“End-Stage” Lupus Nephritis

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Abstract
Patients (39) with lupus (SLE [systemic lupus erythematosus]) nephritis who required dialysis were compared with 36 SLE patients who underwent renal biopsy but did not develop renal failure, to determine prognostic indicators. Nine of the dialyzed patients entered dialysis within the 1st year of their illness and 20 within the first 3 yr. Urinalysis, degree of proteinuria, level of anti-DNA antibody or serum complement, presence of hypertension and amount of immunosuppressive drug given did not distinguish the dialysis and no-dialysis groups. Severely abnormal 1st biopsy morphology by light microscopy, but not EM was associated with a greater risk of dialysis at 1, 3 and 5 yr after biopsy, but 4 of 17 patients dialyzed within 5 yr of biopsy had mildly abnormal 1st biopsies. Serum creatinine equal to or > 1.2 mg/dl at time of 1st biopsy was associated with a greater risk of dialysis at 1 and 3 yr after biopsy. For 15 patients with recorded normal serum creatinine (< 1.2 mg/dl; 9 patients had abnormal serum creatinine at 1st visit), the mean time from 1st abnormal creatinine to dialysis was 4.5 mo. Ten patients were able to discontinue dialysis, 3 transiently. These patients differed from those not able to discontinue dialysis by having more abrupt deterioration of renal function. Four of the 7 patients still off dialysis were treated with pulse methylprednisolone and a 5th underwent plasmapheresis. Fifteen dialysis patients died on dialysis; 8 of active SLE, all within 3 mo. of 1st dialysis. The other 7 died after 3 months and had inactive SLE. Two living patients have had unequivocal flares of SLE while on dialysis. Five patients have had successful transplants. End-stage renal disease occurs rapidly in SLE, is difficult to predict, and is potentially reversible in a subset of patients. This reversibility may be due partly to a strong physiologic rather than anatomic component to renal failure in SLE.

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