| Systemic lupus erythematosus(SLE)is a potentially lethal autoimmune disorder characterized by multiorgan involvement.Lupus nephritis(LN)is a common manifestation and one of the major causes of mortality in patients with SLE.In recent decades,the prognosis of patients with LN has improved significantly,because of earlier diagnosis,better serological monitoring,more judicious use of cytotoxic agents and enhanced management of complications,but there are racial differences in the renal outcomes of patients with LN.Few studies on the long-term renal outcomes of Chinese patients have been reported,all of which were derived from small patient cohorts.Mounting evidence has indicated that hypertension,proteinuria,renal function impairment,and anaemia were the predictive factors for poor renal outcomes.Proteinuria level and blood pressure level during follow-up were found to be associated with renal outcomes.Global sclerosis,cellular crescent,tubular atrophy and interstitial fibrosis were considered to be associated with poor renal outcomes.The renal morphological expressions of LN patients vary considerably,which is related to the location,quantity and pro-inflammatory properties of immune deposits.Classifications based on renal morphology are required to direct therapy and predict prognosis and the ISN/RPS 2003 classification system has been commonly accepted at present.The renal outcomes vary according to different classes.The majority of previous studies showed poor renal outcomes in patients with proliferative LN and favorable renal outcomes in patients with class ? and class ? LN.So far,there has been no report on the comparison of renal outcomes between class ? and class ?+?LN or between class ? and class ?+? LN.The difference of renal outcomes between subclass ?-S and IV-G is still controversial.Thus,we designed the study in two parts:Part One:Renal Outcomes of Patients with Lupus Nephritis and the Risk Factors for Poor Renal OutcomesObjective:Our aim was to observe the clinicopathological characteristics and renal outcomes of 1814 patients with biopsy-proven lupus nephritis(LN)of different classes and to evaluate the clinical and pathological risk factors associated with poor renal outcomes.Methods:Patients with biopsy-proven LN and follow-up period>1year in our center from 1985 to 2008 were included in the present study.The baseline clinicopathological data and follow-up data of the recruited patients were recorded,and the renal biopsy samples were assessed according to the ISN/RPS classification and each pathological lesion was semiquantatively scored.The endpoint was ESRD.Results:The 5-,10-,15-,and 20-year renal survival rates were 93.1%,87.9%,81.0%and 68.3%,respectively.Patients with class ? and class ?+? LN presented with the most severe renal diseases and the most unfavorable renal outcomes,while patients with class ? LN were on the contrary.The long-term renal outcomes of patients with class ? LN were unfavorable rather than those with class ?,and only 60.6%patients with class ? LN were treated with corticosteroids and/or immunosuppressives after the first biopsy.Gender,LN duration,mean arterial pressure(MAP),proteinuria,serum creatinine and haemoglobin at the time of biopsy were independent clinical risk factors for ESRD.Global glomerulosclerosis,cellular crescent,tubular acute injury,interstitial inflammation and thrombotic microangiopathy(TMA)were independent pathological risk factors for ESRD.Additionally,the time-average proteinuria(TA-Pro)and the time-average mean arterial pressure(TA-MAP)during follow-up were important risk factors for ESRD,with better predictive values than the baseline proteinuria and MAP.Conclusions:The results underscored the proteinuria and blood pressure control during follow-up in patients with LN;the proteinuria level should be controlled at least to<1.0 g/24 h and at optimal to<0.5 g/24 h;the MAP should not exceed 96.5 mmHg.More attentions should be paid to the treatment of patients with class ? LN.In addition to glomerular lesions,tubulointerstitial and vascular lesions were also predictors for poor renal outcomes.Part Two:Renal Outcomes of patients with different classes and subclasses Lupus NephritisObjective:To observe the discrepancy between class ? and class ?+?,between class ? and class ?+?,and between subclass ?-S and ?-G on clinicopathological characteristics and renal outcomes and to explore the pathological lesions associated with poor renal outcomes in patients with different classes and subclasses.Methods:The records of all adult patients with biopsy-proven proliferative lupus nephritis in our center from 1985 to 2008 followed for at least 1 year were reviewed.All patients were pathologically classified according to the 2003 ISN/RPS classification system of lupus nephritis and each pathological lesion was semiquantatively scored.The endpoint was ESRD.Results:Patients with class ?+?(class ?+?)presented with more severe proteinuria and chronic pathological lesions and milder acute pathological lesions than patients with class ?(class ?);patients with subclass ?-G presented with more severe hypertension,proteinuria and hypocomplementemia,lower ANCA positivity rate,more severe glomerular cell proliferation and hyaline deposit,and milder fibrinoid necrosis and crescent than patients with subclass ?-S.The renal outcomes between patients with class ? and class ?+?,class ? and class ?+?,subclass ?-S and subclass ?-G were not different respectively.Not only glomerular lesions but also tubulointerstitial and vascular leisons were independent risk factors for ESRD.Conclusions:LN patients with proliferative lesions combined with membranous lesions presented with both clinicopathological characteristics of the two types of lesions,but their renal outcomes were not different from patients with proliferative lesions.Patients with subclass ?-S and subclass ?-G had their own clinicopathological characteristics respectively,but the division of class ? into the two subclasses was not meaningful for predicting renal outcomes. |
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