The treatment of lupus nephritis

Renal outcomes in children with lupus and a family history of autoimmune disease

Genetic factors play an important role in systemic lupus erythematosus (SLE) susceptibility and development of lupus nephritis (LN). The significance, however, of a positive family history of autoimmune disease on renal outcome in SLE patients is unknown. This retrospective study of 64 children with LN investigates whether children with LN and a family history of AID (autoimmune disease; 34 patients) had worse renal outcomes when compared with children who did not have a family history (26 patients) of AID. In four patients the family history was unknown. The primary endpoint was doubling of serum creatinine (sCr) and the secondary endpoint was requiring dialysis or transplant (ESRD). Demographic variables for family history + versus mean age in years (range) at onset of LN were 13.5 (7.4-15.9) versus 13.2 (6.4-19.7); female 26: 34 (76%) versus 24: 26 (92%), P = 0.097; race Black 23 (68%), Caucasian 7 (21%), Asian 1 (2%), Hispanic 3(9%) versus Black 14 (54%), Caucasian 6 (23%), Asian 2 (8%), Hispanic 4 (15%). Three patients died (1.6%); sCr doubled in 6/34 (17.6%) versus 2/26 (7.7%), P = 0.45, followed for 2.8 years (0.8-5.8) and 1.8 years (1.8-1.9), respectively, P = 0.24; sCr doubled plus ESRD in 10/34 (29%) versus 6/26 (23%), P = 0.77, followed for 2.7 years (0.8-5.8) and 2.0 years (0.7-4.1) respectively, P = 0.29. In the family history + group, more Black versus non-Black patients doubled their sCr or reached ESRD, 8/23 (35%) versus 2/11 (18%), P = 0.44. More males and Black patients with LN had a positive family history for AID and were more likely to double their sCr or reach ESRD. These results suggest that a family history of AID impacts on renal outcome in children with SLE.

Cyclophosphamide therapy for lupus nephritis: poor renal survival in Arab children

Despite its widespread use, there are only a few published studies of the use of intravenous high-dose pulse cyclophosphamide in lupus nephritis in children. There are few data about the long-term efficacy and safety of this form of therapy. This study evaluates the clinical efficacy of this regimen in children with severe lupus nephritis followed prospectively over a 5-year period. Nine children with severe active lupus nephritis were enrolled in a treatment regimen of monthly intravenous pulses of cyclophosphamide (0.75-1 g/m(2)) for 6 months and then every 3 months for a total of 36 months. Cyclophosphamide treatment was associated with significant improvement in renal function during treatment. However, data presented here show that 56% of the patients progressed to chronic renal failure and 22% required dialysis 2 years after discontinuation of cyclophosphamide therapy. Hence it seems that this regimen is not effective in our patients in the long term, especially patients who present with high serum creatinine and hypertension.

[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.

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.

Lupus nephritis in childhood and adolescence

Lupus nephritis in childhood usually presents after the age of 10 years, and presentation under 5 years is very rare. More males (F:M ratio 4.5:1) are affected than in adult-onset cases, but the ratio is the same in prepubertal and pubertal children. The incidence of clinically evident renal disease is greater at onset than in adults (82%), the usual presentation being with proteinuria, 50% having a nephrotic syndrome. Half the children show World Health Organisation class IV nephritis in renal biopsies. Neuropsychiatric lupus is present at onset in 30%, may complicate 50% at some point and remains a major problem. Prognosis has improved greatly over the past 30 years, at least in part the result of immunosuppressive treatment. Treatment of the initial phase may be guided by the severity of the renal biopsy appearances, more aggressive treatment including cytotoxic agents, i.v. methylprednisolone and perhaps plasma exchange, although the value of exchange is not established. Controversy persists as to the most effective cytotoxic treatment in the acute phase, both oral and i.v. cyclophosphamide and azathioprine being used in different units. In the chronic maintenance phase it seems established both clinically and histologically that addition of a cytotoxic agent improves outcome, but again the drug and route of administration are contentious. Azathioprine has the advantage of being safe for pregnancy and not gonadotoxic, whilst i.v. cyclophosphamide has been demonstrated to improve results over prednisolone alone in controlled trials and has advantages in non-compliant patients. No trial comparing the two regimes has been carried out, and one is needed. Today children much less commonly go into renal failure, and the main causes of actual death (15% of patients over 10 years) are now infections and extra-renal manifestations of lupus, principally neurological. Morbidity of the disease and the treatment remain a major problem, especially when treatment exacerbates complications of the disease itself, such as infections, osteonecrosis, thrombosis, vascular disease and possibly neoplasia.

A controlled trial of pulse cyclophosphamide versus pulse methylprednisolone in severe lupus nephritis

We carried out a prospective randomized trial comparing pulse cyclophosphamide and pulse methylprednisolone in 29 patients with severe lupus nephritis in activity. Patients were assigned to one of two regimens: monthly pulse cyclophosphamide (0.5-1.0 g/m2 body surface area) for 4 months, followed by bimonthly doses for 4 months and quarterly doses for 6 months (14 patients) or pulse methylprednisolone (10-20 mg/kg weight) initially for 3 consecutive days and thereafter in the same intervals as the alternative regimen (15 patients). The mean follow-up was 15 months. Two patients in the cyclophosphamide group and three in the methylprednisolone group died. Renal failure (doubling of serum creatinine) developed in four patients in the cyclophosphamide group compared with five patients in the methylprednisolone group. Cumulative probability of not doubling serum creatinine was similar for cyclophosphamide and methylprednisolone groups (0.66 vs 0.69, respectively, P > 0.20, after 18 months). Cumulative probability of survival without renal failure was also not significantly different (0.61 and 0.63, respectively, P > 0.20, after 18 months). These results suggest that pulse cyclophosphamide is as effective as pulse methylprednisolone in preserving renal function in patients with severe lupus nephritis.

Long term efficacy of high-dose intravenous methylprednisolone pulses in active lupus nephritis. A 21-month prospective study

The efficacy of a single course of three high dose intravenous (i.v.) methylprednisolone (MP) pulses followed by low dose oral prednisone (PRED) was assessed in a group of patients with active lupus nephritis (LN). At 21 months after such therapeutic regimen in 10 out of 12 patients a complete clinical remission was found, in one patient a partial response with persistent moderate renal failure occurred, while one patient was refractory even to the additional administration of cyclophosphamide. The statistical analysis of repeated measures of a series of biological markers of LN, monitored over the course of the study, evidenced a significant improvement of serum creatinine (p < 0.05), C3 and C4 complement components (p < 0.05), 24-hour proteinuria (p < 0.02) and ESR values (p < 0.05). Moreover, a progressive and significant reduction of mean daily PRED dosage was reported (p < 0.05). We conclude that i.v. MP pulse therapy may exert a substantial long-term control of active LN and may induce steroid-sparing effects.

Controlled trial of pulse methylprednisolone versus two regimens of pulse cyclophosphamide in severe lupus nephritis

Pulse cyclophosphamide is more effective than prednisone alone in preventing renal failure in lupus nephritis. We undertook a randomised, controlled trial to find out whether pulse methylprednisolone could equal pulse cyclophosphamide in preserving renal function in patients with lupus nephritis, and whether there was a difference between long and short courses of pulse cyclophosphamide in preventing exacerbations. 65 patients (60 female, 5 male; median [range] age 29 [10-48] years) with severe lupus nephritis were assigned randomly to monthly pulse methylprednisolone for 6 months (25 patients), monthly pulse cyclophosphamide for 6 months (20), or monthly cyclophosphamide for 6 months followed by quarterly pulse cyclophosphamide for 2 additional years (20). Patients treated with pulse methylprednisolone had a higher probability of doubling serum creatinine than those treated with long-course cyclophosphamide (p less than 0.04). Risk of doubling creatinine was not significantly different between short and long course cyclophosphamide. However, patients treated with short-course cyclophosphamide had a higher probability of exacerbations than those treated with long-course cyclophosphamide (p less than 0.01). An extended course of pulse cyclophosphamide is more effective than 6 months of pulse methylprednisolone in preserving renal function in patients with severe lupus nephritis. Addition of a quarterly maintenance regimen to monthly pulse cyclophosphamide reduces the rate of exacerbations.

Lupus nephritis in a pediatric renal transplant recipient

A case of aggressive lupus nephritis in a pediatric renal transplant patient is described. She initially presented with end-stage glomerulonephritis for which an underlying etiology could not be determined. Ten months after cadaveric renal transplantation, systemic lupus erythematosus was diagnosed, when she developed diffuse proliferative glomerulonephritis in association with antinuclear antibody, anti-double-stranded DNA antibody and extrarenal manifestations of lupus. It is plausible that she developed recurrent rather than de novo lupus nephritis following transplantation. Reactivation of lupus nephritis in a renal transplant is unusual in adults, and is previously unreported in children.