Clinical And Pathological Analysis Of 60 Cases With Lupus Nephritis

Background and ObjectiveLupus nephritis (LN) is the most common and serious clinical manifestations of systemic lupus erythematosus (SLE), and also one of the most common secondary glomerulonephritis. LN impact on the prognosis of SLE, and the renal failure is the main dead cause of SLE. As the clinical manifestations and pathological changes of LN is heterogeneity and diversity, it's positive significance for prognosis and guiding treatment according to the pathological type.This paper aimed at analyse the distribution,clinical manifestation,characteristics of laboratory examination,and the relationship among them of different pathological types in 60 cases with LN by retrospectively reviewed,which had renal biopsy.That can help understand the nature of LN , and provide the basis for the treatment.Methods60 LN patients were included in this study,who choosed in the second clinical hospital of Jilin University from 2004 to 2007.All patients had renal biopsy. The histological classifications were categorized according to 2003 ISN /RPS classification. The combined class ofⅣorⅢandⅤwere recorded asⅣ+ⅤorⅢ+Ⅴ. Clinical data collected from the history records, including age at the time of biopsy, course of SLE disease, the first signs and symptoms,the organ damage. Laboratory results collected from the first biopsy results, including the 24-hour urine protein,urine red blood cell morphology detection,red blood cell(RBC),white blood cell (WBC),hemoglobin values (HGB), platelet (PLT),plasma albumin (ALB),Serum creatinine values (Scr),alanine aminotransferase (ALT),aspartate aminotransferase (AST),anti-dsDNA antibody,anti-Sm antibodies,anti-SSA antibodies,anti-SSB antibodies,anti-ribosomal protein (RNP),Immune globulin,serum C3 and C4. According to the lupus activity index (AI),chronic index (CI),tubulointerstitial (TIL) lesions and SLE disease activity index (SLEDAI) to score the renal pathology. Retrospective analysis of general information, pathological types, clinical and immune characteristics and assess the activeities and chronic degree of different renal pathological types.The qualitative data of clinical and laboratory examination present as the number of case (percentage), and the quantitative data present as mean±standard deviation(±s).The count data used analysis of variance and chisquaretest, and measurement data by t-test, P<0.05 defined as a statistically significant difference.Result1) 51 female patients (85%), age of onset in 15～70 years old, with an average of 35.3±13.9. 9 males (15%), age of onset in 16～34 years old, with an average of 26.7±6.6. Men and women with a ratio of 1:5.7. The average onset age of male patients is younger than the female(P <0.05). 2) The renal histologyical classes showed classⅣ(56.7%),Ⅲ(11.7%),Ⅴ(10.0% ),Ⅱ( 8.3% ),Ⅳ+Ⅴ(8.3% ),andⅢ+Ⅴ(5% ). 3) Liver damage found only in classⅢand classⅣLN. 3 cases of nervous system damage in patients were classⅣLN. Hypertension and serositis were more frequent in classⅣ,Ⅳ+Ⅴ. 4) Latent nephritis and nephritic syndrome were common in classⅡ,ⅢLN , nephrotic syndrome were common in classⅣ,Ⅴ,Ⅳ+Ⅴ,Ⅲ+Ⅴ. 5) The average hemoglobin value of classⅣ,Ⅳ+ⅤLN were lower than other classes significantly (P <0.05). Anemia was more frequent in classⅣ(P<0.05),and the patients of classⅣ+Ⅴwere all anemia. 6) 24-hour urine protein of classⅣ,Ⅴ,Ⅳ+Ⅴ,Ⅲ+ⅤLN were significantly higher than classⅡ,ⅢLN (P <0.05), while plasma albumin level of classⅣ+ⅤLN was the lowest(P <0.05). 7) The rate of renal failure occurred was 30%, which presented only in classⅣ,Ⅴ,Ⅳ+ⅤLN, and the average serum creatinine (Cr) levels of classⅣ,Ⅳ+ⅤLN were significantly higher than others. 8) AI,CI,TIL points of classⅣ,Ⅳ+Ⅴwere significantly higher than other pathological types (P <0.05). 9)The grade 1 of TIL lesion was common in classⅡ,ⅢLN,and the TIL lesion of classⅣ,Ⅳ+ⅤLN was the most serious. The level of Scr is associated with the degree of renal interstitial positively (P <0.05).DiscussionLN is the most common and serious clinical manifesttations of SLE ,which impact on the prognosis of SLE. As the clinical manifestations and renal pathology of LN is heterogeneity and diversity, it's positive significance of LN for prognosis and guiding treatment according to the pathological type, which provide a unified "gold standard" for clinical trials compareing different treatment methods.In this article, according to the latest pathological type standards, analyzed the distribution of histological classes retrospectively, the results showed that the classⅣwas the most common (57%), consistented with previous reports. The rate of classⅣ+Ⅴand classⅢ+Ⅴwas as high as 8% and 5%, and these cases were treated only as classⅣor classⅢ. Therefore, this two classes should be treated as special class of LN, and guiding the correct treatment. The onset age of male patients were from 16 to 34 years old, and the average onset age of male patients were younger than the female, consistented with previous reports.Hypertension and serositis were more frequent in classⅣ,Ⅳ+Ⅴ, consistented with previous reports. 3 cases of nervous system damage in patients were classⅣLN, suggesting that the nervous system damage was partilarly prevalent in classⅣLN.Liver damage caused mainly by vasculitis, prevalented in the classⅢ,ⅣLN. The average hemoglobin of classⅣandⅣ+ⅤLN was the lowest, and anemia of classⅣLN was more frequent. As the TIL score of classⅣ,Ⅳ+ⅤLN were the highest, considered that the cause of anemia was not only for autoimmune hemolytic, but may be generated in less of EPO. Nephrotic syndrome is the major clinical manifestations in this group patients for 75 %. Renal failure only existed in ClassⅣ,Ⅴ,Ⅳ+ⅤLN, whose prognosis were bad relatively. Nephritic syndrome was common in ClassⅡandⅢLN, renal function almost in the normal range, and lower incidence of hypertension in this two classes, and the prognosis was relatively good.LN clinical and pathological manifestations without constant contact, but there are certain relations. This Group 4 patients showed abnormal urine test, but renal pathology including classⅡ～ⅣLN, and 3 patients only with kidney disease as the first symptom,but pathological findings showed classⅣ,Ⅴ,Ⅳ+ⅤLN, this performance may be related to low affinity and low titers of anti-DNA antibody. So it should emphasize the comprehensive judgement for the diagnosis of SLE, which one hand should be the detailed medical history and the examination of immune system, on the other hand, especially for non-typical clinical manifestations of SLE patients, should be actively have renal biopsy to improve the accuracy of clinical diagnosis. At the same time ,we should pay attention to repeat biopsy for patients with changes,then rationally adjust the treatment plan.AI and CI was usually used for estimating the activity and chronic degree of LN, then to decide the therapy.And AI≥10 points, CI≥6 points, suggesting severe illness and poor prognosis. In this group, the AI,CI,TIL score of classⅣand classⅣ+ⅤLN were the highest,so suggesting that the activity of classⅣ,Ⅳ+ⅤLN were the highest, and the clinical manifestations of which were the most prominent, so prognosis were the worst, and we need to take active treatment more quickly. The SLEDAI score of patients were > 9 points, suggesting that patients with kidney disease mostly in lupus activity period, and at the time of choosing the therapy, we should pay attention to the extra-renal clinical manifestations,estimate the right activity of LN.In this group, the renal interstitial lesion of classⅣ,Ⅳ+ⅤLN is the most serious, and with the proteinuria increasing, TIL lesions gradually worsened, TIL lesion became more serious , and the level of Scr became higher. The urine protein of TIL grade 3 is not higher relatively, may because of the significant renal lesion, which always with obvious glomerular sclerosis, the protein leakage reduction instead. The reason of renal failure in LN, may be the activities of LN inflammation, so when the inflammation has subsided, the functional abnormality can recover. One patient with lung and heart disease was dead, suggesting that SLE involving the heart, lungs had poor prognosis, must be treated as soon as possible.Conclusions:1,The classⅣLN(57%) is the most common pathological type, and the onset age of male patients is always younger than female.2,ClassⅡ,ⅢLN mainly as Latent nephritis and nephritic syndrome. And liver damage was particularly prevalent in theⅢ,ⅣLN. 3,ClassⅣ,Ⅳ+ⅤLN have the following characteristics: 1) mainly as nephrotic syndrome, 2) damage to the nervous system was particularly prevalent in the classⅣLN, and hypertension,serositis was particularly prevalent in the classⅣ,Ⅳ+ⅤLN, 3) anemia were the most frequent,and the average hemoglobin value of were the lowest.4) renal failure was more common in this two classes. 5) the activity of kidney disease was highest, and the chronic degree was the highest too.4,ClassⅤ,Ⅲ+ⅤL N mainly as nephrotic syndrome.5,The level of Scr was correlated with the degree of renal interstitial lesion positively.6,For the atypical LN patients, immunological tests and renal biopsy is very useful to improve the accuracy of clinical diagnosis.