title: Standard of treatment and outcomes of adults with lupus nephritis in Africa: a systematic review.
abstract: BACKGROUND
  Lupus nephritis (LN) is a significant cause of mortality and morbidity in patients with systemic lupus erythematosus (SLE) and the severity of disease has been described to be increased in Africans. Observational studies have been conducted; however, the treatment and outcome of African patients with LN has not been rigorously assessed.
  
  
  METHODS
  We conducted a systematic review of studies selected from a PubMed search of outcome in Africans with biopsy-proven LN from 1 January 1990 to 30 June 2015. Studies that gave information on histology, treatment and outcome of patients were included.
  
  
  RESULTS
  Sixteen studies were selected from a search that yielded 302 papers; half were from North Africa, 2/16 (12.5%) were prospective studies and 2/16 (12.5%) were multi-centre studies. The sample size of reported biopsies in the studies ranged from 22 to 246 patients. Only 3/16 (18.8%) studies used more recent criteria for the classification and reporting of renal histology, and proliferative LN (class III and IV) were reported with increased frequency from the studies. For induction therapy, all the studies reported use of corticosteroids while 15/16 (93.8%) of the studies also used cyclophosphamide (CYC) as an induction agent. Overall mortality rates ranged from 7.9% to 34.9% with increased disease activity, kidney failure and infections cited as common causes of mortality. Five-year renal survival was 48-84% while five-year patient survival was 54%-94%. Survival rates were higher for studies reported from North Africa.
  
  
  CONCLUSIONS
  This analysis highlights diagnostic challenges in LN in Africa and shows that a CYC/glucocorticoid-based regimen remains the standard of treatment for adult patients. The contributions of this therapy to reported outcomes of LN in Africa require further exploration.
authors.affiliation: Division of Nephrology and Hypertension, University of Cape Town, South Africa.
authors.forename: O I
authors.initials: OI
authors.lastname: Ameh
authors.affiliation: Non-Communicable Diseases Research Unit, South African Medical Research Council & University of Cape Town, South Africa.
authors.forename: A P
authors.initials: AP
authors.lastname: Kengne
authors.affiliation: Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
authors.forename: D
authors.initials: D
authors.lastname: Jayne
authors.affiliation: Department of Medicine, University of Alberta, Edmonton, Canada.
authors.forename: A K
authors.initials: AK
authors.lastname: Bello
authors.affiliation: Division of Rheumatology, University of Cape Town, South Africa.
authors.forename: B
authors.initials: B
authors.lastname: Hodkinson
authors.affiliation: Division of Rheumatology, University of Cape Town, South Africa.
authors.forename: A
authors.initials: A
authors.lastname: Gcelu
authors.affiliation: Division of Nephrology and Hypertension, University of Cape Town, South Africa Ikechi.Okpechi@uct.ac.za.
authors.forename: I G
authors.initials: IG
authors.lastname: Okpechi
mesh_terms: D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D000328:Adult; D000349:Africa / Q000453:epidemiology; D003520:Cyclophosphamide / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008181:Lupus Nephritis / Q000188:drug therapy* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D059039:Standard of Care; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D000305:Adrenal Cortex Hormones; D003520:Cyclophosphamide
keywords: Africa; MMF; cyclophosphamide; lupus nephritis; systematic review; treatment