CLINICAL AND HISTOPATHOLOGICAL CHARACTERIZATION OF LUPUS NEPHRITIS IN A TERTIARY HEALTH CENTRE, NORTH-EASTERN NIGERIA: REPORT OF FIVE CASES

CLINICAL AND HISTOPATHOLOGICAL CHARACTERIZATION OF LUPUS NEPHRITIS IN A TERTIARY HEALTH CENTRE, NORTH-EASTERN NIGERIA: REPORT OF FIVE CASES. 1 2 3 1 2 Sulaiman MM, Zarami AB, Yerima A, Lawan M, Pindiga UH Background: Lupus nephritis (LN) is an immune complex glomerulonephritis that complicates up to 40% of SLE patients. A kidney biopsy is required for diagnosis and staging of the disease. Case report: We report a cohort of five patients with LN from a tertiary health facility in northeastern Nigeria. The five patients were all women with age ranging from 26 to 55 years, and eGFR of between 6 to 154ml/minute. Four patients had normal kidney size and were biopsied whereas 1 patient had contracted kidney. Diffuse proliferative LN (Class IV) was seen in two patients while the other two patients had glomerular sclerosis (Class VI). Patients were given induction with methylprednisolone and mycophenolate mofetil (MMF). At one year follow up 2(40%) patients were in remission, 1(20%) was on maintenance hemodialysis and 2(40%) patients had died. Conclusion: Lupus nephritis is a common complication of SLE in northeastern Nigeria. Patients have features of advanced kidney disease at presentation. CASE SERIES to develop LN are of younger age, males and black, Hispanic or of Asian ethnicity. Studies have shown that 60% of black SLE patients develop LN, with 25-50% having LN as an initial manifestation


INTRODUCTION
Lupus nephritis (LN) is an immune complex glomerulonephritis that develops as one of the severe organ manifestation of systemic lupus erythematosus (SLE) with ample morbidity and mortality. The pathogenesis is complex and involves immunological, environmental and 1 genetic factors. SLE predominantly affects women of childbearing age, with a female to male ratio of 8:1 to 15:1; the incidence and prevalence of LN is, 2,3 however, variable. The disease occurs in 40 -75% of patients with SLE usually within five years of disease onset and can be an initial manifestation of 2 SLE in most cases. SLE patients that are most likely Renal biopsy not only diagnoses LN, but also determines levels of activity, predicts prognosis and guides treatment 9,10 protocols. All compartments of the kidney are affected in SLE-associated renal disease giving rise to a wide range of morphological changes which includes, mesangial or endocapillary proliferation, tubulointerstitial nephritis and thrombosis or 9 necrotizing arteritis.
Diagnosis of LN in developing countries is challenging due to delay in patients' presentation, lack of reliability of clinical features alone, difficulties performing biopsies, poor correlation between histopathologic and clinical features of the disease; and where biopsies are performed, there are difficulties in differentiating LN from overlapping conditions such as thrombotic microangiopathy, non-steroidal anti-inflammatory drugs (NSAIDs) interstitial nephritis, focal segmental glomerulosclerosis from other causes, 12 and IgA nephropathy.
Despite the reports on the increased disease severity of LN among Blacks and African Americans, there are few reports of biopsy-proven lupus nephritis in Nigeria. In addition, the role of genetics in the pathogenesis of LN in black Africans and the clinical outcomes of the diseases are largely 13,14 underreported. A systematic review conducted on the standard of treatment and outcomes of LN in Africa revealed that only 18.8% used recent criteria to report renal histopathology and more than 90% used cyclophosphamide (CYC) for induction therapy, highlighting the diagnostic challenges in LN in Africa.
We report the clinical and renal histopathologic findings in five patients managed for LN in UMTH Maiduguri, Nigeria.

RESULTS
All the five cases were females with a mean age of 34±11.9 years, referred to renal clinic University of Maiduguri Teaching Hospital from July to October 2020, and the median duration of disease before presentation was 8 months IQR (3 -18). Three (60%) h a d a c l i n i c a l d i a g n o s i s o f c h r o n i c glomerulonephritis and 4 (80%) were hypertensive at presentation. They all had positive ANA with a median eGFR of 28ml/min IQR (10 -95) and normal kidney sizes. Two (40%) were in class IV, and one (20%) was in class V, the remainder were in endstage (class VI). Two (40%) died during treatment of which one was in Class IV and the other in class V. (Table 1

Table1: Clinical and laboratory characteristics of patients with Lupus nephritis
NB: TIN=Tubulointerstitial nephritis, ESRD=End stage renal disease, MPGN=Membranoproliferative glomerulonephritis, N/A= Not available. The management and prognosis of LN is determined by the underlying histopathologic stage and the extent of interstitial fibrosis. All our patients were treated with corticosteroids and MMF as induction therapy to avoid the side effects of cyclophosphamide therapy in childbearing young women. This contrast with the report by 1 3 A m e h e t a l w h i c h s h o w e d t h a t corticosteroid/cyclophosphamide combination was the most common drug combination used in lupus nephritis in Africa. Two (40%) of our patients died; one from complications of COVID-19 and the second from pulmonary embolism. The mortality rate in lupus nephritis was shown to range between 7.9-34.9% 1 9 a m o n g A f r i c a n p a t i e n t s .

CASE REPORT
I n f e c t i o n s , cardiopulmonary involvement, and neurologic complications have been reported as the 20 commonest causes of death in lupus patients. O u r s t u d y i s l i m i t e d b y t h e l a c k o f immunofluorescence study of the biopsy specimen to define type and pattern of complement factor and antibody deposition in the kidneys. Assay of anti-double stranded DNA was not done due to its non-availability in our centre.

CONCLUSION
Lupus nephritis is a common complication of SLE among patients in northeastern Nigeria. We reported five patients with biopsy-confirmed lupus nephritis and their outcome will be improved with early diagnosis and prompt institution of immunosuppressive treatment.

CASE REPORT
Sulaiman MM et al