Clinicopathological features and outcomes of SLE patients with renal injury characterised by thrombotic microangiopathy



Non-immune complex (IC)-mediated renal thrombotic microangiopathy (TMA) has been reported in patients with systemic lupus erythematosus (SLE), but most studies included patients with both renal TMA and IC-mediated lupus nephritis (LN). In this study, the clinicopathological features and outcomes of renal injury characterised by only renal TMA were retrospectively analyzed.


Patients with glomerular and/or vascular TMA in the absence of subendothelial or epithelial immune deposits were screened from 2,332 biopsied of SLE patients. The TMA lesions were divided into glomerular, vascular or both. Acute tubular-interstitial injury was semi-quantitatively analyzed. The podocyte foot process effacement (FPE) was measured by electronic microscopy.


Two hundred fifty-seven (11.0%) renal biopsies revealed TMA, among which 237 biopsies showed TMA coexisting with LN, and 20 (0.9%) biopsies had only renal TMA without or with only mesangial immune deposits. All patients manifested with acute kidney injury and haematological disorders. Among them, 11 (55%) required renal replacement therapy, 12 (60%) had nephrotic syndrome and 13 (65.0%) showed microvascular haemolytic anaemia with thrombocytopenia. Seventeen (85%) biopsies revealed both glomerular TMA and vascular TMA, two had only glomerular TMA and one had vascular TMA. Eight (40%) had no glomerular immune deposits and 12 (60%) showed only mesangial immune deposits. The acute tubulointerstitial injury in patients requiring dialysis was more severe than those not needing dialysis ((43.6 ± 24.9) % vs. (21.7 ± 20.1) %, p = 0.047). FPE of podocytes was positively correlated with proteinuria (r2 = 0.347, p = 0.006). All patients received high-dose methylprednisolone pulse therapy. Four patients received plasma exchange. The renal function of 11 patients requiring dialysis initially recovered after 16.0 (interquartile range [IQR] 9.0, 30.0) days of treatment. During the follow-up of 58.0 (IQR 36.0, 92.3) months, remission was achieved in 19 (95%) patients; only one patient had no response. No patient died or progressed to end-stage renal disease; six patients (30%) relapsed.


Renal TMA, usually accompanying severe renal injury, was not uncommon in SLE patients with renal disease and should be distinguished from immune complex–mediated severe classes of LN. Early intensive immunosuppressive treatment may be associated with a good long-term renal outcome.

Key Points
• Most previous reports of renal TMA in SLE patients were associated with severe types of immune complex–mediated lupus nephritis;
• Renal TMA with glomerular pauci-immune or only mesangial immune deposits was found in SLE patients and clinically presented with severe acute renal injury but good renal outcome;
• Renal TMA should be considered as a unique type of SLE-associated renal injury.

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This study was supported by the National Natural Science Foundation of China (grant number 81770701).

Author information




Wencui Chen designed the study, followed up patient, collected the data, analyzed results and wrote manuscript; Shaoshan Liang assessed the pathological slices and analyzed results; Ke Zuo analyzed results and revised manuscript; Liu Yang collected the data; Caihong Zeng assessed the pathological slices; Weixin Hu designed the study, followed up patient, analyzed results and revised manuscript.

Corresponding author

Correspondence to Weixin Hu.

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This study was approved by ethics committees of Jinling Hospital, Jinling Clinical Medical College of Nanjing Medical University, China (approval no. 2019NZKYKS-003-01).



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Chen, W., Liang, S., Zuo, K. et al. Clinicopathological features and outcomes of SLE patients with renal injury characterised by thrombotic microangiopathy. Clin Rheumatol (2021).

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  • Clinicopathological features
  • Lupus nephritis
  • Outcome
  • Systemic lupus erythematosus
  • Thrombotic microangiopathy