PROGNOSTIC DETERMINANTS IN LUPUS NEPHRITIS - A LONG-TERM CLINICOPATHOLOGICAL STUDY

Over the past 50 years, survival has improved in patients with systemi c lupus erythematosus and associated nephritis. Yet, there are few lon g-term outcome studies in patients with well-defined nephropathy. We e xaminbed the outcome of 439 patients with lupus nephritis who were see n at the Mayo Clinic between 1964 and 1986 in whom renal biopsies were assessed using the World Health Organization (WHO) classification. Th ere were 341 women and 98 men (mean +/- s.d., age 33.5 +/- 14 years); 200 (46%) patients were hypertensive and 249 (57%) had impaired renal function at renal biopsy. All WHO morphologic classes were represented and 339 (77%) patients had class III, IV and V (the more severe forms of nephritis). Follow-up averaged 10.2 years per patient. At last con tact, 286 (65%) patients were alive and 153 (35%) were dead. Overall p atient survival was 80%, 69% and 53% at 5, 10 and 20 years after biops y that was significantly worse than expected survival (P < 0.001). Ten -year cumulative patient survival improved comparing earlier to more r ecent time spans: 64% in 231 patients seen during 1964-75; 76% in 2089 patients studied during 1976-86 (P = 0.03). Survival free of renal fa ilure was 83%, 74% and 64% at 5, 10 and 20 years, and survival was unf avorably influenced by progressive WHO class, hypertension, impaired r enal function, nephrotic range proteinuria, hypoalbuminemia and anemia . Multivariate analysis found impaired renal function, increased urine protein, anemia and younger age to be independent predictors of renal failure. WHO class was not a significant predictor when adjusted for these four factors. Cardiovascular events accounted for 48% of the kno wn deaths and were equally distributed across all WHO classes, followe d by infections, renal failure, malignancy, respiratory failure and ga strointestinal bleeding. Severe nephritis, nephrotic syndrome, hyperte nsion and anemia remain strong predictors of a poor renal outcome. Pro spective randomized studies stratifying for these factors are needed t o find optimal immunosuppressive regimens to improve renal survival.