Idiopathic non-lupus full-house nephropathy is associated with poor renal outcome

Abstract

Background: Full-house immunofluorescence in combination with various histopathologic lesions in the renal biopsies of patients without overt systemic lupus erythematosus (SLE) poses a diagnostic challenge. In this setting, the biopsy findings are sometimes termed non-lupus 'full-house nephropathy' (FHN). It is presently unknown whether idiopathic non-lupus FHN is clinicopathologically and prognostically distinct from lupus FHN.

Methods: We included non-lupus FHN patients and lupus FHN controls (four or more American College of Rheumatology or Systemic Lupus International Collaborating Clinics criteria) who were biopsied between 1968 and 2014 at the Leiden University Medical Centre. Non-lupus FHN patients were studied for progression to SLE and/or the presence of other conditions with FHN. The clinicopathologic characteristics and prognosis of idiopathic non-lupus FHN patients were compared with those of lupus FHN patients.

Results: Of 149 included patients, 32 had non-lupus FHN. During the median follow-up of 20 years, no non-lupus FHN patients developed SLE. In all, 20 non-lupus FHN patients had idiopathic non-lupus FHN, and in 12 patients, secondary non-lupus FHN was considered due to membranous nephropathy (anti-PLA2R-positive, n = 1; cancer-associated, n = 3), IgA nephropathy ( n = 4), infection-related glomerulonephritis ( n = 2) or anti-neutrophil cytoplasmic antibody-associated glomerulonephritis ( n = 2). Idiopathic non-lupus FHN patients were more often male (P < 0.001) than lupus FHN patients and their renal biopsies more often showed a mesangial (P = 0.04) or membranous pattern of injury (P = 0.02) and less intense C1q staining (P = 0.002). Clinically, they presented with lower-range erythrocyturia (P = 0.04), more proteinuria (P < 0.01) and less complement consumption in the classical pathway (P < 0.001) than lupus FHN patients. By multivariable Cox regression analysis of patients with a lupus nephritis class III/IV pattern of injury, idiopathic non-lupus FHN compared with lupus FHN was an independent risk factor for end-stage renal disease [hazard ratio 5.31 (95% confidence interval 1.47-19.24)].

Conclusions: Our results show that the clinical recognition of idiopathic non-lupus FHN as a diagnostic category is critical.

Keywords: LN; full house; non-lupus full house nephropathy; systemic lupus erythematosus.