Partial remission linked to improved survival at 10 years compared with non-response to treatment.
Even partial remission of lupus nephritis may be associated with better patient survival and a reduced risk of progressing to end-stage renal disease (ESRD).
Researchers reviewed 86 renal biopsies from patients with diffuse lupus glomerulonephritis to assess the value of partial remission. They defined partial remission as a 50% reduction in baseline proteinuria to 1.5 g/d or less and less than a 25% increase in baseline creatinine levels.
The team defined complete remission as proteinuria of less than 330 mg/d and a serum creatinine of less than 1.4 mg/dL. The patients were participants in a prospective therapeutic trial of steroids and cyclophosphamide alone or in combination with plasmapheresis and followed for more than 10 years.
“The patients who achieved a partial remission did better than the ones who did not remit at all,” said study investigator Edmund Lewis, MD, professor of nephrology at Rush University Medical Center in Chicago. “Having a partial remission gave a better prognosis, but not nearly as good as the patients who had complete remission. So, one of the things we are concluding from our findings is that if a patient is improving only partially, then their prognosis over 20 years may actually be very good.”
All the biopsies showed diffuse lupus nephritis (diffuse-global in 44 patients and diffuse-segmental in 41 patients; one patient could not be categorized). All the subjects received high-dose prednisone and cyclophosphamide for eight weeks, followed by a steroid taper. Thirty-seven patients (43%) achieved a complete remission, 21 (24%) achieved a partial remission, and 28 (32%) were non-responders.
The mean follow-up was 146 months in the complete remission group, 129 months in the partial remission group, and 78 months in the non-responders group. The mean time to complete re-mission was 16 months; the mean to partial remission was seven months.
The proportion of patients not progressing to ESRD or death at 10 years was significantly less in the patients entering complete or partial remission (84% and 29% for complete and partial remission, respectively, compared with 11% for non-responders). Patient mean survival rate (censoring for ESRD) at 10 years was 95% and 76% for the complete and partial remission groups, respectively, and 46% for the non-responders.
The mean renal survival rate (censoring for death) at 10 years was 94% and 45% for the complete and partial remission groups, respectively, compared with 19% for the non-responders. Mean survival rate without ESRD at 10 years was 92% for the complete remission group, 43% for the partial remission group, and 13% for the non-responders.
“There is a very important message here, especially because the follow-up is so long,” Dr. Lewis said. “We now know how long we need to treat patients and we now know better what nephrologists can expect in patients who are partial responders.”