Successful use of single-dose rituximab for the maintenance of remission in a patient with steroid-resistant nephrotic syndrome

We present the case of a 23-year-old man with steroid-resistant nephrotic syndrome due to minimal change disease who was treated with rituximab. The patient was resistant to conventional therapy. We therefore treated him with a single dose of rituximab (375 mg/m(2)). One month after the administration of rituximab, complete remission was achieved. However, six months later, the patient was administered a second dose of rituximab as the peripheral B cell counts began to recover. Thereafter, at present, that is, one year after the first rituximab administration, complete remission has been maintained. We conclude that rituximab may be an effective treatment agent for resistant nephrotic syndrome and the peripheral B cell count may be a useful marker in such patients for preventing disease relapse.

Effects of sevelamer on the progression of vascular calcification in patients on chronic haemodialysis

BACKGROUND/AIM

Vascular calcification is thought to be associated with a high cardiovascular mortality rate in patients with end-stage renal disease. Control of hyperphosphataemia is important for the treatment of the vascular calcification. The aim of the present study was to evaluate the effects of sevelamer hydrochloride on the progression of aortic calcification in haemodialysis (HD) patients.

METHODS

42 HD patients were studied in this study and divided into two groups (sevelamer vs. calcium). Sevelamer was added and titrated up to achieve serum P control for 6 months. The estimations of aortic calcification index (ACI) by abdominal computed tomography scans were performed twice in each patient. We compared the changes in serum calcium, phosphorus, intact parathyroid hormone, and lipids in two groups.

RESULTS

Serum phosphorus levels decreased significantly from 6.7 +/- 0.7 to 6.2 +/- 0.5 mg/dl with no changes in serum intact parathyroid hormone levels in the sevelamer group (p < 0.01), and increased from 6.5 +/- 1.0 to 6.7 +/- 1.1 mg/dl in the calcium group (p < 0.05). Serum calcium levels did not change in the sevelamer group and calcium group. The serum levels of total cholesterol decreased significantly from 158.5 +/- 20.7 to 146.2 +/- 24.1 mg/dl (p = 0.024) and the low-density lipoprotein cholesterol level from 65.3 +/- 14.4 to 54.7 +/- 11.6 mg/dl (p = 0.014) in the sevelamer group. Serum C-reactive protein decreased significantly from 0.14 +/- 0.13 to 0.08 +/- 0.11 mg/dl in the sevelamer group (p = 0.038) and significantly increased (0.18 +/- 0.09 vs. 0.22 +/- 0.12 mg/dl) in the calcium group (p = 0.042). The mean changes in ACI (DeltaACI) were 3.6 +/- 1.5% in the sevelamer group and 8.2 +/- 3.1% in the calcium group.

CONCLUSIONS

Sevelamer allows a better serum phosphorus control compared with calcium-based phosphate binder and suppresses the progression of aortic calcification in HD patients.

Clinical assessment of low-dose steroid therapy for patients with IgA nephropathy: a prospective study in a single center

BACKGROUND/AIM

No accepted therapy has been established for progressive IgA nephropathy (IgAN). The purpose of the present study was to assess low-dose steroid therapy in the treatment of patients with IgAN.

METHODS

A prospective trial of low-dose steroid therapy was performed in patients with IgAN with mild histological activities. Twenty-four patients in the steroid group and 24 patients in the control group were included in this study. The initial dose of prednisolone was 0.4 mg/kgBW/day (20-30 mg/day), gradually tapered to 5-10 mg/day over 24 months. The patients with mild active inflammatory lesions were treated with prednisolone. The patients assigned to the control group were treated with dipyridamole or zilazep hydrochloride in a dose of 150 or 300 mg/day.

RESULTS

In all of the patients studied, serum creatinine levels did not significantly change over 24 months. However, daily proteinuria significantly reduced after 24 months of steroid therapy (0.97 +/- 0.75 vs. 0.31 +/- 0.51 g/day, P = 0.0012), even if did not change after 24 months of anti-platelet drugs (0.89 +/- 0.49 vs. 0.68 +/- 0.69 g/day, P = 0.2289), respectively. In addition, the grade of hematuria significantly reduced after 24 months of steroid therapy (35.6 +/- 36.3 RBC/HPF vs. 13.7 +/- 28.4 RBC/HPF, P = 0.0249) and 24 months of anti-platelet drugs (30.1 +/- 37.1 RBC/HPF vs. 12.4 +/- 20.3 RBC/HPF, P = 0.0465), respectively. Systolic and diastolic blood pressures did not significantly change during treatment with steroid or anti-platelet drugs. Vascular changes (0.63 +/- 0.73) in the steroid group were lower than those (1.08 +/- 0.88) in the control group (P = 0.008).

CONCLUSION

Our data suggested that low-dose steroid therapy for IgAN patients with mild inflammatory lesions could reduce the amount of urinary protein excretion and prevent deterioration of renal function, provided the histological findings in the renal biopsies showed mild vascular lesions.

[Effects of steroid therapy on membranous nephropathy]

BACKGROUND

Although membranous nephropathy is a common cause of nephrotic syndrome in adults, its treatment remains under debate.

METHODS

To clarify the effects of steroid therapy, the data of 51 Japanese adult patients with idiopathic membranous nephropathy who received treatment at our department were analyzed retrospectively. We divided the patients with nephrotic syndrome and a serum creatinine level <1.7 mg/dL, into two groups: the steroid therapy group (n=20) and the non-steroid therapy group (n=7), and compared the clinical characteristics between the two groups.

RESULTS

Significantly decreased proteinuria levels (p<0.05) after 2 and 5 years were observed in the steroid therapy group as compared to the non-steroid therapy group. There was no significant difference in the serum creatinine levels after 2 and 5 years between the steroid therapy group and the non-steroid therapy group.

CONCLUSION

Steroid therapy in idiopathic membranous nephropathy showed good efficacy in patients with nephrotic syndrome.

Monitoring of blood cyclosporine concentration in steroid-resistant nephrotic syndrome

OBJECTIVE

Cyclosporine has been used for patients with nephrotic syndrome. Because of substantial inter- and intra-patient variability and a narrow therapeutic window, drug monitoring of cyclosporine is mandatory. To confirm the therapeutic effects of a cyclosporine microemulsion (CSAME), the absorption profile of the agent after preprandial administration was determined in steroid-resistant patients with refractory nephrotic syndrome.

METHODS

Fourteen patients were enrolled into the study (mean age, 31.2+/-12; 6 men, 8 women). The patients received 1.5 mg/kg of cyclosporine 30 minutes before breakfast for 6 months. Blood cyclosporine concentration was measured 5 times serially: before administration (C0) and at 1-hour intervals until 4 hours after administration of cyclosporine (C1-C4). In addition, area under the concentration-time curve from 0-4 hours (AUC0-4) was calculated.

RESULTS

After 6 months, CSAME showed marked improvement in proteinuria levels (8.3+/-4.8 g/day vs 0.8+/-0.4 g/day, p<0.001). No changes in serum creatinine and urea nitrogen levels were observed. In 83% of the patients, the CSAME peak concentration appeared within 1 hour after administration (C1). A strong positive correlation was noted between AUC0-4 and C1 (R2=0.90312) and C2 (R2=0.78431). The mean steroid (prednisolone) dose was 40 mg/day when CSAME treatment was started, but a lowering of the dose to 17.5 mg/day (p<0.001) was achieved at 6 months after CSAME therapy.

CONCLUSION

Preprandial administration of CSAME is effective in steroid-resistant patients with refractory nephrotic syndrome. C1 or C2, but not C0, was a good clinical marker for CSAME exposure.

Ruptured arterial aneurysm of the kidney in a patient with microscopic polyangiitis

We present the case of a 55-year-old man with ruptured arterial aneurysm accompanied by microscopic polyangiitis in the kidney. He was admitted to our hospital because of general fatigue, fever and serious numbness of his extremities. Microscopic polyangiitis (MPA) was diagnosed on the basis of cardinal symptoms, including rapidly progressive glomerular nephritis, peripheral nerve disorder and the lung abnormality, as well as positive MPO-ANCA findings. Hemodialysis had to be started on admission because of renal failure. Renal biopsy demonstrated necrotizing glomeruli, crescent formation with interstitial infiltrates. There were no immune deposits on immunofluorescence study or electron micrographs. The pathological diagnosis was necrotizing glomerulonephritis involving small and medium-sized arteries. He was treated with intravenous semi-pulse methylprednisolone therapy because of the intensely pathological renal activation and the abnormal shadow on chest X-ray. The inflammatory reaction subsequently improved, MPO-ANCA decreased and the lung lesions diminished. He complained of sharp pain of sudden onset on his left side. His hemoglobin dropped from 9.8 g/dl to 6.0 g/dl developed in the subsequent hours, but there were no sign of hemorrhage. Abdominal CT scan showed a large left-sided perinephric, intracapsular hematoma. Selective arterial angiography showed multiple aneurysms in renal and hepatic arteries. No active bleeding was present and he recovered with transfusion, supportive therapy and monitoring alone. Multiple aneurysms detected by angiography in the renal and hepatic arteries showed improvement. He is currently stable on regular hemodialysis treatment with a low dose of oral prednisolone.

Effects of lipid-lowering therapy with rosuvastatin on atherosclerotic burden in patients with chronic kidney disease

OBJECTIVE

Although previous studies suggest that treatment of dyslipidemia with statins reduces mortality and morbidity that are associated with cardiovascular disease, only a few studies have examined the efficacy of statins on atherosclerotic status in patients with chronic kidney disease (CKD).

MATERIALS AND METHODS

A 12-month, prospective, randomized study was designed to assess the efficacy of rosuvastatin in reducing circulating atherosclerotic parameters and renal function in patients with CKD. Thirty-eight patients with CKD and LDL cholesterol levels > or =100 mg/dL were randomly assigned to receive 2.5 mg/dL rosuvastatin (group A, n=22) or nonrosuavastatin therapy (group B, n=16). Lipid profile, estimated glomerular filtration rate (eGFR), high sensitivity C-reactive protein (hs-CRP), and intima-media thickness (IMT) were measured before and 12 months after rosuvastatin was added to the treatment.

RESULTS

Total cholesterol, low-density lipoprotein cholesterol, remnant-like particle-cholesterol and triglycerides were significantly reduced only in patients who received rosuvastatin. These parameters remained unchanged in patients who were not treated with rosuvastatin. eGFR was significantly increased from 50.7+/-18.7 mL/min/1.73 m(2) to 53.3+/-20.1 mL/min/1.73 m(2) and a significant reduction of U-P was detected in group A patients (0.17+/-0.29 vs. 0.13+/-0.3 g/day; p<0.01). In addition to the hypolipidemic effect, rosuvastatin treatment significantly reduced hs-CRP (p=0.0054). Moreover, maximal IMT at the baseline (1.89+/-0.98 mm) decreased significantly to 1.75+/-0.87 mm at 12 months (p=0.0231).

CONCLUSION

Rosuvastatin treatment, in addition to its beneficial effect on cholesterol levels, reduced maximal IMT and modified the inflammatory state of these patients.

[Clinico-histopathological analysis of renal changes in MPO-ANCA-associated vasculitis]

OBJECTIVE

The pathological and clinical findings, therapies and prognoses of MPO-ANCA-associated vasculitis, were investigated in cases who showed rapidly progressive nephritic syndrome and received renal biopsy.

METHODS

Vasculitis activity was evaluated by BVAS(Birmingham Vasculitis Activity Score). The renal biopsy findings were evaluated by scoring glomeruli, interstitial and vascular lesions. The renal prognoses were studied by dividing the cases into a dialysis group, which went onto maintenance dialysis in one year and another group without dialysis, which maintained renal functions.

RESULTS

The average age was 58.6 +/- 13.9 years, and the 60s age bracket was the largest. Vasculitis activity was 14.8 +/- 3.2 on the average by BVAS. CRP was 1.2 +/- 1.4 for the kidney-located type group, and 12.6 +/- 10.5 for the multiorgan-damaged group respectively, which shows the former to be significantly lower (p = 0.0079). Serum creatinine at renal biopsy was 3.57 +/- 2.31 mg/dL in the dialysis-independent group, and this was significantly lower than the serum creatinine level of 9.10 +/- 2.6 mg/dL of the dialysis group (p = 0.000259). As for the renal pathological findings, the percentage of global sclerosis among all the glomeruli was 24.7 +/- 19.9% in the dialysis-independent group vs. 68.5 +/- 19.7% in the dialysis group, which shows the latter to be significantly higher (p = 0.002).

CONCLUSION

CRP was significantly higher in the multi-organ-damaged group relative to the kidney-located type group. The percentage of global sclerosis determined by renal biopsy and the amount of serum creatinine at the renal biopsy were key factors in determining the renal prognosis. The absence of a significant correlation between the percentage of crescentic formation and the renal prognosis suggests the possibility of suppressing progress to global sclerosis.

Risk factors for progression in patients with early-stage chronic kidney disease in the Japanese population

OBJECTIVE

Chronic kidney disease (CKD) is an important worldwide health problem. The incidence of end-stage renal disease (ESRD) is increasing steadily around the world, however few studies have discussed the risk factors for progression in patients with early-stage CKD. Therefore, we designed a retrospective cohort study of patients with early-stage CKD to identify the risk factors influencing the annualized slope of the estimated glomerular filtration rate (eGFR).

METHODS AND PATIENTS

In this longitudinal cohort study, baseline examination was conducted in 2012 outpatients treated at the Kidney Center, Tokyo Women's Medical University. Follow-up examinations were completed in 485 patients with stage 1 and stage 2 CKD within the study period (2002-2007). The conventional risk factors for CKD progression, such as proteinuria, blood pressure, serum triglyceride, serum HDL, fasting plasma glucose, smoking habit, hypertension or treatment with antihypertensive medication and body mass index, were examined. The annualized eGFR slope was calculated at the start and end of the study period. Multivariate analysis was performed to determine the associations of the eGFR slope with the predisposing risk factors.

RESULTS

The mean annualized eGFR slope was -1.64 mL/min/1.73 m(2)/year. Concerning the relationship between etiology and the GFR decreasing slope, IgA nephropathy was defined as the worst (-1.80 mL/min/year) due to the high ratio of proteinuria. Proteinuria (-2.13 mL/min/1.73 m(2)/year, p=0.005), smoking habit (-2.06 mL/min/1.73 m(2)/year, p=0.014), low serum HDL (-1.95 mL/min/1.73 m(2)/year, p=0.035), and hypertension (-1.73 mL/min/1.73 m(2)/year, p=0.045) were all significantly related to the eGFR slope. The estimated GFR for the highest BMI quartile was significantly higher than that of the eGFR for the lowest BMI.

CONCLUSION

Proteinuria, smoking habit, hypertension and low HDL were clearly related to accelerated disease progression in patients with early-stage CKD. Therefore, aggressive treatment of these risk factors is essential in the early stages of CKD.

The characteristics of relapse in adult-onset minimal-change nephrotic syndrome

BACKGROUND

Although minimal-change nephrotic syndrome (MCNS) is highly steroid-responsive, the frequency of relapses in some patients is high, necessitating the administration of repeated courses of prednisolone in high doses. It is, therefore, necessary to identify factors that can predict this increased risk of relapse in some patients in order to establish useful treatment methods to reduce the risk.

METHODS

To clarify the factors that might increase the risk of relapses, the data of 82 Japanese adult patients with MCNS receiving treatment at our department were analyzed retrospectively. Of the total, 55 patients (67.1%) experienced relapse after showing an initial response. We divided the patients into two groups; namely, the nonrelapse group (n = 27) and the relapse group (n = 55), and compared the clinico-pathophysiological characteristics between the two groups.

RESULTS

Significantly increased serum immunoglobulin E (IgE) levels (P = 0.0002) and increased frequency of steroid side effects were observed in the relapse group as compared to the nonrelapse group.

CONCLUSIONS

To develop effective therapeutic modalities, it is important to have a thorough understanding of the clinico-pathophysiological characteristics of MCNS patients showing relapse.

Angiotensin-Converting Enzyme Inhibitor Attenuates Monocyte Adhesion to Vascular Endothelium through Modulation of Intracellular Zinc

To elucidate an anti-inflammatory role of angiotensin-converting enzyme inhibitors (ACEIs) in cardiovascular disease, we studied the effect of ACEIs in monocyte adhesion to endothelial cells and underlying molecular mechanisms. Treatment of human monocytic THP-1 cells with monocyte chemoattractant protein-1 (MCP-1; 100 ng/ml; 10 min) significantly increased their adhesion to human umbilical vein endothelial cells (HUVECs) under flow condition (P < 0.001). Preincubation of THP-1 cells with imidaprilat (50 nM; 4 h), an active metabolite of imidapril, reduced MCP-1-triggered THP-1 cell adhesion (P < 0.01). Similar effects were obtained with experiments using human peripheral monocytes (P < 0.05). MCP-1 activated protein kinase C (PKC)alpha in THP-1 cells, resulting in the up-regulation of alpha4 and beta2 integrin. Imidaprilat attenuated MCP-1-induced PKC activation and integrin up-regulation in THP-1 cells. Imidaprilat also inhibited THP-1 cell adhesion induced by phorbol 12-myristate 13-acetate (PMA), a potent PKC activator. In attempt to elucidate the mechanisms for the modulation of PKC activity by imidaprilat, we found that MCP-1 or PMA increased labile zinc in THP-1 cells, which was canceled by imidaprilat. Indeed, zinc/pyrithione activated PKC and increased THP-1 cell adhesion. Zinc chelator as well as PKC inhibitor inhibited these processes, suggesting the role for labile zinc in PKC activation and THP-1 cell adhesion. Imidaprilat attenuated zinc/pyrithione-induced PKC activation and THP-1 cell adhesion. These data suggest that ACEI reduces MCP-1 or PMA-triggered monocyte adhesion to activated HUVECs by modulating labile zinc in monocytes. Our findings may point out a novel anti-inflammatory mechanism of ACEIs in atherogenesis.

Anti-glomerular basement membrane antibody disease with granulomatous lesions on renal biopsy

We present the case of a 56-year-old woman with anti-glomerular basement membrane (anti-GBM) antibody disease accompanied by granulomatous reaction in the kidney. Three months prior to admission to our kidney center, she had suffered from interstitial pneumonia and had a slightly elevated level of MPO-ANCA (13 EU). Her serum level of creatinine was normal (0.72 mg/dl) but proteinuria (1+) and hematuria (2+, 1-4/HF) were present. She was admitted to our hospital because of general fatigue, loss of appetite, high fever (over 38.5 degrees C) and a rapid decline in renal function (creatinine 8.50 mg/dl). Hemodialysis therapy was started immediately after admission. The serological study was negative for MPO-ANCA and PR3-ANCA but positive for anti-GBM antibody (139 EU). Renal biopsy demonstrated necrotizing glomeruli, cellular crescents and grauloma formation with multinucleated giant cells. Immunofluorescence microscopy revealed linear staining of IgG and C3. We diagnosed graulomatous, crescentic and necrotizing glomerulonephritis, patho-logically. She was diagnosed as having anti-GBM antibody disease because alveolar hemorrhage was absent. Steroid therapy including methylprednisolone pulse therapy (500 mg/day, 3 days) and 2 courses of plasma exchange were effective in reducing the fever, anti-GBM antibody titer and C-reactive protein level. Her renal function recovered and she was able to quit hemodialysis therapy 68 days after the start of hemodialysis and she has shown no signs of pulmonary alveolar hemorrhage to date. The present case suggests that intensive therapy may restore renal function in anti-GBM disease even though renal function was sufficiently damaged and required hemodialysis therapy and active pathological changes were observed in renal biopsy specimens.

Wegener's granulomatosis complicated by intestinal ulcer due to cytomegalovirus infection and by thrombotic thrombocytopenic purpura

A 61-year-old woman was admitted to our hospital because of acute kidney injury. She complained of general fatigue, appetite loss, and a high fever. Nodular lesions were observed on chest X-rays and there were >100 erythrocytes per high power field in her urinary sediment. A renal biopsy revealed necrotizing granulomatous glomerulonephritis, and her serum proteinase 3-antineutrophil cytoplasmic antibody (PR3-ANCA) titer was elevated (55 EU). Based on these findings we made a diagnosis of Wegener's granulomatosis (WG). Hemodialysis was started immediately after admission. Steroid therapy was administered and her symptoms were relieved, but her renal function did not improve. On the 50th hospital day her condition suddenly became complicated by hemoperitoneum and massive intestinal bleeding, and the descending, transverse, ascending colon and part of the ileum were surgically resected. The cytomegalovirus (CMV) antigen titer was elevated, and histologic examination of the bowel specimen showed positive staining for CMV in the ulcer lesion, suggesting that CMV infection had caused the bowel hemorrhage. After treatment with ganciclovir, the bleeding was resolved and the CMV antigens became negative. We considered that this patient was further complicated by thrombotic thrombocytopenic purpura (TTP) because of thrombocytopenia, hemolytic anemia and neurologic symptoms. She was treated by plasma exchange. We report here a case of WG complicated by acute intestinal ulcer due to CMV infection and by TTP.

Lamellar nanocomposites based on exfoliated nanosheets and ionic polyacetylenes

Novel lamellar nanocomposites composed of exfoliated SbP2O8- nanosheets and poly(N-methyl-2-ethynyl pyridinium iodide) (PNMe) or poly(N-octadecyl-2-ethynyl pyridinium bromide) (PNO) have been synthesized by exfoliation and re-stacking method. The XRD data of the nanocomposites SbP2O8-:PNMe and PNO:SbP2O8- indicate the formation of nanostructures containing SbP2O8- nanosheets and PNMe or PNO with interlayer expansions of 2.22 and 4.2 nm along the stacking direction of SbP2O8- nanosheets. Formation of these nanocomposites is further supported by the results obtained by FT-IR spectroscopy, scanning transmission electron microscopy and thermogravimetry. The values of electrical conductivity of the polymers and nanocomposites have also been measured.

Functional impact of IgA nephropathy-associated selectin gene haplotype on leukocyte-endothelial interaction

Previously, we discovered single-nucleotide polymorphisms (SNPs) associated with Immunoglobulin A (IgA) nephropathy in selectin genes, which were 712C>T(P238S) in L selectin, -642A>G in the promoter region of L selectin, and 1402C>T(H468Y) in E selectin. Interestingly, these SNPs were in nearly complete linkage disequilibrium, thus two haplotypes, disease-associated TGT and wild-type (Wt) CAC, were constructed. To investigate the functional significance of TGT haplotype, a stable CHO transfectant expressing a P238S-L-selectin variant (CHO-varL) and a recombinant adenovirus vector containing an H468Y-E-selectin variant (Ad-varE) were established and compared to their Wt counterparts. Under flow, CHO-varL exhibited significantly less adhesion over IL-1beta-activated HUVEC monolayers compared to CHO-wtL. Furthermore, a luciferase reporter construct, containing a promoter region of the L-selectin variant (luc-varL), exhibited significantly less transcription activity compared to Wt (luc-wtL). These results suggest that the adhesive interactions and expression level of L selectin in disease-associated haplotypes are significantly compromised, indicating a potential role of these SNPs in the pathogenesis of inflammatory diseases, including IgA nephropathy.

Three-dimensionally ordered macroporous carbons having walls composed of hollow mesosized spheres

Three-dimensionally ordered macroporous carbons were prepared from bimodal polymer-silica colloidal crystals; the resulting carbons had interconnected macropores, and the walls of the macropores were composed of hollow mesosized spheres.

Effects of long-term treatment with mizoribine in patients with proliferative lupus nephritis

AIM

Mizoribine (MZR) is a purine antimetabolic immunosuppressant agent that has few little severe adverse events. We studied whether maintenance therapy with MZR and prednisolone (PSL) in severe proliferative lupus nephritis patients could improve immunity, reduce proteinuria, prevent renal relapse, and reduce steroid dose.

METHOD

Long-term maintenance therapy with MZR and PSL was evaluated in ten patients with biopsy-proven proliferative lupus nephritis. Patients with severe lupus nephritis, who had proteinuria of 0.5 g or more even after treatments with plasma exchange and/or pulse methyl prednisolone, were recruited. MZR at an average dose of 140 +/- 10 (100 - 200) mg was administered two to three times/day in combination with PSL. The average period for the MZR maintenance therapy was 89.7 +/- 5.5 (70 - 126) months. Urine protein excretion, serum hemolytic complement activity (CH50), C3, serum creatinine, general and biochemical blood examinations, anti-ds-DNA antibody were collected at each monthly medical examination.

RESULTS

All patients were females, mean age 43.0 +/- 3.3 years. A significant decrease in proteinuria was noted two years after the combination therapy (p = 0.0016). Five patients experienced lupus nephritis relapse. Patients who did not experience relapses had their MZR combination therapy initiated earlier (p = 0.037) when compared with the patients who experienced relapses. Serum creatinine levels remained unchanged in all patients throughout treatment and follow-up, even during renal relapses. Levels of C3 and CH50 normalized as proteinuria decreased. None of the patients developed serious side effects during MZR treatment. A significant steroid-sparing effect was observed three years after initiating MZR (p = 0.0025).

CONCLUSION

From our long-term observation, maintenance therapy with low-dose PSL combined with MZR can eliminate proteinuria and have steroid-sparing effect. Early initiation of the therapy can protect against renal relapses among severe proliferative lupus nephritis patients without serious side effects.