Long-term preservation of renal function in patients with lupus nephritis receiving treatment that includes cyclophosphamide versus those treated with prednisone only

Mycophenolate mofetil in lupus glomerulonephritis

The optimal treatment of severe lupus nephritis is unclear. Regimens consisting of steroid and cyclophosphamide (CYC) appear to be most effective. However, up to 15% of patients are refractory to CYC treatment, and 30% to 50% of patients still develop end-stage renal disease. Moreover, infection and gonadal toxicity are major concerns of CYC use in patients of the reproductive age. More effective, but less toxic, regimens are needed. Mycophenolate mofetil (MMF) is a new immunosuppressive agent that selectively inhibits activated lymphocytes and renal mesangial cells. Experience with MMF in solid-organ transplantation has shown the safety of this drug and its superiority over azathioprine (AZA) in the prevention of acute graft rejection. Data from experimental models of immune-mediated glomerulonephritis, particularly lupus nephritis, have shown that MMF ameliorates autoimmune phenomena, retards renal damage, and improves outcome. Although the use of MMF in lupus nephritis is still in its preliminary stage, uncontrolled experience has confirmed its efficacy in patients with serious disease recalcitrant to conventional cytotoxic agents. Controlled studies, albeit small and lacking statistical power, have shown that MMF is as effective as CYC in the induction of renal remission in the short term. With the current dosage used in systemic lupus erythematosus, MMF appears to be well tolerated, with no serious toxicities reported. Significantly less ovarian toxicity compared with CYC is particularly attractive for the consideration of MMF in lupus nephritis. However, the lack of long-term efficacy data and comparative studies with standard CYC regimens is the major deterrent for the first-line use of MMF in high-risk patients at this juncture.

Patient preferences for treatment of lupus nephritis

OBJECTIVE

To examine the amount of improvement in renal survival that lupus patients require before choosing cyclophosphamide over azathioprine for the treatment of lupus nephritis.

METHODS

Patients were presented with descriptions of cyclophosphamide and azathioprine and asked to indicate their preferred choice if each conferred an equal probability of renal survival. Strength of preference was assessed by systematically increasing the probability of renal survival of the more toxic treatment until the respondent's choice switched.

RESULTS

Ninety-three well-educated women (mean age +/- SD 40 +/- 7 years) participated in the study. Ninety-eight percent (91/93) of the participants chose azathioprine over cyclophosphamide when both drugs conferred an equal probability of renal survival. Although most subjects switched preferences to cyclophosphamide for better renal survival, 31% (28/91) were unwilling to switch from azathioprine to cyclophosphamide for improved short-term renal survival, and 15% (14/91) were unwilling to switch from azathioprine to cyclophosphamide for improved long-term renal survival.

CONCLUSION

Although the majority of patients switched preferences to cyclophosphamide for better renal survival, a substantial minority was unwilling to accept the toxicity associated with cyclophosphamide, even if it was much better than azathioprine at preventing renal failure.

Renal flares in 91 SLE patients with diffuse proliferative glomerulonephritis

BACKGROUND

Even when treated with current protocols, 25 to 30% of systemic lupus erythematosus (SLE) patients with diffuse proliferative glomerulonephritis (DPGN) evolve to end-stage renal disease (ESRD). The occurrence of renal flares is considered to be an important risk factor for the evolution to ESRD. The aim of this retrospective study was to evaluate the incidence and prognostic significance of renal flares in SLE patients with DPGN and to identify predictors for the occurrence of flares.

METHODS

Ninety-one SLE patients were selected for study based on the following criteria: (a) evidence of renal involvement, (b) a follow-up of at least 6 months after the renal biopsy, and (c) a steady improvement in renal manifestations after the biopsy lasting for at least three months.

RESULTS

Renal flares occurred in 54% of the patients after renal biopsy and appropriate treatment. A younger age at the time of renal biopsy correlated with the occurrence of renal flares. A high activity index (> or =10) and karyorrhexis on histology correlated with the occurrence of nephritic flares. Twenty-seven percent of the patients developed ESRD. The number of renal flares, nephritic flares, and "early" proteinuric flares (that is, those occurring in the first 18 months after renal biopsy) as well as serum creatinine levels, karyorrhexis, and chronicity index on renal histology were correlated with doubling serum creatinine.

CONCLUSIONS

Our results suggest that (a) a distinct subgroup of SLE patients exists, made up of younger patients with extensive, active lesions on renal biopsy, who are at higher risk for renal flares, (b) renal flares represent important predictors of doubling serum creatinine.

Outcome and prognostic indicators of diffuse proliferative lupus glomerulonephritis treated with sequential oral cyclophosphamide and azathioprine

OBJECTIVE

To study the outcome and prognostic indicators of diffuse proliferative glomerulonephritis (DPGN) in patients with systemic lupus erythematosus (SLE) treated with sequential oral cyclophosphamide (CYC) and azathioprine (AZA).

METHODS

SLE patients with biopsy-proven DPGN treated with sequential oral CYC and AZA were studied. Those who achieved renal remission at 12 months were identified, and the clinical predictors of complete remission were evaluated by regression analysis. All patients were followed up until a relapse of the nephritis or a doubling of the serum creatinine level occurred. The timing and risk factors for flares and creatinine doubling were evaluated by Kaplan-Meier analysis and with the Cox proportional hazards model.

RESULTS

We studied 55 patients (47 women, 8 men; mean +/- SD age at renal biopsy 31.1 +/- 10.4 years); 25 (46%) had a serum creatinine level >106 micromoles/liter, and 29 (53%) had nephrotic syndrome. At 12 months posttreatment, 37 (67%) had complete remission and 12 (22%) had partial remission. The initial serum creatinine level was an independent predictor of complete remission. Excluding the 4 patients who were treatment- resistant or died, 21 patients (41%) had renal flares during a median followup of 4 years. The cumulative risk of renal flare was 6% at 1 year, 21% at 3 years, and 32% at 5 years. The median time to relapse was 43 months. The histologic activity score and the mean daily dose of CYC were multivariate predictors of renal flare, by Cox regression. At the last followup visit, 9 of 54 patients (17%) had a doubling of the creatinine level, 6 of whom (11%) underwent dialysis. The cumulative risk of creatinine doubling was 8.4% at 5 years and 18.2% at 10 years. An increasing chronicity index at the time of initial renal biopsy was an independent predictor of deterioration in renal function.

CONCLUSION

Sequential therapy with oral CYC followed by AZA appears to be an effective treatment regimen for DPGN in patients with SLE, with 89% of patients achieving complete or partial remission at 12 months, 62.8% remaining in remission after 5 years, and 81.8% having stable renal function after 10 years. Predictors of treatment resistance and relapse include increasing serum creatinine level, higher histologic activity scores, and a lower dose of CYC. Increasing chronicity indices predict a deterioration of renal function.

Long-term followup of patients treated with total lymphoid irradiation for lupus nephritis

OBJECTIVE

To describe the long-term survival, renal condition, and morbidity outcomes in patients who received total lymphoid irradiation (TLI) for the treatment of lupus nephritis.

METHODS

Twenty-one patients with biopsy-proven, diffuse membranoproliferative glomerulonephritis and significant proteinuria of >2.5 grams/day received TLI from 1980 to 1987 at Stanford University Medical Center. All patients had previously failed to respond to treatment with high-dose corticosteroids or therapy with corticosteroids plus immunosuppressive agents (azathioprine, cyclophosphamide, or chlorambucil).

RESULTS

The mean duration of followup since TLI was 10.7 years. Fifteen of 21 patients (71%) remained alive at the time of this assessment. Nine of the 21 patients (43%) survived without developing end-stage renal disease (ESRD). The probability of long-term survival without ESRD and without need for additional immunosuppressive agents after TLI was 19% (4 of 21). Factors predicting renal failure at the time of TLI included elevated creatinine levels, increased interstitial fibrosis on renal biopsy, and increased fractional excretion of immunoglobulin and albumin. Malignancies were found in 4 patients, and opportunistic infections occurred in 7 patients.

CONCLUSION

Overall, patients with lupus nephritis treated with TLI do not appear to have better 10-year survival with lower incidence of ESRD compared with patients in published series treated with conventional immunosuppressive therapies. However, in this series of patients, treatment with conventional immunosuppressive therapies had been unsuccessful and given the limited number of adverse events and the efficacy seen in some patients, TLI appears to be a reasonable therapeutic option for the treatment of severe lupus nephritis among patients who fail to respond under standard cytotoxic regimens.

Clinical trials in lupus nephritis

Significant advances in the treatment of lupus nephritis have been made in the last 50 years, beginning with the use of high doses of corticosteroids. The addition of intravenous cyclophosphamide (IVC) to steroids, a regimen introduced by the National Institutes of Health, has become the standard of care therapy for severe active nephritis. However, not all patients respond to IVC, and among those who do, manifestations of toxicity (nausea, vomiting, alopecia, sterility, increased risk of infection, and increased risk of malignancy) are frequent. Despite successful induction and maintenance therapy with IVC, there is a relapse rate of more than 50% after 10 years. In recent years, new immunosuppressive agents have been studied as potential alternatives to IVC. The most promising of these appears to be mycofenolate mofetil, which is being evaluated in clinical trials. Biologic agents designed to interfere with the immunologic process leading to B- and T-lymphocyte activation are also being tested as alternative therapies in lupus nephritis.

Prevention of autoantibody formation and prolonged survival in New Zealand Black/New Zealand White F1 mice with an ancient Chinese herb, Ganoderma tsugae

For centuries, Chinese medicine has regarded Ganoderma, a fungus (Myceteae, Amastigomycota, Busidomycetes, Aphyllophorales, Polyporaceae, Ganoderma) also known as 'Ling Zhi' in Mandarin, as a premium remedy for many diseases. Until now, no convincing data regarding its therapeutic effects in vivo on autoimmune diseases have been demonstrated. In this study, a controlled protocol was conducted in which New Zealand Black/White F1 mice were fed standard chow with prednisolone (0.5 mg/kg/day) or Ganoderma tsugae extract, commencing at 2 months of age. It was found that the F1 mice responded well to Ling Zhi extract. Ling Zhi improved the survival rate of lupus mice, decreased the amount of proteinuria, decreased serum levels of anti-dsDNA autoantibody, and showed evidence of decreased perivascular and parenchyma mononuclear cell infiltration in vital organs.

Infections in outpatients with systemic lupus erythematosus: a prospective study

The objective of this study was to assess the incidence and risk factors of infections in 200 SLE outpatients. All outpatients with active or inactive SLE without infections in the previous month were included. They were assessed every 3 months. Major infections were those requiring hospitalization and parental antibiotic therapy; minor infections required oral or topical therapy. Sociodemographic, disease activity using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), therapy and laboratory variables were evaluated. After a follow-up of 22+/-7 months, 65 (32%) patients had infections; 35% of those were major. The most common sites for infection were urinary (26%), skin (23%), systemic (12%), and vaginal (9%). At infection onset, 50 of 65 patients (77%) had disease activity, with a mean SLEDAI score of 6.1. The variables significantly associated with infection in the univariate analyses were the presence of disease activity, SLEDAI score, renal activity, prednisone dose, and IV cyclophosphamide. The only variable associated with infection in the multivariate analyses was a SLEDAI score of 4 or higher. Most infections in SLE outpatients were single, minor, non-life threatening, and associated with disease activity independently of sociodemographic and therapeutic factors.

Risk factors for ovarian failure in patients with systemic lupus erythematosus

The aim of the present study was to identify the risk factors for ovarian failure in patients with systemic lupus erythematosus. Seventy-one women aged 17 to 45 years with systemic lupus erythematosus were studied. Patients were interviewed and their medical records reviewed. Demographic characteristics, clinical and serologic profiles, and menstrual and obstetric histories were recorded. Disease activity was measured by the systemic lupus erythematosus disease activity index. Serum FSH, LH, estradiol, progesterone, TSH, prolactin, and antimicrosomal and antithyroglobulin antibodies were measured. Patients who developed ovarian failure were compared to those who did not. Ovarian failure occurred in 11 patients (15.5%) and nine had premature menopause (11.3%). Cyclophosphamide administration and older patient age were found to be associated with ovarian failure. The cumulative cyclophosphamide dose was significantly higher in patients with ovarian failure than in those without this condition (18.9 vs 9.1 g; P = 0.04). The relative risk for ovarian failure in patients with cumulative cyclophosphamide dose higher than 10 g was 3.2. TSH levels were high in 100% of patients with ovarian failure who had received pulse cyclophosphamide. Ovarian failure, and premature menopause in particular, is common in patients with systemic lupus erythematosus, with the most important risk factors being cyclophosphamide dose and age. Thyroid problems may be another risk factor for ovarian failure in patients with lupus.

Therapy with pulse methylprednisolone and short course pulse cyclophosphamide for diffuse proliferative glomerulonephritis

The incidence of renal flares and the long-term outcome in a group of 33 systemic lupus erythematosus (SLE) patients with diffuse proliferative glomerulonephritis (DPGN) treated with pulse steroids and a short course of pulse cyclophosphamide (CYC) are evaluated. Fifteen patients (45%) experienced a flare of renal disease at some time after the discontinuation of the immunosuppressive (IS) therapy; among these half (24%) were 'early' flares occurring shortly after the discontinuation of therapy, and the other half (21%) were 'late' flares occurring more than 2 y after the discontinuation of the treatment. Nine patients (27%) showed a poor renal outcome at the end of follow-up. On multiple regression analysis, a younger age and a high activity index (AI) on renal histology were found to be correlated with the occurrence of renal flares. Our results suggest that the combination of pulse steroids with a short course of pulse CYC (six to nine pulses) is effective in both controlling disease activity and in preventing the occurrence of renal flares in DPGN. However, short term IS therapy might not be sufficient to maintain disease control in younger patients with active lesions on renal histology. Such patients might be candidates to receive more prolonged IS treatment.

Understanding patient preferences for the treatment of lupus nephritis with adaptive conjoint analysis

BACKGROUND

Incorporation of patient preferences into treatment decisions is an essential component of medical care. Conjoint analysis is an established method of eliciting consumer preferences in market research and is being increasingly used to study patient preferences for health care.

OBJECTIVE

To examine the value of Adaptive Conjoint Analysis (ACA), a unique method of performing conjoint analysis, and to evaluate patient treatment preferences.

RESEARCH DESIGN

Interactive computer survey.

SUBJECTS

Consecutive women (n = 103) with lupus followed in three community rheumatology practices.

MEASURES

ACA was used to assess patients' relative preferences for specific cytotoxic medication characteristics, and to estimate the percentage of women preferring cyclophosphamide over azathioprine for different risk-benefit scenarios.

RESULTS

All participants were able to complete the conjoint task in 14 +/-5 minutes. Of the nine medication characteristics studied, efficacy and risk for infection had the greatest impact on preference (each accounting for 20% of the variation in preferences), suggesting that patients consider differences in the risk for infection equally as important as differences in the probability of renal survival. Premenopausal women wanting more children were less likely to choose cyclophosphamide compared with their counterparts (56% vs. 80%, P = 0.04). Modest changes in the probability of renal survival or risk for major toxicity lowered the percentage of women preferring cyclophosphamide by more than 20%, irrespective of their desire for more children.

CONCLUSIONS

ACA is a feasible method of assessing how patients consider specific medication characteristics and predicting treatment preferences under different risk-benefit scenarios. ACA may be a valuable tool to incorporate patient preferences into medical decision-making.

Treatment of systemic lupus erythematosus

The treatment of systemic lupus erythematosus (SLE) is mainly based on a number of "traditional" drugs such as corticosteroids, antimalarials, azathioprine and cyclophosphamide. However, this scenario is rapidly changing due to the introduction of new compounds. Some of these new agents have been successfully used in other diseases, while others are being specifically designed to interfere with the immune abnormalities seen in SLE. As our knowledge on the mechanisms of immune response increases, new drugs that can interfere with T and B cell interaction and activation, production of anti-dsDNA autoantibodies, immune-complexes deposition and cytokine activation have been developed and some of these are now under investigation in SLE. Although initial data regarding their safety and efficacy are encouraging, caution must be taken before these drugs are considered as the treatment of choice for specific SLE manifestations. Specifically, controlled clinical trials with sufficient number of patients are necessary. If the promising results already available are confirmed, the use of these drugs might represent the keystone in the future management of SLE and other autoimmune diseases.

Cyclosporin A and therapeutic plasma exchange in the treatment of severe systemic lupus erythematosus

Despite treatment with intensive immunosuppressive drug regimens, often the prognosis of patients suffering from systemic lupus erythematosus (SLE) is poor. Side effects such as infections and malignancies often occur. It was the aim of this trial to assess the effect of immunosuppression, in particular with cyclosporin, and the efficacy, safety, and clinical utility of intermittent treatment with therapeutic plasma exchange (TPE) in comparison to previous intensive therapy strategies using corticosteroids, azathioprine, and/or cyclophosphamide. In this prospective trial, 28 patients (24 women, 4 men, aged 36.3 +/- 11.8 years at the diagnosis of SLE) were treated for up to 10 years with drug regimens out of corticosteroids, azathioprine, and/or cyclophosphamide. Then, over a period of up to 8 years, in addition to conventional therapies, especially in active stages of the disease with extremely high concentrations of anti-DNA, anti-nuclear antibodies, and circulating immunocomplexes, TPE sessions were carried out depending on symptomatology. In addition, the patients received cyclosporin. Compared with previous treatment modalities, clinical symptoms improved more quickly and more effectively. During the study period of a mean of 5 years, corticosteroids, azathioprine, and cyclophosphamide were reduced by 40 to 100%. No severe side effects were seen. In acute stages of SLE and in forms with persistently high antibody levels, the addition of TPE sessions and cyclosporin as the basic immunosuppressive drug is mostly very effective with regard to improving clinical symptomatology.

Long-term efficacy of azathioprine treatment for proliferative lupus nephritis

BACKGROUND

Combination therapy with cytotoxic drugs and corticosteroids reduces the risk for renal failure in patients with proliferative lupus nephritis (PLN), but uncertainty remains about the best mode of immunosuppression and its long-term effects. We report long-term results of combined azathioprine-prednisolone treatment for PLN, which has been the therapy of choice for the treatment of PLN at our centre for 15 yr.

PATIENTS AND METHODS

A retrospective cohort study was carried out of 26 lupus patients, seen between 1978 and 1993, with histological and/or clinical evidence of PLN. Therapy consisted of prednisolone 1 mg/kg daily, tapered after 4 weeks to the lowest possible maintenance dose combined with azathioprine up to 2.5 mg/kg. Median duration of azathioprine treatment was 53 months. Standard statistical lifetable analyses were performed.

RESULTS

Median follow-up on 1 January 1998 was 119 months. Patient survival estimates after 5, 10 and 15 yr of follow-up were 96, 91 and 82%, respectively. Four patients (15%) developed end-stage renal failure and three received renal transplants after a mean period of 27 months on haemodialysis. Renal survival estimates after 5, 10 and 15 yr of follow-up were 92, 87 and 87%, respectively. No malignancies were seen during the study period.

CONCLUSION

Azathioprine treatment for 4-1/2 yr was well tolerated in this cohort of Caucasian patients with PLN and was associated with outcomes similar to those reported for pulse cyclophosphamide therapy.

Cyclophosphamide versus methylprednisolone for the treatment of neuropsychiatric involvement in systemic lupus erythematosus

BACKGROUND

Neuropsychiatric involvement in systemic lupus erythematosus is complex and several clinical presentations are related to this disease such as: convulsions, chronic headache, transverse myelitis, vascular brain disease, psychosis and neural cognitive dysfunction.

OBJECTIVES

To assess the efficacy and safety of cyclophosphamide and methylprednisolone in the treatment of neuropsychiatric manifestations of systemic lupus erythematosus on mortality and side effects.

SEARCH STRATEGY

We searched EMBASE, LILACS, Cochrane Controlled Trials Register and MEDLINE up to and including December 1999, additional articles were sought through handsearching in relevant journals, using the search strategy described in the Cochrane Handbook [Dickersin 1994]. There were no language restrictions.

SELECTION CRITERIA

All randomized controlled trials which compared cyclophosphamide to methylprednisolone were to be included. Patients of any age and gender were included if they fulfilled the criterion of the American Rheumatology Association for the diagnosis of systemic lupus erythematosus and presented with any one of the following neuropsychiatric events; convulsions, organic brain syndrome; cranial neuropathy. Outcome measures included the following: a) Overall mortality (primary event); b) Motor and psychiatric deficit (primary event); c) Clinical improvement (secondary event).

DATA COLLECTION AND ANALYSIS

The analysis planned was to do the following: Data would be independently extracted by the two reviewers and cross-checked. The methodological quality of each trial would be assessed by the same two reviewers. Details of the randomisation (generation and concealment), blinding, and the number of patients lost on follow-up would be recorded. The results of each RCT would be summarised on an intention-to-treat basis in 2 x 2 tables for each outcome. External validity would be defined by characteristics of the participants, the interventions and the outcomes. If appropriate, RCTs would be stratified based on control group and category of disease in accordance to the clinical homogeneity (external validity). The results obtained from these different methods are very similar, and therefore, only the results from the Risk Difference method, with the corresponding 95% confidence interval would be presented in this review. The fixed effects model would be used if there was no significant statistical heterogeneity.

MAIN RESULTS

We found no randomised controlled trials comparing cyclophosphamide versus methylprednisolone for the treatment of neuropsychiatric involvement in the systemic lupus erythematosus.

REVIEWER'S CONCLUSIONS

Cyclophosphamide regimen treatment is a form of care in neuropsychiatric involvement in systemic lupus erythematosus with no evidence to prove better effectiveness and safety when compared with methylprednisolone. This systematic review found no randomised controlled trials and its findings must be interpreted as 'no evidence of effect' and not as 'evidence of no effect'.

Remission, relapse, and re-remission of proliferative lupus nephritis treated with cyclophosphamide

Remission, relapse, and re-remission of proliferative lupus nephritis treated with cyclophosphamide.

BACKGROUND

Long-term intravenous cyclophosphamide (IVC) in combination with corticosteroids is standard therapy for proliferative lupus nephritis, but it has limitations. There are few data on long-term remission rates, predictors of relapse, and the ability to achieve a second remission with currently recommended IVC regimens.

METHODS

A cohort of 85 patients with proliferative lupus glomerulonephritis (focal N = 33, diffuse N = 52) treated with IVC was assembled in three institutions. Timing and predictors of remission, relapse, and re-remission were evaluated with Kaplan-Meier analyses and Cox models.

RESULTS

The median time to remission was 10 months, whereas an estimated 22% of patients had not remitted after 2 years. The median time to relapse among 63 patients who had achieved remission was 79 months. In multivariate models, adverse predictors of remission were a delay in the initiation of therapy from the time nephritis was clinically diagnosed [hazard ratio (HR) 0.58, P = 0. 063] and a higher amount of proteinuria (HR 0.86 per 1 g/24 hours, P = 0.014). Predictors of earlier relapse for patients entering remission included a longer time to remission (HR 1.029 per month, P = 0.025), a history of central nervous system involvement (HR 8.41, P = 0.002), and World Health Organization histology (P = 0.01). Among the 23 patients who relapsed during follow-up, the median time to re-remission was 32 months, and with three exceptions, all patients took substantially longer time to remit the second time compared with their first remission (P = 0.01). The time to re-remission was longer in patients who had taken longer to remit the first time (HR 0.979 per month, P = 0.16), in patients who had relapsed earlier after the first remission (HR 1.071 per month, P = 0.002), and in those with evidence of chronicity in the original kidney biopsy (P = 0.015).

CONCLUSIONS

Prolonged courses with a cumulative risk of toxicity are needed to achieve remission in many first-treated patients and in most patients treated for a second time. The optimal management of patients with identified adverse predictors of response needs further study.

[Treatment of lupus nephritis in children]

The severity of renal disease in systemic lupus erythematosus is variable. Renal biopsy is important to guide the treatment. The World Health Organization classification define six different histological categories with possible transformations from one category to another. Histological signs of activity or chronicity are important with respect to prognosis and treatment. Examination of renal biopsy allows predicting the reversibility of histological lesions following therapy. Apart from histological signs of severity, other factors may influence the prognosis: arterial hypertension, initial serum creatinine, the delay between onset of renal disease and treatment, the occurrence of exacerbations of the nephropathy, and the response to therapy by the end of the first year. The prognosis of severe forms of lupus nephritis, mainly diffuse proliferative glomerulonephritis, has improved during the last 20 years. The addition of immunosuppressive agents (cyclophosphamide, azathioprine) to corticosteroids is responsible for this improvement. Methylprednisolone pulses are as effective as oral high doses of prednisone during initial treatment and have fewer side effects. Many authors advocate monthly cyclophosphamide pulses over six months, sometimes followed by quarterly pulse cyclophosphamide. However, such an approach has not been proven to be more effective than an oral course of cyclophosphamide and/or azathioprine. On follow-up, steroid therapy should be slowly tapered, and close monitoring of lupus serological parameters (anti-DNA antibodies, complement), urinary protein excretion rate, urinary sediment and renal function allow one to detect exacerbations of the disease, which may require adapted therapy. While such protocols have improved the outcome, they have potential side effects. In addition to the deleterious effect of steroids on physical appearance, often badly tolerated by adolescents, immunosuppressive treatments increase the risks of severe infectious complications and the risks of cardiovascular complications in young adults.

Prognostic value of renal biopsy and clinical variables in patients with lupus nephritis and normal serum creatinine

OBJECTIVE

To evaluate factors with possible influence on the renal outcome in patients with lupus nephritis but without chronic renal insufficiency (CRI).

METHODS

Renal biopsies from 94 patients were re-assessed with regard to WHO class, activity, chronicity and tubulointerstitial indices without knowledge of clinical features. The outcome parameters were CRI defined as irreversibly increased serum creatinine and renal end stage disease.

RESULTS

The risk ratios (RR) of developing CRI were 2.6 for active urinary sediment, 3.1 for hyaline thrombi and 7.3 for glomerular leukocyte exudation. The RR of renal end stage disease was 5.0 when the duration of renal disease exceeded one year at the time of biopsy and 4.3 when biopsy disclosed a class IV lesion. Glomerular sclerosis was also associated to renal end stage disease.

CONCLUSION

Early renal biopsy and the abovementioned signs of active renal disease carry prognostic information that may have significant therapeutic implications.

Evaluation of recent clinical trials in lupus

Clinical trials in lupus pose many challenges, ranging from small numbers of subjects to endpoints that are difficult to quantify. Improved standardization of both design and appropriate endpoints is necessary. Recent trials have been small in number, with few randomized controlled trials. These trials have evaluated therapies such as methotrexate, cyclosporine A, bromocriptine, immunoadsorption columns, and hydroxychloroquine withdrawal. With the advent of improved techniques as well as newer therapeutic agents, options for the treatment of lupus should begin to grow over the next several years in a fashion similar to that which has been seen in rheumatoid arthritis.

Guidelines for referral and management of systemic lupus erythematosus in adults. American College of Rheumatology Ad Hoc Committee on Systemic Lupus Erythematosus Guidelines

SLE is a complex disorder with variable presentations, course, and prognosis. Since its prevalence is only 1/1,000, most primary care physicians and general internists will not have sufficient experience in the management of moderate-to-severe life-threatening disease. The major tasks of the primary care physician in the diagnosis and management of patients with SLE include early diagnosis, appropriate referral, monitoring patients with mild, stable disease, and collaboration with a specialist in the management of severe disease. Guidelines for the initial evaluation, reasons for referral, and management of mild and severe SLE are provided.

Therapeutic plasma exchange and cyclosporine in the treatment of systemic lupus erythematosus

Despite treatment with intensive immunosuppressive drug regimens, often the prognosis of patients suffering from systemic lupus erythematosus (SLE) is poor. Side effects such as infections and malignant tumors often occur. In the present trial, 21 patients (4 male and 17 female, aged 37.9 +/- 12.8 years) suffering from SLE for 9.4 +/- 2.6 years, were treated for 2.3 +/- 1.8 years with drug regimens of corticosteroids, azathioprine and/or cyclophosphamide. Then, over a period of up to 8 years, in addition to conventional therapies, especially in active stages of the disease with extremely high concentrations of anti-DNA-, antinuclear antibodies and circulating immunocomplexes, therapeutic plasma exchange (TPE) sessions were carried out depending on symptomatology. In addition patients received 2.5 +/- 0.6 mg cyclosporine/kg body weight/day. Compared to previous treatment modalities, clinical symptoms improved more quickly and more effectively (p = 0.046). After 5 to 48 (17.5 +/- 13.8) months, cyclosporine was established as a monotherapy for 8 of 21 patients. In the other cases, corticosteroids, azathioprine and cyclophosphamide were reduced by 40 to 100%. No severe side effects were seen. In acute stages of SLE and in forms with persistently high antibody levels, the addition of TPE sessions and cyclosporine as the basic immunosuppressive drug is usually very effective with regard to improving clinical symptomatology.

Anti-DNA autoantibodies and systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that affects most of the organs and tissues of the body, causing glomerulonephritis, arthritis, and cerebritis. SLE can be fatal with nephritis, in particular, predicting a poor outcome for patients. In this review, we highlight what has been learned about SLE from the study of mouse models, and pay particular attention to anti-DNA autoantibodies, both as pathological agents of lupus nephritis and as DNA-binding proteins. We summarize the current approaches used to treat SLE and discuss the targeting of anti-DNA autoantibodies as a new treatment for lupus nephritis.

Beneficial effect of the inosine monophosphate dehydrogenase inhibitor mycophenolate mofetil on survival and severity of glomerulonephritis in systemic lupus erythematosus (SLE)-prone MRLlpr/lpr mice

The aim of the present study was to evaluate the therapeutic effect of mycophenolate mofetil (MMF) on the course of disease in SLE-prone MRLlpr/lpr mice. Three-months-old mice displaying clinical symptoms of glomerulonephritis were given MMF (100 mg/kg per day) orally via the drinking water. Control mice received i.p. injections of cyclophosphamide (CYC) (1.8 mg/mouse per week) or saline. Survival, albuminuria and haematuria, immunoglobulin levels and anti-dsDNA antibodies in serum, frequencies of immunoglobulin-producing B lymphocytes and glomerular deposits of immunoglobulin and C3 were analysed. The results showed that MMF treatment significantly prolonged survival and reduced the occurrence of albuminuria and haematuria in MRLlpr/lpr mice. In addition, the number of immunoglobulin-producing B cells and serum levels of IgG and IgG anti-dsDNA antibodies were reduced after MMF and CYC treatment. MMF treatment significantly reduced the extent of deposition of C3 in glomeruli. We conclude that the reduced severity of glomerulonephritis following treatment of lupus-prone mice with MMF was as efficacious as that of CYC. These results warrant clinical trials of MMF in SLE patients with glomerulonephritis.

Renal involvement in systemic lupus erythematosus. A study of 180 patients from a single center

Charts of 180 patients (147 women, 33 men) with systemic lupus erythematosus (SLE) complicated by renal involvement were retrospectively analyzed from a series of 436 patients. Mean age at renal disease onset was 27 years. Thirty-six percent of the patients had renal involvement after diagnosis of lupus, for 30.7% of that group it was more than 5 years later. Renal involvement occurred more frequently in young male patients of non-French non-white origin. Patients with renal involvement suffered more commonly from malar rash, psychosis, myocarditis, pericarditis, lymphadenopathy, and hypertension. Anemia, low serum complement, and raised anti-dsDNA antibodies were more frequent. According to the 1982 World Health Organization classification, histologic examination of initial renal biopsy specimen in 158 patients showed normal kidney in 1.5% of cases, mesangial in 22%, focal proliferative in 22%, diffuse proliferative in 27%, membranous in 20%, chronic sclerosing glomerulonephritis in 1%, and other forms of nephritis in 6.5%. Distribution of initial glomerulonephritis patterns was similar whether renal involvement occurred before or after the diagnosis of lupus. Transformation from 1 histologic pattern to another was observed in more than half of the analyzable patients (those who underwent at least 2 renal biopsies). Nephritis evolved toward end-stage renal disease in 14 patients despite the combined use of steroids and cyclophosphamide in 12. Initial elevated serum creatinine levels, initial hypertension, non-French non-white origin, and proliferative lesions on the initial renal biopsy were indicators of poor renal outcome. Twenty-four patients died after a mean follow-up of 109 months from SLE diagnosis. Among our 436 patients, the 10-year survival rate was not significantly affected by the presence or absence of renal involvement at diagnosis (89% and 92%, respectively).

LUPUS NEPHRITIS-A CRITICAL ANALYSIS OF 17 PATIENTS

Over a 3 year period from June 94 to June 97, out of 28 patients of systemic lupus, 17 were diagnosed as renal lupus. Demographic data showed 12 females and 5 males, mean age being 32.2 years (range 12 to 54 years). Mean time gap between presentation and definitive diagnosis was 32.4 days (7 days to 5 years). 2 patients (11.76%) presented renal lupus, one (5.88%) with acute interstitial lung disease and the remaining had the usual systemic manifestations of lupus. Anti dsDNA antibodies were positive in all patients while ANA was negative in 3 cases. Renal involvement consisted of rapidly progressive glomerulonephritis in 2 patients (11.76%), nephrotic syndrome in 4 (23.52%) and non nephrotic range proteinuria in 11 (64.70%) patients. Mean serum creatinine at presentation was 2.4mg/dl (0.8mg/dl to 8.9 mg/dl). Three patients were dialysis dependent. Renal histology on light microscopy comprised of class II lesions in one (5.88%), class III in 4 (23.52%), class IV in 11 (64.70%-including one with crescents) and class V in one (5.88%) patient. All patients with advanced class III/IV lesions were treated with corticosteroids and cyclophosphamide pulses. Except one patient who died of pyopericardium all others improved and their serum creatinine stabilised around 2.3 mg/dl (0.8 to 4.6 mg/dl). The study highlights the importance of early diagnosis and aggressive management in this potentially treatable disease.

'Sustained remission' in a case of SLE following megadose cyclophosphamide

Cytotoxic therapy, especially with cyclophosphamide in the dose 8-20 mg/kg used as intermittent pulses, has been shown to improve both patient and renal survival in systematic lupus erythematosus (SLE), but to date there is no cure for the disease. Owing to the paucity of recognisable clones, the rationale and goal of cytotoxic immunosuppressive therapy in the treatment of immune-mediated diseases as against malignancies is to suppress the aberrant inflammation and immune-mediated reactions responsible for tissue damage, without dangerously suppressing the normal host defence mechanism(s). We report the case of a patient suffering from SLE with nephritis who has remained in sustained remission over the past 8 years without any maintenance therapy following an accidental administration of a single dose of 5000 mg of intravenous cyclophosphamide (44.2 mg/kg body weight). The patient recovered fully from pancytopenia following the injection. Presently, she is asymptomatic and working gainfully. Her laboratory parameters including blood counts, urine analysis, FANA and anti-dsDNA have reverted to normal. Cyclophosphamide in the dose of 30-160 mg/kg has been safely and effectively used in various neoplastic conditions with the aim of destroying every possible tumour cell. The experience of the present case suggests that such an approach may be applicable to SLE.

Outcome criteria for lupus nephritis trials: a critical overview

Lupus nephritis is an important cause of morbidity and mortality in patients with systemic lupus erythematosus. Traditional outcome criteria such as doubling of serum creatinine, end-stage renal disease and death have been used in controlled therapeutic trials, but are limited by their low incidence and the extended period of time required to reach them. More recently, discussions have focused on composite outcome measures, such as remission and relapse, as well as measures of health-related quality of life, general lupus activity and cumulative damage indexes. We review the strengths and weaknesses of several outcome criteria, and we propose criteria for both small pilot studies and large definitive trials.

Lupus nephritis in children

The renal manifestations of systemic lupus erythematosus in childhood range from minor abnormalities detected on urinalysis to severe renal insufficiency requiring renal replacement therapy. Clinically significant renal involvement in systemic lupus erythematosus is more common in children than in adults. Effective treatment for childhood lupus nephritis is available, and the prognosis for affected children has improved over the course of the last 30 years. Corticosteroid therapy remains the cornerstone of treatment for children with lupus nephritis. The addition of cytotoxic agents to corticosteroid treatment improves both the long and short-term prognoses. Cyclosporin may improve the clinical manifestations of lupus nephritis although the disease remains active serologically. Although survival in childhood lupus has improved, complications of therapy result in significant morbidity with distressing frequency. Immunosuppression may result in mortality and morbidity due to opportunistic infections. Individuals with otherwise successful control of renal manifestations of systemic lupus erythematosus may still be left with significant morbidity due to disturbances in growth due to long-term corticosteroid treatment. Psychosocial development may be adversely affected both as a result of chronic illness as well as due to the effects of therapy. Meticulous attention to detail over decades of treatment is necessary to optimize patient outcome in childhood lupus nephritis.

A New Strategy for Treatment of Autoimmune Diseases in Chimeric Resistant MRL/lpr Mice

A new strategy for the treatment of autoimmune diseases in chimeric resistant MRL/lpr mice is established. The strategy includes injection of cyclophosphamide (CY), fractionated irradiation (5 Gy × 2), bone grafts (to recruit stromal cells), and two transplantations of whole bone marrow cells (WBMCs) from allogeneic normal C57BL/6 mice (CY/2X/Bone/2BMT). MRL/lpr mice, thus treated, survived more than 40 weeks (1 mouse survived for >40 weeks, 7 for >50 weeks, and 4 for >60 weeks after these treatments). Immunohistological studies showed that the mice were completely free from both lymphadenopathy and autoimmune diseases such as systemic lupus erythematosis and rheumatoid arthritis. The levels of autoantibodies (IgM/IgG rheumatoid factors and IgM/IgG anti-ssDNA antibodies [Abs]) in the treated mice decreased to those in the normal mice. In addition, successful cooperation among T cells, B cells, and antigen-presenting cells (APCs) was observed. Abnormal T cells with immunophenotypes of B220+/Thy-1+/CD3+/CD4−/CD8−present in untreated MRL/lpr mice disappeared, and the hematolymphoid cells of the treated mice were of donor origin. However, the mice that had been irradiated with 8.5 Gy and then reconstituted with T-cell–depleted BMCs plus bone grafts died within 2 weeks due to the side effect of irradiation. The depletion of CD8+ cells (not CD4+ cells) from WBMCs resulted in graft failure; 60% of the recipient mice, thus treated, died within 2 weeks, and all recipients died by 15 weeks. Furthermore, limiting dilution assays showed that approximately more than 0.5% of T cells contained in the BMCs are necessary not only for engraftment of BMCs but also for long-term disease-free survival of the recipients. In contrast, recipients that had received CD4-depleted BMCs with CY plus fractionated irradiation (5Gy × 2) survived for more than 40 weeks without showing graft-versus-host reaction (GVHR). This indicates that CD8+cells in the BMCs are essential for the successful engraftment of the donor-type hematolymphoid cells.

A New Strategy for Treatment of Autoimmune Diseases in Chimeric Resistant MRL/lpr Mice

A new strategy for the treatment of autoimmune diseases in chimeric resistant MRL/lpr mice is established. The strategy includes injection of cyclophosphamide (CY), fractionated irradiation (5 Gy × 2), bone grafts (to recruit stromal cells), and two transplantations of whole bone marrow cells (WBMCs) from allogeneic normal C57BL/6 mice (CY/2X/Bone/2BMT). MRL/lpr mice, thus treated, survived more than 40 weeks (1 mouse survived for >40 weeks, 7 for >50 weeks, and 4 for >60 weeks after these treatments). Immunohistological studies showed that the mice were completely free from both lymphadenopathy and autoimmune diseases such as systemic lupus erythematosis and rheumatoid arthritis. The levels of autoantibodies (IgM/IgG rheumatoid factors and IgM/IgG anti-ssDNA antibodies [Abs]) in the treated mice decreased to those in the normal mice. In addition, successful cooperation among T cells, B cells, and antigen-presenting cells (APCs) was observed. Abnormal T cells with immunophenotypes of B220+/Thy-1+/CD3+/CD4−/CD8−present in untreated MRL/lpr mice disappeared, and the hematolymphoid cells of the treated mice were of donor origin. However, the mice that had been irradiated with 8.5 Gy and then reconstituted with T-cell–depleted BMCs plus bone grafts died within 2 weeks due to the side effect of irradiation. The depletion of CD8+ cells (not CD4+ cells) from WBMCs resulted in graft failure; 60% of the recipient mice, thus treated, died within 2 weeks, and all recipients died by 15 weeks. Furthermore, limiting dilution assays showed that approximately more than 0.5% of T cells contained in the BMCs are necessary not only for engraftment of BMCs but also for long-term disease-free survival of the recipients. In contrast, recipients that had received CD4-depleted BMCs with CY plus fractionated irradiation (5Gy × 2) survived for more than 40 weeks without showing graft-versus-host reaction (GVHR). This indicates that CD8+cells in the BMCs are essential for the successful engraftment of the donor-type hematolymphoid cells.

Lupus erythematosus: considerations for dentistry

Lupus erythematosus, or LE, is a connective tissue disease that affects a number of organ systems. Patients with this condition can experience several other serious conditions--bleeding, infection, endocarditis, adrenal insufficiency and mucocutaneous disease--that can affect the provision of dental care. The authors describe considerations for managing dental treatment of patients with LE.

Cyclosporine and therapeutic plasma exchange in treatment of progressive autoimmune diseases

Despite treatment with intensive immunosuppressive drug regimens, the prognosis of patients suffering from severe progressive autoimmune diseases like systemic lupus erythematosus (SLE), nephrotic syndrome (NS), and Behçet's disease is poor. Side effects (infections and malignant tumors) often occur. In the present trial, 35 patients suffering from autoimmune diseases (SLE, n = 21; NS, n = 10; and Behçet's disease, n = 4) were treated for 3.7 +/- 2.0 years with 2.5 +/- 0.6 mg cyclosporine/kg body weight/day in addition to corticosteroids alone or in combination with azathioprine and/or cyclophosphamide. In active stages of the diseases with extremely high concentrations of anti-ds-DNA-antibodies, antinuclear antibodies, circulating immunocomplexes, and reduced complement concentrations, therapeutic plasma exchange (TPE) has been applied. Compared with previous treatment modalities, significantly (p < 0.05) more effective and rapid reductions of the antibodies were reached. Clinical disorders improved within 1-6 weeks. All patients reported increased performance and a better quality of life. After 1-12 months, the previously required doses of immunosuppressive drugs and the frequency of TPE could be reduced by 40-100%. After 13.4 +/- 11.8 months in 17 of 35 patients (8 with SLE, 5 with NS, 4 with Behçet's disease), cyclosporine was established as the monotherapy. No severe side effects were registered. In treating active stages of severe progressive autoimmune diseases and forms with persistent high antibody levels, the addition of TPE to conventional therapy was very effective, as observed in both clinical and laboratory parameters.

Immunosuppressive treatment in severe connective tissue diseases: effects of low dose intravenous cyclophosphamide

OBJECTIVE

To review our experience with low dose intravenous pulse cyclophosphamide in the treatment of patients with severe connective tissue diseases.

PATIENTS

Ninety patients (68F:22M) with severe connective tissue diseases received a total of 883 cyclophosphamide pulses with 78 of 90 patients initially having weekly 500 mg pulses for a median of three (2-10) weeks. Diagnoses included: systemic lupus erythematosus (SLE) (n = 43); systemic vasculitides (n = 42); idiopathic inflammatory myopathies (n = 4); mixed essential cryoglobulinaemic vasculitis (n = 1). The median age was 48 (range 22-76) years with a median disease duration of 94 (18-250) months.

RESULTS

Complete or partial remission was noted in 68 of 90 patients (75.5%) after a median follow up of 56 (5-213) months. At follow up significant median changes were noted in SLE patients: erythrocyte sedimentation rate (ESR) from 44 to 22 mm 1st hour; anti-dsDNA antibody concentrations from 81 to 48 IU/ml; proteinuria from 2.5 to 1.5 g/day; serum albumin from 36 to 40 g/l; complement C3 from 0.88 to 0.90 g/l, and C4 from 0.18 to 0.22 g/l. In the vasculitis patients significant median changes were seen in: ESR from 44 to 15 mm 1st hour; C reactive protein (CRP) from 16 to 5 g/dl; neutrophils from 8.55 to 4.3 x 10(9)/l; platelets from 340 to 261 x 10(3)/l, and haemoglobin from 12.6 to 13.2 g/dl. Patients with Churg-Strauss syndrome, Wegener's granulomatosis, and neuropsychiatric lupus showed the best initial response but 58% of Wegener's patients relapsed. Median corticosteroid doses were significantly reduced from 15 (5-60) mg to 10 (3-35) mg daily. Adverse events: infections (7 patients), neutropenia (5), lymphopenia (18), and haemorrhagic cystitis (1 intravenous and 2 oral cyclophosphamide), allergies to mesna (2). None of the women at risk had prolonged amenorrhoea. Five patients doubled their serum creatinine and five died from sepsis (2) or severe disease (3).

CONCLUSION

Treatment of severe connective tissue diseases with 'low dose' intravenous cyclophosphamide pulses compares in efficacy with the higher monthly doses previously advocated. Treatment was well tolerated with fewer adverse effects and most significantly, there were no cases of premature ovarian failure.

Clinical features of Japanese children and adolescents with systemic lupus erythematosus: results of 1980-1994 survey

Marked advances have been made in the past decade in the management of adults with systemic lupus erythematosus (SLE). Therefore, a nationwide retrospective survey was conducted between 1980 and 1994 to investigate the clinical manifestations of SLE in Japanese children and adolescents. Questionnaires were sent to 340 hospitals. Of 405 patients reported by 176 hospitals, 373 patients, diagnosed by the criteria established by the Pediatric Study Group of the Japanese Ministry of Health and Welfare in 1985, were enrolled in the study. Forty-nine of the 354 patients (13.8%) had relatives with a connective tissue disease within the third degree of consanguinity. The frequent manifestations in 373 patients were the presence of antinuclear antibody (98.9%), immunologic disorders (93.0%), hypocomplementemia (87.1%), malar rash (79.6%) and fever (74.0%). Lupus nephritis was present in 148 of the 309 patients (47.9%) at their first visit to a clinic, and 261 of the 373 patients (70.0%) developed renal involvement during the observation period. Of 370 patients, 92 patients (24.9%) exhibited central nervous system lupus. Of 368 patients, 192 patients (52.2%) were treated by methylprednisolone pulse therapy and 148 patients (40.2%) received immunosuppressants in combination with steroid therapy at some stage during the observation period, Survival rate at 5 years from onset was 95.9%. Management of infection, coagulopathies, and central nervous system involvement is essential to improve the prognosis of SLE in Japanese children and adolescents.

Cyclosporin and plasmapheresis in treatment of progressive systemic lupus erythematosus (pSLE)

The prognosis of patients suffering from progressive systemic lupus erythematosus (pSLE) is poor, despite treatment with intensive drug regimens with combinations of corticosteroids, azathioprine and cyclophosphamide. Side-effects such as infections and malignomas often occur. In the present trial, 21 patients (four male, 17 female, aged 37.9 +/- 12.8) suffering from pSLE for 9.4 +/- 2.6 years, were treated for 2.3 +/- 1.8 years with drug regimens as mentioned above. Then, over a period of 6.4 +/- 2.6 (range 1-8) years, in addition to conventional therapies, cyclosporin (2.5 +/- 0.6 mg/kg body wt/d) and, in active stages of the disease with extremely high concentrations of anti-ds-DNA-, anti-nuclear antibodies and circulating immunocomplexes, plasmapheresis (therapeutic plasma exchange (TPE)) have been applied. Compared with previous treatment modalities, significantly (P < 0.05) more effective and rapid reduction of antibodies was achieved. Clinical symptoms improved within 2 to 4 weeks. Under the new therapeutic regimen all patients reported increased performance and a better quality of life. After 5 to 48 (17.5 +/- 13.8) months, cyclosporin was established as mono-therapy for 8/21 patients. In] the other cases, corticosteroids, azathioprine and cyclophosphamide were reduced by 40 to 100%. No severe side-effects were seen. In acute stages of pSLE and in forms with persistently high antibody levels, the addition of TPE to conventional therapy was very effective, with regard to improving both clinical and laboratory parameters.

Treatment of lupus nephritis: a meta-analysis of clinical trials

The best therapeutic choice in lupus nephritis remains shrouded in a body of controversial literature. The purpose of this review was to assess and compare by meta-analysis the efficacy of therapeutic agents used in the treatment of lupus nephritis using outcomes of end-stage renal disease (ESRD) and total mortality. An exhaustive search was performed using MEDLINE (1970 to 1995) and manual search of bibliographic notations and nonindexed sources. Twenty prospective controlled trials with treatment allocation by random assignment or consecutive enrollment were identified using diagnostic evidence of systemic lupus erythematosus based on American Rheumatism Association (ARA) criteria and clinical/biopsy evidence of lupus nephritis. One trial was excluded, resulting in 19 trials (n = 440) using treatment groups of oral prednisone alone, azathioprine with and without concomitant prednisone, oral cyclophosphamide with prednisone, azathioprine and oral cyclophosphamide with prednisone, and intravenous cyclophosphamide with prednisone. Crude risk data was pooled. An adjusted pooled risk was calculated using the random effects model of DerSimonian and Laird. Two measures of clinical effectiveness were used to compare treatments: absolute risk differences and number needed to treat. Analysis was completed between treatment groups as follows: oral prednisone compared with all immunosuppressive agents with prednisone and all treatment groups compared with one another. When compared with oral prednisone alone, immunosuppressive agents used in conjunction with oral prednisone were found to be statistically more effective for both total mortality and ESRD (absolute risk differences, 13.2% and 12.9%, respectively). When treatment groups were compared, intravenous cyclophosphamide in conjunction with oral prednisone was found to be statistically more effective than oral prednisone alone for both total mortality and ESRD (absolute risk differences, 19.9% and 16.2%, respectively). The simultaneous use of azathioprine and oral cyclophosphamide concomitant with oral prednisone was found to be 16.9% more effective than oral prednisone alone in reducing incidence of ESRD. No difference was seen in total mortality and data represented only two studies (n = 30). No immunosuppressive agent was found to be statistically more effective than another for either total mortality or ESRD. Future prospective studies are needed to control for numerous variables and renal function changes to provide more definitive answers.

"Nephritic flares" are predictors of bad long-term renal outcome in lupus nephritis

We retrospectively analyzed the courses of 70 patients with lupus nephritis followed for 5 to 30 years (median 127 months). Patients survival was 100% at 10 years and 86% at 20 years. The probability of not reaching the end point (persistent doubling of plasma creatinine) was 85% at 10 years and 72% at 20 years. A multivariate analysis of variables at presentation showed that male sex (P = 0.005) and hematocrit lower than 36% (P = 0.01) were associated with the end point (relative risk 7.5 and 14). We then analyzed for the role of renal flare-ups, defined either as a rapid increase in plasma creatinine or by an increase in proteinuria. Patients with renal flares of any type had more probabilities of reaching the end point than patients who never had flares (P = 0.03; relative risk 6.8). The hazard of the end point was 27 times higher in patients with flares along with rapid increased in plasma creatinine than in patients without flares or with flares with proteinuria alone (P < 0.00001). This hazard was higher when plasma creatinine did not return to the basal levels within two months after treatment (P < 0.00001).

Cumulative rate of relapse of lupus nephritis after successful treatment with cyclophosphamide

OBJECTIVE

To determine the cumulative rate of relapse of lupus nephritis that has been treated successfully with cyclophosphamide (CYC), and to estimate the association between time to relapse and demographic, clinical, laboratory, and treatment variables.

METHODS

This was an observational study of 48 systemic lupus erythematosus (SLE) patients who were treated successfully with CYC between 1979 and 1993 and followed up thereafter at 3 university hospitals. Demographic and clinical variables, laboratory data during the first month of nephritis, and therapy-related variables were recorded from charts. Renal biopsy specimens were retrieved and analyzed by a pathologist. Relapse of nephritis was the outcome of interest. Descriptive analysis of patients who did and those who did not have a relapse was performed by chi-square test, Fisher's exact test, and Wilcoxon 2-sample test. The cumulative rate of relapse was computed using the actuarial method. Univariate comparisons of time to relapse were computed by log-rank test. Proportional hazards modeling was used to assess the combined effect of patient characteristics that have been hypothesized to be prognostic factors.

RESULTS

Nephritis relapsed in 11 patients. Previous hematologic disorder, arthritis or arthralgia, and the use of CYC in oral form were more frequent in patients who had a relapse. The cumulative rate of relapse was 25% and 46% at 5 years and 10 years, respectively. A significant univariate difference in time to relapse was found when patients were stratified by time from diagnosis to initiation of CYC treatment (< or = 5 months versus > 5 months; P = 0.02). By multivariate analysis, age < 29 years at nephritis onset (relative risk [RR] 6.29, 95% confidence interval [95% CI] 1.13-34.94, P = 0.03) and delay of > 5 months from onset of nephritis to initiation of CYC therapy (RR 3.66, 95% CI 1.06-12.63, P = 0.04) were independently associated with time to relapse.

CONCLUSION

A selected population of SLE patients may have long-term remission of renal disease following successful CYC therapy. Patients in whom CYC treatment is delayed or who are young at the time of nephritis onset are at increased risk of relapse.