A Retrospective Renal Study from a Lupus Vasculitis Clinic

Gaurav Singh¹, Lauren White², Patrick Flynn², Sajan Thomas³, Lakshmanan Jeyaseelan⁴, Mani Thenmozhi⁴, George John³, Paul Kubler⁵, D. Ranganathan^3*

¹Department of Internal Medicine, Princess Alexandra Hospital, Brisbane, Australia.
²Department of Internal Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia.
³Department of Nephrology, Royal Brisbane and Women’s Hospital, Brisbane, Australia.
⁴Department of Biostatistics, Christian Medical College, Vellore, India.
⁵Department of Rheumatology, Royal Brisbane and Women’s Hospital, Brisbane, Australia.

DOI: 10.4236/ojneph.2015.53012                

Abstract

Aim: In July 2009, a combined Renal Rheumatology Lupus Vasculitis (RRLV) clinic, the first of its kind for adult patients in Australia, was started at Royal Brisbane & Women’s Hospital. This is an audit of progression of renal disease to assess if patients attending this clinic had comparable results to published studies of similar cohorts with lupus Nephritis (LN) and vasculitis. Methods: We conducted a retrospective audit of all the patients who attended this clinic from July 2009 to October 2013. There were 33 patients followed up in the vasculitis group and 36 in the LN group. Patients with other connective tissue disorders were excluded from the analysis as the numbers were insignificant. Results: The mean estimated glomerular filtration rate of vasculitis and LN patients improved from 32.06 to 45.82 ml/min/1.73m² and 62.42 to 65.53 ml/min/1.73m² respectively. The mean urine protein/creatinine ratio of vasculitis and LN patients improved from 420 to 85 and 406 to 70 respectively. No patients died in either group. One vasculitis and two LN patients required maintenance dialysis. Three LN patients underwent renal transplantation. Conclusion: The results show excellent patient and renal survival and support the concept of a combined renal rheumatology clinic in managing renal disease from systemic connective tissue disorders.

Keywords

Vasculitis, Lupus Nephritis, Survival, Estimated Glomerular Filtration Rate, Urinary Protein Creatinine Ratio

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Willcocks, L., Jones, R. and Jayne, D. (2011) Lupus Nephropathy and Vasculitis. Medicine, 39, 468-491. http://dx.doi.org/10.1016/j.mpmed.2011.05.014
[2]	de Joode, A.A., Sanders, J.S. and Stegeman, C.A. (2013) Renal Survival in Proteinase 3 and Myeloperoxidase ANCA-Associated Systemic Vasculitis. Clinical Journal of the American Society of Nephrology: CJASN, 8, 1709-1717. http://dx.doi.org/10.2215/CJN.01020113
[3]	Moroni, G., Quaglini, S., Gallelli, B., Banfi, G., Messa, P. and Ponticelli, C. (2013) Progressive Improvement of Patient and Renal Survival and Reduction of Morbidity over Time in Patients with Lupus Nephritis (LN) Followed for 20 Years. Lupus, 22, 810-818. http://dx.doi.org/10.1177/0961203313492576
[4]	Langford, C.A. (2010) Vasculitis. The Journal of Allergy and Clinical Immunology, 125, S216-S225. http://dx.doi.org/10.1016/j.jaci.2009.07.002
[5]	Saxena, R., Mahajan, T. and Mohan, C. (2011) Lupus Nephritis: Current Update. Arthritis Research & Therapy, 13, 240. http://dx.doi.org/10.1186/ar3378
[6]	Vasculitis and Lupus Service, Addenbrooke’s Hospital, UK. http://www.cuh.org.uk/addenbrookes/services/clinical/vasculitis/vasculitis_lupus_index.html
[7]	Ohio State Lupus Clinic, Davis Medical Research Centre, Ohio, USA. http://internalmedicine.osu.edu/rheumatology/patient-care/lupusclinic/
[8]	Paediatric Vasculitis Clinic, Monash Children’s Hospital, Australia. https://www.monashchildrenshospital.org/page/About_Us/Monash_Childrens_Services/Paediatric_ Renal__Continence_Service/
[9]	Kidney International (2012) KDIGO Clinical Practice Guideline for Glomerulonephritis—Chapter 13: Pauci-Immune Focal and Segmental Necrotizing Glomerulonephritis. Kidney Inter, 2, 233-239.
[10]	Kidney International (2012) KDIGO Clinical Practice Guideline for Glomerulonephritis—Chapter 12: Lupus Nephritis. Kidney Inter, 2, 221-232.
[11]	Bertsias, G.K., Tektonidou, M., Amoura, Z., Aringer, M., Bajema, I., Berden, J.H.M., et al. (2012) Joint European League against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) Recommendations for the Management of Adult and Paediatric Lupus Nephritis. Annals of the Rheumatic Diseases, 71, 1771-1782. http://dx.doi.org/10.1136/annrheumdis-2012-201940
[12]	Hahn, B.H., McMahon, M.A., Wilkinson, A., Wallace, W.D., Daikh, D.I., FitzGerald, J.D., et al. (2012) American College of Rheumatology Guidelines for Screening, Treatment, and Management of Lupus Nephritis. Arthritis Care & Research, 64, 797-808. http://dx.doi.org/10.1002/acr.21664
[13]	Hiemstra, T.F., Walsh, M., Mahr, A., Savage, C.O., de Groot, K., Harper, L., et al. (2010) Mycophenolate Mofetil vs. Azathioprine for Remission Maintenance in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Randomized Controlled Trial. JAMA: The Journal of the American Medical Association, 304, 2381-2388. http://dx.doi.org/10.1001/jama.2010.1658
[14]	Jones, R.B., Tervaert, J.W., Hauser, T., Luqmani, R., Morgan, M.D., Au Peh, C., et al. (2010) Rituximab versus Cyclophosphamide in ANCA-Associated Renal Vasculitis. The New England Journal of Medicine, 363, 211-220. http://dx.doi.org/10.1056/NEJMoa0909169
[15]	Stone, J.H., Merkel, P.A., Spiera, R., Seo, P., Langford, C.A., Hoffman, G.S., et al. (2010) Rituximab versus Cyclophosphamide for ANCA-Associated Vasculitis. The New England Journal of Medicine, 363, 221-232. http://dx.doi.org/10.1056/NEJMoa0909905
[16]	Wall, N. and Harper, L. (2012) Complications of Long-Term Therapy for ANCA-Associated Systemic Vasculitis. Nature Reviews Nephrology, 8, 523-532. http://dx.doi.org/10.1038/nrneph.2012.107
[17]	Hahn, B.H., McMahon, M., Wilkinson, A., Dean Wallace, W., Daikh, D.I., FitzGerald, J.D., et al. (2012) American College of Rheumatology Guidelines for Screening, Case Definition, Treatment and Management of Lupus Nephritis. Arthritis Care & Research, 64, 797-808. http://dx.doi.org/10.1002/acr.21664
[18]	Walsh, M., Merkel, P.A., Peh, C.A., Szpirt, W., Guillevin, L., Pusey, C.D., et al. (2013) Plasma Exchange and Glucocorticoid Dosing in the Treatment of Anti-Neutrophil Cytoplasm Anti-body Associated Vasculitis (PEXIVAS): Protocol for a Randomized Controlled Trial. Trials, 14, 73. http://dx.doi.org/10.1186/1745-6215-14-73
[19]	Flossmann, O., Berden, A., de Groot, K., Hagen, C., Harper, L., Heijl, C., et al. (2011) Long-Term Patient Survival in ANCA-Associated Vasculitis. Annals of the Rheumatic Diseases, 70, 488-494. http://dx.doi.org/10.1136/ard.2010.137778
[20]	Zheng, Z., Zhang, L., Liu, W., Lei, Y., Xing, G., Zhang, J., et al. (2012) Predictors of Survival in Chinese Patients with Lupus Nephritis. Lupus, 21, 1049-1056. http://dx.doi.org/10.1177/0961203312445230
[21]	Weng, S.C., Tarng, D.C., Chen, C.M., Cheng, C.H., Wu, M.J., Chen, C.H., et al. (2014) Estimated Glomerular Filtration Rate Decline Is a Better Risk Factor for Outcomes of Systemic Disease-Related Nephropathy Than for Outcomes of Primary Renal Diseases. PloS ONE, 9, e92881. http://dx.doi.org/10.1371/journal.pone.0092881
[22]	Pokroy-Shapira, E., Gelernter, I. and Molad, Y. (2014) Evolution of Chronic Kidney Disease in Patients with Systemic Lupus Erythematosus over a Long-Period Follow-Up: A Single-Center Inception Cohort Study. Clinical Rheumatology, 33, 649-657. http://dx.doi.org/10.1007/s10067-014-2527-0
[23]	Cravedi, P. and Remuzzi, G. (2013) Pathophysiology of Proteinuria and Its Value as an Outcome Measure in Chronic Kidney Disease. British Journal of Clinical Pharmacology, 76, 516-523.
[24]	Inker, L.A., Levey, A.S., Pandya, K., Stoycheff, N., Okparavero, A. and Greene, T. (2014) Early Change in Proteinuria as a Surrogate End Point for Kidney Disease Progression: An Individual Patient Meta-Analysis. American Journal of Kidney Diseases: The Official Journal of the National Kidney Foundation, 64, 74-85. http://dx.doi.org/10.1053/j.ajkd.2014.02.020
[25]	Korbet, S.M., Lewis, E.J., Schwartz, M.M., Reichlin, M., Evans, J. and Rohde, R.D., Lupus Nephritis Collaborative Study Group (2000) Factors Predictive of Outcome in Severe Lupus Nephritis. American Journal of Kidney Diseases: The Official Journal of the National Kidney Foundation, 35, 904-914. http://dx.doi.org/10.1016/S0272-6386(00)70262-9
[26]	Mok, C.C., Kwok, R.C. and Yip, P.S. (2013) Effect of Renal Disease on the Standardized Mortality Ratio and Life Expectancy of Patients with Systemic Lupus Erythematosus. Arthritis and Rheumatism, 65, 2154-2160. http://dx.doi.org/10.1002/art.38006