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      Lupus nephritis: clinical presentations and outcomes in the 21st century

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          Abstract

          Lupus nephritis (LN) is a frequent and severe manifestation of SLE. Along the decades, the epidemiology of LN and its clinical presentation have been changing. However, even though retrospective cohort studies report a decreased mortality rate and an improvement in the disease prognosis, the percentage of patients progressing into end stage renal disease (ESRD) keeps steady despite the improvements in therapeutic strategies. Current in-use medications have been available for decades now, yet over the years, regimens for optimizing their efficacy and minimizing toxicity have been developed. Therapeutic research is now moving towards the direction of precision medicine and several new drugs, targeting selectively different pathogenetic pathways, are currently under evaluation with promising results. In this review, we address the main changes and persistent unmet needs in LN management throughout the past decades, with a focus on prognosis and upcoming treatments.

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          Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus.

          Michelle Petri, Ana-Maria Orbai, Graciela Alarcón … (2012)
          The Systemic Lupus International Collaborating Clinics (SLICC) group revised and validated the American College of Rheumatology (ACR) systemic lupus erythematosus (SLE) classification criteria in order to improve clinical relevance, meet stringent methodology requirements, and incorporate new knowledge regarding the immunology of SLE. The classification criteria were derived from a set of 702 expert-rated patient scenarios. Recursive partitioning was used to derive an initial rule that was simplified and refined based on SLICC physician consensus. The SLICC group validated the classification criteria in a new validation sample of 690 new expert-rated patient scenarios. Seventeen criteria were identified. In the derivation set, the SLICC classification criteria resulted in fewer misclassifications compared with the current ACR classification criteria (49 versus 70; P = 0.0082) and had greater sensitivity (94% versus 86%; P < 0.0001) and equal specificity (92% versus 93%; P = 0.39). In the validation set, the SLICC classification criteria resulted in fewer misclassifications compared with the current ACR classification criteria (62 versus 74; P = 0.24) and had greater sensitivity (97% versus 83%; P < 0.0001) but lower specificity (84% versus 96%; P < 0.0001). The new SLICC classification criteria performed well in a large set of patient scenarios rated by experts. According to the SLICC rule for the classification of SLE, the patient must satisfy at least 4 criteria, including at least one clinical criterion and one immunologic criterion OR the patient must have biopsy-proven lupus nephritis in the presence of antinuclear antibodies or anti-double-stranded DNA antibodies. Copyright © 2012 by the American College of Rheumatology.
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            2019 update of the EULAR recommendations for the management of systemic lupus erythematosus

            Antonis Fanouriakis, Myrto Kostopoulou, Alessia Alunno … (2019)
            Our objective was to update the EULAR recommendations for the management of systemic lupus erythematosus (SLE), based on emerging new evidence. We performed a systematic literature review (01/2007–12/2017), followed by modified Delphi method, to form questions, elicit expert opinions and reach consensus. Treatment in SLE aims at remission or low disease activity and prevention of flares. Hydroxychloroquine is recommended in all patients with lupus, at a dose not exceeding 5 mg/kg real body weight. During chronic maintenance treatment, glucocorticoids (GC) should be minimised to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn. Appropriate initiation of immunomodulatory agents (methotrexate, azathioprine, mycophenolate) can expedite the tapering/discontinuation of GC. In persistently active or flaring extrarenal disease, add-on belimumab should be considered; rituximab (RTX) may be considered in organ-threatening, refractory disease. Updated specific recommendations are also provided for cutaneous, neuropsychiatric, haematological and renal disease. Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion.
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              The classification of glomerulonephritis in systemic lupus erythematosus revisited.

              Jan Weening, Vivette D. D'Agati, Melvin M Schwartz … (2004)
              The currently used classification reflects our understanding of the pathogenesis of the various forms of lupus nephritis, but clinicopathologic studies have revealed the need for improved categorization and terminology. Based on the 1982 classification published under the auspices of the World Health Organization (WHO) and subsequent clinicopathologic data, we propose that class I and II be used for purely mesangial involvement (I, mesangial immune deposits without mesangial hypercellularity; II, mesangial immune deposits with mesangial hypercellularity); class III for focal glomerulonephritis (involving or =50% of total number of glomeruli) either with segmental (class IV-S) or global (class IV-G) involvement, and also with subdivisions for active and sclerotic lesions; class V for membranous lupus nephritis; and class VI for advanced sclerosing lesions. Combinations of membranous and proliferative glomerulonephritis (i.e., class III and V or class IV and V) should be reported individually in the diagnostic line. The diagnosis should also include entries for any concomitant vascular or tubulointerstitial lesions. One of the main advantages of the current revised classification is that it provides a clear and unequivocal description of the various lesions and classes of lupus nephritis, allowing a better standardization and lending a basis for further clinicopathologic studies. We hope that this revision, which evolved under the auspices of the International Society of Nephrology and the Renal Pathology Society, will contribute to further advancement of the WHO classification.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Rheumatology (Oxford)
                Journal ID (iso-abbrev): Rheumatology (Oxford)
                Journal ID (publisher-id): brheum
                Title: Rheumatology (Oxford, England)
                Publisher: Oxford University Press
                ISSN (Print): 1462-0324
                ISSN (Electronic): 1462-0332
                Publication date Collection: December 2020
                Publication date (Electronic): 05 December 2020
                Publication date PMC-release: 05 December 2020
                Volume: 59
                Issue: Suppl 5 , Lupus in the 21st Century
                Pages: v39-v51
                Affiliations
                [1 ] Rheumatology Unit, Department of Medicine, University of Padua
                [2 ] Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico , Milan, Italy
                Author notes

                Gabriella Moroni and Andrea Doria contributed equally to this manuscript.

                Correspondence to: Andrea Doria, Division of Rheumatology, University of Padova, Via Giustiniani, 2, 35128 Padova, Italy. E-mail: adoria@ 123456unipd.it
                Author information
                http://orcid.org/0000-0003-0548-4983
                Article
                Publisher ID: keaa381
                DOI: 10.1093/rheumatology/keaa381
                PMC ID: 7751166
                PubMed ID: 33280015
                SO-VID: 74ff4f8f-29ea-4e92-aa9d-cb5578c905f9
                Copyright © © The Author(s) 2020. Published by Oxford University Press on behalf of the British Society for Rheumatology.
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                History
                Date received : 22 April 2020
                Date accepted : 28 May 2020
                Page count
                Pages: 13
                Funding
                Funded by: GSK, DOI 10.13039/100004330;
                Categories
                Subject: Supplement Papers
                Subject: AcademicSubjects/MED00360

                ScienceOpen disciplines: Rheumatology
                Keywords: lupus nephritis,renal biopsy,classification,risk factors,prognosis,b cells,calcineurin inhibitors
                Data availability:
                ScienceOpen disciplines: Rheumatology
                Keywords: lupus nephritis, renal biopsy, classification, risk factors, prognosis, b cells, calcineurin inhibitors

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