|
 |
Article Review/Hyperlink
|
Baqi N, Moazami S, Singh A, Ahmad H, Balachandra S, Tejani A
Lupus nephritis in children: A longitudinal study of prognostic
factors and therapy
J Am Soc Nephrol
(Jun) 7:924-929 1996

Baqi et al performed a retrospective study of 56 children with lupus
nephritis at SUNY-Brooklyn under the age of 18 (34% less than 12 years).
All patients underwent renal biopsy, graded according to WHO
classification. From 1965-1985, Class III and IV lesions were treated with
high dose or pulse steroids; from 1985-1992, intravenous cyclophosphamide
was also given for these lesions.
Fifty percent of all patients developed
ESRD with a mean follow-up of 5.9 years. They were compared to patients
who did not progress, followed up for a mean of 4.7 years. ESRD was
significantly more likely to occur in children with highest initial serum
creatinine level, presence of hypertension at diagnosis, and Class IV
histology. Median renal survival time for Class IV histology was 2.9 years
compared to 7.2 years for those with Class I-III, however, 42% of their
patients presented already with Class IV disease. Using multivariate
stepwise logistic regression analysis, Class IV biopsy presentation was the
most predictive indicator for the development of ESRD, followed by
hypertension. The combination of low C-3 complement level with elevated
serum creatinine was a significant independent predictor of ESRD.
The authors point out that while several studies suggest decreasing
mortality in children with lupus nephritis, they confirm their earlier
observation that their patient population, with more African-American and
younger patients, had higher rates of morbidity and mortality. One
important conclusion of this study supports the observation that
African-American children with lupus nephritis have more severe disease
with a "dismal" prognosis. This study improved on previous reports by
using only new cases and adding renal biopsy data into the clinical model.
Importantly, the addition of intravenous cyclophosphamide conferred no
additional benefit in preventing progression to end stage renal disease in
Class III and IV patients. This may have been related to the predominance
of African-American children. The importance of identifying and
aggressively treating hypertension at the onset of lupus and the
importance of renal biopsy in providing prognosis, particularly in
African-American children with Class IV disease were stressed.
Comment: While
there will be little argument that aggressive management of hypertension is
essential, this study raises important questions about the role of
cyclophosphamide in the treatment of lupus nephritis in children. As noted
by the authors, a randomized controlled, multi-center study is necessary
to determine the most effective treatment, particularly of Class IV disease
in children.
(N. Kevin Krane, M.D., Tulane University)
Related Folders: |
 |
|
|
|
|