Relative survival of patients with lupus nephritis significantly improved over time in an Italian region: Comment on the article by Faurschou et al


Relative Survival of Patients with Lupus Nephritis Significantly Improved Over Time in an Italian Region: Comment on the Article by Faurschou et al

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).

Figure 1.

Relative survival curves (benchmark: general age- and sex-matched Piemonte population of the same period) of the 76 women with biopsy-proven lupus nephritis observed in a single center from 1968 to 2001. The observed and relative survival of all patients with lupus nephritis are depicted in comparison with that of the general population of the Piemonte Region in the subsequent periods of 1968–1979 (top) and after 1980 (bottom). Relative survival improved significantly, now approaching that of the general population.

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.

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.