Predictors of one year outcome in lupus nephritis: the importance of renal biopsy.

The short-term prognosis of lupus nephritis was evaluated by assessing serum creatinine 12 months after renal biopsy in 87 patients with lupus nephritis. On univariate analysis, significant clinical and laboratory predictors of this outcome included clinical signs of renal injury (serum creatinine, 24-hour urinary protein, prolonged renal disease, nephrotic syndrome, serum albumin), as well as thrombocytopenia, older age, and coexisting illness or hypertension at the time of biopsy. On renal biopsy, diffuse proliferative nephritis, higher activity, chronicity, or tubulointerstitial scores, or subendothelial or subepithelial electron dense deposits predicted a higher serum creatinine 12 months after biopsy. A clinical predictive model was developed which included as independent predictors serum creatinine, age, platelet count and 24-hour urinary protein. Any one of three biopsy variables added information to the clinical prediction model: a marked quantity of subendothelial deposits (p = 0.02), a higher activity index score (p = 0.02), or the presence of diffuse proliferative lupus nephritis (p = 0.05). However, the relative predictive accuracy of the clinical model did not improve with the addition of any of the biopsy variables. The value of renal biopsy in lupus nephritis is discussed based on the ability of biopsy information to confirm the prognosis, to add new predictive information for a group of subjects, and to improve predictive accuracy for individual patients.     

Study of lupus nephritis: its classification and the significance of subendothelial deposits

This study describes the clinical and pathological characteristics of 74 patients with lupus nephritis classified according to renal biopsy findings using light, electron and immunofluorescent microscopy, and further, assesses the significance of subendothelial deposits in evaluating disease activity. In membranous lupus nephritis (14 cases), many cases showed normal renal function even with the nephrotic syndrome, although five cases had little or no urinary abnormalities. Glomerular cellular proliferation was very mild and subepithelial deposits with a few mesangial deposits were the main pathological alterations. Mesangial proliferative lupus nephritis (17 cases) clinically had very mild renal disease. Renal biopsies in this group revealed mesangial deposits with slight cellular proliferation. Although clinical features of mild diffuse proliferative lupus nephritis (16 cases) were similar to those of mesangial lupus nephritis, glomerular loop deposits were seen in addition to mesangial deposits. In moderate diffuse proliferative lupus nephritis (17 cases), renal function was slightly decreased, moderate proteinuria with haematuria were found, and C3 level was low. Renal biopsies showed active proliferative changes, and subendothelial deposits were frequently seen. In severe diffuse proliferative lupus nephritis (10 cases), the duration from onset of SLE to renal biopsy was short. Impairment of renal function, and nephrotic syndrome with haematuria and hypocomplementemia were frequent. Only three patients survived in this group. Renal biopsies demonstrated highly active proliferative and necrotizing changes, and electron microscopy showed massive subendothelial and mesangial deposits accompanied by subepithelial and intramembranous deposits. The amount of subendothelial deposits correlated with those of mesangial deposits and subepithelial deposits in the cases with diffuse proliferative lupus nephritis. Urinary protein loss and histologic activity showed statistically significant correlations with the amount of subendothelial deposits, but C3 levels and creatinine clearance revealed negative correlations with those deposits.     

The clinical and renal biopsy predictors of long-term outcome in lupus nephritis: a study of 87 patients and review of the literature

The prognostic markers in 87 consecutive patients with lupus nephritis who underwent renal biopsy are reported for five clinically relevant long-term outcomes--renal insufficiency, renal failure, death due to renal systemic lupus erythematosus, death due to non-renal SLE and death due to SLE, both renal and non-renal. We have demonstrated that a number of previously neglected or rarely studied predictors were important prognostic markers. These included the duration of renal disease before biopsy, overall severity of SLE, as well as the presence of vasculitis, hypertension or a comorbid ailment. Furthermore, the study confirms the predictive importance of serum creatinine, 24-h urinary excretion of protein, C3, and of the activity and chronicity indices on biopsy. However, overall a simple measure of tubulointerstitial disease was the best predictor obtained from biopsy. Prognostic models based on clinical data alone were developed for each of the five outcomes. The models amplify our clinical understanding of lupus nephritis. Markers of renal severity were most important in predicting renal outcomes such as renal insufficiency and renal failure. Prognostic factors less directly related to renal disease (comorbidity and vasculitis) were important predictors of fatality. A marker of immunologic disease activity (C3) was a valuable predictor for many of the outcomes. Thus markers of disease severity reflecting organ damage due to SLE and other comorbid conditions could be combined with markers of immunologic activity to predict a variety of outcomes of relevance to a clinician. When biopsy data obtained by light or electron microscopy were evaluated for their ability to add new predictive information to the clinical models, only a limited value for biopsy was noted. It is likely that this reflected the close correlational relationships between clinical and biopsy variables, the strong clinical models generated, and the inclusion in the clinical models of the previously neglected clinical variables, duration of renal disease before biopsy and the presence of vasculitis or comorbid disease.     

Lupus Nephritis: Clinical and Pathological Correlation

Overall patient survival of 83 and 65 per cent at five and 10years respectively from onset of nephritis was similar to otherrecently published series. In contrast to the latter, the severeproliferative group had a significantly worse outcome than theother proliferative groups (p<0.01) and only patients inthis group progressed to end-stage renal failure. Haematuria was more common (p<0.05) in the severe group andthere was a striking correlation between histologic activityassessed semiquantitatively (Table 1) and urinary red cell count(p<0.001). There was no correlation between serum creatinine,proteinuria or chronic lesions with urinary red cell count.In contrast to a previous study there was no correlation betweenthe presence of hyaline thrombi on initial biopsy and subsequentdevelopment of glomerular sclerosis. Although the value of renal biopsy has been questioned, we suggestthat it remains a most important investigation in the managementof lupus nephritis. Determination of urinary red cell count provides a most usefulmonitor of disease activity and response to treatment.     

Study of Lupus Nephritis in Males

Clinical and pathological findings were studied in 23 male patientswith lupus nephritis who were followed up for a period of 41±36months after renal biopsy. Age at renal biopsy was 31±14years and 19 patients (83 per cent) were between 15 and 50 yearsold. C3 and C4 levels were below normal in 23 (100 per cent)and 16 (70 per cent) respectively, CH₅₀ was <25 u/ml in 67per cent, and antinuclear and anti-DNA antibodies were foundin 87 per cent and 82 per cent respectively. Serum albumin levelincreased from 2.9±0.8 g/dl to 3.7±0.8 g/dl duringthe follow up period (p<0.01), while urinary protein decreasedfrom 2.0±2.3 g/day to 1.4±2.5 g/day. There wasa significant improvement in the degree of haematurai (p <0.01),but serum creatinine levels showed no change (mean 1.5 mg/ml).Active proliferative lupus nephritis of, moderate or severedegree was observed in 65 per cent of patients at the initialbiospsy. A trend to regression in this activity was seen inmost serial biopsies, but the chronicity index showed a slightincrease. These data demonstrate that systemic lupus erythematosusin males, in comparison to our previous report of the diseasein female patients, is accompanied by more active nephritis,but that is follows a benign course with therapy.     

Clinical Status of Patients After 10 Years of Lupus Nephritis

Little information is available about the clinical status andoutcome of patients with a long history of lupus nephritis.We have reviewed the dossiers of 25 patients (23 women and twomen) who have been monitored by our Unit for more than 10 yearsafter the diagnosis of lupus nephritis. At presentation themean age was 28.5±10.33 (SD) years, the mean plasma creatininewas 136.1±144.7 (SD) nmol/1, the mean proteinuria was3.02±2.7 (SD) g/day. At initial renal biopsy 18 patientsshowed diffuse proliferative glomerulonephritis, six patientsshowed membranous glomerulonephritis and one showed focal proliferativeglomerulonephritis. All patients but one were treated with corticosteroidsand 18 were also given immunosuppressive agents. At the lastobservation (16±4.6(SD) years after presentation), 19patients have normal plasma creatinine (11 of them show proteinurialess than 0.2 g/day) and six patients show increased plasmacreatinine (mean 203.3±61.9 (SD) mmol/l). Eleven patientshave been without any treatment for 88±64 (SD) months.The incidence of lupus flare-ups fell significantly after thetenth year (0.31/patient/year between 0 and 10 versus 0.11 betweenyears 11 and 27; p=0.01). No case of pericarditis or cerebritisoccurred after the tenth year. Only one case of cerebral thrombosisoccurred before the tenth year, but ten severe atheroscleroticcardiovascular and cerebrovascular complications were seen afterthe tenth year (two cardiac infarcts, three angina pectoris,four cerebral thrombosis, one cerebral haemorrhage). Two casesof cancer (thyroid and lung) occurred after the tenth year.The professional rehabilitation was good in most patients. These data show that patients with diffuse lupus nephritis mayhave excellent kidney survival and a good degree of rehabilitationeven in the long term. Moreover the activity of the diseaseseems to quench over the time. However these patients have anincreased risk of cardiovascular, cerebrovascular and neoplasticcomplications.     

超声引导下经皮肾穿刺活检的临床意义

目的探讨灰阶B超引导下对肾脏疾病患者进行经皮肾组织穿刺活检的临床价值。方法采用GE200Pro黑白超声仪、穿刺探头、自动活检枪及组织切割针对肾下极进行穿刺,穿刺组织分别送光镜、电镜及免疫学检查。结果36例患者利用组织切割针进行肾穿刺,取出组织44条,电镜共检出452个肾小球送病理学检查,检出弥漫系膜增生性肾小球肾炎17例,IgA肾病8例,糖尿病肾病伴乙型肝炎相关肾炎1例,狼疮性肾炎2例,糖尿病肾病3例,局灶系膜增生性肾小球肾炎2例,肾小球轻微病变3例。结论经皮肾穿刺活检,对了解肾脏疾病的病理类型,指导临床治疗及判断疾病预后具有十分重要的意义。该方法操作简便、成功率高、并发症少,值得推广。     

Antiendothelial cell antibodies in lupus: correlations with renal injury and circulating markers of endothelial damage

Systemic lupus erythematosus is characterized by the productionof a broad spectrum of autoantibodies. Autoantibodies directedagainst endothelial cells (AECA) have been particularly welldocumented. We investigated associations between such antibodies,double-stranded DNA (dsDNAb), phospholipid (cardiolipin, ACA),and indices of activity and chronicity scored on renal biopsyspecimens from 22 patients with acute lupus. AECA were presentin 73% of these patients, and both the percentage of patientswith AECA and the mean antibody titre fell significantly aspatients entered remission. When patients already on immunosuppressivetherapy were excluded from analysis (n = 7), only levels ofAECA and DNAb (p = 0.02) correlated with histological evidenceof active lesions and the presence of glomerular epithelialcell crescents; no correlation was found with chronic changesin the renal biopsies. Serum von Willebrand factor (vWf) andserum total protein S levels, two parameters reflecting endothelialcell function, were also measured during acute disease and remission.vWf concentrations were elevated during acute disease (m = 1.9lU/ml, p = 0.02), but the values did not correlate with AECAtitres. In contrast, total protein S levels were reduced (0.81lU/ml vs. 0.97 lU/ml, p = 0.01) during active disease, but remainedwithin the normal range (0.56–1.16 lU/ml). Furthermore,protein S levels were inversely related to levels of AECA (r= –0.4, p = 0.01). AECA were therefore present in mostpatients with acute lupus nephritis and were associated withhistological evidence of active renal injury and serologicalevidence of endothelial cell dysfunction. These data provideindirect support for a pathogenic role for AECA in lupus nephritis.     

Antiendothelial cell antibodies in lupus: correlations with renal injury and circulating markers of endothelial damage

Systemic lupus erythematosus is characterized by the productionof a broad spectrum of autoantibodies. Autoantibodies directedagainst endothelial cells (AECA) have been particularly welldocumented. We investigated associations between such antibodies,double-stranded DNA (dsDNAb), phospholipid (cardiolipin, ACA),and indices of activity and chronicity scored on renal biopsyspecimens from 22 patients with acute lupus. AECA were presentin 73% of these patients, and both the percentage of patientswith AECA and the mean antibody titre fell significantly aspatients entered remission. When patients already on immunosuppressivetherapy were excluded from analysis (n = 7), only levels ofAECA and DNAb (p = 0.02) correlated with histological evidenceof active lesions and the presence of glomerular epithelialcell crescents; no correlation was found with chronic changesin the renal biopsies. Serum von Willebrand factor (vWf) andserum total protein S levels, two parameters reflecting endothelialcell function, were also measured during acute disease and remission.vWf concentrations were elevated during acute disease (m = 1.9lU/ml, p = 0.02), but the values did not correlate with AECAtitres. In contrast, total protein S levels were reduced (0.81lU/ml vs. 0.97 lU/ml, p = 0.01) during active disease, but remainedwithin the normal range (0.56–1.16 lU/ml). Furthermore,protein S levels were inversely related to levels of AECA (r= –0.4, p = 0.01). AECA were therefore present in mostpatients with acute lupus nephritis and were associated withhistological evidence of active renal injury and serologicalevidence of endothelial cell dysfunction. These data provideindirect support for a pathogenic role for AECA in lupus nephritis.     

The Clinical and Renal Biopsy Predictors of Long-term Outcome in Lupus Nephritis: A Study of 87 Patients and Review of the Literature

The prognostic markers in 87 consecutive patients with lupusnephritis who underwent renal biopsy are reported for five clinicallyrelevant long-term outcomes - renal Insufficiency, renal failure,death due to renal systemic lupus erythematosus, death due tonon-renal SLE and death due to SLE, both renal and non-renalWe have demonstrated that a number of previously neglected orrarely studied predictors were Important prognostic markers.These Included the duration of renal disease before biopsy,overall severity of SEE, as well as the presence of vasculitis,hypertension or a comorbid ailment Furthermore, the study confirmsthe predictive Importance of serum creatinine, 24-h urinaryexcretion of protein., C3, and of the activity and chronicityindices on biopsy. However, overall a simple measure of tubulointerstitialdisease was the best predictor obtained from biopsy. Prognostic models based on clinical data alone were developedfor each of the five outcomes. The models amplify our clinicalunderstanding of lupus nephritis. Markers of renal severitywere most Important In predicting renal outcomes such as renalInsufficiency and renal failure. Prognostic factors less directlyrelated to renal disease (comorbidity and vasculitis) were importantpredictors of fatality. A marker of immunologic disease activity(C3) was a valuable predictor for many of the outcomes. Thusmarkers of disease severity reflecting organ damage due to SLEand other comorbid conditions could be combined with markersof Immunologic activity to predict a variety of outcomes ofrelevance to a clinician. When biopsy data obtained by light or electron microscopy wereevaluated for their ability to add new predictive informationto the clinical models, only a limited value for biopsy wasnoted. It is likely that this reflected the close correlationalrelationships between clinical and biopsy variables, the strongclinical models generated, and the inclusion in the clinicalmodels of the previously neglected clinical variables, durationof renal disease before biopsy and the presence of vasculitisor comorbid disease.     

狼疮肾炎尿毒症预后的影响因素探讨 --附102例报告

目的:探讨影响狼疮肾炎尿毒症患者预后的因素,为控制尿毒症的发生和发展提供依据。方法:通过随访方式追踪狼疮肾炎尿毒症患者的临床、实验室及治疗的资料,采用COX回归模型,进行单因素及多因素分析。结果:102例狼疮肾炎尿毒症患者中,有37例死亡(占36.3%),多因素分析显示血尿酸、Ccr、肾萎缩与否和血尿素氮对预后有显著影响,且为独立因素,而临床分型、性别、狼疮活动指数和血肌酐并不是影响预后的独立因素。结论:高水平的尿酸和血尿素氮为独立危险因素,而肾无萎缩和Ccr的维持有利于肾功能的改善。     

肾病患者血清B因子检测的临床意义

目的探讨肾病患者血清B因子(BF)检测的临床意义。方法对146例不同肾病患者进行了BF水平的检测,对其中28例狼疮肾患者同时作抗核抗体(ANA)、抗ds-DNA及肾功能指标的对比分析。结果各肾病组BF水平由低到高依次为肾病综合征和慢性肾衰<<急性肾炎<慢性肾炎和狼疮肾<<健康对照组("<<"表示P<0.01;"<"表示P<0.05;无比较者表示P>0.05)。狼疮肾患者中ANA阳性组与阴性组,抗ds-DNA阳性组与阴性组之间BF水平均无明显差别(P>0.05),但肾功能受损严重者与肾功受损不明显者有显著差别(P<0.01)。结论动态地监测血清BF对急、慢性肾炎及狼疮肾疗效的观察和预后的判断有一定的指导意义。     

Late onset systemic lupus erythematosus and lupus-like disease in patients with apparent idiopathic glomerulonephritis

We report 17 patients who presented with either apparent idiopathic glomerulonephritis (16 patients) or post-streptococcal glomerulonephritis (one patient). Doubts arose about the nature of these patients' disease, either because their initial renal histology was suggestive of systemic lupus erythematosus (SLE) in the absence of its clinical or serological features, or because they developed with time the clinical or serological features of SLE. Three patients had a positive antinuclear antibody (ANA) test at the onset of their illness, but normal levels of serum binding of double-stranded DNA (dsDNAB). In another four patients the dsDNAB was slightly raised but with a negative ANA. On renal biopsy the predominant appearance was membranous glomerulonephritis (GN) in 10, subendothelial mesangiocapillary GN (MCGN) in three, and focal segmental glomerulosclerosis in two; one patient each had a focal proliferative GN and a diffuse endocapillary GN. On 1 micron renal sections stained with toluidine blue, 10 patients had immune deposits at multiple sites within the glomeruli. Over a period of one to 14 years, six patients developed extrarenal features suggestive of SLE, nine a positive ANA, and 12 increased serum levels of dsDNAB. Five patients became hypocomplementaemic. Cryoglobulins were isolated from the sera of 10 out of 12 patients; seven contained DNA. Separated cryoglobulin IgG from eight patients showed antibody activity directed against both ss and dsDNA in four, and against dsDNA only in three. On the basis of the clinical, histological and serological observation during follow-up five patients were reclassified as definite SLE, four as probable SLE and two as possible SLE. Rarely, SLE may present with nephritis as the sole disease manifestation, antedating other clinical features and even immunological markers of the disease by years. In addition, some patients with a glomerulonephritis may show clinical and immunological, or histological features of SLE, but do not fit accepted definitions of the disease.     

Image-directed color Doppler ultrasonography of kidney in systemic lupus nephritis

We evaluated intrarenal arterial waveforms with image-directed color Doppler ultrasonography in 21 patients with systemic lupus erythematosus (SLE). The systolic–diastolic ratio, resistive index, and pulsatility index were compared with serum creatinine levels, creatinine clearance, and quantitation of urinary protein excretion, as well as with histopathologic scores of specimens obtained from 9 patients who underwent renal biopsy. Doppler parameters were in the normal ranges in all patients, without showing significant correlation with any of the histopathologic scores or laboratory parameters except creatinine levels. We conclude that image-directed color Doppler ultrasonography is of no practical value in the evaluation of lupus nephritis during the early stages of the disease. © 1995 John Wiley & Sons, Inc.     

Clinical indicators which necessitate renal biopsy in type 2 diabetes mellitus patients with renal disease

Background: The diagnosis of diabetic nephropathy (DN) is always based on clinical grounds. However, the necessity for renal biopsy of type 2 diabetes mellitus (DM) patients with renal disease to establish the diagnosis remains unclear. Methods: We retrospectively studied 50 type 2 diabetic patients performed with renal biopsy between December 2002 and December 2006. Based on renal pathology, patients were divided into group I: DN alone, group II: non‐diabetic renal disease (NDRD) superimposed on DN and group III: isolated NDRD. Factors like DM > 10 years, retinopathy, previous minimal proteinuria without sudden heavy proteinuria, no glomerular haematuria and non‐small‐sized kidney were collected to evaluate their sensitivity, specificity, positive predictive value and negative predictive value for prediction of DN or NDRD in type 2 diabetic patients. Results: Group I consisted of 24 patients, group II 15 patients and group III 11 patients. Acute interstitial nephritis was the most prevalent second renal disease in our study. Sensitivity and specificity for group I was poor in five features except high sensitivity in no sudden heavy proteinuria (83.3%) and non‐small‐sized kidney (95.8%). Comparable retinopathy, sudden heavy proteinuria and haematuria (p > 0.05) was noted between the three groups. Significant biopsy indicators included higher serum albumin, lower urinary daily protein excretion and lower 24‐h creatinine clearance (C_Cr) rate (p < 0.05). Conclusion: Our study demonstrated that DM > 10 years and retinopathy did not exclude NDRD in type 2 DM patients, and need for renal biopsy. Higher serum albumin, lower urinary daily protein and 24‐h C_Cr were indicative for biopsy to exclude NDRD.     

Elevated soluble CD163 predicts renal function deterioration in lupus nephritis: a cohort study in Eastern China

ObjectiveThis study investigated the association between soluble scavenger receptor differentiation antigen 163 (sCD163) and the severity and prognosis of renal injury in lupus nephritis (LN).MethodsSerum sCD163 levels in 121 Eastern Chinese patients with LN who underwent renal biopsy were determined by enzyme-linked immunosorbent assays. Clinical data were collected, and the glomerular filtration rate and disease activity score of lupus were calculated. Pathological classification was performed, and renal pathological scores were assessed by the activity index (AI) and chronic index (CI). Kaplan–Meier survival curves were drawn to evaluate prognosis.ResultsThe pathological classification, AI and CI scores in the high sCD163 group were increased. The sCD163 levels were positively correlated with serum creatinine, blood urea nitrogen, AI scores and CI scores and negatively correlated with the estimated glomerular filtration rate. Kaplan–Meier survival analysis showed that the incidence of renal endpoint events was increased in the high sCD163 group compared with the normal sCD163 group.ConclusionThe serum sCD163 level correlates with the severity of LN and is an important indicator of poor renal prognosis in patients with LN.     

狼疮肾炎肾小管间质损伤的临床分析

目的:探讨狼疮肾炎肾小管间质损伤的临床病理及患者预后情况。方法:回顾性分析2013年9月～2016年5月在我院肾内科经肾活检确诊为狼疮肾炎300例患者的临床资料。根据2003年国际标准对300例患者重新进行病理分型,分别计算各型狼疮肾炎小管间质损伤类型的发生率,并运用秩和检验分析不同病变类型肾小管间质损伤和发生Ⅳ型病理转型的狼疮肾炎转型前后肾小管间质损伤的差异。结果:间质炎细胞浸润的发生率最高,为86.67%;其次为间质纤维化和肾小管萎缩,发生率分别为67.00%和66.67%;而肾小管上皮细胞变性发生率最低,为55.00%。各类型肾小管间质损伤程度不一,差异有统计学意义,P0.05;Ⅱ型(无TIL及轻度TIL占81.03%)肾小管间质损伤程度明显轻于Ⅲ型(无TIL及轻度TIL占60.00%)和Ⅳ型(无TIL及轻度TIL占48.42%),差异有统计学意义,P0.05;但Ⅲ型和Ⅳ型间的肾小管间质损伤程度相比较,差异无统计学意义,P0.05。结论:各型狼疮肾炎患者都较容易出现肾小管间质损伤,但损伤程度各有差异;肾小管间质损伤程度不会影响Ⅳ型狼疮肾炎的病理转型,且病理转型前后肾小管间质损伤程度改变不明显;肾小管间质损伤可影响患者的预后,损伤程度越重,预后越差。     

Clinical significance of renal biopsy in subacute lupus erythematosus

The renal biopsy plays an important role in the clinical evaluation of patients with lupus erythematosus. From numerous studies of renal biopsies in patients with lupus nephritis, it has become clear that although renal lesions are quite varied, the pattern of renal involvement correlates well with the clinical outcome. The broad spectrum of the lesions seen in lupus nephritis has been attributed to individual differences in the immune response in different patients or in the same patient during the course of illness. A classification of lupus nephritis authorized by the World Health Organization is presented. The classification combines all of the morphologic modalities of biopsy interpretation and semiquantitative assessment of activity and chronicity. The clinical correlation of this histologic classification is emphasized and demonstrates that the specific nature of the renal histopathology can predict both the acute and long term course of renal disease in lupus nephropathy and be useful in determining the management of individual patients.     

Kidney biopsy in SLE. I. A clinical-morphologic evaluation

The relationship between renal morphology and clinical disease was analysed in 148 patients with SLE attending a lupus clinic. Patients were not selected for renal disease. Renal tissue was assessed according to the World Health Organization classification of lupus nephritis, the presence of active and chronic lesions was recorded and disease activity was measured according to a standard protocol. All sections of the classification were represented in this group of patients. Active and chronic lesions were more likely to occur among patients with Class III/IV (proliferative glomerulonephritis), than in any other category. Patients with Class III/IV biopsy were more likely to have evidence of clinical renal disease than patients in Class II (mesangial). However, almost half of the Class II patients had some evidence of renal disease, including elevated serum creatinine, as well as important non-glomerular lesions. Without biopsy they might have been thought to have proliferative lesions and been treated more aggressively. Two patients with proliferative glomerulonephritis had no clinical evidence of renal disease. Thus, at the time of biopsy results renal histological examination did not uniformly correlate with clinical renal disease.     

Immune complex deposits in systemic lupus erythematosus kidney without histological or functional alterations.

This study demonstrates that in systemic lupus erythematosus (SLE), the presence of immune complexes on the glomerular basement membrane (GEM) does not invariabley result in histological and/or functional lesions of the kidney. Among a group of 29 lupus patients, six subjects were selected for thorough investigation, because their renal function was normal or only slightly altered though they had suffered from SLE for 20 months to 18 years. All patients had antinuclear factor, anti-native-DNA antibody and a low level of complement; 3 had anti-denatured-DNA antibody, 2 had denatured DNA-anti-denatured-DNA circulating complexes and 3 had anti-RNA-protein antibody. Kidney biopsies disclosed either no histological lesion or minimal changes in five of them and diffuse proliferative glomerulonephritis in one. By contrast, using the immunofluorescent technique, granular deposits containing the third component of complement (C3) were found on the GBM of all patients; IgG was present in 5 cases, IgM in 3, fibrinogen in two cases and around the tubules of one. Electron microscopy confirmed the presence of subendothelial and mesangial deposits. Our results also showed a good correlation between the importance of deposits and the presence of denatured DNA-anti-denatured-DNA circulating complexes. From the data obtained in these 6 cases as well as in the 23 other patients of the group, 3 categories of lupus patients could be distinguished with regard to kidney involvement: 1) patients with insignificant histological lesions, no immune deposits and essentially normal function; 2) patients with definite histological lesions, immune deposits and renal insufficiency and 3) patients with few if any histological lesions and little functional impairment contrasting with important immune deposits. The resistance of some patients to the mephrotoxic effects of immune deposits shows that lupus nephritis depends on intricate pathogenic mechanisms and suggests that these are possible antagonized by "protective" factors.