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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA-AFRICA  
Year : 2011  |  Volume : 22  |  Issue : 2  |  Page : 377-380
Clinical features and histological patterns of lupus nephritis in Eastern Nepal


1 Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
2 Department of Dermatology and Venereology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
3 Department of Pathology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal

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Date of Web Publication18-Mar-2011
 

   Abstract 

To determine the clinical profile and patterns of lupus nephritis patients in Eastern Nepal, we studied 38 patients fulfilling the 1982 revised criteria of American College of Rheu­matology for systemic lupus erythematous (SLE), followed up from January 2004 to January 2008. Arthritis was a common initial feature in addition to variable cutaneous, cardiac, pulmonary and neuropsychiatric manifestations. Renal biopsy showed grade 1 changes in 5 (13.5%) patients, grade 2 changes in 13 (35.1%) patients, grade 3 changes in 9 (24.3%) patients, grade 4 changes in 7 (18.9%) patients, grade 5 changes in 2 (5.4%) patients, and grade 6 changes in 2.7% patients. Antinuclear antibody (ANA) assay and anti-ds DNA were positive in 78.4 and 81.1%, respec­tively. We conclude that mesangial proliferative glomerulonephritis (grade 2) was the most common pattern of lupus nephritis encountered in our study. Timely diagnosis and treatment may improve the overall patients' survival.

How to cite this article:
Dhakal SS, Sharma SK, Bhatta N, Bhattarai S, Karki S, Shrestha S, Rijal S, Karkil P. Clinical features and histological patterns of lupus nephritis in Eastern Nepal. Saudi J Kidney Dis Transpl 2011;22:377-80

How to cite this URL:
Dhakal SS, Sharma SK, Bhatta N, Bhattarai S, Karki S, Shrestha S, Rijal S, Karkil P. Clinical features and histological patterns of lupus nephritis in Eastern Nepal. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2020 Jun 6];22:377-80. Available from: http://www.sjkdt.org/text.asp?2011/22/2/377/77651

   Introduction Top


Systemic lupus erythematosus (SLE) is a mul­tisystem autoimmune disease primarily occur­ring in young women and is characterized by variable clinical and laboratory manifestations.

Renal involvement is common in SLE. Ab­normal urinalysis with or without an elevated plasma creatinine concentration is present in a large proportion of patients at the time of diag­nosis and may eventually develop in up to 75% of the cases. The most frequently observed abnormality is proteinuria. [1] There are a num­ber of types of renal disease in SLE, usually differentiated by a renal biopsy, with immune complex-mediated glomerular diseases being the most common. In addition, nonlupus renal diseases may be observed. [2]

In the present study, we determine the cli­nical features including histopathological pat­terns of lupus nephritis from Eastern Nepal.


   Methods Top


All patients of age more than 15 years and sa­tisfying the revised American College of Rheumatology criteria (1982) for SLE were inclu­ded in the study over a period of four years from January 2004 to January 2008. [3] Routine investigations including complete blood count, erythrocyte sedimentation rate (ESR), urinaly­sis, 24 hour urine protein excretion, blood urea, serum creatinine were done in all the pa­tients. Immunological investigations like anti­nuclear antibody (ANA), anti-ds DNA, rheu­matoid factor were done in all the patients. Other investigations such as chest X-ray, ECG, and ultrasound of the abdomen were done where required. All the patients were subjected to percutaneous renal biopsies. The slides were viewed by an independent pathologist and gra­ding was done according to the revised World Health Organization (WHO) criteria in 1995 as follows: grade 1 (minimal mesengial glome­rulonephritis), grade 2 (mesengial proliferative lupus nephritis), grade 3 (focal propliferative glomerulonephritis), grade 4 (diffuse prolifera­tive nephritis), grade 5 (membranous nephritis), and grade 6 (glomerulosclerosis). [4]


   Results Top


Thirty-seven SLE patients were enrolled for the study during the study period. All the pa­tients were females (100%). The mean age of the onset of the disease was 31.62 years (range 14-54 years); 20 (54.1%) patients were bet­ween 20 and 40 years, and 29 (78.4%) patients had less than one year of disease duration.

[Table 1] shows the initial clinical manifesta­tions in the study patients. Arthritis was a com­mon initial manifestation in 29 (78.4%) pa­tients. The dermatological manifestations in­cluded malar rash, photosensitivity, oral ulcer, telangiectasia in the face, Raynaud's phenome­non, and discoid rash. In addition, fever, sei­zure, pleural effusion, pericardial effusion were present.
Table 1: Initial clinical manifestation in the lupus study patients.

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Anemia was observed in 33 (89.2%) patients: normocytic normochromic in 18 patients, mic­rocytic hypochromic in 12 patients, and dimor­phic anemia in 3 patients. Thrombocytopenia was also observed in 5 (13.5%) patients. 24­hour urinary protein ranged from more than 150 mg/dL to 500 mg/dL in 21.6% of the pa­tients, from 500 mg/dL to 1.5 g/dL in 56.8% patients, more than 1.5 g/dL to 3 g/dL in 10.8% patients, and more than 3 g/dL in 10.8% patients. ANA was positive in 29 (78.4%) pa­tients, anti-ds DNA in 30 (81.1%) patients, and rheumatoid factor in 5 (16.2%) patients. Two patients had a history of abortion in which one was positive for anti-phospholipid antibodies. Serum creatinine was <1.2 mg/dL in 32 (86.5%) patients and ≥1.2 mg/dL in 5 (13.5%) patients.

The renal biopsies showed grade 1 changes in 5 (13.5%) patients, grade 2 changes in 13 (35.1%) patients, grade 3 changes in 9 (24.3%) patients, grade 4 changes in 7 (18.9%) patients, grade 5 changes in 2 (5.4%) patients, and grade 6 changes in (2.7%) patients.


   Discussion Top


All the patients in our study were females. This could be due to hormonal factors and the fact that females of many mammalian species have higher antibody responses than males. [5]

In the present study, the patients' age ranged from 14 to 54 years, median age at disease onset was 31.62 years similar to that reported earlier. [6],[7],[8]

In the present study, arthritis was seen in 78.4% of patients as the initial clinical mani­festation, which is more than what was repor­ted earlier (44-68.5%). [7],[9],[10]

The cutaneous lesions including malar rash, photosensitivity, oral ulcer, Raynaud's pheno­menon and discoid rash were seen in 81.1, 78.4, 56.8, 37.8 and 21.6% patients, respec­tively. In comparison with other studies, we noticed great variation in incidence, clinical heterogeneity and severity of disease due to environmental, cultural and genetic variability in the various ethnic and racial groups. [11],[12]

In our present study, anemia was observed in a higher percentage than that seen in other reports. [13] In a resource-poor setting such as our country, patients usually present late in the course of the illness, which may be the reason for the high percentage of anemic patients due to chronic disease. [Table 2] shows the compa­rison with other studies published from other developing and developed countries in terms of the clinical and laboratory stigmata of the disease.
Table 2: Cumulative findings of clinical and immunological manifestations of SLE in the Eastern Nepal study and its comparison with other series.

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In our study, 78.4% of patients had 24 hour urinary protein excretion more than 500 mg/day. The comparative data in the series by Feng et al, Malaviya et al and Radhamadhavan et al were 36, 8, and 7.4%, respectively. [9],[7],[10] This could be due to a variability of gender, age and ethnicity. [14] As lupus nephritis is present in most patients with SLE, even when they do not have clinical manifestation, kidney biopsy to rule out or rule in lupus nephritis is required. [15]

In the present study, ANA, anti-ds DNA and positive rheumatoid arthritis (RA) factor were observed in a comparable percentage with those reported in the study of Paul et al. [13]

We conclude that mesangial proliferative glo­merulonephritis (grade 2) was the most com­mon pattern of lupus nephritis encountered in our study. Timely diagnosis and treatment may improve the overall patients' survival.

 
   References Top

1.Clinical features of SLE. In: Textbook of Rheu-matology, Kelley WN, (Ed), WB Saunders, Philadelphia 2000.  Back to cited text no. 1
    
2.Baranowska-Daca E, Choi YJ, Barrios R, et al. Non lupus nephritides in patients with sys­temic lupus erythematosus: a comprehensive clinicopathologic study and review of the lite­rature. Hum Pathol 2001;32:1125.  Back to cited text no. 2
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3.Tan EM, Cohen AS, Fries JF, et al. The 1982 revised criteria for the classification of sys­temic lupus erythematosus. Arthritis Rheum 1982;25:1271. Updated by Hochber MC. Updating the American College of Rheu­matology revised criteria for the classification of systemic lupus erythematosus. Arhtritis Rheum 1997;40:1725.  Back to cited text no. 3
    
4.Weening JJ, D'Agati VD, Schwartz MM, et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol 2004;15:241-50.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Hahn BH. Systemic lupus erythematosus. In: Kasper DL, Braunwald E, Fouci AS, (eds). Harrison's principles of Internal Medicine, Vol.2 16 th Ed. New York: McGraw-Hill; 2005; 1960-7.  Back to cited text no. 5
    
6.Masi AT, Kaslow RA. Sex effects in SLE-a clue to pathogenesis. Arthritis Rheum 1978;21: 480.  Back to cited text no. 6
[PUBMED]    
7.Malaviya AN, Singh RR, Kumar A, De A, Kumar A, Aradhye S. SLE in Northern India. A review of 329 cases. J Assoc Phys India 1988;36:476-80.  Back to cited text no. 7
    
8.Vaidya S, Samant RS, Nadkar MY, Borges NE. Systemic lupus erythematosus-review of two hundred and twenty patients. JIRA 1997;5:14-8.  Back to cited text no. 8
    
9.Feng BH, Boey ML. Systemic lupus erythe­matosus in Chinese-The Singapore experience. Rheumatol Int 1982;2:151-4.  Back to cited text no. 9
    
10.Madhavan R. SLE-The Madras experience. J Assoc Phys India 1988;36:481-4.  Back to cited text no. 10
    
11.Kole AK, Ghosh A. Cutaneous manifestation of SLE in tertiary referral center. Indian J Dermatol 2009;54:2:.  Back to cited text no. 11
    
12.Lasman SD, Provost TT. Cutaneous manifes­tation of SLE. Rheum Dis North Am 1994;20: 195.  Back to cited text no. 12
    
13.Paul BJ, Fassaludeen M, Nandakumar, Razia MV. Clinical profile of Systemic Lupus Erythematosus in Northern Kerala. J Indian Rheumatol Assoc 2003;11:94-7.  Back to cited text no. 13
    
14.Seligman VA, Lum RF, Olson JL, et al. Dermographic differences in the development of lupus nephritis: a retrospective analysis. Am J Med 2002;112:726.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  
15.Molino C, Fabbian F, Longhini C. Clinical approach to lupus nephritis: recent advances. Eur J Intern Med 2009;20(5):447-53  Back to cited text no. 15
    

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Correspondence Address:
Subodh Sagar Dhakal
Assistant Professor, Department of Internal Medicine, B. P. Koirala Institute of Health Sciences, Dharan
Nepal
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PMID: 21422651

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