|Year : 2015 | Volume
| Issue : 3 | Page : 81-84
Clinical and Histological Profile of Lupus Nephritis Patients Attending in a Tertiary Care Center
Rajat Sanker Roy Biswas1, Biplob Bhattacharjee2
1 Department of Internal Medicine, Chattagram Maa Shishu O General Hospital, Chittagong, Bangladesh
2 Department of Cardiology, Chittagong Medical College, Chittagong, Bangladesh
|Date of Web Publication||24-Jul-2015|
Rajat Sanker Roy Biswas
Chattagram Maa Shishu O General Hospital, Chittagong
Source of Support: None, Conflict of Interest: None
Background and Objectives: Lupus nephritis (LN) is one of the serious manifestations of systemic lupus erythematosus (SLE). It has diversities of clinical and histological presentations. Hence, the main objective of this study is to sort out the clinical and histological varieties of LN in a tertiary care setting of Bangladesh. Materials and Methods: For the study, 30 patients of SLE with renal involvement were selected. Diagnosis of SLE was done on the basis of American Rheumatological Criteria (ACR). After consent, all patients were undergone renal biopsy and tissue was analyzed for histological type and presence or absence of immunoglobulin were also analyzed by direct immuneflurescence study. Data after compilation analyzed by SPSS version 20. Results: All the patients found to have LN were female and most (73.2%) of the patients were at child bearing age between 21 and 40 years. Anti-ds DNA was positive among all (100%) patients and antinuclear antibody was positive among 19 (63%). Among all patients 6 (20%) had ≥3 g proteinuria. The common histological type was found class IV, which was 40% of total patients. A patient of LN found to have histological feature of acute glomerulonephritis. Conclusion: In conclusion, it can be said that LN have varied clinical profile with different histological types.
Keywords: Histological type, lupus nephritis, proteinuria
|How to cite this article:|
Biswas RR, Bhattacharjee B. Clinical and Histological Profile of Lupus Nephritis Patients Attending in a Tertiary Care Center. J Integr Nephrol Androl 2015;2:81-4
|How to cite this URL:|
Biswas RR, Bhattacharjee B. Clinical and Histological Profile of Lupus Nephritis Patients Attending in a Tertiary Care Center. J Integr Nephrol Androl [serial online] 2015 [cited 2021 Jan 20];2:81-4. Available from: http://www.journal-ina.com/text.asp?2015/2/3/81/161430
| Introduction|| |
Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with multisystem involvement having different clinical and immunological manifestation characterized by the presence of antinuclear antibodies (ANAs). , Renal involvement in SLE occurs in 40-75% patients most frequently in a period of 5 years after the onset of the disease. It is one of the strongest predictors of a poor outcome. 
Six clinical manifestations are encountered in patients with lupus nephritis (LN).  Diffuse proliferative glomerulonephritis is usually is the most serious renal manifestations of SLE. Particularly, LN and infection are the leading causes of mortality in the first decade of disease. Since nephritis is asymptomatic in most lupus patients, urinalysis should be ordered in any person of suspected SLE. The therapy of LN varies according to the histological classes. So, renal biopsy is useful in planning current and near future therapies.
Kidney is the commonest vital organ that can be involved in SLE. Early detection of renal involvement is essential to predict irreversible renal damage and renal failure. Glomerular filtration rate gradually deteriorates in relation with degree and type of renal pathology. Estimated glomerular filtration rate (eGFR) can be easily calculated from the serum creatinine level and this may be used to predict the histological pattern. As these tests are cost effective these are patients' friendly. Renal biopsy is to be done in this study to identify stages of renal damage.
| Materials and Methods|| |
Present study was done in a tertiary care center of Bangladesh in duration of 1 year. All patients clinically diagnosed as SLE were evaluated first for renal involvement by 24 h urinary total protein estimation. Patients having UTP >500 mg/24 h were selected for the study purposively. In this way, 30 consecutive patients were included in the study. SLE with co-morbid condition such as, end-stage renal disease, central nervous system (psychosis, seizure), and cardiac involvement (pericarditis, pericardial effusion), uncontrolled hypertension, diabetes mellitus (DM) were excluded due to potential contraindication of renal biopsy. From all eligible subjects after getting all relevant clinical history regarding SLE and LN was noted, physical examination findings also was collected. For biochemical and hematological analysis 10 cc venous blood was collected from the patient with all aseptic precaution. Patients were evaluated for the eligibility of renal biopsy and screening test were done before final inclusion for biopsy. Patients were thoroughly informed about the risk and benefit of the renal biopsy and after getting informed written consent in the morning biopsy was planned. Renal biopsy was done by the researcher himself or trained expert with direct supervision of the attending nephrologist after maintaining proper procedure. Laboratory investigations were done in the Department of Biochemistry of the tertiary hospital and biopsy specimen was examined by same histopathologist for tissue diagnosis and immunological test like direct immunofluorescene test. No control group was taken as it is an observation study. All relevant information for each individual study subject was recorded on a pretested data sheet. All data after collection were compiled and analyzed by using computer based software SPSS version 20 (IBM Corp., Armonk, NY). P value is considered as statistically significant when it is <0.05.
| Results|| |
Among the total 30 patients who were all female most (73.3%) were 21-40 years age range and only 2 (6.7%) were >40 years [Table 1]. Twenty-four (80%) had regular menstruation, 10 (33.3%) patients had history of oral contraceptive pills intake, 2 (6.7%) patients had history of abortion and 13 (43.3%) patients had history of fetal loss [Table 2]. Mild anemia (Hb% 10-12 g/dL) was present in 19 (63.3%) and edema was present in 28 (93.3%) patients. High blood pressure was found in 8 (26.8%) patients and autoimmune disease like thyroiditis was found in 6 (22.1%) and DM was found in 4 (13.4%) patients [Table 3]. Among all 7 (23.3%) had proteinuria 500/mg/g/day, 10 (33.4%) had 1-2 g/day, 7 (23.3%) had 2-3 g/day and >3 g/day was found in 6 (20%) of patients [Table 4]. ANA was found positive in 19 (63.3%) [Table 5]a] and anti-ds DNA antibody was found positive in all (100%) study populations [Table 5]b]. After evaluation of renal biopsy, 2 (6.7%) was found in Class II LN, 9 (30%) patients had Class III LN, 12 (40%) had Class IV LN 4 (13.3%) had Class V LN [Table 6]. One was having acute poststreptococcal glomerulonephritis and 2 (6.7%) patients were not evaluated due to inadequate specimen. IgG, IgM, IgA was found deposited in the renal biopsy specimen. Among them IgG was 18 (60%), IgM was 7 (23%) and IgA was 5 (16.5%) [Table 7].
|Table 2: Distribution of gynecological and obstetrical variables (n = 30)|
Click here to view
| Discussion|| |
This was a cross-sectional study to see the clinical and histological findings of LN patients in 30 patients with SLE at a tertiary care hospital of Bangladesh. There was a female preponderance in the studied patients, where all patients were found female. This is an unexpected results as most of the studies show there was also adult male patients affected by SLE. Cameron et al.  has reported a male to female ratio of 1:8-1:14 in a series of adult patients. In the present study, the female preponderance might be due to small sample size which was only 30 or lack of registry of male patients during the 6 months study period.
Regarding the age group of patients where most of the patients included were 20-40 years of age. The mean age of the patients in our study was 28.42 years. SLE is a disease of child bearing age.  The median age of onset of SLE is 24 years in a series reported by Malaviya et al. 
Some patients had history of abortion and fetal loss. In SLE as antiphospholipid antibody syndrome is an important associated findings, which causes premature fetal death and repeated abortion. Different studies done earlier  also proves this findings.
Most common hematological abnormality was anemia (57.5%). Various studies have shown a similar findings.  In a series of studies reviewed by Budman and Steinberg  anemia occurred in 57-78% of patients with SLE. Iron deficiency anemia, Anemia of chronic disease and autoimmune hemolytic anemia are the common cause of anemia in SLE. Investigations to evaluate etiology of anemia such as iron studies, serum folate levels, and bone marrow examinations have not been done due to financial constraints.
Regarding 24 h UTP loss 1-2 g/day protein loss in urine was found in 10 (33.3%) patients and >3 g/day protein loss was also found in 6 (20%) patients. These findings are consistent with the previous study. 
There is frequent association between hypertension and renal disease in SLE. Our study could not establish any statistical significant association between renal involvement and hypertension. The number studied are probably too small to bring out a significant association. However it was found that 5 out of 8 patients with hypertension were eventually to have LN. Our study had also 6 patients of thyroid disorder in the form of autoimmune thyroiditis and 4 patient of DM. SLE is an autoimmune disease and it may be associated with other autoimmune disease. However the numbers in our study were too small to bring any such association.
The most common criteria satisfied was ANA and anti-ds DNA positivity. It was seen that 19 (63.3%) patients had ANA positivity whereas all 30 (100%) patients had anti-ds DNA antibody in all of our patients. This is not an expected finding as ANA negative lupus is a rare clinical entity in our setting. ANA is the most sensitive indicator of the presence of SLE. ANA positivity is reported to be positive in about 90-95% of cases. The findings of present study regarding ANA might be due to laboratory variations of immunological results.
Regarding examination of renal biopsy no patient was found in Class I group. Most of the patients were in Class III (9 [30%]) and Class IV (40%). In the present study a patient was found to having histologic features of poststreptococcal glomerulonephritis, but had significant proteinuria with other diagnostic features of LN. Two biopsy specimen could not be evaluated due to inadequate specimen. The renal biopsy findings were consistent with the previous study. 
A study  done in Iran where patients with biopsy proven LN were evaluated clinically and laboratory parameters used to evaluate how close the diagnosis correlated with WHO and/or ISN/RPS 2003 classification of LN. There were 144 patients of whom 84.7% were females with a mean age of 25.6 ± 10.3 years at the time of renal biopsy. However in our study, no male patient was found during the study period. It needs further multicenter large scale study to see whether LN is more common among female in the context of Bangladesh. In that study  the most frequent SLE presenting features were arthralgia, edema, and hypertension which is consistent with the present study also. According to their study  WHO Class IV and ISN/RPS Class IV were compatible with these most frequent SLE presenting features in 56% and 54.9% of the cases, respectively. Present study also documents that Class IV is the most common histological type of LN in the context of Bangladesh. That previous study  highlighted that edema, hypertension, increased blood urea nitrogen and creatinine, increased 24 h urine protein excretion and decreased serum albumin level were related with a worse class of LN. They also concluded that there is a correlation between some clinical and laboratory findings, and histopathological lupus classification on renal biopsy, which remains indispensable in the management of LN. There are some limitations of the present study, mainly antiphospholipid antibody test was not done, severity of LN was not well documented and patients were not followed up for long to see further clinical, laboratory, and histological changes of renal status.
| Conclusion|| |
In this study, all patients were female of child bearing age and all patients had anti-ds DNA positivity and some had ANA positivity. 1-2 g/day proteinuria was a common finding. Hypertension was also a common association with LN. Some patients were associated with other autoimmune disease like thyroiditis and DM. There is diversity of histological findings of LN patients.
| Acknowledgments|| |
Special thanks to all patients who gave consent for renal biopsy.
| References|| |
Alba P, Bento L, Cuadrado MJ, Karim Y, Tungekar MF, Abbs I, et al.
Anti-dsDNA, anti-Sm antibodies, and the lupus anticoagulant: Significant factors associated with lupus nephritis. Ann Rheum Dis 2003;62:556-60.
Popeseu E, Lonescu R. Compendium of Rheumatology. Bucharest: McGraw Hill; 2000. p. 117-33.
Berden JH. Lupus nephritis nephrology forum. Kidney Int 1997;52:538-58.
Cameron SJ. Lupus nephritis. Disease of the month. J Am Soc Nephrol 1999;10:413-22.
Voulgarelis M, Kokori SI, Ioannidis JP, Tzioufas AG, Kyriaki D, Moutsopoulos HM. Anaemia in systemic lupus erythematosus: Aetiological profile and the role of erythropoietin. Ann Rheum Dis 2000;59:217-22.
Malaviya AN, Singh RR, Kumar A, De A, Kumar A, Aradhye S. Systemic lupus erythematosus in northern India: A review of 329 cases. J Assoc Physicians India 1988;36:476-80, 484.
Budman DR, Steinberg AD. Hematologic aspects of systemic lupus erythematosus. Current concepts. Ann Intern Med 1977;86:220-9.
Pollak VE, Pirani CL. Renal histologic findings in systemic lupus erythematosus. Mayo Clin Proc 1969;44:630-44.
Nezhad ST, Sepaskhah R. Correlation of clinical and pathological findings in patients with lupus nephritis: A five-year experience in Iran. Saudi J Kidney Dis Transpl 2008;19:32-40.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]