‘What we see that kills patients’: Managing cardiovascular event risk in lupus nephritis
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Managing cardiovascular event risk is critical to preventing morbidity and mortality in lupus nephritis, especially among groups at increased risk for the disease, according to a speaker at the 2021 Rheumatology Nurses Society annual conference.
Alvin F. Wells, MD, PhD, director of the Rheumatology and Immunology Center in Franklin, Wisconsin, and adjunct assistant professor at Duke University Medical Center, described lupus, which is derived from the Latin word for wolf, as a “vicious type creature.”
“Forty-five percent of patients with lupus will get lupus nephritis,” he added.
Women are at increased risk for lupus nephritis in SLE, as are non-white patients, including those who are black and Hispanic, according to Wells. “Black and Hispanic patients tend to have more advanced disease at presentation,” he said. “Their biopsies can be extremely impacted when we see them at baseline.”
Higher creatinine and more proteinuria are also observed in these non-white patient groups. “They are more likely to go onto end stage renal disease,” Wells said.
Of particular concern is that many of these patients are in their 20s, 30s and 40s, according to Wells. He noted that this, in turn, puts many non-white patients with lupus nephritis at a three-fold greater risk for mortality than age-matched controls. “That can be a travesty in many of these young patients.”
Wells raised questions as to why black and Hispanic patients are so severely impacted. “Is it background disease or socioeconomic issues?” he said. “Comorbid disease like obesity? Delays to care?”
While women are more likely to progress from SLE to lupus nephritis, men have a worse prognosis, according to Wells.
Beyond demographics, Wells reviewed some of the adverse outcomes that can occur in lupus nephritis, including myocardial infarction and cardiovascular disease. “The risk for myocardial infarction is eight times greater than age-matched controls,” Wells said. “If I have a young patient with lupus nephritis, I make sure their blood pressure, cholesterol and obesity are under control. This is what we see that kills patients: myocardial infarction and cardiovascular events.”
The most recent EULAR guidelines for lupus nephritis emerged in 2020, while the ACR’s last document was in 2012. Wells hopes that the ACR will update their recommendations soon.
In the meantime, he follows one key stipulation recommended by the European organization. “The Europeans say to monitor patients every 3 months,” he said.
In addition, Wells also noted that when patients cross the threshold of excreting >0.5g/day of protein, a biopsy is recommended. “In Europe, they have a lower threshold for biopsy,” Wells said. “Biopsy is critical. If there is a delay to biopsy, there is a delay to therapy. A delay to therapy can lead to a bad prognosis.”
Treating to the target of a protein urine ratio to 0.5 g/day to 0.7 g/day and following patients every 3 months is critical to preventing dialysis, end-stage-renal disease and mortality in these patients. Wells offered insight as to reaching that target.
While hydroxychloroquine ultimately proved ineffective in COVID-19, Wells believes that this is the “year of antimalarials” because the drug has shown efficacy in lupus nephritis. “I call it the methotrexate of lupus,” he said. “Every patient should get it.”
Part of the reason hydroxychloroquine is essential in lupus nephritis is because it has cardiovascular benefit, according to Wells.
The other key player in the lupus nephritis armamentarium is steroids. However, he echoed the concerns other clinicians have with these drugs. “Start with a higher dose and then back off over the long-term,” he said, suggesting that the dose should be reduced to 7.5 mg per week within 6-12 months.
Beyond hydroxychloroquine and steroids, immunosuppressive drugs like cyclophosphamide or mycophenolate mofetil may only yield responses in half of patients.
Turning back to cardiovascular complications, Wells is not shy about prescribing antihypertensive medications or helping patients manage their diabetes or obesity. “We want to make sure every facet of this disease is under control,” he said. “When patients get a response, they will go into complete remission. If they get into complete remission, they are going to do well long-term.”
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Wells AF. Lupus Nephritis (LN): Just One Type of Lupus You Need to Know About. Presented at: Rheumatology Nurses Society annual conference; August 4-7, 2021 (virtual meeting).
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