Letters to the Editor
Relative survival of patients with lupus nephritis significantly improved over time in an Italian region: Comment on the article by Faurschou et al
Article first published online: 26 JUL 2010
Copyright © 2010 by the American College of Rheumatology
Arthritis Care & Research
Volume 62, Issue 12, pages 1812–1813, December 2010
How to Cite
Stratta, P., Canavese, C., Ciccone, G. and Rosso, S. (2010), Relative survival of patients with lupus nephritis significantly improved over time in an Italian region: Comment on the article by Faurschou et al. Arthritis Care Res, 62: 1812–1813. doi: 10.1002/acr.20296
- Issue published online: 30 NOV 2010
- Article first published online: 26 JUL 2010
- Accepted manuscript online: 26 JUL 2010 12:00AM EST
To the Editors:
In an article published recently in Arthritis Care & Research, Faurschou et al evaluated a cohort of 100 patients with lupus nephritis (LN), and they concluded that their study was “the first to provide standardized mortality estimates based on long-term followup data for patients with biopsy-proven LN” (1). However, we believe this is not correct, since we first published a study of a similar cohort of 90 patients with biopsy-proven LN diagnosed over a similar calendar-year period (1968–2001, at our center) and evaluated relative survival compared with that of the sex- and age-matched general population of our region (2).
As in the study by Faurschou et al, the number of women in our study was prevalent (76 [84%] of 90), as were those presenting with World Health Organization proliferative classes (52 [58%] of 90). However, in our experience, both patient and renal long-term prognosis (mean ± SD followup 14 ± 8 years, [minimum 1, maximum 30]) significantly improved over time, as did the relative survival of patients with vasculitis in the same calendar period (3). Death and dialysis occurred in 27 (30%) of 90 cases and in 15 (17%) of 90 cases, respectively, but multivariate analyses showed that the risks of patient and renal death decreased (−75% for the second period and −86% for the third period), with a further analysis showing that the risk was reduced by 8% at each year of diagnosis after 1968 (hazard ratio [HR] 0.921, 95% confidence interval [95% CI] 0.859–0.986).
Improvement in the survival rate of the cohort of women was seen at any time of followup, up to a relative survival rate at 5, 10, and 15 years (0.939, 0.921, and 0.850, respectively), and in the last period nearly approaching that expected for the general population (0.993, 0.983, and 0.967, respectively) (Figure 1). Significant changes were observed over time in therapeutic schedules employed during the induction-remission phase, mainly for the methylprednisolone pulses (+4.6% every 10-year period; P = 0.0001) (HR 0.030 [95% CI 0.002–0.533], P = 0.016), plasma exchange (+4.1% every 10-year period; P = 0.0618), oral cyclophosphamide (+6.1% every 10-year period; P = 0.0456), and intravenous cyclophosphamide (+3.8% every 10-year period; P = 0.0060), while the use of azathioprine decreased (−5.9% every 10-year period; P = 0.024).
Obviously, we cannot attribute the reasons for such an improvement in survival to just ourselves, since general improvement in both medical care and earlier detection of the disease may have strongly contributed to these results. However, we can reasonably believe that our improved “nephrologic” approach (better manipulation of steroids and other immunosuppressants, as well as judicious employ of renal biopsy) to this disease over time has been an important tool (4, 5).
Since our goal is continuous improvement in the quality of care, our focus is now on reducing the burden of drugs in order to improve the quality of life in long-term survivors. However, if what has been said is true, that people work for eros (love) or argyrion (money), an extended sense of eros should be satisfaction. Sometimes, the perception of satisfaction in our work may help others to live longer.
We focused our life on treating patients with renal diseases, and in the autumn of our professional cycle, our experience suggests we strike a balance. Looking at our patients with LN, we are now worried about the long-term side effects of drugs, but we can appreciate the fact that their life has been considerably lengthened.
Rarely does one have the possibility of being profoundly satisfied with his job, notwithstanding the hard work, failures, mistakes, doubts, and disappointments (5). Furthermore, it is obvious that the perspective each physician has of his own work is different from the one he obtains by viewing the world's health problems; his part probably being like a drop in the ocean. However, as laypeople we believe what we have done in life is important. As doctors, it may be enough to be aware of having contributed to the length of our patients' lives (6). The World Health Organization's fourth commandment is “To add years to life” (7). For women with LN, we did.
- 1Long-term mortality and renal outcome in a cohort of 100 patients with lupus nephritis. Arthritis Care Res (Hoboken) 2010; 62: 873–80., , , , .
- 2Life expectancy of women with lupus nephritis now approaches that of the general population. Int J Immunopathol Pharmacol 2009; 22: 1135–41., , , , , , et al.
- 3Improvement in relative survival of patients with vasculitis: study of 101 cases compared to the general population. Int J Immunopathol Pharmacol 2008; 21: 631–42., , , , , , et al.
- 4Risk management of renal biopsy: 1387 cases over 30 years in a single centre. Eur J Clin Invest 2007; 37: 954–63., , , , , , et al.
- 5Treating lupus nephritis: guideline from the Italian Society of Nephrology. G Ital Nefrol 2007; 24 Suppl 37: 50–63. In Italian., , , , , , et al.
- 6Why are doctors so unhappy? BMJ 2001; 322: 1073–4..
- 7World Health Organization. 2010. URL: http://www.who.int.
Piero Stratta MD*, Caterina Canavese MD*, Giovannino Ciccone MD, Stefano Rosso MD, * Amedeo Avogadro University, Novara, Italy, University of Torino, Torino, Italy, St. Giovanni-Molinette Hospital, Torino, Italy.