medwireNews: Three years is the minimum duration of sustained clinical remission needed to protect patients with lupus nephritis (LN) against impaired kidney function and damage accrual, show research findings.
Patients who achieved this duration of clinical remission had a significant 41.1% reduction in accrual of damage on the Systemic Lupus International Collaborating Clinics damage index (SDI) compared with baseline versus nonsignificant reductions of 20.4–24.8% with shorter remission durations.
They were also a significant 90% less likely to develop impaired kidney function, defined as an estimated glomerular filtration rate (eGFR) below 60 mL/min per 1.73 m2 for at least 3 months, than patients who never achieved remission, increasing to 91% with 4 or more years of clinical remission.
The study involved a total of 293 patients with biopsy-proven LN and a median follow-up of 15.7 years, during which 84.3% of the patients achieved sustained clinical remission lasting 8.7 years and beginning a median 2.0 years after onset of the condition. Sustained clinical remission was defined as a Systemic Lupus erythematosus Disease Activity Index 2000 score of 0, including a proteinuria level below 0.5 g/24 hours and an eGFR above 60 mL/min per 1.73 m2 for at least a year with or without treatment.
Most of the patients had no chronic kidney damage at baseline, with just 11.8% of patients scoring above 0 on the SDI, where a higher score indicates greater overall damage. By the end of follow-up, scores had increased in just over half (55%) of patients, and the duration of sustained clinical remission correlated inversely with this increase.
Three years was identified as the shortest period of clinical remission to significantly protect against an increase in SDI. Indeed, Andrea Doria (University of Padova, Italy) and colleagues report that damage increased in 58% of patients who achieved the 3-year threshold versus 86% of patients who did not.
They calculated that the average annual increase in damage was 0.04 points among patients who achieved at least 3 years of clinical remission versus 0.11 points for those who did not.
Among the 224 LN patients with the longest follow-up of more than 10 years, 22.3% developed impaired kidney function. Sustained clinical remission of at least 2, 3, and 4 years was achieved by a respective 85%, 80%, and 78%, whereas 14% of patients never achieved sustained clinical remission.
The investigators report that at least 3 years of clinical remission was the minimum duration found to be protective against impaired kidney function. Among patients who achieved this, 99%, 96%, and 91% were free of impaired kidney function at 10, 20, and 25 years. This compared with significantly lower corresponding rates of 87%, 68%, and 40% for patients who never achieved sustained clinical remission.
Uncontrolled arterial hypertension was found to be an independent predictor of SDI increase and impaired kidney function, the team notes in Annals of the Rheumatic Diseases, “underscoring the need for prevention of comorbidities to halt progression towards overall and kidney-limited damage.”
Higher doses of oral glucocorticoids during clinical remission were not associated with increased risk for either outcome, observe Doria et al, which suggests that “control of disease activity plays a major role in avoiding damage progression during the acute stages of the disease.”
They also point out that pulse glucocorticoids were independently associated with a reduced risk for SDI increase, which the authors say “reinforces the recommendation of preferring pulses over oral [glucocorticoids] in active stages of disease.”
Doria and associates conclude that “pursuing at least 3 years of clinical remission encompassing both the renal and extrarenal domains could significantly improve prognosis in LN patients by avoiding [impaired kidney function] in most of them.”
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Ann Rheum Dis 2025; doi:10.1016/j.ard.2025.02.004
