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Predictors of Relapse and End Stage Kidney Disease in Proliferative Lupus Nephritis: Focus on Children, Adolescents, and Young Adults

Keisha L. Gibson^*, Debbie S. Gipson^*, Susan A. Massengill, Mary Anne Dooley, William A. Primack^*, Maria A. Ferris^*, and Susan L. Hogan^*

^* Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Pediatric Nephrology, Levine’s Children’s Hospital at Charlotte Medical Center, Charlotte, North Carolina; and Division of Rheumatology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina

Correspondence: Dr. Keisha Gibson, 6005 Burnett-Womack Building, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7155. Phone: 919-966-2561; Fax: 919-966-4251; E-mail: kgibson{at}med.unc.edu

Background and objectives: The prevalence and significance of remission and relapse in children, adolescents, and young adults with lupus nephritis in the United States are poorly understood. Patterns and predictors of disease progression in a southeastern U.S. pediatric cohort with severe lupus nephritis are presented.

Design, settings, participants, & measurements: Individuals age 21 or less with kidney biopsy-proven lupus nephritis followed in the Glomerular Disease Collaborative Network were included. Cox regression models were used to evaluate predictors of relapse and end stage kidney disease (ESKD).

Results: Seventy-three subjects with a mean age of 15.6 ± 3.4 yr were included. Five-year kidney survival was 77%. Complete and partial remission rates within 1 yr of induction therapy were 25 and 64%, respectively. Relapse and ESKD rates were similar between complete and partial responders. Relapse occurred in 35% of responders (complete or partial) in 45 ± 32 mo. Disease relapse was a predictor of ESKD (HR = 10.12, P <ü0.0001). Treatment resistance was documented in African Americans more often than non-African Americans (eight versus 0; P = 0.03). ESKD HR associated with treatment resistance was 6.25, P <ü0.002.

Conclusions: Remission whether complete or partial is associated with improved kidney survival in children with lupus nephritis. Nephritis relapse is a strong predictor of progression to ESKD. Treatment resistance portends a high risk of ESKD and disproportionately affects African American children with lupus nephritis.