Saudi Journal of Kidney Diseases and Transplantation

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


Subodh Sagar Dhakal1, Sanjib Kumar Sharma1, Narendra Bhatta1, Sabina Bhattarai2, Smriti Karki3, Shailendra Shrestha1, Suman Rijal1, Prahlad Karkil1,  
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

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

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«SQ» 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;22:377-380


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 2022 Jan 17 ];22:377-380
Available from: https://www.sjkdt.org/text.asp?2011/22/2/377/77651


Full Text

 Introduction



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



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



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}

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



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}

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.

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