Examining Remission Status as a Predictor of Long-Term Renal Survival in Lupus Nephritis

Complete remission was a significant and useful predictor of renal survival, defined as no end-stage renal disease (ESRD) or death, in patients with lupus nephritis receiving induction therapy, according to a report published recently in The Journal of Rheumatology.

Given the poor prognosis associated with lupus nephritis, it is important to establish effective clinical outcomes that can be used as accurate predictors of future long-term renal survival. Remission status in a clinical setting had never been examined to assess long-term outcomes.

Investigators retrospectively analyzed data from the Hopkins Lupus Cohort. The patients (n=176; 91.5% women; 53.4% black) were assessed at 24 months after biopsy for remission status and monitored thereafter for long-term renal survival, without ESRD or death. Complete, partial, or no remission were assessed using modified versions of the Aspreva Lupus Management Study (mALMS) and the Belimumab International Lupus Nephritis Study (mBLISS-LN) criteria.

At 24 months post-biopsy, 59.1% and 40.9% met the complete remission criteria for mALMS and mBLISS-LN, respectively, and 30.1% and 16.5% met the partial criteria. During the follow-up period, 18 participants either died or developed ESRD. Compared with participants with partial or complete remission, individuals with no remission at 24 months were at increased risk for renal death, as measured by mALMS (P =.0038) and mBLISS-LN (P =.0097) criteria.

On multivariate adjustment, patients in complete remission were less likely than patients who were not in remission to have ESRD or to die, using both mALMS (hazard ratio [HR], 0.228; 95% CI, 0.063-0.828; P = .0246) and mBLISS-LN (HR, 0.254; 95% CI, 0.082-0.787; P = .0176) criteria. Participants in partial remission at 24 months were also less likely to experience renal death, but the finding was not statistically significant.

Chronic renal insufficiency was measured as a secondary outcome, with the condition developing in 45 participants during follow-up. According to mALMS criteria, individuals in complete (HR, 0.077; P <.0001) and partial (HR, 0.152; P <.0001) remission were less likely to experience insufficiency. Based on mBLISS-LN criteria, participants in complete remission (HR 0.122; P <.0001), but not participants in partial remission (HR, 0.611; P = .1824), were significantly less likely to experience this outcome.

Study strengths included a large original sample size (>500 patients), the use of multiple definitions of remission, and the extensive collection of outcomes and data points.

The researchers also noted several limitations, including the single-center study design that may limit generalizability, limited power for detection of small differences, potential misclassification of some data, and the use of only 24 months of data to evaluate remission status.

The authors noted that the effect of partial remission on long-term renal survival requires further investigation and clinical monitoring. They recommended future multicenter studies to confirm their findings and explore this effect and suggested evaluating renal death using other remission status timeframes.

Please refer to the original article for funding disclosures and conflicts of interest.

Reference

Davidson JE, Fu Q, Ji B, et al. Renal remission status and longterm renal survival in patients with lupus nephritis: a retrospective cohort analysis [published online March 1, 2018]. J Rheumatol. doi:10.3899/jrheum.161554