| Objective We made the retrospective analysis for all renal flare of type IV LN patients to further recognize the situation of renal flare in LN patients in China. This study aimed to identify clinical characteristics of renal flares in class IV Lupus nephritis patients. Then, we made the retrospective analysis for all renal flare of type IV LN patients to identify clinical and serological risk factors for renal flares.Methods A retrospective analysis of collected data from renal flare in class IV Lupus nephritis patients of Department of Nephropathy in Lanzhou University Second Hospital was conducted to determine the incidence of renal flares, relapse time, clinical presentations, treatment, outcomes and risk factors. Cox’s proportional hazards model for estimating the hazard ratio and the 95% confidence interval (CI) was used to identify the predictive factors for the development of renal relapse. Time to renal relapse from achieving remission was analyzed by the Kaplan-Meier method and comparisons were performed using the log rank test.Results1.Patient Clinical and Demographic Characteristics:In this study, there were 351 Class IV LN patients complied regular follow-up with integrated data.100 patients occurred renal flare (28.49%),144 patients in non recurrence group (41.03%),53 patients were in initial treatment group,54 patients were NR. The renal flare group mean follow-up time was 49.50 (13～207) months, and the average age was (30.86 ± 9.74) years old. There were 83 cases of female (83%) and 17 cases of male (17%). The course of SLE was 19.50 (4.25,60) months. The course of LN was 9(2,24) months. No flare group mean follow-up time was 33.00 (13～220) months and the average age was (29.74 ± 9.68) years old. There were 125 cases of female (86.81%) and 19 cases of male (13.19%). The course of SLE was 23.50 (4,60) months. The course of LN was 7.50 (1,36) months. There were no statistically significant differences in age, sex, course of SLE and LN between the two groups.2. Baseline clinical and laboratory profiles at lupus nephritis onset:At baseline, there were higher proportion of arthralgia, alopecia, elevated globulin, RNP antibody positive, the glomerular capillary thrombosis and non inflammatory necrotizing vasculopathy in renal flare patients compared with those patients without renal relapses (P<0.05)3. Induction and maintenance strategies before renal flare:The majority of patients with class Ⅳ lupus nephritis had 6 months of induction therapy with regimens based on either mycophenolate mofetil or cyclophosphamide, and prednisone combined tripterygium wilfordii was mainly choices for maintenance therapy, there were no statistical difference in these treatment regimens between the two groups. The PR time in two groups had significant difference.4. Renal flare:The mean duration of renal flare was (31.15±26.74) months, no adherence including tapering or withdrawal of immunosuppressive therapy was one of causes of renal flare.66 patients (66%) with nephritic flares and 31 patients (31%) with nephritic flares, there were no difference in flare time between these two category of renal flare patients. The patients flare rate is 8% and 23% within 12 months and 24 months.24 patients with renal flares performed repeat renal biopsy and were done in renal flare time,11 patients showed progression to a higher class of nephritis (7 with class V,1 with class Ⅲ, the pathological type of the other 3 patients were unknown). Upon renal flare, the inductive regiments were mainly prednisolone combination with CTX (23.29%), tripterygium wilfordii (23.29%), MMF (16.44%) and multitarget immunosuppressive treatment (16.44%). There was no statistical significance between the four types of treatment therapy.5.Outcomes of renal flare:Over the follow-up period, among the renal flare patients, the incidence rate of doubling of creatinine and end stage of renal failure was 31% and 9%, it occurred in 92% and 70.9% of patients within 5 and 10 years of renal survival, and the patients survival rate is 95.2% and 80.4% within 5 and 10 years, there were higher rate of doubling of creatinine, end stage of renal failure and death in renal flare patients compared with those patients without renal relapses (P<0.05)6. Predictors of renal relapse in LN patients:Kaplan-Meier shows that renal flare rates were significantly different between the patients with CR and those with PR. Kaplan-Meier cumulative renal flare rates according to anti-RNP antibody positivity, anti-SSB positivity antibody, elevated globulin, with the glomerular capillary thrombosis and with non inflammatory necrotizing vasculopathy were significantly different. In univariate and multivariate Cox regression analysis shows the following parameters emerged as renal flare predictors:gastrointestinal symptoms, positive for SSB antibody and elevated globulin.Conclusion Renal flares of Class IV Lupus nephritis were more frequent, which mainly occured during maintenance therapy. Patients with PR have a higher renal flare rate than the CR ones. Gastrointestinal symptoms, positive for SSB antibody and elevated globulin was associated with a higher probability of renal relapse. The renal flare rates were not different among inductive treatment regimens; however, single prednisone as maintenance therapy had a higher renal flare rate than other maintenance therapies. |
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