Division of Rheumatology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.
Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York.
Clin J Am Soc Nephrol. 2022 Aug;17(8):1150-1158. doi: 10.2215/CJN.01280122. Epub 2022 Jul 26.
Lupus nephritis remains a common cause of morbidity and mortality in systemic lupus erythematosus (SLE). Current guidelines recommend performing a kidney biopsy at a urine protein-creatinine ratio of ≥0.5 g/g. However, cross-sectional studies reported a high prevalence of active histologic lupus nephritis lesions, and even chronic irreversible scarring, in patients with low-grade proteinuria. This study was initiated to assess disease progression in patients with SLE and low-grade proteinuria to identify risk factors for progression to overt proteinuria suggestive of clinical lupus nephritis.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients with SLE who had an incident urinary protein-creatinine ratio of ≥0.2 and <0.5 g/g without known lupus nephritis were identified from the Einstein Rheumatic Disease Registry. Patients who developed a random urinary protein-creatinine ratio of ≥0.5 g/g with or without biopsy during the follow-up period were defined as "progressors." Patients who progressed to a urinary protein-creatinine ratio of ≥0.5 g/g within 2 years of developing a urinary protein-creatinine ratio of ≥0.2 and <0.5 g/g were defined as "fast progressors," a subgroup expected to benefit most from early biopsies and therapeutic interventions.
Among 151 eligible patients with SLE and low-grade proteinuria at study entry, 76 (50%) progressed to a urinary protein-creatinine ratio of ≥0.5 g/g, of which 44 underwent a clinically indicated biopsy. The median (interquartile range) time from a urinary protein-creatinine ratio of ≥0.2 and <0.5 g/g to progression was 1.2 (0.3-3.0) years. Of the 20 biopsies performed in the first 2 years, 16 specimens showed active, treatable lupus nephritis. Low complement and shorter SLE duration at low-grade proteinuria onset were associated with progression to overt proteinuria across different analyses. Other associated factors included hypertension, diabetes mellitus, younger age, and the presence of hematuria.
In this longitudinal cohort of patients with SLE and low-grade proteinuria at study entry, over half progressed to a urinary protein-creatinine ratio of ≥0.5 g/g in a short time period.
狼疮肾炎仍然是红斑狼疮（SLE）患者发病和死亡的常见原因。目前的指南建议在尿蛋白/肌酐比值≥0.5 g/g 时进行肾活检。然而，横断面研究报告称，在低蛋白尿症患者中，活动性组织学狼疮肾炎病变，甚至慢性不可逆性瘢痕，仍有很高的发生率。本研究旨在评估 SLE 合并低蛋白尿患者的疾病进展情况，以确定进展为明显蛋白尿提示狼疮肾炎的危险因素。
设计、地点、参与者和测量方法：从爱因斯坦风湿病登记处中，发现了一批具有 SLE 且首次出现尿蛋白/肌酐比值≥0.2 且<0.5 g/g 而无已知狼疮肾炎的患者。在随访期间发生随机尿蛋白/肌酐比值≥0.5 g/g 且伴有或不伴有活检的患者被定义为“进展者”。在首次出现尿蛋白/肌酐比值≥0.2 且<0.5 g/g 后 2 年内进展为尿蛋白/肌酐比值≥0.5 g/g 的患者被定义为“快速进展者”，该亚组预计从早期活检和治疗干预中获益最大。
在 151 名 SLE 合并低蛋白尿症患者中，有 76 名（50%）进展为尿蛋白/肌酐比值≥0.5 g/g，其中 44 名患者进行了临床指征性活检。从尿蛋白/肌酐比值≥0.2 且<0.5 g/g 到进展的中位（四分位间距）时间为 1.2（0.3-3.0）年。在最初 2 年内进行的 20 次活检中，16 例标本显示为活动性、可治疗的狼疮肾炎。低补体和低蛋白尿症发病时的 SLE 病程较短与不同分析中进展为显性蛋白尿有关。其他相关因素包括高血压、糖尿病、年龄较小和血尿。
在本研究开始时具有 SLE 和低蛋白尿症的纵向队列中，超过一半的患者在短时间内进展为尿蛋白/肌酐比值≥0.5 g/g。
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