Lupus Nephritis in an Inner City African American Population. An overview

Franco C, Yoo W, and Zeng, X.

Departments of Internal Medicine and Pathology.
Wayne State University
Detroit Michigan

Authors:

Carlos Franco MD. Department of Internal Medicine Department. Wayne State University, Detroit Medical Center. Detroit, Michigan. 48201 United States.

Wonsuk Yoo. Assitant Professor. Medicine Department. Wayne State University, Detroit Medical Center. Detroit, Michigan. 48201 United States.

Zeng Xu MD. Assistant Professor. Department of Pathology. Wayne State University, Detroit Medical Center. Detroit, Michigan. 48201 United States.

Keywords: lupus, nephritis, creatinine, dialysis, proteinuria, complement.

Background

Renal involvement is a major clinical event in patients with systemic lupus erythematous. Several studies suggest African American ethnicity is associated with poorer outcomes. Socioeconomic reasons were attributed to this trend in several cases as well as genetic and immunologic factors.
Some papers estimate there is an association between higher creatinine, low C3, thrombocytopenia, hypertension and ESRD in this population.

Methods

We performed a retrospective study of African American patients diagnosed with lupus nephritis by biopsy in an inner city African American population between 1996 and 2006. The objective of the study was to expose the clinical presentation of this condition in this specific population. Features studied included age, creatinine, complement levels, albumin, use of Angiotensin Enzyme Converting Inhibitors or Angiotensine Receptor Blockers, sedimentation rate, hypertension, family history of lupus, necessity of dialysis and death. A multivariable logistic regression model was applied for analysis and the odds ratios and their 95% confidence intervals for study features were provided.

Results

98 patients were originally involved in the study, of those, 67 were able to be analyzed.
88.06 % (59) of patients were women and 11.94 % (8) were men.
Class II patients comprised 8.96 % of the cases, class III 17.91 %, class IV 52.24 %, class V 17.91 %, class VI 2.99 %. No patient with class I was available for study.
Mean creatinine for class II lupus nephritis was 2.5, for class III was 4.1, for class IV was 5.8, for class V 0.9, for class VI 1.5 with no statistical significant difference among the groups.
The mean age for patients in class II was 29.6 years, 32.2 years for class III, 36.9 years for class IV, 39.6 years for class V and 35 years for class VI. There is statistically significant difference between patients in Class II and class V (odds ratio estimates, 95% CI 0.509 to 0.988). Otherwise there was no age difference among the other classes of lupus nephritis.
The albumin in patients with class IV is lower than the other groups, but the result is not statistically significant. The mean albumin level for patients in class II was 2.3, for patients with class III was 2.2, for patients in class IV was 1.8, for class V it was 2 and for class VI was 2.4.
ACEIs/ARBs were used in 50% of patients with class II, 58.3 % of class III, 57.1 % of class IV, 83.3% of class V and 50% of class VI. There is a trend to prescribe these medications in patients with Class V lupus nephritis.
Decreased complement levels were found in 83.3% of patients with class II, 100 % of patients with class III, 91.4 % of patients with class IV, 100 % of patients with class V, and 100 % of patients with class VI.

Hypertension was seen in 83.3% of patient in class II, 50 % of patients in class III, 74.2% of patients in class IV, 91.6 % of patients in class V and 100 % of patients in class VI. No statistical significant difference was found.
ESR values were more elevated in class III and IV lupus nephritis. Mean ESR for class II was 34.6 mm/hr, for class III 60 mm/hr, 59.5 mm/hr for class IV, 49.8 mm/hr for class V, 8 mm/hr for class VI.
Anticardiolipin antibodies were found in 40 % of patients with class II and III lupus nephritis, 61 % of patients with class IV, 57.1 % of patients with class V and 0% of patients with class VI. There is a tendency for positive values in patients with class IV and V lupus nephritis.
Family history of lupus was found in 33.3 % of class II patients, 41.6% of class III, 14.2 % of class IV, 33.3% of class V, 50 % of class VI patients.
Dialysis was used in 16.6% of patients with class II, 33.3% of patients with class III, 48.5% of patients with class IV, 0% of patients with class V and 50 % of patients with class VI.
Regarding causes of death, sepsis, GI bleeding and pulmonary embolism were found.
One patient with class III died from sepsis, one patient with class IV also died from sepsis, Pulmonary embolism was the cause of death in one patient with class IV and also in one patient with class V. GI bleed was the cause of death in 1 patient with class IV.

Conclusions

98 patients were originally involved in the study, of those, 67 were able to be analyzed.

Systemic lupus erythematosus affects more commonly women. In this study, 88 % of the patients were women.
In our African Americans patients with lupus nephritis no statistically significant differences were found for hypertension, creatinine, use of ACEIs/ARBs, ESR and albumin levels among the different classes. Nonetheless there are some interesting trends noted.
Most patients diagnosed with lupus nephritis were in class IV (52.4%, 35 patients).
Patients with class IV lupus nephritis have higher creatinine values and lower albumin kevels.
ESR values are more elevated in class III and IV lupus nephritis.
Complement levels were found to be uniformly decreased in all patients, especially in patients with class III, IV, V, VI.
Class IV and V lupus nephritis test positive for anticardiolipin antibodies more often.
We found statistically significant age difference between class II and class V lupus nephritis, class II patients being younger. This difference is not noted among other groups.
ACEIs/ARBs, are prescribed in at least 50% of patients with lupus nephritis. Of note, this number goes up to 83% in patients with class V. A theoretical explanation of this is that membranous lesions are associated with more proteinuria.
Patients with class IV and VI more often required dialysis than other classes.
Regarding causes of death, sepsis, GI bleeding and pulmonary embolism were found. Most deaths occurred in Class IV lupus nephritis.
We observe that in our African American population Class IV lupus nephritis is more common and in general is associated to worse outcomes.

Frst Published March 2009

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