Resistivity Index (RI): A Fast and Reliable Indicator of Lupus Nephritis Severity (original) (raw)
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International Research Journal of Medicine and Medical Sciences, 2018
Lupus nephritis (LN) affects up to 60% of patients with systemic lupus erythematosus (SLE), either as the initial manifestation or during the disease course. Moreover, LN has a negative impact on survival of SLE patients. Accordingly, it is mandatory to identify specific and feasible markers able to guide clinicians towards the adequate therapeutic option in LN patients. The aim of this work was to evaluate the predictive value of renal resistance index (RRI), measured by Doppler Sonography in comparison with disease activity score, serologic and biopsy parameters in patients with LN. This study was carried out on forty three SLE patients, they were categorized into two groups: Group I included thirty three patients with LN and Group II included ten patients without LN and Group III included ten healthy subjects of matched age and sex as control group. All were subjected to history taking, clinical examination, assessment of disease activity by SLEDAI, laboratory investigations including FBG, blood urea, serum creatinine, serum albumin, CBC, ESR, CRP, complete urine analysis, 24 hour urine protein, eGFR, serum ANA, anti ds-DNA titre, C3, C4 and renal Doppler with measurement of RRI. Renal biopsy was done for those with LN. The mean value of RRI was statistically significantly higher in group I than that of group II and group III. Out of 33 cases of LN cases, 6 patients had RRI of 0.7 and above giving a percentage of 18.18%. LN patients with RRI higher than 0.7 had statistically significant higher age, mean serum creatinine and blood urea levels and a lower eGFR, higher chronicity index of renal biopsy. RRI is of clinical significance in predicting the chronicity index of renal biopsy which is a major determinant of renal outcome so it is useful as non invasive technique to evaluate chronicity in patients with LN, therefore justifying aggressive immune suppression but further follow-up studies are needed to evaluate its role in predicting response to treatment.
Evaluation of Clinical Outcomes and Renal Vascular Pathology among Patients with Lupus
Clinical Journal of the American Society of Nephrology, 2012
Background and objectives The objective of this study was to determine the clinical significance of renal vascular lesions in lupus nephritis. Design, setting, participants, & measurements Renal vascular lesions defined as thrombotic microangiopathy, lupus vasculopathy, uncomplicated vascular immune deposits, and arterial sclerosis were evaluated in relation to renal and vascular morbidity and overall mortality. Results Biopsies from 161 patients revealed thrombotic microangiopathy (13), lupus vasculopathy (5), and arterial sclerosis (93). No renal vascular lesions were found in 24.8% of patients. At the time of biopsy, arterial sclerosis or lupus vasculopathy patients were older (arterial sclerosis=37.9613.0 and lupus vasculo-pathy=44.468.9 versus controls=33.168.9 years, P,0.05), and the mean arterial pressure was higher in all groups compared with controls. Nephritis subtype, activity indices, and proteinuria were similar between groups, estimated GFR was lower in arterial sclerosis (70.5633.3 versus 84.5626.6 ml/min per 1.73 m 2 , P=0.03), and chronicity index (thrombotic microangiopathy=3.5, lupus vasculopathy=4.5, and arterial sclerosis=2.5) was higher in all renal vascular lesions subgroups versus controls (1.0, P,0.05). In 133 patients with similar follow-up, the association between renal vascular lesions and vascular events was significant (Fisher exact test, P=0.002) and remained so after multivariate analysis (exact conditional scores test, P=0.04), where the difference between arterial sclerosis and uncomplicated vascular immune deposits was most noticeable (odds ratio [95% confidence interval]=8.35[0.98, 83.12], P=0.05). The associations between renal vascular lesions, renal outcomes, and death were not significant, likely because of insufficient power. Conclusions Renal vascular lesions are common in SLE patients with nephritis and may be associated with arterial vascular events.
Renal function assessment in patients with systemic lupus erythematosus
Rheumatology International
Few studies have evaluated the glomerular filtration rate (GFR) in patients with systemic lupus erythematosus (SLE). Even though the National Kidney Foundation (NKF) suggests using the equations to estimate GFR, rheumatologists continue using creatinine clearance (CCl). The main objective of our study was the assessment of different equations to estimate GFR in patients with SLE: Simplified MDRD study equation (sMDRD), CCl, Cockcroft Gault (CG), CG calculated with ideal weight (CGi), Mayo Clinic Quadratic (MCQ), and Chronic Kidney Disease Epidemiology Collaboration Equation (CKD-EPI). CKD-EPI was considered as the reference standard, and it was compared with the other equations to evaluate bias, correlation (r), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), percentage of measurement of GFR between 70–130% of GFR measured through CKD-EPI (P30) and to compute the ROC curves. Adequacy of the 24-h urine collection was evaluated. To classify patients into GFR < 60 ml/min/1.73 m2, the best sensitivity and NVP were obtained with sMDRD: the best PPV and specificity with MCQ. P30 was 99.3% with sMDRD, 77.5% CCl, 91.7% CG, 96.7% CGi, and 77.2% with MCQ. The lowest bias was for sMDRD and the highest for CCl. Only 159 (52.6%) urine collections were considered adequate, and when these patients were re-evaluated, the statistical results improved for CCl. CGi was better in general than CG. CCl should not be considered as an adequate GFR estimation. Ideal weight is better than real weight to calculate GFR through CG in patients with SLE.
Diagnostic Tools for Sensitive Estimation of Renal Function & Early Detection of Lupus Nephritis
Introduction: Systemic Lupus Erythematous (SLE) is a systemic autoimmune disease where the immune system mistakenly attacks the body cells and tissues, resulting in a state of chronic inflammation and tissue damage. SLE is characterized by unpredictable course, with periods of flares alternating with remissions. It can affect any part or body tissues, including heart, joints, skin, lungs, liver, nervous system, blood vessels, but still the kidney affection is one of the most commonly involved visceral organs in SLE. Although only approximately 50% of patients with SLE develop clinically evident renal disease, biopsy studies demonstrate some degree of renal involvement in most patients. Acute or chronic renal impairment may develop with lupus nephritis leading to acute or end stage renal disease. Early recognition and management of these cases can reduce the percentage of development of end stage renal disease among these patients to less than 5% of cases. Nephron is the functioning unit of the kidney, whose function is always effected as an early response to inflammation; this function can be evaluated through the estimation of the glomerular filtration rate (secretory function) as well as its excretory function. So searching for a more sensitive and specific indicator for early detection of disease flare or activity depends on the estimation of the nephron function. Aims of the study: The aims of the study are: to evaluate the most sensitive and accurate diagnostic tool to assess glomerular function and glomerular filtration rate (GFR) in lupus nephritis patients, in relation to clinical manifestations and laboratory indices, as a trial for early detection of lupus nephritis, to investigate whether dynamic renal 99mTechnetium Diethylene Triamine Penta Acetic Acid (99mTc-DTPA) Glomerular Filtration Rate (GFR) is a more sensitive indicator of the degree of renal involvement in lupus nephritis patients than laboratory measurement of serum creatinine level and creatinine clearance (CrCl) through estimated Glomerular Filtration Rate (eGFR) formulae, and to assess renal morphology by static renal 99mTechnetium Di-Mercapto Succinic Acid (99mTc-DMSA), as well as split function of both kidneys in view of renal ultrasonography (U/S). Patients & Methods: Twenty-eight patients with biopsy-proven lupus nephritis selected according to WHO classification for renal staging. The disease activity was recorded using Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) to detect active disease requiring increased treatment for activity. Immunological profiles, including ANA, anti-dsDNA, complement levels (C3, C4) were assessed. Kidney function tests, including serum creatinine, blood urea nitrogen (BUN), creatinine clearance (CrCl), glomerular filtration rate (GFR) using Cockcroft– Gault (CG),the 4-variable abbreviated Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration Formula (CKD-EPI) method, urinalysis with microscopy, 24 hours urinary proteins, as well as total serum proteins and serum albumin were measured. Dynamic 99mTechnetium labeled with Diehtylene Triamine Penta Acetic Acid (99mTc-DTPA) radioisotope renal scan was done for all patients as a part of assessment of renal GFR in all patients in the study group. Another static study was done using 99mTechnetium Di-Mercapto Succinic Acid (99mTc DMSA) to assess the morphological status as well as the split function of both kidneys in view of renal ultrasonography. Results: This study was carried out on 28 patients: 9 males (32.1%) and 19 females (67.9%).Their age ranged from (16-44 years) with a mean age (23.57± 9.57 years). Their height ranged from (147-169cm) with a mean height (155.14±7.97) and weight ranged from (37-84.5 kg) with a mean weight (59.66±16.69). As regards the renal histopathology results, 4 patients (14.28%) had mesangial glomerulonephritis, 15 patients (53.57%) had focal proliferative glomerulonephritis, 6 patients (21.42%) had diffuse proliferative glomerulonephritis, and 3 patients (10.71%) had membranous glomerulonephritis. In patients with impaired renal function the 99mTc-DTPA GFR values and C-G estimated GFR values was decreased significantly with P value <0.05, however, that GFR values obtained by the C-G estimated formula showed a total bias (– 15 ml/min/1.73m2) and relative bias (-21%). Whereas, the estimated GFR obtained by MDRD, and CKD-EPI equations are still markedly underestimating the GFR values, among the same group of patients with total bias (-28 &-26 ml/min/1.73m2) and relative bias (-40% &-37%) respectively. MDRD as well as CKD-EPI equations for estimation of GFR tend to underestimate the GFR value among patients with impaired renal functions. In the patients group with preserved (normal or near normal renal function) the measured GFR by 99mTc-DTPA dynamic renal scintigraphy showed a comparable results to that obtained from the C-G equations total bias (-5 ml/min/1.73m2) and relative bias (-5%), whereas, the GFR values are much higher in equations of MDRD, and CKD-EPI with a total bias (+5 & + 10 ml/min/1.73m2) and a relative bias (+5% & +10%) respectively. MDRD as well as CKD-EPI equations for estimation of GFR tend to overestimate the GFR value among patients with normal or near normal renal functions. There was a significant decrease in the 99mTc-DTPA measured GFR value among patients with stage III and stage IV glomerulonephritis, with a P value < 0.05, Whereas, the GFR values obtained by the C-G formula showed significant decrease only among patients with stage IV glomerulonephritis (P value = 0.016). On the other hand, (MDRD & CKD-EPI formulae) showed insignificant decreased GFR values among patients with stage III & stage IV glomerulonephritis, but they showed significantly increased GFR values among patients with stage II & stage V glomerulonephritis. Conclusion: 99mTc-DTPA as a glomerular agent provides a sensitive, physiological, reliable, accurate and reproducible method for assessment of renal function throughout different disease stages in patients with confirmed diagnosis of lupus nephritis (LN), when compared to other methods evaluating renal function in these patients. It provided a proper evaluation of the nephron function, including renal blood flow condition, the secretory function of the nephrons, as well as nephron's excretory function before and after intravenous diuretics injection. Besides, 99mTc-DMSA as a tubular agent provides a sensitive morphological image of the kidney that can help in estimation of the split function of both kidneys as well as evaluation of the disease course, compared to the traditional morphological imaging modalities (renal ultrasonography). (2016). Diagnostic Tools for Sensitive Estimation of Renal Function & Early Detection of Lupus Nephritis. J. Middle East North Afr. sci, 2(2), 34-47]. (p-ISSN 2412-9763)-(e-ISSN 2412-8937). http://www.jomenas.org. 4 Keywords: Renal isotopes scan in SLE/lupus nephritis, GFR-DTPA, DMSA, early lupus nephritis.
Comparative study of kidney affection in SLE patients with and without antiphospholipid syndrome
The Egyptian Rheumatologist, 2012
Aim of the work: To evaluate the incidence, clinical associations and outcome of APS nephropathy in SLE patients with 2ry APS. Patients and methods: We studied 64 female SLE patients with nephritis; 32 of them had 2ry APS (group 1) and the rest without 2ry APS (group 2). Demographic, clinical and serological data were prospectively evaluated. Systemic lupus erythematosus disease activity index (SLEDAI) and Systemic Lupus International Collaboration Clinics/ACR damage index (SLICC) were assessed. Renal duplex, renal 99m Tc-dimercaptosuccinic) scan (DMSA scan) and renal magnetic resonance angiography (MRA) were all used to detect renal vascular affection. Results: There were statistically significant differences between the two examined groups regarding damage index (p = 0.000), hypertension (p = 0.02), thrombocytopenia (p = 0.000), flLDL (p = 0.008), flC3 (p = 0.01) and TMA (p = 0.04). In group 1: MR angiography detected 7 patients with RAS: 5 patients with renal artery thrombosis that showed a significant association with TMA and proteinuria (p = 0.002, p = 0.004: p < 0.001, p = 0.02, respectively). Patients with RAS had ›DBP, ›s.creatinine and ›TGs (p = 0.004, p = 0.005 and p = 0.0003, respectively). Renal DMSA
Prognostic Role of Measurement of Renal Resistive Index in Systemic Sclerosis
Mediterranean Journal of Rheumatology, 2021
Objective: The spectrum of vascular involvement in systemic sclerosis (SSc) includes digital ulcers, gangrene, Raynaud's phenomenon, renovascular disease, and pulmonary hypertension (PH). Recognition of markers of subclinical vascular disease in SSc is an area of active research, but such studies are limited. This study assesses the role of measurement of the renal resistive index (RRI) as an early marker of renal and systemic vasculopathy. It is a step forward towards examining the possibility of a "unified vascular phenotype' in SSc. Methods: In this single-centre prospective study, RRI was calculated for SSc patients >18 years age. Elevated RRI (>0.7) was correlated with renal function (eGFR and proteinuria) and systemic vasculopathy manifestations like digital ulcers, digital infarcts, and PH. Results: A total of 73 patients with mean (SD) age 41.8(10.9) years were included. Mean (SD) RRI in the right and left renal artery was 0.65(0.08) and 0.66(0.07), respectively. 16 (21.9%) patients had elevated RRI (>0.7). A strong negative correlation was noted between elevated RRI and eGFR (r=-0.96, p=0.03). The percentage of patients with overt proteinuria was higher in the group with elevated RRI (20% versus 7%) (p=0.16). Similarly, digital ulcers (56% vs 33%) and digital pitting (50% vs 35%.) were numerically higher in the group with raised RRI, although statistical significance was not reached because of small numbers (p=0.09 and 0.28, respectively). No correlation of RRI with PH was identified. Conclusion: RRI correlates well with asymptomatic renal dysfunction and holds promise in the assessment of systemic vasculopathy. However, validation in studies with a larger sample size is needed.