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4793 Pdf.Pdf Research Article ISSN: 2351-8200 JMSR 2016, Vol III; N°2: 286-295 RENAL BIOPSY IN LUPUS NEPHROPATHY: GENERAL FEATURES AND PREDITORS OF BAD PROGNOSIS Souad Mikou1, Mohamed Arrayhani1, 2 Tarik Sqalli 1, 2 1 Department of Nephrology, Hassan IId University Hospital, Fes, Morocco. 2 Medical School of Fez, Sidi Mohammed BenAdellah University Hospital, Fes, Morocco. ABSTRACT Introduction: Lupus nephritis is one of the most serious manifestations of systemic lupus erythematosus (SLE). It’s responsible for a high morbid-mortality in young subjects. The aim of our study is to establish lupus nephritis epidemiology in our population, histological features and predictive factors of proliferative and active injuries and predictors of bad prognosis. Results: Were enrolled 71 biopsies finding lupus nephritis among 700 kidney biopsies conducted in our nephrology department during the period of 6 years (10.14%).The average age of patients was 32.69 ± 11.48 years. A female predominance was observed (sex-ratio =0.2). The main indication for biopsy was the concomitant existence of proteinuria, hematuria and renal failure (48%). In univariate analysis, we retained as predictive factors of proliferative and active form: spring season flare with a maximum in June, pre-existing lupus nephritis, lymphopenia and nephrotic syndrome. Risks of progression to chronic renal failure were: female gender in 90% of cases (p <0.001), hypertension at admission (p <0.004), positive anti-Nuclear and anti- DNA Antibodies (p <0.04), renal failure at admission (p <0.0001). Morbidity associated with lupus nephritis is related to female gender (p <0.001), hypertension (p <0.001), renal failure at admission (p <0.001) and need for hemodialysis (p <0.001). Conclusion: Lupus nephritis is severe in our series of 71 biopsies, with a high frequency of proliferative forms. Looking out the stigma of renal involvement during the disease progression and largest reflection of renal biopsy indications could improve the diagnosis and the management of LN. Keywords: Classification, Lupus Nephritis, Renal Biopsy, Spring, Predictive Factors, Prognosis. Corresponding Author: Dr. Souad Mikou E-mail: [email protected] Tel.: 00212655192050 Adress: Service de Néphrologie – CHU Hassan II. Route de Sidi Harazem 30000, Fès. Copyright © 2012- 2016 Dr S Mikou and al. This is an open access article published under Creative Commons Attribution -Non Commercial- No Derives 4.0 International Public License (CC BY-NC-ND). This license allows others to download the articles and share them with others as long as they credit you, but they can’t change them in any way or use them commercially. INTRODUCTION immunological labeling techniques providing a better approach to this disease. The systemic lupus erythematosus is a polymorphic Lupus Kidney damages are mostly glomerular. autoimmune systemic disease. It is characterized by They are defined by the International Classification a succession of outbreaks leaving various effects ISN / RPS 2003. However, tubular, interstitial and depending on the severity of outbreak and injury vascular injuries can be found. Hormonal, type. immunological and genetic factors in lupus Lupus nephritis is one of the most serious pathogenesis has been suggested by several studies, manifestations of systemic lupus but the environmental nature is poorly understood erythematosus (SLE). It is responsible of a high and few studies have been able to establish causal morbi-mortality in young subjects. links, particularly solar exposure, geographical and Renal biopsy is an essential step in lupus nephritis seasonal distribution of outbreaks. management strategy. It contributes to diagnosis, prognosis evaluation and therapeutic choice. It specifies histological injury and their extent; establish their classification and determine active and chronic signs. Greater precision is ensured by 286 Research Article ISSN: 2351-8200 JMSR 2016, Vol III; N°2: 65-68 The aims of our study were: 21 June), Summer (22 June-21 September) and 1 Establish lupus nephritis epidemiology. Fall (September 22 -December 21). 2 Analyze histological features especially their - Medical background: High blood pressure, proliferative and active distribution. Miscarriages, lupus. 3 Look for predictive factors of proliferative and - Discovery Circumstances: active injuries. - Already known lupus: 4 Identify predicting factors of bad prognosis. 1 Lupus nephritis is newly suspected or relapse of a preexisting renal impairment. MATERIAL AND METHODS 2 Onset lupus: revealed by an acute renal injury, nephrotic syndrome, non-nephrotic proteinuria. Study Diagram - At admission we sought: 1 Hypertension: defined by a systolic and / or This study was retrospectively conducted in both diastolic blood pressure ≥140/90 mmHg. nephrology- transplant -hemodialysis department 2 Microscopic hematuria on dipstick then and Pathology Laboratory of Hassan IId University confirmed by cytological examination of urine Hospital for a period of six years, from January defined by the presence of 5 RBCs/mm3 2008 until December 2013. without any urinary tract infection and menstruation. Patients 3 Proteinuria on dipstick and confirmed by dosing on two 24 hours urine samples. It is We selected patient records with lupus nephritis considered positive if the flow is >300 mg / injuries in renal biopsy in order to study clinical, day and nephrotic if the flow is >3 g / day. biological, immunological and outcomes 4 Renal impairment defined by a serum parameters. Subsequently, Clinical, biological and creatinine ˃ 12mg / l. histological showdown has been carried out to - Among extra-renal lupus group, we noted all confirm the renal impairment of lupus. cutaneous, arthritis, hematological, Inclusion criteria: Were enrolled all patients older neurological and cardiac impairment occurred than 16 years and whose clinical and biological data during the follow-up period. meet at least four criteria of "the American College - Laboratory tests for SLE disease activity of Rheumatology (ACR)" for diagnosis of systemic include the following: lupus erythematosus and whose renal biopsy 1 Antibodies to double-stranded DNA (ds DNA), concluded lupus nephritis. antinuclear antibodies and anti-phospholipid Exclusion criteria: Were excluded from our study antibodies. - Children under 16 years 2 Complement (C3, C4) seeking - Renal biopsies performed in other hospitals. hypocomplementemia - Patients followed in other health services. Lupus nephritis is staged according to the Compiling data classification revised by the International Society of Nephrology (ISN) and the Renal Were selected all renal biopsies concluding for Pathology Society (RPS) in 2003[1], as lupus nephritis from the anatomo-pathologic follows: registry of our nephrology departement. The histo- - Class I – Minimal mesangial lupus nephritis immunologic and pathologic data were collected - Class II – Mesangial proliferative lupus from renal biopsies records. nephritis All biopsies were examined within the Anatomic - Class III – Focal lupus nephritis (active and pathology laboratory by light microscopy and direct chronic; proliferative and sclerosing) immune-fluorescence technique. - Class IV – Diffuse lupus nephritis (active and Demographic, clinical and laboratory Data were chronic; proliferative and sclerosing; segmental collected from medical records and the HOSIX- and global) NET information system installed since 2011. - Class V – Membranous lupus nephritis - Class VI – Advanced sclerosis lupus nephritis Variables We studied the following parameters: - Date of renal biopsy: month, year, seasons. The four seasons were defined as follows: Winter (22 December- March 21), Spring (22 March- 287 Research Article ISSN: 2351-8200 JMSR 2016, Vol III; N°2: 65-68 Lupus nephritis activity is classified according Statistical analysis to the HILL score: Glomerular Activity Index Statistical analysis is performed in laboratory of Glomerular proliferation 0-3 epidemiology and clinical research of the Medicine Polymorphonuclear leucocytes 0-3 and Pharmacy school of Fez. We used the SPSS Fibrinoid necrosis (0-3)x2 version 17.0 software. This study is initially Cellular crescents (0-3)x2 descriptive and analytic. Quantitative variables are Hyaline deposits (0-3) glomerular monocytes (0-3) expressed as mean ± standard deviation of the Maximum 24 mean, and were compared using the Student test. Tubular-interstitial Activity Index Categorical variables were expressed as numbers Tubular cell pyknosis 0-3 and percentage and compared by Chi tests 2. A p Tubular nuclear activation 0-3 value <0.05 was considered significant. Univariate Tubular cell necrosis 0-3 analysis is then used to determine the predictive Tubular cell flattening 0-3 criteria of active lesions and / or proliferative renal Macrophages in tubular lumens 0-3 biopsy and the risk factors for adverse Epithelia cells in tubular lumens 0-3 developments. Interstitial inflammation 0-3 Maximum 21 Chronic Lesions Index Results Glomerulonecrosis 0-3 Glomerular scars 0-3 Since 2008, 71 patients were followed in our Fibrous crescents 0-3 nephrology department for confirmed lupus Tubular atrophy 0-3 nephritis on renal biopsy, it represent 10.14% of all Interstitial fibrosis 0-3 renal biopsies performed in our department during Maximum 15 this period (n = 700). The average age of patients Immunofluorescence Index was 32.69 ± 11.48 years, with extremes ranging Glomerular capillary IF (0-4)x6 from 16 years to 70 years. A female predominance Glomerular mesangial IF (0-4)x6
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