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Wang M, Zhou J, Niu Q, Wang H. Mechanism of tacrolimus in the treatment of lupus nephritis. Front Pharmacol 2024; 15:1331800. [PMID: 38774214 PMCID: PMC11106426 DOI: 10.3389/fphar.2024.1331800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/19/2024] [Indexed: 05/24/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is a complex autoimmune disorder, with more than half of the patients developing lupus nephritis (LN), which significantly contributes to chronic kidney disease (CKD) and end-stage renal disease (ESRD). The treatment of lupus nephritis has always been challenging. Tacrolimus (TAC), an effective immunosuppressant, has been increasingly used in the treatment of LN in recent years. This review aims to explore the mechanisms of action of tacrolimus in treating LN. Firstly, we briefly introduce the pharmacological properties of tacrolimus, including its role as a calcineurin (CaN) inhibitor, exerting immunosuppressive effects by inhibiting T cell activation and cytokine production. Subsequently, we focus on various other immunomodulatory mechanisms of tacrolimus in LN therapy, including its effects on T cells, B cells, and immune cells in kidney. Particularly, we emphasize tacrolimus' regulatory effect on inflammatory mediators and its importance in modulating the Th1/Th2 and Th17/Treg balance. Additionally, we review its effects on actin cytoskeleton, angiotensin II (Ang II)-specific vascular contraction, and P-glycoprotein activity, summarizing its impacts on non-immune mechanisms. Finally, we summarize the efficacy and safety of tacrolimus in clinical studies and trials. Although some studies have shown significant efficacy of tacrolimus in treating LN, its safety remains a challenge. We outline the potential adverse reactions of long-term tacrolimus use and provide suggestions on effectively monitoring and managing these adverse reactions in clinical practice. In general, tacrolimus, as a novel immunosuppressant, holds promising prospects for treating LN. Of course, further research is needed to better understand its therapeutic mechanisms and ensure its safety and efficacy in clinical practice.
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Affiliation(s)
| | | | | | - Hongyue Wang
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
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Jiang Y, Tao M, Chen J, Luo L, You Q, Wu H, Zhang N. Calcineurin inhibitors in the treatment of systemic lupus erythematosus during pregnancy: A narrative review with emphasis on efficacy and safety. Eur J Obstet Gynecol Reprod Biol 2024; 294:148-155. [PMID: 38245953 DOI: 10.1016/j.ejogrb.2023.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 11/21/2023] [Accepted: 12/31/2023] [Indexed: 01/23/2024]
Abstract
Systemic lupus erythematosus (SLE) predominantly affects child-bearing women, leading to an elevated risk of maternal and fetal complications and adverse pregnancy outcomes. Since some medications can cross the placental barrier that persist a threat to both mother and fetus, the risk-benefit ratio of SLE medications should be taken into consideration during pregnancy. Calcineurin inhibitor (CNI), mainly including cyclosporin A, tacrolimus, and voclosporin, is a category of immunosuppressive agents that inhibit calcium/calmodulin-dependent phosphatase calcineurin to block T cell activation. Based on the current clinical evidence, CNI is an alternative in pregnant SLE patients with persistent disease activity (especially lupus nephritis patients) and non-responders to azathioprine. However, there is no comprehensive review that summarizes the efficacy and safety profile of CNI for SLE management during pregnancy. This review presents a summary on the utilization of CNI for SLE management during pregnancy, including the mechanism of action, gestational amelioration of lupus flare, and the balance of maternal benefit-fetal risk, which may provide more references for the management of SLE pregnancies.
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Affiliation(s)
- Yi Jiang
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Min Tao
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Jingjing Chen
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Lihua Luo
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Qingxia You
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Hong Wu
- Department of Rheumatology and Immunology, The First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Nian Zhang
- Department of Traditional Chinese Medicine, The Second Hospital Affiliated to Army Medical University, Chongqing 400037, China.
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Rosli FZ, Shaharir SS, Abdul Gafor AH, Mohd R, Aizuddin AN, Osman S. Cost-effectiveness of cyclophosphamide and non-cyclophosphamide in the induction therapy of Malaysian lupus nephritis patients. Lupus 2022; 31:1138-1146. [PMID: 35608373 DOI: 10.1177/09612033221103205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a paradigm shift in the induction therapy for proliferative lupus nephritis (LN). Apart from cyclophosphamide (CYC), mycophenolate mofetil and calcineurin inhibitors have emerged as an alternative option of treatment. OBJECTIVE We aimed to compare the cost-effectiveness analysis (CEA) per year, adverse events and renal damage at 24 months between CYC and non-CYC agents (calcineurin inhibitors or mycophenolate) as induction treatment among proliferative lupus nephritis (LN) patients. METHODS This was a retrospective and non-controlled study involving biopsy-proven proliferative LN patients (class III or IV with or without V) in the clinic registry from 2017 to 2019. Their medical records were reviewed to determine the date and type of induction, treatment effectiveness, adverse events and renal damage at 24 months. The total cost of treatment included capital cost (building, furniture and equipment) and recurrent cost (emolument, supply/drug, lab investigations, administrative cost and utilities). Treatment effectiveness was defined as renal remission (partial or complete) at 6 months without relapse up to 24 months. The cost-effectiveness analysis (CEA) was expressed as cost per remission per year in Malaysian Ringgit (MYR). RESULTS There were a total of 95 inductions with CYC and 27 with non-CYC in 94 LN patients. There was no significant difference in the total mean cost per patient/year between CYC (MYR 18460.26 ± 6500.76) compared to non-CYC (MYR 19302.10 ± 6778.22), p = 0.569. The CEA for CYC was MYR 20,632.06 (GBP 3,538.78) while non-CYC was MYR 20,846.27 (GBP 3,575.52) and mean difference MYR 214.21 (GBP 37.44). There was significantly higher capital cost, consumables, utility, maintenance, administration (p < 0.001) and lab investigations (p = 0.046) in the CYC arm. There was a trend of a higher infection requiring outpatient antibiotic treatment in CYC group (p = 0.05), but similar renal damage outcome with the non-CYC group.Conclusion: For treatment of proliferative LN, there was no significant difference in the CEA and renal damage between CYC and non-CYC induction treatment. There was a trend of a higher rate of infections in the CYC group. Hence, the decision to treat patient with CYC or MMF should be tailored to individual patients, by considering the risk of infection in a particular patient.
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Affiliation(s)
- Fatimah Z Rosli
- Faculty of Medicine, Department of Internal Medicine, 60607Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Syahrul S Shaharir
- Faculty of Medicine, Department of Internal Medicine, 60607Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Abdul H Abdul Gafor
- Faculty of Medicine, Department of Internal Medicine, 60607Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Rozita Mohd
- Faculty of Medicine, Department of Internal Medicine, 60607Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Azimatun N Aizuddin
- Department of Public Health, 60607Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | - Sabrizan Osman
- Department of Public Health, 60607Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
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Kapsia E, Marinaki S, Michelakis I, Liapis G, Sfikakis PP, Tektonidou MG, Boletis J. New Insights Into an Overlooked Entity: Long-Term Outcomes of Membranous Lupus Nephritis From a Single Institution Inception Cohort. Front Med (Lausanne) 2022; 9:809533. [PMID: 35492303 PMCID: PMC9047916 DOI: 10.3389/fmed.2022.809533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/24/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Pure membranous lupus nephritis (MLN) accounts for 10–20% of total cases of lupus nephritis and is generally associated with a better patient and renal survival compared to proliferative classes. Studies of MLN are limited by small sample size and heterogeneity of included populations since patients with pure MLN and those with mixed classes are usually examined together. Aim of the Study To describe clinical and laboratory characteristics of patients with pure MLN, therapeutic regimens, response to treatment, renal relapses, and their long-term renal survival and to define prognostic factors of remission and relapse. Methods We retrospectively studied an inception cohort of 27 patients with histologically proven pure MLN. Clinical, laboratory and therapeutical parameters were recorded at diagnosis, at different time points (3–6–9–12–18–24–36–72 months) during the course of the disease, at time of renal flare, and at last follow up visit. Results 48.1% (13/27) of patients were treated with mycophenolic acid (MPA), 29.6% (8/27) with cyclophosphamide (CYC), and 3.7% (1/27) with cyclosporine (all in combination with corticosteroids). Five patients (18.5%) did not receive any immunosuppressive treatment. Mean duration of treatment was 4.7 ± 2.3 years. Median time to complete remission was 9 months (IQR = 7) and median time to partial remission was 4 months (IQR = 4). No clinical or laboratory parameter was found to be significantly associated with time to remission. Time to remission was not significantly affected by either of the two treatment regimens (CYC and MPA) (p = 0.43). Renal flare was observed in 6 (22%) of the 27 patients in a median time of 51 months (IQR = 63). Proteinuria >1 g/24 h at 1 year significantly correlated with risk of flare (OR 20, p = 0.02). After a median follow up period of 77 months, all patients had an eGFR > 60 ml/min/1.73 m2 (mean eGFR 100 ± 32 ml/min/1.73 m2). Conclusions In a small cohort of patients with pure MLN, long-term renal survival was very good. With the limitation of the small sample size, we could not find any baseline clinical, biochemical or therapeutic factor that could predict time to remission. Proteinuria > 1 g/24 h at 1 year should be further examined in larger cohorts as a possible predictor of flare.
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Affiliation(s)
- Eleni Kapsia
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
- *Correspondence: Eleni Kapsia
| | - Smaragdi Marinaki
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Ioannis Michelakis
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - George Liapis
- Department of Pathology, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Petros P. Sfikakis
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Maria G. Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - John Boletis
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
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Shin JI, Li H, Park S, Yang JW, Lee KH, Jo Y, Park S, Oh J, Kim H, An HJ, Jeong G, Jung H, Lee HJ, Kim JS, Nam SW, Koyanagi A, Jacob L, Hwang J, Yon DK, Lee SW, Tizaoui K, Kronbichler A, Kim JH, Smith L. Induction and Maintenance Treatment of Lupus Nephritis: A Comprehensive Review of Meta-Analyses. J Clin Med 2022; 11:jcm11020343. [PMID: 35054037 PMCID: PMC8780781 DOI: 10.3390/jcm11020343] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/16/2021] [Accepted: 12/18/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lupus nephritis (LN) is present in over 50% of patients with systemic lupus erythematosus (SLE) which is managed with immunosuppressive and immunomodulatory therapies. However, several novel therapeutic approaches for LN are under investigation due to the adverse effects spectrum of conventional therapy; Methods: We performed a comprehensive review of meta-analyses aggregating the comparative efficacies of various pharmacotherapies for LN. We conducted a literature search and retrieved a total of 23 meta-analyses and network meta-analyses for summarization. Pharmacotherapies were evaluated across six major outcomes: remission, relapse, mortality, end stage kidney disease (ESKD) progression, infection, and malignancy. RESULT Calcineurin inhibitors (CNI), particularly tacrolimus (TAC), in combination with glucocorticoids (GC) outperformed cyclophosphamide (CPA) with GC in the rate of remission, either complete or partial remission, and in terms of infectious complications. In maintenance therapy, MMF was superior to azathioprine (AZA) as the MMF-treated patients had lower relapse rate. INTERPRETATION This review aggregates evidence of therapy for clinicians and sheds light on comparative efficacies of alternative LN treatments. As more promising agents are entering the market, such as voclosporin, belimumab, and obinutuzumab, LN management might undergo significant changes during the next years.
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Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
| | - Han Li
- University of Florida College of Medicine, Gainesville, FL 32610, USA;
| | - Seoyeon Park
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (J.W.Y.); (J.S.K.)
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
| | - Yongsuk Jo
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Seongeun Park
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Jungmin Oh
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Hansol Kim
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Hyo Jin An
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Gahee Jeong
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Haerang Jung
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Hyun Jung Lee
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Jae Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (J.W.Y.); (J.S.K.)
| | - Seoung Wan Nam
- Department of Rheumatology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, 08830 Barcelona, Spain; (A.K.); (L.J.)
- Catalan Institution for Research and Advanced Studies, Pg. Lluis Companys 23, 08010 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, 78019 Madrid, Spain
| | - Louis Jacob
- Research and Development Unit, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, 08830 Barcelona, Spain; (A.K.); (L.J.)
- Centro de Investigación Biomédica en Red de Salud Mental, 78019 Madrid, Spain
- Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, 78000 Montigny-le-Bretonneux, France
| | - Jimin Hwang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Dong Keon Yon
- Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul 02447, Korea;
| | - Seung-Won Lee
- Department of Data Science, Sejong University College of Software Convergence, Sungkyunkwan University School of Medicine, Seoul 05006, Korea;
| | - Kalthoum Tizaoui
- Laboratory of Microorganisms and Active Biomolecules, Sciences Faculty of Tunis, University Tunis El Manar, Tunis 1068, Tunisia;
| | | | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 26426, Korea
- Correspondence:
| | - Lee Smith
- Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge CB1 1PT, UK;
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Eren N, Gungor O, Sarisik FN, Sokmen F, Tutuncu D, Cetin GY, Yazici A, Gökçay Bek S, Altun E, Altunoren O, Cefle A. Renal Tubular Acidosis in Patients with Systemic Lupus Erythematosus. Kidney Blood Press Res 2021; 45:883-889. [PMID: 33108786 DOI: 10.1159/000509841] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/01/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Renal tubular acidosis (RTA) is a clinical manifestation that occurs with insufficiency in restoring bicarbonate or disruption in hydrogen ion elimination as a result of a disruption in tubulus functions, causing normal anion gap-opening metabolic acidosis. In the present study, we aimed to investigate the prevalence of RTA in the largest systemic lupus erythematosus (SLE) patient population to date. MATERIALS AND METHODS SLE patients, who were followed up in 2 different healthcare centers, were included. Patients with metabolic acidosis (pH <7.35 and HCO3 <22 mEq/L) in venous blood gas analysis were determined. The serum and urine anion GAP of these patients were estimated, and the urine pH was assessed. RTA presence was evaluated as metabolic acidosis with a normal serum anion gap and a positive urine anion GAP. RESULTS A total of 108 patients were included in the present study. The mean age of the patients was 41.5 ± 1.2 and 87% were female. The SLE diagnosis duration was 75 ± 5 months. The mean creatinine value was 0.6 ± 0.1 mg/dL and the mean eGFR was 111 ± 2 mL/min. According to the blood gas analysis, 18 patients (16.7% of the total) had RTA. Sixteen of these patients had type 1 RTA and 2 had type 2 RTA; type 4 RTA was not determined in any of the patients. CONCLUSION RTA should be considered in SLE patients even if they have normal eGFR values. This is the largest study to examine the prevalence of RTA in SLE patients in the literature.
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Affiliation(s)
- Necmi Eren
- Department of Nephrology, Medical Faculty, Kocaeli University, Kocaeli, Turkey,
| | - Ozkan Gungor
- Department of Nephrology, Medical Faculty, Kahramanmaraş Sutcu Imam University, Kahramanmaras, Turkey
| | - Feyza Nur Sarisik
- Department of Nephrology, Medical Faculty, Kahramanmaraş Sutcu Imam University, Kahramanmaras, Turkey
| | - Fatih Sokmen
- Department of Nephrology, Medical Faculty, Kahramanmaraş Sutcu Imam University, Kahramanmaras, Turkey
| | - Didem Tutuncu
- Department of Nephrology, Medical Faculty, Kahramanmaraş Sutcu Imam University, Kahramanmaras, Turkey
| | - Gozde Yildirim Cetin
- Department of Nephrology, Medical Faculty, Kahramanmaraş Sutcu Imam University, Kahramanmaras, Turkey
| | - Ayten Yazici
- Department of Rheumatology, Medical Faculty, Kocaeli University, Kocaeli, Turkey
| | - Sibel Gökçay Bek
- Department of Nephrology, Medical Faculty, Kocaeli University, Kocaeli, Turkey
| | - Eda Altun
- Department of Nephrology, Gölcük State Hospital, Kocaeli, Turkey
| | - Orcun Altunoren
- Department of Nephrology, Medical Faculty, Kahramanmaraş Sutcu Imam University, Kahramanmaras, Turkey
| | - Ayse Cefle
- Department of Rheumatology, Medical Faculty, Kocaeli University, Kocaeli, Turkey
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van Gelder T, Huizinga RB, Lisk L, Solomons N. Voclosporin: a novel calcineurin inhibitor with no impact on mycophenolic acid levels in patients with SLE. Nephrol Dial Transplant 2021; 37:917-922. [PMID: 33527141 PMCID: PMC9035351 DOI: 10.1093/ndt/gfab022] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Indexed: 12/14/2022] Open
Abstract
Background An open-label phase 1 study was conducted to evaluate the effect of voclosporin following dosing with mycophenolate mofetil (MMF) on blood levels of mycophenolic acid (MPA, the active moiety of MMF) and MPA glucuronide (MPAG, the pharmacologically inactive metabolite of MMF) in subjects with systemic lupus erythematosus (SLE) and to assess the safety and tolerability of the combination. Methods MMF was orally administered at a dose of 1 g twice a day for at least 28 days prior to the study and continued at the same dose throughout the study. Voclosporin was orally administered at a dose of 23.7 mg twice a day for 7 consecutive days (Days 1–7), starting on the evening of Day 1 and ending with the morning dose on Day 7. Dense pharmacokinetic blood samples were collected pre-dose in the morning and from 0.25 to 12 h after the morning doses. Analyses were derived by non-compartmental methods. Results In 24 patients, MPA exposure [maximum serum concentration (Cmax) and area under the concentration curve from time 0 to 12 h (AUC0–12)] was similar in the presence and absence of voclosporin, with treatment ratios of 0.94 and 1.09, respectively [Cmax 16.5 μg/mL (Day 1) versus 15.8 (Day 7), AUC0–12 39.1 μg/h/mL (Day 1) versus 40.8 (Day 7)]. MPAG exposure showed a small increase in the presence of voclosporin (12% for Cmax and 27% for AUC0–12). Combination therapy was well tolerated. Conclusions There is no clinically meaningful interaction between voclosporin and MMF. As changes in exposure to MPA may affect efficacy and safety, these data confirm that voclosporin and MMF can be administered concomitantly without the need for dose adjustment.
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Affiliation(s)
- Teun van Gelder
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Laura Lisk
- Aurinia Pharmaceuticals, Victoria, BC, Canada
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Calcineurin and Systemic Lupus Erythematosus: The Rationale for Using Calcineurin Inhibitors in the Treatment of Lupus Nephritis. Int J Mol Sci 2021; 22:ijms22031263. [PMID: 33514066 PMCID: PMC7865978 DOI: 10.3390/ijms22031263] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 12/18/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a broad spectrum of clinical presentations that can affect almost all organ systems. Lupus nephritis (LN) is a severe complication that affects approximately half of the systemic erythematosus lupus (SLE) patients, which significantly increases the morbidity and the mortality risk. LN is characterized by the accumulation of immune complexes, ultimately leading to renal failure. Aberrant activation of T cells plays a critical role in the pathogenesis of both SLE and LN and is involved in the production of inflammatory cytokines, the recruitment of inflammatory cells to the affected tissues and the co-stimulation of B cells. Calcineurin is a serine-threonine phosphatase that, as a consequence of the T cell hyperactivation, induces the production of inflammatory mediators. Moreover, calcineurin is also involved in the alterations of the podocyte phenotype, which contribute to proteinuria and kidney damage observed in LN patients. Therefore, calcineurin inhibitors have been postulated as a potential treatment strategy in LN, since they reduce T cell activation and promote podocyte cytoskeleton stabilization, both being key aspects in the development of LN. Here, we review the role of calcineurin in SLE and the latest findings about calcineurin inhibitors and their mechanisms of action in the treatment of LN.
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9
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Abstract
PURPOSE OF REVIEW Update on the diagnosis, treatment, and monitoring of lupus nephritis. RECENT FINDINGS The recent criteria enable the earlier classification of lupus nephritis based on kidney biopsy and compatible serology. Treatment of active nephritis includes low-dose intravenous cyclophosphamide or mycophenolate, followed by maintenance immunosuppression. Recent trials have suggested superiority of regimens combining mycophenolate with either calcineurin inhibitor or belimumab, although their long-term benefit/risk ratio has not been determined. Encouraging results with novel anti-CD20 antibodies confirm the effectiveness of B cell depletion. Achievement of low-grade proteinuria (< 700-800 mg/24 h) at 12-month post-induction is linked to favorable long-term outcomes and could be considered in a treat-to-target strategy. Also, repeat kidney biopsy can guide the duration of maintenance immunosuppression. Lupus nephritis has increased cardiovascular disease burden necessitating risk-reduction strategies. An expanding spectrum of therapies coupled with ongoing basic/translational research can lead to individualized medical care and improved outcomes in lupus nephritis.
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Affiliation(s)
- Myrto Kostopoulou
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Christina Adamichou
- 4th Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, 71008 Voutes-Stavrakia, Heraklion, Greece
| | - George Bertsias
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, 71008 Voutes-Stavrakia, Heraklion, Greece.
- Laboratory of Rheumatology, Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology-FORTH, Heraklion, Greece.
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10
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Hao GX, Song LL, Zhang DF, Su LQ, Jacqz-Aigrain E, Zhao W. Off-label use of tacrolimus in children with glomerular disease: Effectiveness, safety and pharmacokinetics. Br J Clin Pharmacol 2020; 86:274-284. [PMID: 31725919 DOI: 10.1111/bcp.14174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022] Open
Abstract
Glomerular diseases are leading causes of end-stage renal disease in children. Tacrolimus is frequently used off-label in the treatment of glomerular diseases. The effectiveness, safety and pharmacokinetic data of tacrolimus in the treatment of glomerular diseases in children are reviewed in this paper to provide evidence to support its rational use in clinical practice. The remission rates in previously published studies were different. In 19 clinical trials on children with nephrotic syndrome, the overall remission rate was 52.6-97.6%. In four clinical trials on children with lupus nephritis, the overall remission rate was 81.8-89.5%. In a pilot study with paediatric Henoch-Schönlein purpura nephritis patients, the overall remission rate was 100.0%. Infection, nephrotoxicity, gastrointestinal symptoms and hypertension are the most common adverse events. Body weight, age, CYP3A5 genotype, cystatin-C and daily dose of tacrolimus may have significant effects on the pharmacokinetics of tacrolimus in children with glomerular disease. More prospective controlled trials with long follow-up are needed to demonstrate definitely the effectiveness, safety and pharmacokinetics of tacrolimus in children with glomerular diseases.
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Affiliation(s)
- Guo-Xiang Hao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Lin-Lin Song
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Dong-Feng Zhang
- Department of Pediatric Nephrology, Children's Hospital of Hebei Province affiliated to Hebei Medical University, Shijiazhuang, China
| | - Le-Qun Su
- Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
| | - Evelyne Jacqz-Aigrain
- Department of Pediatric Pharmacology and Pharmacogenetics, Hôpital Robert Debré, APHP, Paris, France
| | - Wei Zhao
- Department of Clinical Pharmacy, School of Pharmaceutical Sciences, Shandong University, Jinan, China.,Department of Pharmacy, Shandong Provincial Qianfoshan Hospital, the First Hospital Affiliated with Shandong First Medical University, Jinan, China
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Hiramatsu Y, Yoshida S, Kotani T, Nakamura E, Kimura Y, Fujita D, Nagayasu Y, Shabana K, Makino S, Takeuchi T, Arawaka S. Changes in the blood level, efficacy, and safety of tacrolimus in pregnancy and the lactation period in patients with systemic lupus erythematosus. Lupus 2018; 27:2245-2252. [PMID: 30394835 DOI: 10.1177/0961203318809178] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We investigated the efficacy and safety of tacrolimus (TAC) by monitoring its serum concentration for mothers and infants in pregnant patients with systemic lupus erythematosus (SLE). METHODS We measured trough concentrations of TAC in 25 pregnant patients with SLE to assess influence of TAC on the disease activity. Additionally, we measured the concentrations of TAC in umbilical arterial blood, breast milk, and breastfed infants to investigate the safety of TAC for the mothers and infants. RESULTS The trough concentrations of TAC in the mothers significantly decreased in the second trimester as compared with those before pregnancy. However, the decrease in the trough concentrations of TAC did not lead to the deterioration of SLE. When examined, the doses of TAC were significantly lower in the second trimester and postpartum in the deteriorating group than those in the non-deteriorating group. There were no adverse events by TAC in mothers and fetuses. The concentrations of TAC in the umbilical cord blood were lower than those in the maternal blood. The relative infant dose in breastfed infants of TAC was < 1%. The level of TAC in infant bloods was below detectable limits. CONCLUSION These findings suggest that TAC is one of the most effective and safest immunosuppressive drugs for use in pregnant patients with SLE.
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Affiliation(s)
- Y Hiramatsu
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - S Yoshida
- 2 Department of Internal Medicine, Arisawa General Hospital, Osaka, Japan
| | - T Kotani
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - E Nakamura
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - Y Kimura
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - D Fujita
- 3 Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Y Nagayasu
- 3 Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - K Shabana
- 4 Department of Pediatrics, Osaka Medical College, Osaka, Japan
| | - S Makino
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - T Takeuchi
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - S Arawaka
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
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Tunnicliffe DJ, Palmer SC, Henderson L, Masson P, Craig JC, Tong A, Singh‐Grewal D, Flanc RS, Roberts MA, Webster AC, Strippoli GFM. Immunosuppressive treatment for proliferative lupus nephritis. Cochrane Database Syst Rev 2018; 6:CD002922. [PMID: 29957821 PMCID: PMC6513226 DOI: 10.1002/14651858.cd002922.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cyclophosphamide, in combination with corticosteroids, has been first-line treatment for inducing disease remission for proliferative lupus nephritis, reducing death at five years from over 50% in the 1950s and 1960s to less than 10% in recent years. Several treatment strategies designed to improve remission rates and minimise toxicity have become available. Treatments, including mycophenolate mofetil (MMF) and calcineurin inhibitors, alone and in combination, may have equivalent or improved rates of remission, lower toxicity (less alopecia and ovarian failure) and uncertain effects on death, end-stage kidney disease (ESKD) and infection. This is an update of a Cochrane review first published in 2004 and updated in 2012. OBJECTIVES Our objective was to assess the evidence and evaluate the benefits and harms of different immunosuppressive treatments in people with biopsy-proven lupus nephritis. The following questions relating to management of proliferative lupus nephritis were addressed: 1) Are new immunosuppressive agents superior to or as effective as cyclophosphamide plus corticosteroids? 2) Which agents, dosages, routes of administration and duration of therapy should be used? 3) Which toxicities occur with the different treatment regimens? SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 2 March 2018 with support from the Cochrane Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any immunosuppressive treatment for biopsy-proven class III, IV, V+III and V+VI lupus nephritis in adult or paediatric patients were included. DATA COLLECTION AND ANALYSIS Data were abstracted and the risks of bias were assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) and measures on continuous scales calculated as mean differences (MD) with 95% confidence intervals (CI). The primary outcomes were death (all causes) and complete disease remission for induction therapy and disease relapse for maintenance therapy. Evidence certainty was determined using GRADE. MAIN RESULTS In this review update, 26 new studies were identified, to include 74 studies involving 5175 participants overall. Twenty-nine studies included children under the age of 18 years with lupus nephritis, however only two studies exclusively examined the treatment of lupus nephritis in patients less than 18 years of age.Induction therapy Sixty-seven studies (4791 participants; median 12 months duration (range 2.5 to 48 months)) reported induction therapy. The effects of all treatment strategies on death (all causes) and ESKD were uncertain (very low certainty evidence) as this outcome occurred very infrequently. Compared with intravenous (IV) cyclophosphamide, MMF may have increased complete disease remission (RR 1.17, 95% CI 0.97 to 1.42; low certainty evidence), although the range of effects includes the possibility of little or no difference.Compared to IV cyclophosphamide, MMF is probably associated with decreased alopecia (RR 0.29, 95% CI 0.19 to 0.46; 170 less (129 less to 194 less) per 1000 people) (moderate certainty evidence), increased diarrhoea (RR 2.42, 95% CI 1.64 to 3.58; 142 more (64 more to 257 more) per 1000 people) (moderate certainty evidence) and may have made little or no difference to major infection (RR 1.02, 95% CI 0.67 to 1.54; 2 less (38 less to 62 more) per 1000 people) (low certainty evidence). It is uncertain if MMF decreased ovarian failure compared to IV cyclophosphamide because the certainty of the evidence was very low (RR 0.36, 95% CI 0.06 to 2.18; 26 less (39 less to 49 more) per 1000 people). Studies were not generally designed to measure ESKD.MMF combined with tacrolimus may have increased complete disease remission (RR 2.38, 95% CI 1.07 to 5.30; 336 more (17 to 1048 more) per 1000 people (low certainty evidence) compared with IV cyclophosphamide, however the effects on alopecia, diarrhoea, ovarian failure, and major infection remain uncertain. Compared to standard of care, the effects of biologics on most outcomes were uncertain because of low to very low certainty of evidence.Maintenance therapyNine studies (767 participants; median 30 months duration (range 6 to 63 months)) reported maintenance therapy. In maintenance therapy, disease relapse is probably increased with azathioprine compared with MMF (RR 1.75, 95% CI 1.20 to 2.55; 114 more (30 to 236 more) per 1000 people (moderate certainty evidence). Multiple other interventions were compared as maintenance therapy, but patient-outcome data were sparse leading to imprecise estimates. AUTHORS' CONCLUSIONS In this review update, studies assessing treatment for proliferative lupus nephritis were not designed to assess death (all causes) or ESKD. MMF may lead to increased complete disease remission compared with IV cyclophosphamide, with an acceptable adverse event profile, although evidence certainty was low and included the possibility of no difference. Calcineurin combined with lower dose MMF may improve induction of disease remission compared with IV cyclophosphamide, but the comparative safety profile of these therapies is uncertain. Azathioprine may increase disease relapse as maintenance therapy compared with MMF.
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Affiliation(s)
- David J Tunnicliffe
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Lorna Henderson
- NHS LothianRenal DepartmentRoyal Infirmary of EdinburghEdinburghUKEH16 4SA
| | - Philip Masson
- Royal Free London NHS Foundation TrustDepartment of Renal MedicineLondonUK
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Allison Tong
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Davinder Singh‐Grewal
- The Sydney Children's Hospitals NetworkDepartment Paediatric RheumatologyThe Children's Hospital at WestmeadCnr Hainsworth and Hawkesbury RoadsWestmeadNSWAustralia2145
| | - Robert S Flanc
- Monash Medical CentreDepartment of NephrologyClayton RdClaytonVICAustralia3168
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
| | - Angela C Webster
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
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Abstract
PURPOSE OF REVIEW With advancement in our understanding of pathogenic mechanisms in systemic lupus erythematosus (SLE), there is tremendous enthusiasm in examining drugs, old and new, to improve outcomes. This review highlights recent trials' successes and impasses that have come to fore. RECENT FINDINGS Among B-cell therapies, belimumab continues its run of successes with sustained safety and tolerability documented in a long-term extension as well as the likely approval of a subcutaneous formulation in the near future. With greater antibody-dependent cytotoxicity and less immunogenicity, there is hope for obinituzumab to succeed where its anti-CD 20 predecessors have failed. Drugs targeting type I interferons - sifalimumab and anifrolumab - have been efficacious albeit with an increase in incidence of Herpes zoster infections. There is also renewed interest in evaluating the efficacy of calcineurin inhibitors, specifically tacrolimus in the induction and maintenance of lupus nephritis. Introspection into clinical trial designs have highlighted the effects of entry criteria, end points, background medications and geographical differences on study outcomes. SUMMARY There are at least 50 drugs and targets being evaluated in SLE. In addition to developing new drugs to treat lupus, future trials have to focus on more effective study designs to improve chances of trial success.
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14
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Chen Y, Sun J, Zou K, Yang Y, Liu G. Treatment for lupus nephritis: an overview of systematic reviews and meta-analyses. Rheumatol Int 2017; 37:1089-1099. [DOI: 10.1007/s00296-017-3733-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/04/2017] [Indexed: 12/29/2022]
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Ward F, Bargman JM. Membranous Lupus Nephritis: The Same, But Different. Am J Kidney Dis 2016; 68:954-966. [DOI: 10.1053/j.ajkd.2016.07.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 07/06/2016] [Indexed: 01/07/2023]
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Abstract
PURPOSE OF REVIEW Despite recent developments and treatment successes, the outcome, and prognosis of patients with lupus nephritis (LuN) have not greatly changed since the 1980s. This review covers the application of new concepts to the understanding of renal inflammation and the study of new pharmacologic agents to improve patient outcomes. RECENT FINDINGS Studies have shown that the presence of anti-vimentin antibodies and T follicular helper cells in patient biopsies is associated with more severe interstitial inflammation, which has been tied to faster disease progression and onset of end-stage renal disease. Additionally, data regarding the role of serum IgE antidouble-stranded DNA antibodies in LuN by means of mediating IFN1 production by plasmacytoid dendritic cells are highlighted. Finally, a thorough review of completed and currently open clinical trials of therapeutic agents is provided. SUMMARY Current management of LuN is guided almost exclusively by glomerular involvement. Based on the data provided in this review, we argue that renal tubulointerstitial inflammation is no less important and represents an overlooked feature in the current clinical approach to patients. Tubulointerstitial inflammation is driven by both adaptive and innate immune mechanisms that are still poorly understood. Studying these pathogenic processes promises to reveal new therapeutic opportunities for those LuN patients with the worst prognosis. VIDEO ABSTRACT Alternate video abstract introduction (see Video, Supplemental Digital Content 1, with introduction by two of the authors - VL and KT). Abstract Video: http://links.lww.com/COR/A35.
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Affiliation(s)
- Kimberly Trotter
- Section of Rheumatology and Gwen Knapp Center for Lupus and Immunology Research, University of Chicago, Chicago, IL, 60637
| | - Marcus R. Clark
- Section of Rheumatology and Gwen Knapp Center for Lupus and Immunology Research, University of Chicago, Chicago, IL, 60637
| | - Vladimir M. Liarski
- Section of Rheumatology and Gwen Knapp Center for Lupus and Immunology Research, University of Chicago, Chicago, IL, 60637
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