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Johnson NM, Koumpouras F. Chimeric antigen receptors: "CARs" in the fast lane for rheumatology. Curr Opin Rheumatol 2024; 36:176-183. [PMID: 38517338 DOI: 10.1097/bor.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
PURPOSE OF REVIEW Recent advances in hematology-oncology have pioneered cell-mediated elimination of pathologic B-cell populations employing chimeric antigen receptor (CAR) T cells. In this review, we discuss recent adoption of CAR-T treatment for severe refractory autoimmune disease. We highlight unique aspects of the autoimmune model and review current clinical data regarding treatment of rheumatologic disease. RECENT FINDINGS To date, several CAR-Ts are FDA approved for Multiple Myeloma and B-cell malignancies and have demonstrated extraordinary clinical responses in refractory disease. Realizing the central role of B-cells in certain autoimmune diseases, CAR-T is now being explored for achieving drug-free remission induction, and potentially cure, of several rheumatologic diseases. The largest experience to date in the field of autoimmunity, building off the University Hospital Erlangen groups' earlier success treating a single patient with CD19-CAR in severe refractory SLE, Mackensen et al. enrolled five patients in a compassionate use program. Following autologous CD19-CAR T infusion, they demonstrated drug-free clinical and laboratory remission for at least 12 months in all five patients, with reconstitution of B cells expressing a naïve phenotype. SUMMARY CAR-T treatment has shown striking drug-free responses in severe lupus and other autoimmune diseases, creating a need for further exploration and development.
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Affiliation(s)
- Nathan M Johnson
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Jourde-Chiche N, Costedoat-Chalumeau N, Baumstarck K, Loundou A, Bouillet L, Burtey S, Caudwell V, Chiche L, Couzi L, Daniel L, Deligny C, Dussol B, Faguer S, Gobert P, Gondran G, Huart A, Hummel A, Kalbacher E, Karras A, Lambert M, Le Guern V, Lebourg L, Loubière S, Maillard-Lefebvre H, Maurier F, Pha M, Queyrel V, Remy P, Sarrot-Reynauld F, Verhelst D, Hachulla E, Amoura Z, Daugas E. Weaning of maintenance immunosuppressive therapy in lupus nephritis (WIN-Lupus): results of a multicentre randomised controlled trial. Ann Rheum Dis 2022; 81:1420-1427. [PMID: 35725295 PMCID: PMC9484365 DOI: 10.1136/annrheumdis-2022-222435] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/07/2022] [Indexed: 11/05/2022]
Abstract
Objectives Lupus nephritis (LN) is a frequent complication of systemic lupus erythematosus (SLE). Severe (proliferative) forms of LN are treated with induction immunosuppressive therapy (IST), followed by maintenance IST, to target remission and avoid relapses. The optimal duration of maintenance IST is unknown. The WIN-Lupus trial tested whether IST discontinuation after 2‒3 years was non-inferior to IST continuation for two more years in proliferative LN. Methods WIN-Lupus was an investigator-initiated multicentre randomised controlled trial. Patients receiving maintenance IST with azathioprine or mycophenolate mofetil for 2–3 years, and hydroxychloroquine, were randomised (1:1) into two groups: (1) IST continuation and (2) IST discontinuation. The primary endpoint was the relapse rate of proliferative LN at 24 months. Main secondary endpoints were the rate of severe SLE flares, survival without renal relapse or severe flare, adverse events. Results Between 2011 and 2016, 96 patients (out of 200 planned) were randomised in WIN-Lupus: IST continuation group (n=48), IST discontinuation group (n=48). Relapse of proliferative LN occurred in 5/40 (12.5%) patients with IST continuation and in 12/44 (27.3%) patients with IST discontinuation (difference 14.8% (95% CI −1.9 to 31.5)). Non-inferiority was not demonstrated for relapse rate; time to relapse did not differ between the groups. Severe SLE flares (renal or extrarenal) were less frequent in patients with IST continuation (5/40 vs 14/44 patients; p=0.035). Adverse events did not differ between the groups. Conclusions Non-inferiority of maintenance IST discontinuation after 2‒3 years was not demonstrated for renal relapse. IST discontinuation was associated with a higher risk of severe SLE flares. Trial registration number NCT01284725.
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Affiliation(s)
- Noemie Jourde-Chiche
- Nephrology, AP-HM, Marseille, France .,C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France
| | - Nathalie Costedoat-Chalumeau
- entre de recherche épidémiologie et biostatistiques de Sorbonne Paris Cité, Universite de Paris, Paris, France.,Centre de référence maladies rares, Hôpital Cochin, AP-HP, Paris, France
| | - Karine Baumstarck
- Laboratoire de Santé Publique, CERESS, Aix-Marseille Universite, Marseille, France
| | - Anderson Loundou
- Laboratoire de Santé Publique, CERESS, Aix-Marseille Universite, Marseille, France
| | - Laurence Bouillet
- Internal Medicine, Centre Hospitalier Universitaire Grenoble, Michallon Hospital, Grenoble, France
| | - Stéphane Burtey
- C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France.,Nephrology, AP-HM, Marseille, France
| | | | | | - Lionel Couzi
- Nephrology, CHU Bordeaux GH Pellegrin, Bordeaux, France
| | - Laurent Daniel
- C2VN, INSERM, INRAE, Aix-Marseille Universite, Marseille, France.,Laboratoire d'Anatomie Pathologique, AP-HM, Marseille, France
| | | | - Bertrand Dussol
- Nephrology, AP-HM, Marseille, France.,Centre d'Investigation Clinique, AP-HM, Marseille, France
| | - Stanislas Faguer
- Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France
| | | | | | - Antoine Huart
- Nephrology and Organ Transplantation, CHU Toulouse, Toulouse, France
| | - Aurélie Hummel
- Nephrology, Necker-Enfants Malades Hospitals, Paris, France
| | | | - Adexandre Karras
- Nephrology, Hopital Europeen Georges Pompidou, Paris, France.,Universite Paris Descartes, Paris, France
| | | | | | | | - Sandrine Loubière
- Support Unit for Clinical Research and Health Economics, AP-HM, Marseille, France
| | | | | | - Micheline Pha
- Médecine Interne 2, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, Paris, France
| | | | | | | | | | - Eric Hachulla
- Internal Medicine, Lille University School of Medicine, Lille, France
| | - Zahir Amoura
- Centre de reference maladies auto-immunes et systemiques, Internal Medicine, AP-HP, Paris, France
| | - Eric Daugas
- Nephrology, AP-HP, Paris, France.,INSERM U1149, Universite de Paris, Paris, France
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Moroni G, Frontini G, Ponticelli C. When and How Is It Possible to Stop Therapy in Patients with Lupus Nephritis: A Narrative Review. Clin J Am Soc Nephrol 2021; 16:1909-1917. [PMID: 34162696 PMCID: PMC8729481 DOI: 10.2215/cjn.04830421] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Glucocorticoids and other immunosuppressants still represent the cornerstone drugs for the management of SLE and lupus nephritis. The refined use of these drugs over the years has allowed us to obtain stable disease remission and improvement of long-term kidney and patient survival. Nevertheless, a prolonged use of immunosuppressive agents may be accompanied by severe and even life-threatening side effects. Theoretically, a transient or even definitive withdrawal of immunosuppression could be useful to prevent iatrogenic morbidities. For many years, however, the risk of SLE reactivation has held clinicians back from trying to interrupt therapy. In this review, we report the results of the attempts to interrupt glucocorticoids and other immunosuppressive agents in lupus nephritis and in SLE. The available data suggest that therapy withdrawal is feasible at least in patients enjoying a complete clinical remission after a prolonged therapy. A slow and gradual reduction of treatment under medical surveillance is needed to prevent flares of activity. After therapy withdrawal, around one-quarter of patients may have kidney or systemic flares. However, most flares may respond to therapy if rapidly diagnosed. The other patients can enter stable remission for even 20 years or more. The use of antimalarials can help in maintaining the remission after the withdrawal of the immunosuppressive therapy. A repeated kidney biopsy could be of help in deciding to stop therapy, but given the few available data, it cannot be considered essential.
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Affiliation(s)
- Gabriella Moroni
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, Milan, Italy
| | - Giulia Frontini
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico Milano, Milan, Italy
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5
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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Pourafshar N, Karimi A, Wen X, Sobel E, Pourafshar S, Agrawal N, Segal E, Mohandas R, Segal MS. The utility of trough mycophenolic acid levels for the management of lupus nephritis. Nephrol Dial Transplant 2019; 34:83-89. [PMID: 29548021 DOI: 10.1093/ndt/gfy026] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 01/11/2018] [Indexed: 01/27/2023] Open
Abstract
Background Monitoring of mycophenolic acid (MPA) levels may be useful for effective mycophenolate mofetil (MMF) dosing. However, whether commonly obtained trough levels are an acceptable method of surveillance remains debatable. We hypothesized that trough levels of MPA would be a poor predictor of area under the curve (AUC) for MPA. Methods A total of 51 patients with lupus nephritis who were on MMF 1500 mg twice a day and had a 4-h AUC done were included in this study. MPA levels were measured prior to (C0) and at 1 (C1), 2 (C2) and 4 (C4) h, followed by 1500 mg of MMF. The MPA AUC values were calculated using the linear trapezoidal rule. Regression analysis was used to examine the relationship between the MPA trough and AUC. Differences in the MPA trough and AUC between different clinical and demographic categories were compared using t-tests. Results When grouped by tertiles there was significant overlap in MPA, AUC 0-4 and MPA trough in all tertiles. Although there was a statistically significant correlation between MPA trough levels and AUC, this association was weak and accounted for only 30% of the variability in MPA trough levels. This relationship might be even more unreliable in men than women. The use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was associated with increased MPA trough levels and AUC at 0-4 h (AUC0-4). Conclusion Trough levels of MPA do not show a strong correlation with AUC. In clinical situations where MPA levels are essential to guide therapy, an AUC0-4 would be a better indicator of the adequacy of treatment.
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Affiliation(s)
- Negiin Pourafshar
- Division of Nephrology, Center for Immunity, Inflammation and Regenerative Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia.,Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida
| | - Ashkan Karimi
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Xuerong Wen
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida
| | - Eric Sobel
- Disvision of Rheumatology, Department of Medicine, University of Florida, Gainesville, Florida.,North Florida/South Georgia Veterans Health system, Gainesville, Florida
| | - Shirin Pourafshar
- Division of Nephrology, Center for Immunity, Inflammation and Regenerative Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Nikhil Agrawal
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida
| | - Emma Segal
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida
| | - Rajesh Mohandas
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida.,North Florida/South Georgia Veterans Health system, Gainesville, Florida
| | - Mark S Segal
- Division of Nephrology, Hypertension and Renal Transplant, Department of Medicine, University of Florida, Gainesville, Florida.,North Florida/South Georgia Veterans Health system, Gainesville, Florida
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Cunha C, Alexander S, Ashby D, Lee J, Chusney G, Cairns TD, Lightstone L. Hydroxycloroquine blood concentration in lupus nephritis: a determinant of disease outcome? Nephrol Dial Transplant 2019; 33:1604-1610. [PMID: 29186572 DOI: 10.1093/ndt/gfx318] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 09/25/2017] [Indexed: 12/13/2022] Open
Abstract
Background Hydroxychloroquine (HCQ) is a recommended drug in systemic lupus erythematosus (SLE). It has a long terminal half-life, making it an attractive target for therapeutic drug monitoring. The aim of this study was to establish a relationship between blood HCQ concentration and lupus nephritis activity. Methods We conducted a retrospective observational study with data collected from clinical and laboratory records. Inclusion criteria were patients followed in the lupus clinic with biopsy-proven International Society of Nephrology/Renal Pathology Society Classes III, IV or V lupus nephritis on HCQ for at least 3 months (200-400 mg daily) and with HCQ levels measured during treatment. Exclusion criteria were patients on renal replacement therapy at baseline or patients lost to follow-up. Results In 171 patients, the HCQ level was measured in 1282 samples. The mean HCQ blood level was 0.75±0.54mg/L and it was bimodally distributed. An HCQ level <0.20 mg/L [232 samples (18.1%)] appeared to define a distinct group of abnormally low HCQ levels. For patients in complete or partial remission at baseline compared with those remaining in remission, patients with renal flare during follow-up had a significantly lower average HCQ level (0.59 versus 0.81 mg/L; P= 0.005). Our data suggest an HCQ target level to reduce the likelihood of renal flares >0.6 mg/L (600 ng/mL) in those patients with lupus nephritis. Conclusion HCQ level monitoring may offer a new approach to identify non-adherent patients and support them appropriately. We propose an HCQ minimum target level of at least 0.6 mg/L to reduce the renal flare rate, but this will require a prospective study for validation.
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Affiliation(s)
- Cátia Cunha
- Nephrology Department, Centro Hospitalar de VilaNova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Suceena Alexander
- Nephrology Department, Christian Medical College Vellore, Vellore, Tamilnadu, India
| | - Damien Ashby
- Imperial College Lupus Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Janet Lee
- Leslie Brent Laboratory, Imperial College Healthcare NHS Trust, London, UK
| | - Gary Chusney
- Leslie Brent Laboratory, Imperial College Healthcare NHS Trust, London, UK
| | - Tom D Cairns
- Imperial College Lupus Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Liz Lightstone
- Imperial College Lupus Centre, Imperial College Healthcare NHS Trust, London, UK.,Section of Renal Medicine, Department of Medicine, Imperial College London, UK
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8
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Sumethkul K, Kitumnuaypong T, Angthararak S, Pichaiwong W. Low-dose cyclosporine for active lupus nephritis: a dose titration approach. Clin Rheumatol 2019; 38:2151-2159. [PMID: 30937637 DOI: 10.1007/s10067-019-04469-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 01/14/2019] [Accepted: 02/06/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Achievement of complete renal remission (CR) is an important goal in lupus nephritis (LN) treatment. The use of cyclosporine (CsA) for active LN has been challenged because of variations in CsA doses and reports of adverse reactions (AR). METHOD A cohort of 62 patients with active LN (induction-resistant LN and flared LN) who were treated with CsA was evaluated. CsA was started at 50 mg/day and titrated up 25 mg/day every 2-4 weeks until CR was achieved or until treatment termination because of AR. RESULTS The range of CsA dosage was 50-200 mg/day, and mean CsA dose was 102.8 ± 50.43 mg/day (1.73 ± 0.91 mg/kg/day). CsA plus mycophenolate mofetil and prednisolone was administered to 35.5% of patients, while the other 64.5% were treated with CsA and prednisolone. 90.32% had achieved CR and 4.84% had partial remission after 12 months of treatment. UPCR (urinary protein:creatinine ratio) decreased significantly in both groups (2.58 ± 3.37 to 0.36 ± 0.71 and 2.32 ± 1.45 to 0.29 ± 0.24 respectively) (P < 0.001). Non-renal activity including arthritis, alopecia, hematologic and cutaneous conditions improved in all patients. Patients whose prednisolone dose were increase received higher doses of prednisolone at baseline than patients who had stable prednisolone dose, but after 12 months the difference in dosage was insignificant (p = 0.58). CONCLUSION Patients with active LN can be effectively treated with low dose CsA, and the dose titration approach can lead to 90.32% CR with low AR rates. No difference in clinical response was observed among patients who received CsA plus prednisolone or CsA plus MMF and prednisolone.
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Affiliation(s)
- Kittiwan Sumethkul
- Rheumatology Unit, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Bangkok, 10400, Thailand.
| | - Tasanee Kitumnuaypong
- Rheumatology Unit, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Bangkok, 10400, Thailand
| | - Sungchai Angthararak
- Rheumatology Unit, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Bangkok, 10400, Thailand
| | - Warangkana Pichaiwong
- Nephrology Unit, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Bangkok, 10400, Thailand
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Abstract
Systemic lupus erythematosus (SLE) is a systemic disease of unknown aetiology with variable course and prognosis. Lupus nephritis (LN) is one of the important disease manifestations of SLE with considerable influence on patient outcomes. Immunosuppression therapy has made it possible to control the disease with improved life expectancy and quality of life. In the last few decades, various studies across the globe have clarified the role, dose and duration of immunosuppression currently in use and also provided evidence for new agents such as mycophenolate mofetil, calcineurin inhibitors and rituximab. However, there is still a need to develop new and specific therapy with less adverse effects. In this review, the current evidence of the treatment of LN and its evolution, and new classification criteria for SLE have been discussed. Also, rationale for low-dose intravenous cyclophosphamide as induction agent followed by azathioprine as maintenance agent has been provided with emphasis on individualized and holistic approach.
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Affiliation(s)
- Ajay Jaryal
- Department of Nephrology, Indira Gandhi Medical College (IGMC), Shimla, India
| | - Sanjay Vikrant
- Department of Nephrology, Indira Gandhi Medical College (IGMC), Shimla, India
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10
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Moroni G, Gatto M, Raffiotta F, Binda V, Frangou E, Lightstone L, Boumpas DT. Can we withdraw immunosuppressants in patients with lupus nephritis in remission? An expert debate. Autoimmun Rev 2018; 17:11-18. [DOI: 10.1016/j.autrev.2017.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/04/2017] [Indexed: 12/30/2022]
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11
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Insights into the epidemiology and management of lupus nephritis from the US rheumatologist's perspective. Kidney Int 2016; 90:487-92. [PMID: 27344205 DOI: 10.1016/j.kint.2016.03.042] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 03/14/2016] [Accepted: 03/24/2016] [Indexed: 12/13/2022]
Abstract
Lupus nephritis is a common and severe manifestation of systemic lupus erythematosus that disproportionately affects nonwhites and those in lower socioeconomic groups. This review discusses recent data on the incidence, prevalence, and outcomes of patients with lupus nephritis with a focus on low-income US Medicaid patients. We also review recent guidelines on diagnosis, treatment, and screening for new onset and relapses of lupus nephritis. Finally, we discuss the management of lupus nephritis from a rheumatologist's perspective, including vigilance for the common adverse events related to disease and treatment, and we review prevention and new treatment strategies.
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Morris HK, Canetta PA, Appel GB. Impact of the ALMS and MAINTAIN trials on the management of lupus nephritis. Nephrol Dial Transplant 2012; 28:1371-6. [PMID: 23233523 DOI: 10.1093/ndt/gfs447] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Current treatment of lupus nephritis consists of both induction and maintenance therapy, with the latter being designed to consolidate remissions and prevent relapses. Long-term maintenance treatment with intravenous cyclophosphamide was effective but associated with considerable toxicity. A small but well-designed controlled trial found that for post-induction maintenance therapy, both oral mycophenolate mofetil (MMF) and oral azathioprine were superior in efficacy and had reduced toxicity than a regimen of continued every third month intravenous cyclophosphamide. Although these oral agents were rapidly accepted and utilized as maintenance medications, their usage was based on scant evidence and there were no comparisons between the two. Recently, two relatively large, randomized, well-controlled, multicenter trials dealing with maintenance therapy for severe lupus nephritis have been completed. The Aspreva Lupus Management Study (ALMS) maintenance and MAINTAIN nephritis trials provide important information regarding the comparative efficacy and safety of MMF and azathioprine as maintenance therapies, as well as information on the effect of dosage and duration of treatment with these agents.
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Affiliation(s)
- Heather K Morris
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons and Columbia University Medical Center, New York, NY 10032, USA
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13
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Sprangers B, Monahan M, Appel GB. Diagnosis and treatment of lupus nephritis flares--an update. Nat Rev Nephrol 2012; 8:709-17. [PMID: 23147758 DOI: 10.1038/nrneph.2012.220] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Relapses or flares of systemic lupus erythematosus (SLE) are frequent and observed in 27-66% of patients. SLE flares are defined as an increase in disease activity, in general, requiring alternative treatment or intensification of therapy. A renal flare is indicated by an increase in proteinuria and/or serum creatinine concentration, abnormal urine sediment or a reduction in creatinine clearance rate as a result of active disease. The morbidity associated with renal flares is derived from both the kidney damage due to lupus nephritis and treatment-related toxic effects. Current induction treatment protocols achieve remission in the majority of patients with lupus nephritis; however, few studies focus on treatment interventions for renal flares in these patients. The available data, however, suggest that remission can be induced again in a substantial percentage of patients experiencing a lupus nephritis flare. Lupus nephritis flares are independently associated with an increased risk of deterioration in renal function; prevention of renal flares might, therefore, also decrease long-term morbidity and mortality. Appropriate immunosuppressive maintenance therapy might lead to a decrease in the occurrence of renal and extrarenal flares in patients with SLE, and monitoring for the early detection and treatment of renal flares could improve their outcomes.
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Affiliation(s)
- Ben Sprangers
- Department of Medicine, Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
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14
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Abstract
Immunotherapy has been used for the treatment of renal diseases for a long time, and there has been significant progress in such treatment. This review focuses on the use of immunotherapy for the treatment of glomerular diseases. The use of immunosuppression in the treatment of minimal change disease, membranous nephropathy, primary focal segmental glomerulosclerosis, lupus nephritis, immunoglobulin-A nephropathy, antineutrophil cytoplasmic antibody-associated disease, and anti-glomerular basement membrane disease is discussed.
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Affiliation(s)
- Ajay Kher
- The Transplant Institute, Beth Israel Deaconess Medical Center, 110 Francis Street, 7th Floor, Boston, MA 02215, USA.
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Opastirakul S, Chartapisak W. Pulse cyclophosphamide induction treatment in Thai children with diffuse proliferative lupus nephritis. Nephrology (Carlton) 2011; 17:269-73. [PMID: 22181066 DOI: 10.1111/j.1440-1797.2011.01554.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To report the effectiveness of pulse cyclophosphamide induction therapy and to identify predictors for unresponsiveness to treatment in Thai children. METHODS Children with biopsy-proven diffuse proliferative lupus nephritis admitted to Chiang Mai University hospital between 2001 and 2006 were retrospectively studied. Patients received a test dose of 750 mg/m(2) at the first month followed by six cycles of monthly cyclophosphamide (IVCY) at a dose of 1 g/m(2) (maximum 1 g) as induction therapy. Responsiveness to treatment, defined as urinary protein to creatinine ratio of less than 0.3 with normalization of C3 level and clinical remission, was assessed at the end of the induction period. Gender, age at onset, duration of disease before treatment, hypertension, clinical nephrotic syndrome, amount of proteinuria, serum creatinine, creatinine clearance, serum C3 level and crescentic formation were compared between responsive and nonresponsive groups. Maintenance therapy with quarterly pulse IVCY or Azathioprine or Mycophenolate mofetil was given for 18-24 months after remission. RESULTS Twenty nine patients with a mean age of 10.3 ± 2.6 years were studied. Hypertension, microscopic haematuria and nephrotic-range proteinuria were seen in 66%, 86% and 60% of the patients, respectively. Forty-one per cent of biopsies showed cellular or fibrocellular crescents. Twenty patients (69%) achieved remission at the end of induction therapy. There were no significant differences in all parameters studied between responsive and nonresponsive groups. The relapse rate after maintenance therapy was 58.8%. CONCLUSION Our results show that pulse cyclophosphamide is an effective regimen for induction therapy in children with diffuse proliferative glomerulonephritis. No definite predictor for unresponsiveness was detected in this study.
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Affiliation(s)
- Sauwalak Opastirakul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Abstract
Proliferative lupus nephritis is the most severe form of lupus nephritis. Outcomes of this disease are affected by ethnicity, clinical characteristics, irreversible damage on renal biopsy, initial response to treatment and future disease course (for example, the occurrence of renal flares). Initial intensive (induction) treatment of proliferative lupus nephritis is aimed at achieving remission, but optimal duration and intensity are not well defined. A combination of intravenous cyclophosphamide and corticosteroids have been shown to decrease the risk of end-stage renal disease, but are associated with substantial acute toxic effects (such as infections) and chronic toxic effects (such as ovarian failure). In white populations, low-dose cyclophosphamide is a reasonable alternative to high-dose cyclophosphamide as it is similarly effective and associated with less toxicity. Mycophenolate mofetil is as effective as high-dose intravenous cyclophosphamide in terms of inducing remission and similar in terms of safety. Although most patients respond to induction treatment, remission is often only achieved after patients are switched to maintenance treatment. As maintenance treatment, mycophenolate mofetil is superior to azathioprine and azathioprine is similarly effective to ciclosporin in terms of prevention or reducing the risk of relapse. Rituximab should be reserved for patients with refractory disease. Treatment of lupus nephritis should be individually tailored to patients, with more aggressive therapy reserved for patients at high risk of renal dysfunction and progression of renal disease.
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Gargah T, Goucha-Louzir R, Lakhoua MR. Place du mycophénolate mofétil dans la néphropathie lupique proliférative de l’enfant. Nephrol Ther 2010; 6:564-8. [DOI: 10.1016/j.nephro.2010.07.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 07/06/2010] [Accepted: 07/06/2010] [Indexed: 11/15/2022]
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Szeto CC, Tam LS. Maintenance treatment of proliferative lupus nephritis can be discontinued after remission in some patients. ACTA ACUST UNITED AC 2007; 2:672-3. [PMID: 17124522 DOI: 10.1038/ncpneph0333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2006] [Accepted: 08/31/2006] [Indexed: 11/09/2022]
Affiliation(s)
- Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong.
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