Kidney histopathology in predicting flares following drug withdrawal in proliferative lupus nephritis in clinical remission

Aishwarya Gopal; Chengappa Kavadichanda; Mohan Sreelekha Gayathri; Mamatha Gorijavolu; Devender Bairwa; Christina Mary Mariaselvam; Bheemanathi Hanuman Srinivas; Molly Mary Thabah; Vir Singh Negi

doi:10.1007/s00296-023-05497-x

Kidney histopathology in predicting flares following drug withdrawal in proliferative lupus nephritis in clinical remission

Rheumatol Int. 2023 Nov 21. doi: 10.1007/s00296-023-05497-x. Online ahead of print.

Affiliations

¹ Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India.
² Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India. doc.chengappa@gmail.com.
³ Department of Medicine, AIIMS, Bilaspur, Himachal Pradesh, India.
⁴ Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
⁵ Executive Director, AIIMS Bilaspur, Himachal Pradesh, India.

PMID: 37987842
DOI: 10.1007/s00296-023-05497-x

Abstract

Residual renal histopathological activity at clinical remission in Proliferative Lupus Nephritis (PLN) can predict renal flare upon immunosuppression withdrawal. Data on the role of histological renal remission in predicting extra-renal flares is lacking. We assessed renal histopathology prior to drug withdrawal and the occurrence of renal and extra-renal flares over 52 weeks after drug withdrawal in PLN patients in long-term clinical remission. This is a subgroup analysis of a non-inferiority, open-label randomized (1:1) controlled trial. Patients with biopsy-proven Class III/IV LN in the past (biopsy 1), on immunosuppressants (IS) ≥ 3 years, in clinical remission for ≥ 1 year, on stable prednisolone dose (≤ 7.5 mg/day) plus a maintenance IS and hydroxychloroquine (HCQ) were subjected to a repeat renal biopsy (biopsy 2). Individuals with biopsy 2 having activity index (AI) < 4/24 were randomised to either prednisolone or IS withdrawal. Primary end-point was the proportion experiencing a flare [SELENA-SLEDAI flare index (SFI)] at week 52. Twenty-eight eligible patients underwent biopsy 2 and randomized to prednisolone (n = 15) and IS (n = 13) withdrawal. At biopsy 1, 12 (43%) had class III, 15 (53.5%) had class IV, and 1 (3.5%) had class III + V. At biopsy 2, PLN persisted in 4 (14.2%) while 18 (64.2%) were in histological remission (AI = 0) with 6 (21.4%) in class II. Following drug withdrawal, 9/28 (32%) had flares especially musculoskeletal (55.5%), mucocutaneous (44.4%), and renal (33.3%). Among the four persistent PLN patients, one of the two (50%) with AI = 1 had extra-renal flare while both the two with AI = 2 (100%) had renal and extra-renal flares. In those with histological remission (biopsy 2), 6/18 (66.6%) experienced extra-renal flare of whom one also had renal flare. Upon drug withdrawal, renal histopathology findings with any activity index can predict renal flare while histological remission is not enough to predict extra-renal flare, thus making it an unsuitable marker for deep SLE remission.

Keywords: Disease flare; Renal biopsy; Systemic lupus erythematosus.