# Clinical Presentation and Long-Term Outcomes of Lupus Nephritis in Palestine: A Multicenter Retrospective Study

## TL;DR

This study examines lupus nephritis in Palestinian patients, finding that most cases are in young women and that certain factors increase risk of severe outcomes.

## Contribution

The study provides population-specific insights into LN in Palestine, identifying risk factors for ESRD and mortality.

## Key findings

- Most patients were female and aged 15-29, with class IV and III biopsy results being most common.
- Hypertension and elevated creatinine strongly predicted progression to ESRD and death.
- Early detection and aggressive treatment are emphasized to improve outcomes in high-risk patients.

## Abstract

Introduction: Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that frequently affects the kidneys, resulting in lupus nephritis (LN). LN significantly impacts patient morbidity and mortality, with varying clinical presentations and treatment responses across populations. This retrospective study aimed to describe the demographic, clinical, laboratory, and histopathological features of Palestinian patients with biopsy-confirmed LN, and to assess treatment strategies and patient outcomes.

Methods: This multicenter retrospective study was conducted between November 2023 and May 2024 across three major Palestinian hospitals: An-Najah National University Hospital, Al-Watani Hospital, and Al-Makassed Hospital. We reviewed the medical records of patients with SLE who underwent renal biopsy between July 2016 and December 2023. A total of 78 patients with SLE who had biopsy-confirmed LN were included. For each patient, demographic characteristics (age, sex, family history), clinical features (comorbidities, systemic manifestations), and laboratory parameters (serum creatinine, blood urea nitrogen (BUN), proteinuria, hematuria, complement levels, antinuclear antibody, and anti-double-stranded DNA) were extracted from medical records. Histopathological findings were reviewed using light microscopy and immunofluorescence. Treatment modalities, including corticosteroids, disease-modifying antirheumatic drugs (DMARDs), and additional immunosuppressive agents, were documented. Outcomes were categorized into remission, progression to end-stage renal disease (ESRD), or death. Statistical analyses were performed using IBM SPSS version 22 (IBM Corp., Armonk, NY), with descriptive statistics applied to summarize patient characteristics and Fisher’s exact test employed to examine associations between variables and outcomes.

Results: A total of 78 patients with biopsy-confirmed LN were analyzed, of whom 63 (80.8%) were females. The most common age group was 15-29 years (46.2%). Hypertension (30.7%) and diabetes mellitus (8.0%) were the leading comorbidities. Proteinuria was present in 90.8% of patients, with nephrotic-range proteinuria (>3.5 g/day) in 48.7%, while hematuria was observed in 70.1%. Hypocomplementemia was common, with low C3 in 61.3% and low C4 in 62.1%. The most frequent biopsy classes were class IV (47.1%) and class III (22.9%). Regarding outcomes, 71 patients (91.0%) remained in remission with ongoing treatment, five patients (6.4%) progressed to ESRD requiring dialysis, and two patients (2.6%) died due to LN complications. Male sex was significantly associated with dialysis dependency (p < 0.001), while hypertension was also strongly linked to dialysis outcomes (p = 0.035). Elevated serum creatinine (>1.5 mg/dL) and BUN (>20 mg/dL) were strongly associated with both ESRD and mortality (p < 0.001 and p = 0.01, respectively).

Conclusion: This study sheds light on LN patients in Palestine, highlighting the high morbidity and mortality rates. It emphasizes early detection and aggressive management, especially in patients with hypertension and elevated creatinine levels, to improve outcomes and reduce progression to ESRD.