Analysis of the consistency of rheumatologists' clinical judgements about the necessity of immunosuppression

Houzou P^*

Department of Clinical Rheumatology, University Hospital of Kara, Togo

Abstract

Introduction: In cases with lupus nephritis it's necessary to define the need for immunosuppressive remedy according to histological class observed in renal vivisection. Objective: To estimate the agreement between the opinions of six independent clinical rheumatologists regarding the need for immunosuppression and the result of renal vivisection in cases with lupus nephritis.

Materials and methods: Across-sectional study on the agreement between a individual test in adult cases with systemic lupus erythematous. Each rheumatologist prognosticated the outgrowth of the vivisection. In order to estimate the agreement, a dichotomous qualitative outgrowth was defined and was considered zero if it wasn't necessary to add a cytotoxic (classes I, II and VI), and else was (classes III, IV, V or combinations). The chance agreement and kappa statistics with a confidence interval of 95 was measured.

Results: Information was collected on 34 cases, with an aggregate of 204 prognostications made by 6 rheumatology interns. Rheumatologists were correct in their clinical print in 180 cases (88.2 concordance rate, overall kappa of0.62 (95 CI = 0.48 –0.76)). Of the 204 scripts generated, 162 corresponded to proliferative forms of lupus nephritis, for which the rheumatologists anticipated the need for immunosuppression in 153 and failed to treat in 9 cases (5.5, or about 1 in 18).

Conclusions: The clinical opinion of rheumatologist is relatively successful in defining the need for immunosuppression. In general, expert opinion could ultimately be offered as an indispensable choice to renal vivisection for the case.

Keywords

COVID- 19; SARS- CoV- 2 • Immunosuppression • People with rheumatic conditions • Vaccination

Introduction

Lupus nephritis( LN) is one of the most frequent and serious complications of systemic lupus erythematous ( SLE).1 One- third of the grown-ups with SLE have LN at the time of the opinion of their complaint, and over to two- thirds of cases may have this complication during the course thereof.2 In a European series of 1000 cases followed- up during 10 times LN was demonstrated in 279 cases( 28).3 In the cohort of the Latin American Group for the Study of Lupus – GLADEL, 51 of cases hadln.4 In a Colombian multicentercrosssectional study which included 467 cases, 51 of them had LN [1, 2].

Presently the transnational guidelines recommend performing a renal vivisection in all cases with suspected LN, 6, 7, 8 still, there has always been contestation about the true part of the renal vivisection to guide the treatment or to define a prognostic. The poor trustability, the costs and the complications of this invasive procedure should also be taken into account. The critical point when choosing the treatment for a case with LN is to determine whether or not it's a proliferative form that indicates the addition of immunosuppression with cytotoxic agents.

Both the American and the European guidelines suggest the same treatment scheme for the forms of LN classes III, IV, III V and IV V, which can be done with cyclophosphamide or mycophenolate, or the change to the other in case that there isn't response with the first one. For the pure form V there's some preference for starting with mycophenolate; still, cyclophosphamide is also an option in this script and actually this class of LN is rare in its pure form since utmost of the times is set up combined with a class III or IV proliferative form [3].

Although the experts also recommend the renal vivisection to determine vascular and interstitial changes or histological exertion and regularity scores, recommendations regarding this information aren't set up in the guidelines for treatment. With respect to the prognostic in LN, given that proteinuria and renal function at the time of onset are the primary predictors of the genuine difficulties; various investigations have revealed that the donation of the vivisection appears to be on the borderline. In our diurnal practice we've also observed that adherence, frequently affected by the force of medicines by the insurance companies, appears to be one of the most critical factors that define the prognostic of the individual case [4, 5].

Since the main information of the renal vivisection consists in secerning the classes of LN that need cytotoxic agents from those that don't in order to guide the treatment, we wonder if, with the clinical and laboratory information available before the vivisection, the rheumatologist would be suitable to gain the same information and to approach the need for immunosuppression of the case.

Our objects were to determine the agreement between the clinical opinion of the rheumatologists and the final decision for immunosuppression grounded on the result of the renal vivisection in cases with LN, to determine the agreement between the histological class of LN suspected by the rheumatologists and the one eventually observed in the renal vivisection considering 3 scripts of clinical interest( classes I or II versus classes III, IV, III V or IV V versus class V), and eventually to quantify the degree of empirical approximation of the rheumatologists to the exertion and regularity scores reported in the renal vivisection[6].

Materials and Method

Cross-sectional study on the agreement of a individual test. We included adult cases, treated during the time 2014 at the San Vicente Foundation University Hospital of the megacity of Medellin, Colombia, with SLE24 and suspected LN to whom a renal vivisection was requested. In this sanitarium every case with SLE and possible LN is estimated and treated by the Service of Rheumatology, which determines if a renal vivisection is needed. At the time of requesting the vivisection was transferred via dispatch a brief [7].

Results

Information from 34 cases aged than 18 times with SLE and clinical opinion of LN was collected. All the invited rheumatologists accepted to share. The six professionals, five from Medellin and one from Bogota, work in academic medical centres. The National University of Colombia in Bogota trained two of them, while the University of Antioquia in Medellin trained the other four. Three of the rheumatologists have lower than 5 times of experience, 2 of them between 5 and 10 times, and the sixth more [8].

Discussion

In our study we show that 6 adult rheumatologists, using only clinical and laboratory information, were suitable to directly prognosticate the need or not for immunosuppression with cytotoxic agents defined by the result of the renal vivisection in cases with SLE and suspected LN in88.2 of the occasions. We observed a high perceptivity of the clinical judgment to determine the necessity for using cytotoxic agents in cases with proliferative forms of LN (only one of every 18 cases who need [9, 10].

Acknowledgement

None

Conflict of Interest

None of the authors reported conflict of interest applicable for the prosecution and publication of this work.

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