Mortality rates in lupus nephritis haven’t improved in three decades

Survival and end-stage renal disease rates in patients with lupus nephritis (LN) have not changed significantly in the past 30 years, UK figures show.

According to lead author Professor David Isenberg from the UCL Centre for Rheumatology in London and colleagues, the findings ‘strongly’ suggest that the use of conventional immunosuppressives and steroids has been optimised in patients with lupus nephritis and new management approaches are now needed.

The research team reviewed the medical records of 219 patients with LN who had attended the UCL Centre for Rheumatology over the last three decades [see paper here]. They divided patients into four groups, depending on the decade they were diagnosed: 1975–1985 (D1), 1986–1995 (D2), 1996–2005 (D3) and 2006–2015 (D4).

Figures showed the five-year mortality rates decreased dramatically from 24.1% in the first decade to 4% in the second decade. However, over the next two decades they remained stable at 4.3% in D3 and 6.3% in D4.

The study authors noted that this was despite the introduction of mycophenolate mofetil in the mid 1990s, the reduction in the standard dose of cyclophosphamide from a total of over 10 g to a 3 g regimen, a more thorough control of high blood pressure, and, more recently, the use of rituximab.

“Despite these measures, we appear to have reached a plateau in 5-year mortality and progression to ESRD, suggesting that new therapeutic and management approaches, as well as strategies to enhance compliance, are needed to further improve outcomes in LN patients,” they wrote in their paper published in Rheumatology.

The data also showed that serological and histological patterns changed over time, with a reduction in class IV nephritis (51.7% in D1 to 27.1% in D4), and increase in class II nephritis (10% in D2 to 18.8% in D4) and anti-extractable nuclear antigen antibody positivity (17.2% in D1 to 83.3% in D4).

Ethnic distribution also shifted, with a decreasing proportion of Caucasians (58.6% in D1 to 31.3% in D4) and an increase in African-ancestry (17.2% in D1 to 39.6% in D4) and Asians (17.2% to 29.2%), a finding which the research team said likely reflected changes in London’s population.

The authors acknowledged that because the data was from a single centre it was difficult to generalise the results.

“However, it does allow for a consistency of approach, and we believe that our key observation that newer modes of therapy are needed to improve both mortality and morbidity is correct,” they said.

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