Short-Term Outcome of Sub-Saharan Africans with Proliferative Lupus Nephritis Treated with Cyclophosphamide Versus Mycophenolate Mofetil

Abstract

Introduction: Proliferative classes of lupus nephritis are the most frequently reported in the literature, with a prevalence ranging from 40% to 80% of cases. These classes are clearly associated with the poorest medium-term prognosis. This study was conducted to assess the progression of proliferative lupus nephritis following induction therapy in Sub-Saharan African patients. Patients and Methods: A retrospective and descriptive study was performed over a 10-year period, from January 1, 2007, to December 31, 2016, in the nephrology department of Aristide Le Dantec Hospital in Dakar. Patients diagnosed with proliferative lupus nephritis were included. The diagnosis was based on renal biopsy findings consistent with proteinuria exceeding 0.5 g/24h or active urinary sediment, classified according to the 2003 ISN/RPS classification (Classes III or IV, with or without Class V). Epidemiological, clinical, biological, histological, therapeutic, and outcome data were collected. Glomerular Filtration Rate (GFR) was estimated using the Modification of Diet in Renal Disease (MDRD) formula. Nephrotic proteinuria was defined as >3 g/24h. Patients received either intravenous cyclophosphamide (1 g/m 2 /month) or mycophenolate mofetil (2 g/day), combined with methylprednisolone (15 mg/kg for 3 days) followed by prednisone (1 mg/kg/day), alongside hydroxychloroquine. Follow-up lasted 6 months, with remission and resistance defined per EULAR/ERA/EDTA criteria. Results: Among 64 Black patients with lupus nephritis, 44 cases of proliferative glomerulonephritis were identified, representing a prevalence of 68.7%. The mean age was 31.8 ± 11.2 years, with 33 women and 11 men (sex ratio: 0.3). Renal edema was present in 36 patients (81.8%), and hypertension was noted in 22 patients (mean systolic blood pressure 141 mmHg, mean diastolic blood pressure 91 mmHg). Mean serum creatinine was 24.2 mg/L ± 23.2, with renal failure in 45.5% of patients. Mean proteinuria was 3.9 g/24h ± 2.7, and nephrotic syndrome was observed in 72.7% of cases. Histological classification included Class III in 11.3%, Class IV in 27.3%, Class III + V in 43.2%, and Class IV + V in 18.2%. Cyclophosphamide was administered to 22 patients, and mycophenolate mofetil to 10 patients. Of the 44 patients, 35 were followed for 6 months, with 9 lost to follow-up. Remission rates (complete and partial) were 36.8% for cyclophosphamide and 66.6% for mycophenolate mofetil, with resistance rates of 63.2% and 33.4%, respectively. Five deaths occurred due to pulmonary embolism, bacterial meningitis, pulmonary tuberculosis, and indeterminate causes in two cases. Chronic renal failure developed in 8 patients. Infectious complications affected 38.6% of patients, with cutaneous (32%), urogenital (24%), and pulmonary (16%) localizations being the most common. Conclusion: The risk of progression to chronic renal failure was relatively high. Patients treated with mycophenolate mofetil exhibited a higher remission rate compared to those treated with cyclophosphamide. The hypothesis of an ethnic influence on therapeutic response warrants further investigation.