Resum
Background: Systemic Lupus Erythematosus (SLE) is a multi-systemic autoimmune disease. Renal involvement is a common complication, causing considerable mortality and morbidity.SLE is rarely reported among black Africans, though recent reports from Nigeria indicate otherwise. Nephritis, though a common complication of SLE has rarely been reported as the initial diagnosis of lupus among black Africans.
Aims: The aim of our study is to highlight the clinical, laboratory and histological features in Nigerian patients presenting with features of nephritis and subsequent diagnosis of SLE.
Methods: This is a three year prospective study of patients with renal diseases, who were admitted to the rheumatology and nephrology units of the Lagos State University Teaching Hospital (LASUTH) Ikeja. Serology, biochemical, haematologic tests, kidney biopsy were done.
Results: Twelve patients were studied (F11; M1); mean age 30.4 years (SD± 9.8);mean illness 8weeks(SD±6.6) . Six patients had a nephritic condition. Nine of the patients had baseline hypertension while 3 had a rapidly progressive nephritis. Two patients had baseline End Stage Renal Disease (ESRD).All had dipstick proteinuria 2+ / 3+ , mean protein creatinine ratio 2.2 (SD ±0.6) ,mean 24hr protein 2.8gm(SD±2.7);more than 10 red blood cells/hpf haematuria(n-6),hyaline casts(n-5), granular casts(n-2),mean GFR 31.4ml/min(SD±21.3),mean serum creatinine 6.9mg/dl(SD± 5.3); mean urea 138.8mg/dl(SD±56.2). For the serology, Anti Nuclear Antibody (ANA) was positive in all the 12 subjects; positive anti dsDNA -10 patients; ENA - 10. Renal biopsy showed mostly WHO/ISSN classes III, IV and V. Treatment was with Euro Lupus regimen and rituximab/cyclophosphamide. Four patients had dialysis. In terms of the outcome, there were 3 deaths while 9 patients were discharged.
Conclusion: A high index of suspicion is needed to diagnose Lupus Nephritis in black Africans especially when their presentations do not fulfil the America College of Rheumatology (ACR) diagnostic criteria for SLE.
Keywords: Renal, diseases, initial, diagnosis, lupus
Résumé
Introduction: Le lupus érythémateux disséminé (SLE) est une maladie multi-systémique. Une atteinte rénale est une complication courante, cause de morbidité et mortalité considérable. Le SLE est rarement signalée chez les noirs africains. Le but de notre étude est de mettre en évidence les laboratoires cliniques, et des caractéristiques histologiques chez des patients nigérians présentant des caractéristiques de la néphrite et diagnostic ultérieur d’SLE.
Méthodes: Il s’agit d’une étude prospective de trois ans des patients atteints de maladies rénales, qui ont été admis dans les unités de rhumatologie et de néphrologie au centre universitaire hospitalier d’Ikeja, l’état de Lagos(LASUTH). Les examens sérologiques, des tests biochimiques, hématologiques et biopsie rénale ont été effectuées.
Résultats: Douze patients ont été l’objet d’étude (F11; M1); âge moyen 30,4 années (SD ± 9,8); signifier maladie 8 semaines (SD ± 6,6). Six patients avaient une maladie néphrétique. Neuf des patients présentaient une hypertension de base alors que 3 avaient une néphrite rapidement progressive. Deux patients avaient référence d’insuffisance rénale terminale (IRT). Tout avait évalué: protéinurie 2/3, signifie protéine créatinine 2.2 (SD ± 0,6), 24hr protéines 2.8 gm(SD±2.7) ; plus de 10 globules rouges/hpf hématurie (n-6), hyalines (n-5), moulages granulaires (n-2), équivalent au GFR 31,4 ml/min(SD±21.3), taux de sérum créatinine moyenne 6,9 mg/dl(SD± 5.3) ; équivalent à la concentrationd’urée de 138.8mg/dl(SD±56.2). Pour la sérologie, ANA a été positif dans l’ensemble des 12 sujets; positif anti ADN bicentenaire -10 patients; ENA - 10. Biopsie rénale a montré surtout qui/ISSN classes III, IV et V. Le traitement était avec Euro Lupus chimio et rituximab/cyclophosphamide. Quatre patients avaient fait la dialyse. En termes de résultat, il y a eu 3 décès et 9 patients ont été déchargés.
Conclusion: Un indice élevé de suspicion est nécessaire pour diagnostiquer la néphropathie lupique chez les Africains noirs en particulier lorsque leurs présentations ne remplissent pas les critères de diagnostic de l’ACR pour SLE.
Correspondence: Prof. O.O. Adelowo, Department of Medicine, LASUTH, Ikeja, Lagos, Nigeria. E-mail: femiadelowo2003@yahoo.com.
Referències
Adelowo OO and Oguntona SA. Pattern of systemic lupus erythematosus among Nigerians Clin Rheumatol. 2009 Jun; 28(6):699-703.
Adelowo OO, Oguntona AS and Ojo O. Neuropsychiatric systemic lupus erythematosus among Nigerians. Afr J Med med sci. 2009 Mar; 38(1):33-38.
Tan EM, Cohen AS, Fries JF, Masi AT, et al. The 1982 revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum 1982;25:1271–1277.
Dooley MA, Aranow C and Ginzler EM. Review of ACR renal criteria in systemic lupus erythematosus. Lupus 2004; 13: 857–860.
Petri M Orbai AM, Alarcón GS, Gordon C, et al. Derivation and validation of SLE Collaborating Clinic Classification(SLICC) criteria for SLE. Arthritis Rheum,2012 Aug 64(8): 2677-2686.
Bernatsky S, Boivin JF, Joseph L, et al. Mortality in systemic lupus erythematosus. Arthritis Rheum 2006; 54:2550–2557.
Korbet SM, Schwartz MM, Evans J and Lewis EJ. Severe lupus nephritis: racial differences in presentation and outcome. J Am Soc Nephrol. 2007 Jan; 18(1):244-254.
Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis 2012 Nov;71(11):1771-1782.
Bastian HM, Roseman JM, Mcgwin G Jr et al. Systemic lupus erythematosus in three ethnic groups. XII. Risk factors for lupus nephritis after diagnosis. Lupus (2002) 11: 152-160.
Okpechi IG, . Ayodele OE, Jones ES, et al.. Outcome of patients with membranous lupus nephritis in Cape Town South Africa. Nephrol. Dial. Transplant. . 2012 Sep;27(9):3509-3515.
Okpechi IG, Swanepoel CR, Tiffin N, et al. Clinicopathological insights into lupus nephritis in South Africans: A study of 251 patients. Lupus. . 2012 Aug;21(9):1017-1024.
Olugbenga EA , Okpechi IG and Swanepoel CR. Predictors of poor renal outcome in patients with biopsy-proven lupus nephritis. Nephrology. June 2010:15(4): 482-490.
Winston Williams, DM; Dipak Shah, DM; Lincoln A and Sargeant, DM. The Clinical and Epidemiologic Features in 140 Patients with Lupus Nephritis in a Predominantly Black Population from One Centre in Kingston, Jamaica. Am J Med Sci 2004;327(6): 324–329.
C Flower, A Hennis, IR Hambleton and G Nicholson. Lupus nephritis in an Afro-Caribbean population: renal indices and clinical outcomes. Lupus (2006) 15, 689–694.
Diallo AD, Nochy D, Niamkey E and Yao Beda B. Etiologic aspects of nephrotic syndrome in Black African adults in a hospital in Abidjan. Bull Soc Pathol Exot. 1997; 90(5): 342-345.
Bertsias G, Cervera R and Boumpas DT. Systemic lupus erythematosus: pathogenesis, clinical manifestations and diagnosis. Eular On-line Course on Rheumatic Diseases,2011, module 17: page 6
Cervera R, Khamashta MA, Font J, Sebastiani GD et al. Systemic lupus erythematosus: clinical and immunologic patterns of disease expression in a cohort of 1,000 patients. The European Working Party on Systemic Lupus Erythematosus. Medicine (Baltimore) 1993; 72:113-124.
Kasitanon N, Magder LS and Petri M. Predictors of survival in systemic lupus erythematosus. Medicine (Baltimore) 2006;85:147–156.
Rabanni MA,Tahir MH, Siddiqui BK, Ahmad B et al. Renal involvement in Systemic lupus erythematosus in Pakistan. J.Pak MedAssoc.2005 Aug: 55(8):328-332.
Contreras G, Lenz O, Pardo V, Borja E et al: Outcomes in African Americans and Hispanics with lupus nephritis. Kidney Int 2006; 69 : 1846 –1851.
Alebiosu CO and Ayodele OE . Global burden of Chronic Kidney Disease and the way forward.Ethn Dis 2005 Summer,15(3) 418-423.
Thumboo J, Fong KY, Chia HP, Chung HH et al. Clinical predictors of nephritis in systemic lupus erythematosus. Ann Acad Med Singapore 1998; 27:16 – 20.
Boumpas DT, Austin HA, Fessler BJ, et al. Systemic lupus erythematosus: emerging concepts. Part 1: renal, neuropsychiatric, cardiovascular, pulmonary, and hematologic disease. Ann Intern Med 1995; 122:940-950.
Balow JE, Boumpas DT and Austin HA. Systemic lupus erythematosus and the kidney. In Lahita RG, ed. Systemic lupus erythematosus. San Diego: Academic Press, 1999: 657-685.
Chen YE, Korbet SM, Katz RS, et al. Value of a complete or partial remission in severe lupus nephritis. Clin J Am Soc Nephrol 2008;3:46-53.
Reeves WH, Satoh M and Richards HB. Origins of antinuclear antibodies pg 1271-1277. In: Lahita RG, ed. Systemic lupus erythematosus, Elsevier, 1999, San Diego.
Isenberg D, Appel GB, Contreras G, et al. Influence of race/ethnicity on response to lupus nephritis treatment: the ALMS study. Rheumatology (Oxford) 2010; 49:128–140.
Hahn BH, McMahon MA, Alan Wilkinson, et al. American College of Rheumatology Guidelines for Screening, Treatment, and Management of Lupus Nephritis. Arthritis Care and Research .Vol. 64, No. 6, June 2012, pp 797–808.
Dooley MA, Jayne D, Ginzler EM, et al (ALMS Group).Mycophenolate versus azathioprine as maintenance therapy for lupus nephritis. N Engl J Med. 2011 Nov 17;365(20):1886-1895.
Houssiau FA, D’Cruz D, Sangle S, Remy P et al. Azathioprine versus Mycophenolate mofetil for long-term immunosuppression in lupus nephritis: results from the MAINTAIN Nephritis Trial. Ann Rheum Dis. 2010 Dec; 69(12):2083-2089.
Ng KP, Cambridge G, Leandro M, et al. B cell depletion therapy in systemic lupus erythematosus: long-term follow- up and predictors of response. Ann Rheum Dis.2007 Sept; 66(9):1259-1262.