Retrospective Study
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Nephrol. Jun 25, 2025; 14(2): 102713
Published online Jun 25, 2025. doi: 10.5527/wjn.v14.i2.102713
Clinicopathological characteristics and long-term outcomes of adult patients with proliferative lupus nephritis
Saima Ahmed, Tabassum Elahi, Muhammed Mubarak, Ejaz Ahmed
Saima Ahmed, Tabassum Elahi, Ejaz Ahmed, Department of Nephrology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
Muhammed Mubarak, Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi 74200, Sindh, Pakistan
Author contributions: All authors were involved in the conceptualization of the manuscript and its development, execution, analysis of results, primary drafting, and critical revision, and have read and agreed to the published version.
Institutional review board statement: The present study was approved by the Institutional Review Board of Sindh Institute of Urology and Transplantation (SIUT-ERC-2020/PA-227), and the study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Informed consent statement: All patients provided informed consent.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Muhammed Mubarak, PhD, Professor, Department of Histopathology, Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi 74200, Sindh, Pakistan. drmubaraksiut@yahoo.com
Received: October 28, 2024
Revised: February 25, 2025
Accepted: March 4, 2025
Published online: June 25, 2025
Processing time: 165 Days and 2.4 Hours
Abstract
BACKGROUND

Proliferative lupus nephritis (PLN) is the most severe form of lupus nephritis (LN). There are limited data available on renal outcomes of PLN from developing countries.

AIM

To determine the clinicopathological characteristics and long-term outcomes in terms of remission, requirement of kidney replacement therapy (KRT), and patient survival.

METHODS

A retrospective analysis was conducted on biopsy-proven focal or diffuse PLN cases diagnosed between 1998 and 2019 at the Sindh Institute of Urology and Transplantation and followed up at the renal clinic for a minimum of 5 years. All patients were induced with a combination of intravenous cyclophosphamide and corticosteroids for 6 months, followed by maintenance treatment with azathioprine (AZA) or mycophenolate mofetil (MMF). Data were analyzed using Statistical Package for the Social Sciences, version 22.0. P ≤ 0.05 was considered statistically significant.

RESULTS

The mean age at the onset of systemic lupus erythematosus was 24.12 years ± 8.89 years, and at LN onset, 26.63 years ± 8.61 years. There was a female predominance of 184 (88.9%) cases. Among baseline characteristics, reduced estimated glomerular filtration rate, presence of hypertension, requirement of KRT, and underlying renal histology (International Society of Nephrology/Renal Pathology Society class IV than class III) were significantly associated with end-stage kidney disease (ESKD) and mortality. The renal outcomes were negatively correlated with age, duration of symptoms, and 24-hour urinary protein excretion. The overall remission rate was 89.8% at the end of induction therapy. At 5 years, 141 (68.11%) patients were in complete and partial remission (94 [45.4%] and 47 [22.7%], respectively). In total, 19 (9.2%) patients required KRT on presentation, and at 5 years, 38 (18.4%) patients developed ESKD, and 28 (13.5%) patients died. Thirty-four (16.4%) patients had a renal relapse, more with AZA than MMF (30 [88.2%] vs 4 [11.76%], respectively; P = 0.04). Renal survival at 6 months was 89.8%, while at 5 years, it was 68.11%, showing a significant improvement in patients who did not need KRT at the time of presentation (P < 0.0001).

CONCLUSION

Baseline renal functions, requirement of KRT, and diffuse proliferative disease were the most relevant prognostic factors for kidney survival among this cohort. Short-term renal outcomes were good. Long-term outcomes were poorer with AZA-based maintenance therapy than with MMF, with more ESKD and mortality.

Keywords: Systemic lupus erythematosus; Lupus nephritis; Proliferative lupus nephritis; Estimated glomerular filtration rate; End-stage kidney disease; Kidney replacement therapy

Core Tip: Lupus nephritis (LN) presents significant variability in clinical manifestations and treatment response. Although current treatments have markedly improved outcomes for patients with proliferative LN (PLN), a significant number of patients still gradually progress to end-stage kidney disease. There is still a lack of understanding about the factors that affect therapy non-response and the survival rates of patients with PLN, particularly from developing countries. This study aims to bridge these gaps, enhancing understanding of outcome disparities between developed and developing countries.