title: A Longitudinal Analysis of Outcomes of Lupus Nephritis in an International Inception Cohort Using a Multistate Model Approach.
abstract: To study bidirectional change and predictors of change in estimated glomerular filtration rate (GFR) and proteinuria in lupus nephritis (LN) using a multistate modeling approach.
  
  
  
  Patients in the Systemic Lupus International Collaborating Clinics inception cohort were classified annually into estimated GFR state 1 (>60 ml/minute), state 2 (30-60 ml/minute), or state 3 (<30 ml/minute) and estimated proteinuria state 1 (<0.25 gm/day), state 2 (0.25-3.0 gm/day), or state 3 (>3.0 gm/day), or end-stage renal disease (ESRD) or death. Using multistate modeling, relative transition rates between states indicated improvement and deterioration.
  
  
  
  Of 1,826 lupus patients, 700 (38.3%) developed LN. During a mean ± SD follow-up of 5.2 ± 3.5 years, the likelihood of improvement in estimated GFR and estimated proteinuria was greater than the likelihood of deterioration. After 5 years, 62% of patients initially in estimated GFR state 3 and 11% of patients initially in estimated proteinuria state 3 transitioned to ESRD. The probability of remaining in the initial states 1, 2, and 3 was 85%, 11%, and 3%, respectively, for estimated GFR and 62%, 29%, and 4%, respectively, for estimated proteinuria. Male sex predicted improvement in estimated GFR states; older age, race/ethnicity, higher estimated proteinuria state, and higher renal biopsy chronicity scores predicted deterioration. For estimated proteinuria, race/ethnicity, earlier calendar years, damage scores without renal variables, and higher renal biopsy chronicity scores predicted deterioration; male sex, presence of lupus anticoagulant, class V nephritis, and mycophenolic acid use predicted less improvement.
  
  
  
  In LN, the expected improvement or deterioration in renal outcomes can be estimated by multistate modeling and is preceded by identifiable risk factors. New therapeutic interventions for LN should meet or exceed these expectations.
authors.affiliation: Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: John G
authors.initials: JG
authors.lastname: Hanly
authors.affiliation: Institute of Public Health and University of Cambridge, University Forvie Site, Cambridge, UK.
authors.forename: Li
authors.initials: L
authors.lastname: Su
authors.affiliation: Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada.
authors.forename: Murray B
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authors.lastname: Urowitz
authors.affiliation: Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico.
authors.forename: Juanita
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authors.lastname: Romero-Diaz
authors.affiliation: University of Birmingham, College of Medical and Dental Sciences, Birmingham, UK.
authors.forename: Caroline
authors.initials: C
authors.lastname: Gordon
authors.affiliation: Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea.
authors.forename: Sang-Cheol
authors.initials: SC
authors.lastname: Bae
authors.affiliation: McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Sasha
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authors.lastname: Bernatsky
authors.affiliation: University of Calgary, Calgary, Alberta, Canada.
authors.forename: Ann E
authors.initials: AE
authors.lastname: Clarke
authors.affiliation: Cedars-Sinai Medical Center and University of California, Los Angeles, David Geffen School of Medicine.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Wallace
authors.affiliation: Oklahoma Medical Research Foundation, Oklahoma City.
authors.forename: Joan T
authors.initials: JT
authors.lastname: Merrill
authors.affiliation: University College London, London, UK.
authors.forename: David A
authors.initials: DA
authors.lastname: Isenberg
authors.affiliation: University College London, London, UK.
authors.forename: Anisur
authors.initials: A
authors.lastname: Rahman
authors.affiliation: State University of New York Downstate Medical Center, Brooklyn.
authors.forename: Ellen M
authors.initials: EM
authors.lastname: Ginzler
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, Maryland.
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authors.affiliation: Arthritis Research UK Epidemiology Unit, Manchester Academic Health Sciences Centre, University of Manchester, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, and Manchester Academic Health Science Centre, Manchester, UK.
authors.forename: Ian N
authors.initials: IN
authors.lastname: Bruce
authors.affiliation: University of North Carolina, Chapel Hill.
authors.forename: M A
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authors.affiliation: Centre Hospitalier Universitaire de Québec and Université Laval, Quebec City, Canada.
authors.forename: Paul
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authors.lastname: Fortin
authors.affiliation: Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada.
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authors.initials: DD
authors.lastname: Gladman
authors.affiliation: Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jorge
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authors.lastname: Sanchez-Guerrero
authors.affiliation: Landspitali University Hospital, Reykjavik, Iceland.
authors.forename: Kristjan
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authors.lastname: Steinsson
authors.affiliation: Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Rosalind
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authors.affiliation: The Rayne Institute, St Thomas' Hospital, King's College London School of Medicine, London, UK.
authors.forename: Munther A
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authors.affiliation: Feinstein Institute for Medical Research, Manhasset, New York.
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authors.lastname: Aranow
authors.affiliation: University of Alabama at Birmingham.
authors.forename: Graciela S
authors.initials: GS
authors.lastname: Alarcón
authors.affiliation: University of Alabama at Birmingham.
authors.forename: Barri J
authors.initials: BJ
authors.lastname: Fessler
authors.affiliation: University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Susan
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authors.lastname: Manzi
authors.affiliation: University Hospital Lund, Lund, Sweden.
authors.forename: Ola
authors.initials: O
authors.lastname: Nived
authors.affiliation: University Hospital Lund, Lund, Sweden.
authors.forename: Gunnar K
authors.initials: GK
authors.lastname: Sturfelt
authors.affiliation: Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, UK.
authors.forename: Asad A
authors.initials: AA
authors.lastname: Zoma
authors.affiliation: Karolinska Institute, Stockholm, Sweden.
authors.forename: Ronald F
authors.initials: RF
authors.lastname: van Vollenhoven
authors.affiliation: Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Barcelona, Spain.
authors.forename: Manuel
authors.initials: M
authors.lastname: Ramos-Casals
authors.affiliation: BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain.
authors.forename: Guillermo
authors.initials: G
authors.lastname: Ruiz-Irastorza
authors.affiliation: Emory University School of Medicine, Atlanta, Georgia.
authors.forename: S Sam
authors.initials: SS
authors.lastname: Lim
authors.affiliation: University of California at San Diego, La Jolla.
authors.forename: Kenneth C
authors.initials: KC
authors.lastname: Kalunian
authors.affiliation: Istanbul University, Istanbul, Turkey.
authors.forename: Murat
authors.initials: M
authors.lastname: Inanc
authors.affiliation: Medical University of South Carolina, Charleston.
authors.forename: Diane L
authors.initials: DL
authors.lastname: Kamen
authors.affiliation: University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Christine A
authors.initials: CA
authors.lastname: Peschken
authors.affiliation: Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
authors.forename: Soren
authors.initials: S
authors.lastname: Jacobsen
authors.affiliation: Hospital for Joint Diseases, New York University, Seligman Centre for Advanced Therapeutics, New York, New York.
authors.forename: Anca
authors.initials: A
authors.lastname: Askanase
authors.affiliation: Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Chris
authors.initials: C
authors.lastname: Theriault
authors.affiliation: Institute of Public Health and University of Cambridge, University Forvie Site, Cambridge, UK.
authors.forename: Vernon
authors.initials: V
authors.lastname: Farewell
mesh_terms: D000328:Adult; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D038622:Internationality; D007676:Kidney Failure, Chronic / Q000209:etiology*; D008137:Longitudinal Studies; D008181:Lupus Nephritis / Q000150:complications* / Q000503:physiopathology*; D008297:Male; D015233:Models, Statistical; D011507:Proteinuria / Q000209:etiology*