Choosing treatment for proliferative lupus nephritis

Variability of the impact of adverse events on physicians' decision making

Background

Physicians frequently differ in their treatment recommendations. However, few studies have examined the reasons underlying these differences. The objective of this study was to examine whether physicians vary in the importance they attach to specific adverse events for two treatment options found in recent randomized controlled trials to have equivalent efficacy and overall toxicity.

Methods

A Max-Diff survey was administered to physicians attending a national scientific conference to quantify the influence of 23 specific adverse events on decision making related to two treatment options for vasculitis. This approach was chosen because it results in greater item discrimination compared to rating scales. We used Hierarchical Bayes modeling to generate the relative importance score for each adverse event and examined the association between physicians’ characteristics and the five most influential factors.

Results

118 physicians completed the survey. The mean age (SD) was 48 years (10); 68% were male and 81% reported spending the majority of time in clinical practice. There was significant variability in the ratings of the relative importance of all adverse events, except those that were mild and easily reversible. We found a positive correlation between increasing physician age with ratings of sepsis (r = 0.29, p = 0.002) and opportunistic infection (r = 0.23, p = 0.016), and an inverse association between age with progressive multifocal leukoencephalopathy (r = - 0.28, p = 0.003). Physician sex, work setting, location, and number of patients with vasculitis seen per year were not associated with the influence of specific adverse events on decision making.

Conclusion

Our findings demonstrate that physicians differ substantially in how they perceive the importance of specific adverse events which may help explain observed unwarranted variability in physicians’ recommendations in clinical practice. Further efforts are needed to ensure that the reasons underlying variability in physicians’ recommendations are transparent.

Major lupus organ involvement: severe lupus nephritis

Lupus nephritis is a common and severe complication of systemic lupus erythematosus. A number of patients have nephritis as a presenting feature that, in its severe form, can shortly lead to end-stage renal disease and/or death. Renal flare usually occurs a few years after the first episode and is remarkably predominant in the Asian population. Frequent monitoring for renal flare enhances early recognition and timely treatment. The mainstay therapy continues to be the prolonged use of cytotoxic/immunosuppressive drugs that have a number of undesirable effects, particularly ovarian failure and development of opportunistic infections. This review will focus on the pathogenesis and the unique genetic factors found in Asian patients with lupus nephritis. Here, we propose an appropriate management scheme for the treatment of lupus nephritis in Asian patients.

Treatment of active lupus nephritis with the novel immunosuppressant 15-deoxyspergualin: an open-label dose escalation study

INTRODUCTION

As the immunosuppressive potency of 15-deoxyspergualin (DSG) has been shown in the therapy of renal transplant rejection and Wegener's granulomatosis, the intention of this study was to evaluate the safety of DSG in the therapy of lupus nephritis (LN).

METHODS

Patients with histologically proven active LN after prior treatment with at least one immunosuppressant were treated with 0.5 mg/kg normal body weight/day DSG, injected subcutaneously for 14 days, followed by a break of one week. These cycles were repeated to a maximum of nine times. Doses of oral corticosteroids were gradually reduced to 7.5 mg/day or lower by cycle 4. Response was measured according to a predefined decision pattern. The dose of DSG was adjusted depending on the efficacy and side effects.

RESULTS

A total of 21 patients were included in this phase-I/II study. After the first DSG injection, one patient was excluded from the study due to renal failure. Five patients dropped out due to adverse events or serious adverse events including fever, leukopenia, oral candidiasis, herpes zoster or pneumonia. Eleven out of 20 patients achieved partial (4) or complete responses (7), 8 were judged as treatment failures and 1 patient was not assessable. Twelve patients completed all nine cycles; in those patients, proteinuria decreased from 5.88 g/day to 3.37 g/day (P = 0.028), Selena-SLEDAI (Safety of Estrogens in Lupus Erythematosus-National Assessment-systemic lupus erythematosus disease activity index) decreased from 17.6 to 11.7. In 13 out of 20 patients, proteinuria decreased by at least 50%; in 7 patients to less than 1 g/day.

CONCLUSIONS

Although the number of patients was small, we could demonstrate that DSG provides a tolerably safe treatment for LN. The improvement in proteinuria encourages larger controlled trials.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00709722.

Mycophenolate mofetil for induction therapy of lupus nephritis: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Although the accepted standard of care for induction of lupus nephritis has been cyclophosphamide, recent trials suggest that mycophenolate mofetil may be as or more effective and less toxic. A systematic review and meta-analysis were performed to determine the risk for failure to induce remission of lupus nephritis in patients who were treated with mycophenolate mofetil compared with cyclophosphamide.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Studies were identified by a search of electronic databases, bibliographies, and conference proceedings and by contacting experts. Randomized trials that compared mycophenolate mofetil with cyclophosphamide for induction therapy in adults with biopsy-proven lupus nephritis were eligible. The primary outcome was failure to induce a remission of nephritis as defined by the original studies (based on proteinuria, renal function, and urine sediment).

RESULTS

Four studies that included 268 patients and had homogeneous results across studies were identified. In a fixed-effects model, the pooled relative risk for failure to induce remission for mycophenolate mofetil compared with cyclophosphamide was 0.70. The relative risk for the composite outcome of death or end-stage renal disease for mycophenolate mofetil compared with cyclophosphamide was 0.44. Leukopenia and amenorrhea occurred more frequently in cyclophosphamide-treated patients.

CONCLUSIONS

Treatment of lupus nephritis with mycophenolate mofetil compared with cyclophosphamide reduces the risk for failure to induce remission during induction therapy and may reduce the risk for death or end-stage renal disease. Mycophenolate mofetil may be considered as a first-line induction therapy for the treatment of lupus nephritis in patients without severe renal dysfunction.

Outcome of chilean patients with lupus nephritis and response to intravenous cyclophosphamide

Several recent open studies suggest that the response rates of lupus nephritis to intravenous (IV) cyclophosphamide are lower than those observed in clinical trials. One explanation could be ethnic differences; for example, black patients more frequently have treatment-resistant lupus nephritis. Another could be the inclusion of patients who are noncompliant with therapy. From our register of 268 systemic lupus erythematosus (SLE) patients examined between 1973 and 1996, 61 patients were treated for proliferative lupus nephritis (17 had World Health Organization [WHO] type III and 43 had WHO type IV) and were followed through to 2001. Exclusion criteria included a serum creatinine level >3 mg/dL. In this retrospective study, we assessed renal outcome and survival with an endpoint of end-stage renal disease (ESRD) or death (Kaplan-Meier). In the univariate analysis, worse prognostic factors for survival were serum creatinine >1.3 mg/dL (p < 0.001), age <30 years (p < 0.001), class 2 renal function stage (p < 0.03), and renal biopsy activity index >7 (p < 0.02). In the subgroup of 26 patients treated with IV cyclophosphamide, survival at 5 and 10 years was 82% and 73%, respectively. The dosage of IV cyclophosphamide was slightly lower than usual and used for a shorter period (median = 23 months) than what is usually recommended because of the high frequency of complications. Renal outcome of the IV cyclophosphamide-treated patients was poorer than that reported in the National Institutes of Health series (ESRD: 15% versus 3%). This low survival rate could reflect the short course and lower doses of IV cyclophosphamide used or ethnic differences. These data emphasize the need for continuous research for better-tolerated drug schemes for treatment of our lupus nephritis patients.

Justice and health care in the rheumatic diseases

Coping with a chronic disease is a formidable challenge. Owing to the disabling consequences of their underlying conditions, individuals who suffer with a chronic rheumatic disease have especially daunting lives with their existence often dominated by their health-related needs. Due to the high prevalence, the demographic distribution, indeed the very nature of the rheumatic diseases, too many sufferers of these conditions in our society remain disenfranchised with respect to their access to health care. Those who come from already disadvantaged socioeconomic circumstances face particularly difficult challenges. Rheumatologists and their allied health professionals, therefore, have a moral obligation to ensure greater fairness to their patients--those already compromised by the natural lottery that gave them their disease. To enhance the appreciation of this problem and to motivate the rheumatic disease community, we attempt to identify those variables that create the need for and imperil access to medical care for the rheumatic diseases. The implications of these observations are then explored from the ethical perspective of justice. We conclude with suggestions as to how to change the health care system to address these problems.

Genetic models for the clearance of apoptotic cells

The immunogenic potential of nuclear antigens exposed during apoptosis, together with considerable animal data suggesting that impaired apoptotic clearance can result in systemic lupus erythematosus (SLE)-like autoimmunity, has lent support to the idea that self-immunization with apoptotic debris is a key driving mechanism in lupus. The multiple roles of complement receptors, diverse scavenger receptors, and intermediate proteins that bind to and opsonize apoptotic cells indicate a complex web of interactions leading to the clearance of apoptotic debris. Disturbances in parts of this system may lead to lupus or to lupus exacerbations. Therapy directed toward augmenting clearance and decreasing concomitant inflammation may lead to improved management of SLE.