Background Lupus nephritis (LN) is a serious complication of systemic lupus erythematosus (SLE). With current therapies, a high remission rate is observed, this being the most important prognostic factor. Currently, therapy is guided by findings in the renal biopsy, following the ISN/RPS classification. Although recommended by EULAR, Austin and Hill's morphological indexes are not routinely obtained.
Objectives To analyze the importance and applicability of the different morphological indexes in predicting response to treatment and prognosis.
Methods Retrospective single center study of consecutive SLE and biopsy proven LN patients, diagnosed from 2010 to 2016. We evaluated the following outcomes: clinical remission, renal function and proteinuria at end of follow-up (FUP) (g/24h). Complete remission was defined as a reduction of proteinuria to <0,5g/24h, inactive urinary sediment and serum creatinine <115% of baseline; partial remission same parameters, except proteinuria <1g/24h if initial value <3h/24h, or reduction to <3g/24h if initial value >3g/24h. The studied predictors were the INS/RPS LN classification and the morphological indexes described by Austin (Activity and Chronicity) and Hill, obtained after histomorphological review of renal biopsies. Statistical analysis was performed with STATA software.
Results During 6 years, there were 46 biopsy-proven LN cases, 84,8% (n=39) woman, median 35 years old (27 – 42,5) and 57,6% (n=19) caucasian. 39 patients were already known to have SLE, 7,44 (1,13 – 12,3) years previously.
The median FUP was 31,9 (13,2 – 45,6) months. Based on biopsy findings, 35 patients were started on immunosuppression – induction in 50% of cases with MMF and in 50% with cyclophosphamide; maintenance in 81% with MMF, the remaining with azathioprine. Complete remission was achieved in 58% of patients, 27% achieving partial remission. We observed 4 LN relapses. 96% (n=44) of the patients survived at the end of FUP, with a median serum creatinine of 0,8 mg/dl (0,7 – 0,99), eGFR 99,8 ml/min (71,2 – 116,8) and proteinuria of 0,6 g/24h (0,2 – 1,6).
We observed that Class IV patients had, at presentation, lower eGFR (67,3 vs 94,6 ml/min; p=0,02), higher proteinuria (4,26 vs 2,37; p=0,02) and a tendency towards higher C3 consumption (58,9 vs 77,4; p=0,06). We did not observe correlations between ISN/RNP Classification and the outcomes at the end of FUP.
The correlations between clinical findings and morphological indexes (Hill and Austin) are summarized in table 1:
Both the Hill biopsy index and the Chronicity index were correlated with renal function and proteinuria at the end of FUP. The Activity index correlated with the immunological findings – C3, C4 and anti-dsDNA.
Conclusions EULAR guidelines suggest that histomorphological evaluation in LN should go beyond ISN/RNP classification, and our data supports that – we observed a correlation between the renal outcomes and the indexes described by Austin and Hill.
Disclosure of Interest None declared