records and clinical status of the patient was noted. Complete and partial response was defined as urinary protein excretion <0.5 g/day and 0.5-2.9 g/day with >50% reduction in proteinuria to sub nephrotic range with a stable or improved renal function. No response/ treatment failure was defined as a sustained 25% increase in serum creatinine. Relapse was defined as persistent increase in proteinuria >1 g/day after complete remission or a doubling of proteinuria with values >2 g/day after achieving partial remission, or recurrence of active urinary sediment and/or an increase of ≥ 25% in serum creatinine. Renal failure was defined as creatinine value more than 1.4mg/dl. Data was analyzed using Chi-square test and ANOVA

Results:

Mean age of the cohort was 28.8±11.5 years.  79.2% of the patients were females. Hypertension, hypothyroidism, and diabetes was noted in 34(25.6%), 32(24.1%) and 9(6.8%) patients respectively. A total of 89 (66.9%) were early MLN i.e. presented within one year of diagnosis of lupus. 53.4% of patients presented with nephrotic syndrome. Baseline Hemoglobin(g/dl), creatinine(mg/dl), albumin(g/dl) and proteinuria(g/24hours) were 9.85±1.83 , 1.10±0.87, 2.87±0.87 and 3.64±2.63  respectively. Mean eGFR was 96.24±37.04 ml/min/1.73 m². Pure class V and Mixed class were seen in 74 (55.6%) and 59 (44.4%) patients respectively. Full house pattern was noted in 98 (73.7%) patients. Follow-up duration ranged from 6 to 197 months. Median follow up duration was 41 months [IQR 15-83 months]. Regimen A and Regimen B were received by 86 (64.7%) and 47 (35.3%) patients respectively. At last follow up, complete response, partial response and no response was noted in 94 (70.7%), 27 (20.3%) and 12 (9%) patients respectively. Treatment response did not show a significant association with age, sex, comorbidity status, hemoglobin, WBC, platelets, type of MLN (pure/mixed), other clinical findings and various antibodies. Partial/no response was significantly associated with elevated creatinine, proteinuria and presence of blood vessel hyalinosis, interstitial fibrosis and tubular atrophy on biopsy. Partial/no response was also significantly associated in patients who received cyclophosphamide (p<0.05). On follow up, 23(17.3%) patients developed relapse, of which nephrotic syndrome relapse was seen in 14 patients. No significant association between treatment and relapse was seen (p=0.168). Kaplan-Meier analysis revealed no statistically significant difference between two treatment groups for sustainability of complete response (p=0.500).

Conclusions:

The long-term outcomes of MLN showed a promising treatment response but with a high relapse rate. Patients who received MMF had an advantage over those receiving CYC in maintenance of complete response, though relapse rates were independent of treatment type

I have no potential conflict of interest to disclose.

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