Discussion
The study results pleasantly surprised clinicians who regularly treat patients with SLE.
“These data suggest that advances in therapy have had a significant impact on major morbidities in SLE, which is remarkable and reassuring,” says Anca D. Askanase, MD, MPH, director and founder of the Columbia University Lupus Center and associate professor of medicine in the Division of Rheumatology at Columbia University Irving Medical Center in New York City, as well as a member of the Lupus Foundation of America’s Medical and Scientific Advisory Council.
“There are several very provocative findings from the study,” says Brad H. Rovin, MD, FACP, FASN, professor of medicine and pathology, the Lee A. Hebert Distinguished Professor of Nephrology and the director of the Division of Nephrology and vice chairman of medicine for research at Ohio State University Wexner Medical Center in Columbus, Ohio. “First, the duration of SLE before the diagnosis has increased significantly over the three time periods, with the longest difference in the modern era. Concomitant with this, the severity of [lupus nephritis] at presentation, based on serum creatinine, rapid renal deterioration and chronicity on biopsy, has declined in the current era.”
This may suggest that SLE is being diagnosed earlier, Dr. Rovin says. In turn, patients receive appropriate treatments, so lupus nephritis is less severe than in the past when it does develop.
Dr. Rovin, who is also a member of the Lupus Foundation of America’s Medical and Scientific Advisory Council, believes the finding of hypertension as a risk factor and the absolute levels of chronic kidney disease in the lupus nephritis population over time were two other important findings.
“One take-home lesson is the importance of meticulous blood pressure control in patients with lupus who develop lupus nephritis,” Dr. Rovin says. “This is a modifiable risk factor for poor kidney outcomes that can be readily addressed by the patient’s caregivers.”
“There also should be a lower threshold to perform renal biopsies [because] this can lead to improved renal outcomes,” says Jane E. Salmon, MD, who is the Collette Kean Research Professor at the Hospital for Special Surgery in New York City.
“Another take-home message is that better and more consistent use of immunosuppressive therapy seems to decrease end-stage renal disease,” Dr. Salmon says.
When reflecting on applicability of the study results to her own patient mix, Dr. Salmon sees some parallels. “At Hospital for Special Surgery, we have always been concerned when we see hypertension, increased creatinine and lack of consistent baseline immunosuppression in lupus nephritis patients. Further confirmation that these features are associated with a worse prognosis for renal disease underscores our need to continue to aggressively monitor and treat them,” she says.
Dr. Askanase points out differences in patient populations. “The population of patients at Columbia University Medical Center is predominantly Hispanic and black, of lower socioeconomic status, with complicated insurance and medical coverage issues, making it difficult to generalize some of these findings to our cohort and the U.S. patient population.”
Additionally, data from the U.S. Renal Data System, a national population-based registry of all people with end-stage renal disease on dialysis, show that incidence rates of end-stage renal disease due to lupus nephritis seem to be stable over time (1996–2004) despite therapeutic advances, Dr. Askanase says.2
