Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2011  |  Volume : 22  |  Issue : 4  |  Page : 815--817

Renal biopsy findings in lupus nephritis


Khader N Mustafa1, Tariq N Aladily2, Maha S Shomaf2, Ayman M Wahbeh3,  
1 Department of Rheumatology, Jordan University Hospital, Amman, Jordan
2 Department of Pathology, Jordan University Hospital, Amman, Jordan
3 Department of Nephrology, Jordan University Hospital, Amman, Jordan

Correspondence Address:
Tariq N Aladily
Department of Pathology, Jordan University Hospital, Amman
Jordan




How to cite this article:
Mustafa KN, Aladily TN, Shomaf MS, Wahbeh AM. Renal biopsy findings in lupus nephritis.Saudi J Kidney Dis Transpl 2011;22:815-817


How to cite this URL:
Mustafa KN, Aladily TN, Shomaf MS, Wahbeh AM. Renal biopsy findings in lupus nephritis. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2020 Jul 13 ];22:815-817
Available from: http://www.sjkdt.org/text.asp?2011/22/4/815/82728


Full Text

To the Editor,

Lupus nephritis (LN) is a major cause of both morbidity and mortality in systemic lupus erythematosus (SLE). The outcome of renal disease correlates well with the histological findings, early diagnosis and therapy. Recently, there has been an increasing awareness among Arab countries about the significance of this disease, reflected by the attempts for performing statistical and analytical studies about LN patients. [1],[2],[3],[4],[5]

Jordan University Hospital is a tertiary care university-based hospital in Amman, Jordan, with 500 bed capacity. It receives a large number of patients from all parts of Jordan, providing a good representative sample for the study. We planned to study the pathological findings of renal biopsy in patients with LN who were admitted to our center and to compare our results with similar data from other Arab and Asian countries.

There were 363 patients clinically diagnosed to have SLE in Jordan University Hospital from January 1990 to September 2009, and among them, 65 (18%) had histopathologically proven LN. We retrospectively reviewed the records and histopathological findings of those 65 adequate kidney biopsies. Proteinuria and deterioration of renal function were the main indication for biopsy. Prior to the kidney biopsy, all patients were subjected to kidney function tests, urine analysis, serum albumin estimation, 24-hour urine collection for protein, coagulation parameters and serologic markers for auto-antibodies. Biopsies were done under ultrasound guidance, using a spring-loaded biopsy needle. The biopsy material was divided into two samples. The first sample was fixed in 10% neutral buffered formalin for various light microscopic examinations and the second sample was sent in normal saline for immunofluorescence study. Electron microscopic examination was not available.

Each kidney biopsy from lupus patients was evaluated according to WHO classification and then for the National Institution of Health (NIH)-modified semiquantitative histologic scoring index. The prevalence of LN was more common in females, with a female to male ratio of 3.8:1. The mean age of onset for LN was 24.8 years, with a range between 6 and 60 years. Renal involvement coincided with the onset of SLE in 71% of patients, while the remaining had a late onset of renal involvement ranging from 1 to 14 years.

The predominant group according to WHO classification was class IV, seen in 39 (60%) cases. The second most common was class II, found in 12 (18%) cases. Classes V and III were present in 8 (12%) and 5 (7%) patients, respectively. One patient had class VI (2%). Overlapping pattern was present in 3 cases (4.6%). Those cases were categorized under the higher class. When applying the NIH scoring system for LN, activity index was prominent in classes III and IV. Classes II and V were more related to chronicity index, although it was seen in all classes. "Full House" immuno-fluorescence pattern was detected in 43 cases (66%), two-thirds of which were of class IV. Vasculopathy, which was mainly nonspecific arteriolosclerosis, was noted in 30 cases (46%), with no specific class predilection. However, it correlated well with the presence of hypertension.

It seems that LN is responsible for a significant proportion of kidney diseases in Jordan and is probably the most common cause of secondary glomerulonephritis. [6],[7] This heralds the need for prompt detection and early intervention by clinicians. The management and prognosis of LN require the evaluation of histological class and the activity-chronicity indices. [8]

Ethnic variation in the prevalence, incidence and severity of LN is well documented in the literature. [9] Among Arabs, the role of ethnicity is still unknown, and only a few reports have been published in this regard. [1] The age and sex ratio in our study corresponds well with the data published so far, [10] which shows disease proclivity for young females in their reproductive age period. The prevalence of kidney involvement among lupus patients was only 28%, which is lower than what was reported in Arab populations (37-69%). [1] This is probably due to the fact that only patients with evidence of significant proteinuria had renal biopsies.

When comparing the results, one can find a difference in the prevalence WHO classes of LN among Arab populations who had mainly classes II, III and IV [Table 1]. Surprisingly, the Jordanian population was closest to Saudis [2] and Indo-Asian people. [1] {Table 1}

We relate these differences to the small size of the samples, [1],[3],[4],[5] and therefore, there is a need for large multi-center studies involving many countries. Early detection, elevated serum creatinine and the socioeconomic status of the patient are pivotal factors that markedly influence disease progression. [11],[12] The activity- chronicity indices in our study, along with the pattern of immunofluorescence, are in accordance with what is expected, and with the data published in other series. [13] A larger multicenter study would perhaps be confirmatory.

References

1Al Attia HM. Lupus Nephritis among Arabs - Differences with other Races; Emphasis on Clinicopathological and Serological Perspectives. Saudi J Kidney Dis Transpl 2000;11(3):370-80.
2Al Arfaj AS, Khalil N, Al Saleh S. Lupus nephritis among 624 cases of systemic lupus erythematosus in Riyadh, Saudi Arabia. Rheumatol Int 2009;29(9):1057-67.
3Ebrahim RA, Farid EM, Greally JF. SLE in Bahrain: A review of clinical and laboratory data in 50 Bahraini patients. Emirates Med J 2002;20(2):147-52.
4Uthman IW, Muffarij AA, Mudawar WA, Nasr FW, Masri AF. Lupus nephritis in Lebanon. Lupus 2001;10(5):378-81.
5Barsoum RS, Francis MR. Spectrum of glomerulonephritis in Egypt. Saudi J Kidney Dis Transpl 2000;11(3):421-9.
6Said R, Hamzeh Y. Tarawneh M. The Spectrum of Glomerulopathy in Jordan. Saudi J Kidney Dis Transpl 2000;11:430-3.
7Wahbeh AM, Ewais MH, Elsharif ME. Spectrum of glomerulonephritis in adult Jordanians at Jordan university hospital. Saudi J Kidney Dis Transpl 2008;19(6):997-1000.
8Al Salloum AA. Lupus nephritis in childhood. Saudi J Kidney Dis Transpl 2003;14(1):43-56.
9Crosslin KL, Wiginton KL. The impact of race and ethnicity on disease severity in SLE. Ethn Dis 2009;19:301-7.
10Rus V, Maury EE, Hochberg MC. Epidemiology of Systemic Lupus Erythematosus. In: Wallace DJ, Hahn BH, eds. Dubois' Lupus Erythematosus. 7 th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:34-44.
11Barr RG, Seliger S, Appel GB, et al. Prognosis in proliferative lupus nephritis The role of socioeconomic status and race/ethnicity. Nephrol Dial Transplant 2003;18(10):2039-46.
12Faurschou M, Starklint H, Halberg P, Jacobsen S. Prognostic factors in lupus nephritis: diagnostic and therapeutic delay increases the risk of terminal renal failure. J Rheumatol 2006;33 (8):1464-6.
13Al-Zahrani IH, Qayyum A. Lupus nephritis: Clinicopathological correlation. Saudi Med J 2007;28(10):1503-5.