5 Questions About Gaps in Quality of Care in Lupus Nephritis

Lupus nephritis (LN) is a serious manifestation of systemic lupus erythematosus (SLE). Individuals with SLE have an increased risk of developing kidney disease; up to 60% of patients develop kidney involvement.¹ Of those who develop kidney disease, 10% to 30% progress to kidney failure within 15 years.¹

A study by Ishita Aggarwal, MD, a senior rheumatology fellow at George Washington University Hospital in Washington, DC, and colleagues evaluated data on quality measures for the screening, diagnosis, and treatment of LN among 250 participants from the California Lupus Epidemiology Study.²

Results showed high performance scores for LN management across various health care settings. However, more improvement in care is needed.

Rheumatology Consultant caught up with Dr Aggarwal about the research.

Rheumatology Consultant: What prompted you to conduct your study?

Ishita Aggarwal: Individuals with lupus have a very high incidence of kidney disease. In our study, we looked closely at how rheumatologists and other providers manage patients with lupus. Additionally, we wanted to know if providers are following the American College of Rheumatology guidelines for the management of lupus and are regularly screening patients for kidney disease. We looked at the quality of care at 25 community and academic clinical practices in the San Francisco Bay Area, California. This is the first study of its kind to look at multiple clinical sites; we looked across many different health care settings, such as academic centers, community clinics and large health systems, and were able to capture a diverse population. 

RHEUM CON: Were you surprised by the study findings?

IA: Overall, treatment for lupus nephritis was very good once the diagnosis was made, but screening for this manifestation of lupus was very inconsistent across practices. The academic clinics performed somewhat better than community clinics across all quality of care measures, even after adjusting for patient characteristics and disease severity. I was not surprised that patients with lupus are generally receiving excellent care once it is discovered they have lupus nephritis and are initiated on treatment with the appropriate therapies quickly. The disease can be very acute and have many complications, so I am glad that lupus nephritis is recognized, and patients are beginning treatment soon after diagnosis. Still, there is some room for improvement in screening for lupus nephritis so that the condition is recognized as early as possible. Also, there is still a gap in patients undergoing timely kidney biopsy. Only two-thirds of participants in our cohort underwent kidney biopsy within 1 year of lupus nephritis diagnosis.

RHEUM CON: What gaps in lupus quality of care still need to be addressed?

IA: It is important to see patients regularly. It can be difficult to get the message across to patients about the importance of potential complications of lupus if they are not seen on a regular basis. Additionally, undergoing screening for kidney disease is a large gap that still needs to be addressed. Rheumatologists should screen patients for LN early to also help minimize morbidities that may develop. Screening should include a quantitative test for protein in the urine; a urinalysis alone is inadequate. Regular screening should also include evaluation of complements and anti-double stranded DNA levels. Patients should receive a kidney biopsy if there is suspicion for lupus nephritis unless there is a contraindication, prior to the initiation of treatment. If there is lupus nephritis, immunosuppression should begin within 1 month. Blood pressure control is also important for those with renal disease. 

There is also a gap between the care received in community practices compared with academic centers. There are a number of factors that contribute to this, including the physician’s knowledge of aggressive treatments and recognizing the patient is developing LN. The high volume of lupus patients seen at academic centers may account for the differences in care that we saw in our study. There are also gaps in quality of care of men with lupus. Men with lupus often experience more severe progression to kidney disease, so there needs to be even more aggressive screening in this population.

RHEUM CON: Will the gaps in quality of care be difficult to address?

IA: There are many factors that prevent patients from receiving regular care for their disease. In our study, we looked at specific patient factors, including education and socioeconomic status, and found that many people do not have access to rheumatologists. San Francisco has a very high volume of rheumatologists, but in other parts of the country there are gaps to accessing regular rheumatology care. This will require changes in practice patterns and being more aggressive with screening and education. This is always a hard thing to change.

RHEUM CON: What should a rheumatologist keep in mind when managing lupus, with or without nephritis, outside of a community setting? 

IA: Rheumatologists have to keep in mind that lupus is a very difficult diagnosis for patients to comprehend. Lupus can present in many different ways. Sometimes the biggest hurdle is convincing the patient that they have lupus and convincing them of the severity of potential complications with untreated lupus. Rheumatologists have to be very patient with educating patients and helping them deal with this chronic disease. The most important thing is to see patients regularly to help them understand the possible complications related to lupus and how to prevent them. 

References:

1. Maroz N, Segal MS. Lupus nephritis and end-stage kidney disease. Am J Med Sci. 2013;346(4):319-323. doi:10.1097/MAJ.0b013e31827f4ee3.
2. Aggarwal I, Li J, Trupin L, et al. Quality of care for the screening, diagnosis, and management of lupus nephritis across multiple healthcare settings. Arthritis Care Res (Hoboken). 2020;72(7):888-896. doi:10.1002/acr.23915.

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