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International Journal of Nephrology
Volume 2015, Article ID 857316, 6 pages
http://dx.doi.org/10.1155/2015/857316
Research Article

Clinicopathological Correlation in Asian Patients with Biopsy-Proven Lupus Nephritis

Division of Nephrology, Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok 10400, Thailand

Received 8 January 2015; Revised 5 March 2015; Accepted 5 March 2015

Academic Editor: Richard Fatica

Copyright © 2015 Bancha Satirapoj et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

A total of 244 patients with lupus nephritis (219 women (89.8%) with a female to male ratio of 9 : 1) were included in the study. Clinical and laboratory findings at renal biopsy are clinically valuable in identifying different renal classifications of lupus pathology, activity, and chronicity index. Patients with class IVG had significantly higher proportions of microscopic hematuria, proteinuria, hypertension, impaired renal function, anemia, hypoalbuminuria, and positive anti-DNA antibody. All of these findings correlated well with high activity index and chronicity index of lupus pathology. Considering these correlations may help to determine the clinicopathologic status of lupus patients.

1. Introduction

Renal involvement is one of the most severe complications of systemic lupus erythematosus (SLE) and the clinical presentation of lupus nephritis (LN) is highly variable, ranging from mild asymptomatic proteinuria to rapidly progressive glomerulonephritis [1, 2]. The renal morphological expression can vary considerably among patients or within an individual over time [3, 4]. Performing renal biopsies to accurately determine the prognosis and to guide treatment in LN patients is greatly needed. Recently, the International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2003 classification of LN was proposed [5].

It has been generally agreed upon that renal morphological lesions and some clinical and laboratory features are correlated. Several studies are available on the clinicopathological correlation in LN subjects mainly from developed countries [6, 7]. However, very few publications are currently available concerning the demographic, clinical, and pathological features of LN and their correlations in Thailand [8]. Therefore, this study aimed to assess the clinical and basic laboratory features of Thai patients with biopsy-proven LN class according to ISN/RPS 2003 classification, renal pathological activity, and chronicity index in patients with LN. Clinical records were reviewed and information regarding renal function, serological activity, and urinary protein is collected and compared across histological classes.

2. Methods

2.1. Subjects

Patients with LN who underwent renal biopsy between 2010 and 2013 in Phramongkutklao and Siriraj Hospitals, Bangkok, Thailand, were included in this study. All patients met the American College of Rheumatology (ACR) revised criteria for the classification of SLE [9]. For inclusion, patients had to have adequate renal biopsy samples for histological diagnosis, including >10 glomeruli. For the patients who had repeated biopsies, samples and clinical records at the time of the first biopsy were used. Consequently, data of 244 patients were available in the study. For included patients, clinical records and laboratory parameters at the time of biopsy were collected. The research followed the tenets of the Declaration of Helsinki; informed consent was obtained, and the research was approved by the institutional review board.

2.2. Renal Pathological Diagnosis

Renal biopsy-confirmed LN cases were classified according to the 2003 ISN/RPS classification [5]. Data regarding immunofluorescence findings were available for 100% of the patients. Activity indices (AIs) and chronicity indices (CIs) were calculated (maximum scores, 24 for AI and 12 for CI) and interstitial fibrosis was evaluated for each biopsy specimen and was graded semiquantitatively using a scoring system from 0 to 3 (0 = no changes, 1 = mild, 2 = moderate, and 3 = severe) [10].

2.3. Data Collection

Demographic data (sex, age, and duration of disease), extrarenal SLE manifestations, systolic blood pressure (SBP), diastolic blood pressure (DBP), anti-dsDNA antibody, anti-nuclear antibodies, and biochemical parameters white blood cells, hemoglobin, blood urea nitrogen, serum creatinine and estimated glomerular filtration rate (GFR), serum albumin, serum complement, urine protein creatinine ratio (UPCR), and previous immunosuppressive treatments at the time of kidney biopsy were obtained from the patient records. Nephrotic syndrome was defined as clinical edema, an increase in the UPCR of ≥3.5 g/gCr and serum cholesterol of >200 mg/dL, and a decrease in serum albumin to ≤3.0 g/dL. Nephrotic range proteinuria was defined as UPCR of ≥3.5 g/gCr.

2.4. Statistical Analysis

Data with normal distribution and nonnormal distribution were summarized as mean ± SD and median and range, respectively. Categorical variables were presented as percentage. For multiple comparisons, univariate analysis of variance (ANOVA) with post hoc analysis by Dunnett was used followed by the least significance difference test. Pearson’s correlation and Chi square tests were used to compare frequency variables and correlation among different variables. Multivariate model using a stepwise regression analysis was performed to correct for confounders. A backward stepwise elimination process was used to remove any other covariates. All statistical evaluations were performed using the SPSS Program, version 12.0 (SPSS, Chicago, IL, USA). A value of <0.05 was considered statistically significant.

3. Results

A total of 244 patients were included in this study. The mean patient age at renal biopsy was 34.0 ± 12.0 years. Significant differences of mean age were observed between LN classes and in particular mean age was significantly low in patients with class IVG compared with patients with class V. Of the 244 patients, 219 (89.8%) were female with a female to male ratio of 9 : 1. Various treatment regimens were used, all of which included prednisolone (92.6%), cyclophosphamide (34.8%), azathioprine (29.5%), and mycophenolate mofetil (MMF) (16.0%) (Table 1).

Table 1: The demographic and clinical findings at renal biopsy by LN class.
3.1. Clinical and Laboratory Parameters Associated with Each LN Class (Tables 1 and 2)
Table 2: Renal findings at renal biopsy by LN class.

In patients with LN class II, blood pressure was well controlled and renal function was well preserved: mean serum creatinine was 1.2 ± 0.8 mg/dL and mean estimated GFR was 76 ± 32.4 mL/min/1.73 m2. Urinary findings were microscopic hematuria (57.1%) and mild degree of proteinuria with mean urinary protein of 1.3 ± 0.5 g/gCr. Importantly, no patients with nephrotic syndrome or nephrotic range protein were detected. Patients with serologically active anti-dsDNA antibody comprised 42.9%.

Data were compared between class III and other classes. In class III, blood pressure was well controlled. Renal function was well preserved and no significant difference was observed with classes II and IV: mean serum creatinine was 0.9 ± 0.5 mg/dL and mean estimated GFR was 98.2 ± 31.7 mL/min/1.73 m2. Microscopic hematuria was significantly higher in patients with class III (63.2%) than in patients with class V (32.1%). Urinary protein excretion was moderate: mean urinary protein was 3.4 ± 2.4 g/gCr, and frequency of nephrotic syndrome was 18.4%. Significant differences were found in levels of proteinuria in class III and class II. Serologically active anti-dsDNA antibody (86.8%) in patients with class III was significantly higher than in patients with class II (42.9%).

Patients with class IVG had the most severe nephritis as follows: SBP, 144.2 ± 22.8 mmHg; DBP, 89.5 ± 14.2 mmHg; serum creatinine, 1.5 ± 1.1 mg/dL; estimated GFR, 68.4 ± 37.2 mL/min/1.73 m2; urinary protein, 4.7 ± 3.3 g/gCr; serum albumin, 2.8 ± 0.6 g/dL; and hemoglobin, 10 ± 2.2 g/dL. At the time of renal biopsy, 92 (78.6%) patients were hypertensive (blood pressure ≥ 140/90 mmHg) and 44 (37.6%) patients exhibited impaired GFR (GFR < 50 mL/min/1.73 m2). In comparison with other classes, patients with class IVG had a significant increase in serum creatinine, blood pressure, proteinuria, and frequency of microscopic hematuria and a significant decrease in estimated GFR, serum albumin, and hemoglobin (Tables 1 and 2). A significantly high frequency of nephrotic syndrome (33.3%) and active anti-dsDNA antibody (80.7%) were observed. Data were similar between classes IVG and IVS, but patients with class IVS tended be less severe nephritis profiles including blood pressure, renal function, serum albumin, hemoglobin, and frequency of nephrotic syndrome.

In class V, blood pressure was well controlled. Renal function was significantly higher in class V patients than patients with class IVG (estimated GFR 95.3 ± 38.2 versus 68.4 ± 37.2 mL/min/1.73 m2, ). Microscopic hematuria was significantly lower in patients with class V (32.6%) than in patients with class IVG (73.5%) and class IVS (74.4%). Urinary protein excretion was high: mean urinary protein was 5.1 ± 3.8 g/gCr, and a significantly high frequency of nephrotic syndrome (41.9%) was observed compared with class II. However, no significant differences were found in levels of proteinuria in class V with class IV. Serologically active anti-dsDNA antibody in patients with class V was 69.8%.

3.2. Renal Pathological Findings

The relative frequency of each class was as follows: class II (mesangial proliferative LN) 2.9%, class III (focal proliferative LN) 15.6%, class IVG (diffuse global proliferative LN) 50%, class IVS (diffuse segmental proliferative LN) 16%, and class V (membranous LN) 17.6%. Patients of class III + V were considered to be class III and patients of class IV + V were considered to be class IV. No class VI was diagnosed at the initial renal biopsy. Patients with classes III and IV had a higher activity index, percentage of endocapillary proliferation, glomerular leukocyte infiltration, hyaline thrombi, fibrinoid necrosis, cellular crescents, and interstitial inflammation (Table 3). Patients with class IV had a higher chronicity index, percentage of fibrous crescents, tubular atrophy, and interstitial fibrosis (Table 3).

Table 3: The renal pathological findings at renal biopsy by LN class.
3.3. Clinical Parameters Associated with Renal Pathological Activity and Chronicity Index

Univariate analysis was performed to assess the relationship between clinical parameters with renal pathological activity and chronicity index. SBP, DBP, BUN, serum creatinine, UPCR, and presence of serositis, microscopic hematuria, and anti-dsDNA were positively correlated with renal pathological activity index, whereas age, estimated GFR, hemoglobin, and serum albumin were negatively correlated with renal pathological activity index. After multiple regression analyses, significant correlations were found among age, DBP, serum creatinine, estimated GFR, hemoglobin, serum albumin, UPCR, and presence of microscopic hematuria and anti-dsDNA antibody with renal pathological activity index (Table 4).

Table 4: Univariate and multivariate regression analyses demonstrating clinical factors showing correlation with renal pathological activity index (AI).

Renal pathological chronicity index was positively correlated significantly with SBP, DBP, BUN, serum creatinine, UPCR, and presence of serositis but negatively correlated with estimated GFR, hemoglobin, and serum albumin. After multiple regression analyses, significant correlations were found among serum creatinine, estimated GFR, hemoglobin, UPCR, and presence of microscopic hematuria and anti-dsDNA antibody with renal pathological chronicity index (Table 5).

Table 5: Univariate and multivariate regression analyses demonstrating clinical factors showing correlation with renal pathological chronicity index (CI).

4. Discussion

The study demonstrated the correlation of various demographic and laboratory findings in cases of biopsy-proven LN with the pathological features on renal biopsies. One of the most common findings was class IVG (48%). At renal biopsy, a higher microscopic hematuria, impaired GFR, proteinuria, anemia, hypoalbuminemia and hypertension, and the presence of positive anti-DNA antibody were all associated with the worst class, that is, class IV. These parameters were also correlated with high renal pathological activity and chronicity index in patients with LN.

Renal survival is mainly determined by the severity of renal involvement and renal classification [11]. The discrepancy may be related to differences in ethnicity or to different severity of renal disease in LN at biopsy. Several clinical characteristics related to lupus classification in our study confirmed those previously reported [1214]. Initially, significant differences were observed in the degree of nephritic and nephrotic features including microscopic hematuria, high blood pressure, impaired renal function, high proteinuria, and presence of anti-dsDNA antibody between LN classes II and IVG/IVS. Importantly, no patients with nephrotic syndrome or nephrotic range proteinuria were detected in class II. Unfortunately, the data in our series offered no way of distinguishing among the different clinical findings among patients with LN classes III and IV. Additionally, there was no difference in all extrarenal manifestations among each class.

Our patients with class IV or V had massive proteinuria with lower serum albumin levels than those of patients with class II. Regarding the difference between class IV and class V, no statistical difference was found in proteinuria, serum albumin, and cholesterol levels in this study, suggesting that all clinical features of nephrotic syndrome may be unimportant to define LN class IV and class V, whereas significant differences were observed in nephritic parameters including microscopic hematuria, anemia, high blood pressure, and impaired renal function between LN classes V and IV in initial biopsy finding. The results from our study on biopsy-proven cases of LN largely concur with the previously reported study [15]. Finally, our findings indicated that, at the same level of proteinuria without microscopic hematuria, anemia, high blood pressure, and impaired renal function might prefer diagnosis of LN class V compared with LN class IV.

Histological activity and chronicity index were strongly predictive for renal function outcome [16] and these measurements were used to grade the individual morphologic components in a given biopsy as a guide to treat and predict the renal survival in patients with LN [17, 18]. Previous studies have shown that serum creatinine and proteinuria had a significant positive correlation with high activity and chronicity index on pathological features of LN [13, 14]. Our results support this finding; advanced age and nephritic parameters including blood pressure, serum creatinine, estimated GFR, hemoglobin, serum albumin, UPCR, and presence of microscopic hematuria and anti-dsDNA antibody had a significant positive correlation with high renal pathological activity and chronicity index. We speculated that all nephritic features might reflect renal activity and chronicity scores, especially immunologic disease activities in patients with SLE.

Our study had several limitations, including its retrospective design and assessment of a small number of patients in LN class II. Furthermore, a possibility of differences in immunosuppressive agents may have occurred before inclusion and during the follow-up period. Evaluation of other clinical factors potentially affecting clinical features, such as other medications and socioeconomic status, would be interesting but was undetermined in this study. Larger prospective trials are still required to ascertain consistent baseline clinical markers.

In conclusion, this study indicates that clinical and laboratory findings at renal biopsy are clinically valuable in identifying different renal classifications of lupus pathology, activity, and chronicity index. Our results suggest that patients with class IVG had significantly higher proportions of microscopic hematuria, proteinuria, hypertension, impaired renal function, anemia, hypoalbuminuria, and positive anti-DNA antibody. All of these findings correlated well with high activity index and chronicity index of lupus pathology.

Conflict of Interests

None of the authors have a conflict of interests to declare in relation to this work.

Acknowledgments

The authors would like to thank Dr. Ratana Chawanasuntorapoj, Division of Nephrology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand, for providing data. This work was supported by grant from Department of Medicine, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand.

References

  1. R. Cervera, M. A. Khamashta, J. Font et al., “Morbidity and mortality in systemic lupus erythematosus during a 10-year period: a comparison of early and late manifestations in a cohort of 1,000 patients,” Medicine, vol. 82, no. 5, pp. 299–308, 2003. View at Publisher · View at Google Scholar · View at Scopus
  2. B. Satirapoj, J. Wongchinsri, N. Youngprang et al., “Predictors of renal involvement in patients with systemic lupus erythematosus,” Asian Pacific Journal of Allergy and Immunology, vol. 25, no. 1, pp. 17–25, 2007. View at Google Scholar · View at Scopus
  3. F. Yu, Y. Tan, L.-H. Wu, S.-N. Zhu, G. Liu, and M.-H. Zhao, “Class IV-G and IV-S lupus nephritis in Chinese patients: a large cohort study from a single center,” Lupus, vol. 18, no. 12, pp. 1073–1081, 2009. View at Publisher · View at Google Scholar · View at Scopus
  4. K. I. Dibbs, Y. Sadovsky, X.-J. Li, S. S. Koide, S. Adler, and A.-R. Fuchs, “Estrogenic activity of RU 486 (mifepristone) in rat uterus and cultured uterine myocytes,” American Journal of Obstetrics and Gynecology, vol. 173, no. 1, pp. 134–140, 1995. View at Publisher · View at Google Scholar · View at Scopus
  5. J. J. Weening, V. D. D'Agati, M. M. Schwartz et al., “The classification of glomerulonephritis in systemic lupus erythematosus revisited,” Journal of the American Society of Nephrology, vol. 15, no. 2, pp. 241–250, 2004. View at Google Scholar
  6. Z. Shariati-Sarabi, A. Ranjbar, S. M. Monzavi, H. Esmaily, M. Farzadnia, and A. A. Zeraati, “Analysis of clinicopathologic correlations in Iranian patients with lupus nephritis,” International Journal of Rheumatic Diseases, vol. 16, no. 6, pp. 731–738, 2013. View at Publisher · View at Google Scholar · View at Scopus
  7. S. Chen, Z. Tang, Y. Zhang, Z. Liu, H. Zhang, and W. Hu, “Significance of histological crescent formation in patients with diffuse proliferative lupus nephritis,” American Journal of Nephrology, vol. 38, no. 6, pp. 445–452, 2014. View at Publisher · View at Google Scholar · View at Scopus
  8. P. Parichatikanond, N. D. Francis, P. Malasit et al., “Lupus nephritis: clinicopathological study of 162 cases in Thailand,” Journal of Clinical Pathology, vol. 39, no. 2, pp. 160–166, 1986. View at Publisher · View at Google Scholar · View at Scopus
  9. M. C. Hochberg, “Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus,” Arthritis and Rheumatism, vol. 40, no. 9, p. 1725, 1997. View at Google Scholar · View at Scopus
  10. H. A. Austin III, L. R. Muenz, K. M. Joyce et al., “Prognostic factors in lupus nephritis. Contribution of renal histologic data,” The American Journal of Medicine, vol. 75, no. 3, pp. 382–391, 1983. View at Publisher · View at Google Scholar · View at Scopus
  11. M. Faurschou, H. Starklint, P. Halberg, and S. Jacobsen, “Prognostic factors in lupus nephritis: diagnostic and therapeutic delay increases the risk of terminal renal failure,” Journal of Rheumatology, vol. 33, no. 8, pp. 1563–1569, 2006. View at Google Scholar · View at Scopus
  12. I. G. Okpechi, C. R. Swanepoel, N. Tiffin, M. Duffield, and B. L. Rayner, “Clinicopathological insights into lupus nephritis in South Africans: a study of 251 patients,” Lupus, vol. 21, no. 9, pp. 1017–1024, 2012. View at Publisher · View at Google Scholar · View at Scopus
  13. H. Nasri, A. Ahmadi, A. Baradaran et al., “Clinicopathological correlations in lupus nephritis; a single center experience,” Journal of Nephropathology, vol. 3, no. 3, pp. 115–120, 2014. View at Publisher · View at Google Scholar
  14. F. Mitjavila, V. Pac, I. Moga et al., “Clinicopathological correlations and prognostic factors in lupus nephritis,” Clinical and Experimental Rheumatology, vol. 15, no. 6, pp. 625–631, 1997. View at Google Scholar · View at Scopus
  15. Q. Chen, Z. Liu, W. Hu, H. Chen, C. Zeng, and L. Li, “Class V lupus nephritis: a clinicopathologic study in 152 patients,” Journal of Nephrology, vol. 16, no. 1, pp. 126–132, 2003. View at Google Scholar · View at Scopus
  16. S. Emre, I. Bilge, A. Sirin et al., “Lupus nephritis in children: prognostic significance of clinicopathological findings,” Nephron, vol. 87, no. 2, pp. 118–126, 2001. View at Publisher · View at Google Scholar · View at Scopus
  17. A. J. Howie, N. Turhan, and D. Adu, “Powerful morphometric indicator of prognosis in lupus nephritis,” QJM, vol. 96, no. 6, pp. 411–420, 2003. View at Publisher · View at Google Scholar · View at Scopus
  18. B. H. Rovin and S. V. Parikh, “Lupus nephritis: the evolving role of novel therapeutics,” The American Journal of Kidney Diseases, vol. 63, no. 4, pp. 677–690, 2014. View at Publisher · View at Google Scholar · View at Scopus