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Wenderfer SE, Cooper JC. Do we really need cyclophosphamide for lupus nephritis? Pediatr Nephrol 2024; 39:3193-3200. [PMID: 38607424 DOI: 10.1007/s00467-024-06367-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/13/2024]
Abstract
A 14-year-old patient presents with hematuria and proteinuria. Clinical evaluation reveals a positive anti-nuclear antibody titer, positive anti-double stranded DNA antibody and hypocomplementemia. Systemic lupus erythematosus (SLE) is diagnosed based on the 2019 EULAR/ACR (European League Against Rheumatism/American College of Rheumatology) classification criteria (Aringer et al. Arthritis Rheumatol 71:1400-1412, 2019). A kidney biopsy is performed that confirms the presence of immune complex glomerulonephritis, ISN-RPS (International Society of Nephrology/Renal Pathology Society) class IV (Bajema et al. Kidney Int 93:789-796, 2018). According to the latest clinical practice guidelines (Rovin et al. Kidney Int 100:753-779, 2021; Fanouriakis et al. Ann Rheum Dis 83:15-29, 2023), there are alternatives to treating this patient with cyclophosphamide. But what if this patient also presented with oliguria and volume overload requiring intensive care and dialysis? What if this patient also presented with altered mental status and seizures, and was diagnosed with neuropsychiatric lupus? What if this patient was also diagnosed with a pulmonary hemorrhage and respiratory failure? The clinical practice guidelines do not address these scenarios that are not uncommon in patients with SLE. Moreover, in some countries worldwide, patients do not have the privilege of access to biologics or more expensive alternatives. The purpose of this review is to evaluate the contemporary options for initial treatment of nephritis in patients with SLE.
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Affiliation(s)
- Scott E Wenderfer
- Department of Pediatrics, The University of British Columbia, Vancouver, BC, Canada.
- Pediatric Nephrology, BC Children's Hospital, Vancouver, BC, Canada.
| | - Jennifer C Cooper
- Department of Pediatrics, University of Colorado, Denver, CO, USA
- Pediatric Rheumatology, Children's Hospital Colorado, Aurora, CO, USA
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Kawazoe M, Nanki T. Comparison of efficacy of continuous mycophenolate mofetil with sequential cyclophosphamide and tacrolimus as maintenance therapy for lupus nephritis. Lupus 2024; 33:319-327. [PMID: 38232223 DOI: 10.1177/09612033241228177] [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] [Indexed: 01/19/2024]
Abstract
OBJECTIVES To evaluate the renal response to mycophenolate mofetil (MMF) as maintenance therapy for lupus nephritis (LN) in Japanese patients, we compared the efficacy of MMF and the sequential use of monthly intravenous cyclophosphamide (IVCY) followed by tacrolimus (TAC). METHODS We examined 14 patients with LN who were treated with continuous MMF as induction and maintenance therapies (MMF group) and 10 patients with LN who received monthly IVCY as induction therapy followed by maintenance therapy with TAC (IVCY-TAC group). We assessed the therapeutic effects of each treatment regimen on renal manifestations and serological findings over a 36-month period after treatment initiation. RESULTS Mean urine protein-to-creatinine ratios in the MMF and IVCY-TAC groups significantly decreased from 2.75 to 0.11 g/gCr and from 3.26 to 0.22 g/gCr, respectively. Significant improvements in serum immunological variables (serum complement C3 or C4 levels and the anti-double-stranded DNA antibody titer) and reductions in the SLE disease activity index and daily prednisolone dosages were observed in both groups during induction therapy and were maintained during maintenance therapy. Efficacy was similar between the MMF and IVCY-TAC groups. CONCLUSION MMF has potential as an effective treatment for renal manifestations in Japanese patients throughout induction and maintenance therapies for LN, as an alternative to conventional IVCY-TAC therapy, and as a glucocorticoid-sparing agent.
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Affiliation(s)
- Mai Kawazoe
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
| | - Toshihiro Nanki
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan
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Babalola KT, Arora M, Ganugula R, Agarwal SK, Mohan C, Kumar MNVR. Leveraging Lymphatic System Targeting in Systemic Lupus Erythematosus for Improved Clinical Outcomes. Pharmacol Rev 2024; 76:228-250. [PMID: 38351070 PMCID: PMC10877736 DOI: 10.1124/pharmrev.123.000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/21/2023] [Accepted: 12/06/2023] [Indexed: 02/16/2024] Open
Abstract
The role of advanced drug delivery strategies in drug repositioning and minimizing drug attrition rates, when applied early in drug discovery, is poised to increase the translational impact of various therapeutic strategies in disease prevention and treatment. In this context, drug delivery to the lymphatic system is gaining prominence not only to improve the systemic bioavailability of various pharmaceutical drugs but also to target certain specific diseases associated with the lymphatic system. Although the role of the lymphatic system in lupus is known, very little is done to target drugs to yield improved clinical benefits. In this review, we discuss recent advances in drug delivery strategies to treat lupus, the various routes of drug administration leading to improved lymph node bioavailability, and the available technologies applied in other areas that can be adapted to lupus treatment. Moreover, this review also presents some recent findings that demonstrate the promise of lymphatic targeting in a preclinical setting, offering renewed hope for certain pharmaceutical drugs that are limited by efficacy in their conventional dosage forms. These findings underscore the potential and feasibility of such lymphatic drug-targeting approaches to enhance therapeutic efficacy in lupus and minimize off-target effects of the pharmaceutical drugs. SIGNIFICANCE STATEMENT: The World Health Organization estimates that there are currently 5 million humans living with some form of lupus. With limited success in lupus drug discovery, turning to effective delivery strategies with existing drug molecules, as well as those in the early stage of discovery, could lead to better clinical outcomes. After all, effective delivery strategies have been proven to improve treatment outcomes.
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Affiliation(s)
- K T Babalola
- The Center for Convergent Bioscience and Medicine (CCBM) (K.T.B., M.A., R.G., M.N.V.R.K.), Division of Translational Science and Medicine, College of Community Health Sciences (K.T.B., M.A., R.G., M.N.V.R.K.), Alabama Life Research Institute (K.T.B., M.A., R.G., M.N.V.R.K.), and Department of Biological Sciences (M.A., R.G., M.N.V.R.K.), The University of Alabama, Tuscaloosa, Alabama; Section of Immunology, Allergy and Rheumatology, Department of Medicine, Biology of Inflammation Baylor College of Medicine, One Baylor Plaza, Houston, Texas (S.K.A.); Department of Biomedical Engineering, University of Houston, Houston, Texas (C.M.); Chemical and Biological Engineering, University of Alabama, Tuscaloosa, Alabama (M.N.V.R.K.); and Center for Free Radical Biology (M.N.V.R.K.) and Nephrology Research and Training Center, Division of Nephrology, Department of Medicine (M.N.V.R.K.), University of Alabama at Birmingham, Birmingham, Alabama
| | - M Arora
- The Center for Convergent Bioscience and Medicine (CCBM) (K.T.B., M.A., R.G., M.N.V.R.K.), Division of Translational Science and Medicine, College of Community Health Sciences (K.T.B., M.A., R.G., M.N.V.R.K.), Alabama Life Research Institute (K.T.B., M.A., R.G., M.N.V.R.K.), and Department of Biological Sciences (M.A., R.G., M.N.V.R.K.), The University of Alabama, Tuscaloosa, Alabama; Section of Immunology, Allergy and Rheumatology, Department of Medicine, Biology of Inflammation Baylor College of Medicine, One Baylor Plaza, Houston, Texas (S.K.A.); Department of Biomedical Engineering, University of Houston, Houston, Texas (C.M.); Chemical and Biological Engineering, University of Alabama, Tuscaloosa, Alabama (M.N.V.R.K.); and Center for Free Radical Biology (M.N.V.R.K.) and Nephrology Research and Training Center, Division of Nephrology, Department of Medicine (M.N.V.R.K.), University of Alabama at Birmingham, Birmingham, Alabama
| | - R Ganugula
- The Center for Convergent Bioscience and Medicine (CCBM) (K.T.B., M.A., R.G., M.N.V.R.K.), Division of Translational Science and Medicine, College of Community Health Sciences (K.T.B., M.A., R.G., M.N.V.R.K.), Alabama Life Research Institute (K.T.B., M.A., R.G., M.N.V.R.K.), and Department of Biological Sciences (M.A., R.G., M.N.V.R.K.), The University of Alabama, Tuscaloosa, Alabama; Section of Immunology, Allergy and Rheumatology, Department of Medicine, Biology of Inflammation Baylor College of Medicine, One Baylor Plaza, Houston, Texas (S.K.A.); Department of Biomedical Engineering, University of Houston, Houston, Texas (C.M.); Chemical and Biological Engineering, University of Alabama, Tuscaloosa, Alabama (M.N.V.R.K.); and Center for Free Radical Biology (M.N.V.R.K.) and Nephrology Research and Training Center, Division of Nephrology, Department of Medicine (M.N.V.R.K.), University of Alabama at Birmingham, Birmingham, Alabama
| | - S K Agarwal
- The Center for Convergent Bioscience and Medicine (CCBM) (K.T.B., M.A., R.G., M.N.V.R.K.), Division of Translational Science and Medicine, College of Community Health Sciences (K.T.B., M.A., R.G., M.N.V.R.K.), Alabama Life Research Institute (K.T.B., M.A., R.G., M.N.V.R.K.), and Department of Biological Sciences (M.A., R.G., M.N.V.R.K.), The University of Alabama, Tuscaloosa, Alabama; Section of Immunology, Allergy and Rheumatology, Department of Medicine, Biology of Inflammation Baylor College of Medicine, One Baylor Plaza, Houston, Texas (S.K.A.); Department of Biomedical Engineering, University of Houston, Houston, Texas (C.M.); Chemical and Biological Engineering, University of Alabama, Tuscaloosa, Alabama (M.N.V.R.K.); and Center for Free Radical Biology (M.N.V.R.K.) and Nephrology Research and Training Center, Division of Nephrology, Department of Medicine (M.N.V.R.K.), University of Alabama at Birmingham, Birmingham, Alabama
| | - C Mohan
- The Center for Convergent Bioscience and Medicine (CCBM) (K.T.B., M.A., R.G., M.N.V.R.K.), Division of Translational Science and Medicine, College of Community Health Sciences (K.T.B., M.A., R.G., M.N.V.R.K.), Alabama Life Research Institute (K.T.B., M.A., R.G., M.N.V.R.K.), and Department of Biological Sciences (M.A., R.G., M.N.V.R.K.), The University of Alabama, Tuscaloosa, Alabama; Section of Immunology, Allergy and Rheumatology, Department of Medicine, Biology of Inflammation Baylor College of Medicine, One Baylor Plaza, Houston, Texas (S.K.A.); Department of Biomedical Engineering, University of Houston, Houston, Texas (C.M.); Chemical and Biological Engineering, University of Alabama, Tuscaloosa, Alabama (M.N.V.R.K.); and Center for Free Radical Biology (M.N.V.R.K.) and Nephrology Research and Training Center, Division of Nephrology, Department of Medicine (M.N.V.R.K.), University of Alabama at Birmingham, Birmingham, Alabama
| | - M N V Ravi Kumar
- The Center for Convergent Bioscience and Medicine (CCBM) (K.T.B., M.A., R.G., M.N.V.R.K.), Division of Translational Science and Medicine, College of Community Health Sciences (K.T.B., M.A., R.G., M.N.V.R.K.), Alabama Life Research Institute (K.T.B., M.A., R.G., M.N.V.R.K.), and Department of Biological Sciences (M.A., R.G., M.N.V.R.K.), The University of Alabama, Tuscaloosa, Alabama; Section of Immunology, Allergy and Rheumatology, Department of Medicine, Biology of Inflammation Baylor College of Medicine, One Baylor Plaza, Houston, Texas (S.K.A.); Department of Biomedical Engineering, University of Houston, Houston, Texas (C.M.); Chemical and Biological Engineering, University of Alabama, Tuscaloosa, Alabama (M.N.V.R.K.); and Center for Free Radical Biology (M.N.V.R.K.) and Nephrology Research and Training Center, Division of Nephrology, Department of Medicine (M.N.V.R.K.), University of Alabama at Birmingham, Birmingham, Alabama
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Elaziz MMA, Gamal SM, Fayed A, Abu-Zaid MH, Ghoniem SA, Teleb DA. High- and low-dose cyclophosphamide in Egyptian lupus nephritis patients: a multicenter retrospective analysis. Z Rheumatol 2024; 83:115-123. [PMID: 37582953 PMCID: PMC10879243 DOI: 10.1007/s00393-023-01386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Lupus nephritis (LN) is a common serious presentation of systemic lupus erythematosus. Cyclophosphamide (CYC) and mycophenolate mofetil (MMF) are listed as the first-line drugs in induction therapy for LN. OBJECTIVE This study aimed to compare high- and low-dose CYC in a cohort of Egyptian LN patients. PATIENTS AND METHODS The data of 547 patients with class III/IV active LN who received CYC as induction therapy were retrospectively analyzed. Whereas 399 patients received 6‑monthly 0.5-1 g/m2 CYC doses, 148 patients received six biweekly 500 mg CYC doses. Demographic data, laboratory test results, and disease activity index were recorded and compared at presentation and at 6, 12, 18, 24, and 48 months of follow-up. RESULTS After 48 months, the proportion of patients maintaining normal creatinine levels was higher in the group receiving induction therapy with high-dose CYC (67.9%, 60.4%, p = 0.029), and these patients also had higher proteinuria remission at 36 (26.6%, 14.8%, p = 0.014) and 48 months (24.3%, 12.8%, p = 0.006). Comparison of patient outcomes according to both induction and maintenance therapy showed the best results in patients who received high-dose CYC and continued MMF as maintenance therapy. CONCLUSION High- and low-dose CYC are comparable in early phases of treatment. However, after a longer duration of follow-up, high-dose CYC was associated with higher remission rates in the current cohort.
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Affiliation(s)
| | - Sherif M Gamal
- Rheumatology and Rehabilitation Department, Faculty of medicine, Cairo University Hospital, Cairo University, Al Kasr Al Aini, Old Cairo, Cairo Governorate, 4240310, Cairo, Egypt
| | - Ahmed Fayed
- Department of Internal Medicine, Nephrology Unit, Cairo University Hospital, Cairo, Egypt
| | | | - Shada A Ghoniem
- Rheumatology and Rehabilitation Department, Faculty of medicine, Cairo University Hospital, Cairo University, Al Kasr Al Aini, Old Cairo, Cairo Governorate, 4240310, Cairo, Egypt.
| | - Doaa A Teleb
- Rheumatology and Rehabilitation Department, Faculty of medicine, Cairo University Hospital, Cairo University, Al Kasr Al Aini, Old Cairo, Cairo Governorate, 4240310, Cairo, Egypt
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Garal-Pantaler E, Schultze M, Georgiou ME, Pignot M, Gairy K, Hunnicutt JN. Real-World Burden of Immunosuppressant-Treated Lupus Nephritis: A German Claims Database Analysis. Rheumatol Ther 2024; 11:113-127. [PMID: 38001304 PMCID: PMC10796872 DOI: 10.1007/s40744-023-00623-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023] Open
Abstract
INTRODUCTION This retrospective cohort study (GSK213737) aimed to characterize treatment patterns, healthcare resource utilization (HCRU), and costs in patients with lupus nephritis (LN) initiating immunosuppressant therapy in clinical practice in Germany, to better understand the full picture of the real-world burden of LN. METHODS Adult patients with LN who initiated mycophenolate mofetil (MMF), intravenous cyclophosphamide (CYC), azathioprine (AZA), tacrolimus, cyclosporin A, or rituximab therapy in 2011-2017 (index therapy) were identified from the Betriebskrankenkassen German Sickness Fund database. Treatment patterns, including immunosuppressant discontinuations, and therapy switches, were assessed (maximum follow-up 4 years). Corticosteroid use, HCRU, and total economic costs were also evaluated. HCRU and costs were compared with matched controls (individuals without systemic lupus erythematosus [SLE]/LN matched by age, sex, and baseline Charlson Comorbidity Index). RESULTS Among 334 patients with LN, the median (interquartile range) duration of index immunosuppressant therapy use was 380.5 (126, 1064) days. Of those patients with 4 years complete enrollment, 70.8% had ≥ 1 discontinuation and 28.8% switched therapy. While most patients (71.2%) received only one immunosuppressant, gaps in treatment were common. After 1 year of follow-up, 41.6% of patients had a prednisone-equivalent corticosteroid dose of ≥ 7.5 mg/day. Patients with LN had greater HCRU use for most categories assessed and increased mean total costs per person-year versus controls (€15,115.99 versus €4,081.88 in the first year of follow-up). CONCLUSIONS This real-world analysis demonstrated the considerable burden of immunosuppressant-treated LN in Germany, with a high rate of discontinuations, frequent use of high-dose corticosteroids, and substantial HCRU/costs.
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Affiliation(s)
- Elena Garal-Pantaler
- Health Care Research and Health Economics (Versorgungsforschung und Gesundheitsökonomie), Team Gesundheit GmbH, Essen, Germany
| | - Michael Schultze
- Berlin Center for Epidemiology and Health Research, ZEG Berlin GmbH, Berlin, Germany
| | | | - Marc Pignot
- Berlin Center for Epidemiology and Health Research, ZEG Berlin GmbH, Berlin, Germany
| | - Kerry Gairy
- Value Evidence and Outcomes, GSK, Brentford, Middlesex, UK
| | - Jacob N Hunnicutt
- Value Evidence and Outcomes, GSK, 1250 South Collegeville Road, Collegeville, PA, 19426, USA.
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Abuelsoud NN, El Khateeb EM. Genetic polymorphisms effect on cyclophosphamide's tolerability and clinical efficacy in Egyptian patients with lupus nephritis. Pharmacogenet Genomics 2023; 33:172-180. [PMID: 37611146 DOI: 10.1097/fpc.0000000000000506] [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: 08/25/2023]
Abstract
OBJECTIVES Many studies were conducted to determine the association between genetic polymorphisms in CYP2B6 c.516G>T and cyclophosphamide (CYC) efficacy or toxicity, no studies were focused on both clinical efficacy and toxicity of CYC. This study aimed to investigate the relationship between the CYP2B6 c.516G>T polymorphism (rs 3745274) and 17 different parameters related to CYC efficacy and tolerability in Egyptian patients with lupus nephritis (LN). METHODS A prospective cohort study on 142 LN patients with a mean age of 36.26 was conducted at Kasr Al Ainy School of Medicine, Cairo University, Egypt after the exclusion of 14 patients due to receiving an interacting medication with CYC. All clinical parameters related to CYC efficacy or toxicity were recorded and compared between the different genotypes. RESULTS There was a statistically significant difference between different genotypes in 11 out of 13 of the studied efficacy-related parameters. Many of the studied clinical parameters revealed that CYC's efficacy was associated with the presence of the T allele. There was a statistically significant difference between different genotypes in hepatotoxicity, diarrhea, and blood-related toxicities. CONCLUSION To our knowledge, this study is the first study that focused on studying 17 different parameters related to CYC efficacy and tolerability. Our findings paint a picture of the function that CYP2B6 polymorphisms play in Egyptian LN patients. Pre-treatment evaluation of CYP2B6 rs 3745274 may account for some individual differences in treatment response.
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Affiliation(s)
- Nermeen N Abuelsoud
- Department of Pharmacy Practice and Clinical Pharmacy, College of Pharmacy, Egyptian Russian University
| | - Engy M El Khateeb
- Department of Clinical and Chemical Pathology, Kasr Al Aini School of Medicine, Cairo University, Egypt
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Silver R, Craigo S, Porter F, Osmundson SS, Kuller JA, Norton ME. Society for Maternal-Fetal Medicine Consult Series #64: Systemic lupus erythematosus in pregnancy. Am J Obstet Gynecol 2023; 228:B41-B60. [PMID: 36084704 DOI: 10.1016/j.ajog.2022.09.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multisystem, inflammatory autoimmune disease characterized by relapses (commonly called "flares") and remission. Many organs may be involved, and although the manifestations are highly variable, the kidneys, joints, and skin are commonly affected. Immunologic abnormalities, including the production of antinuclear antibodies, are also characteristic of the disease. Maternal morbidity and mortality are substantially increased in patients with systemic lupus erythematosus, and an initial diagnosis of systemic lupus erythematosus during pregnancy is associated with increased morbidity. Common complications of systemic lupus erythematosus include nephritis, hematologic complications such as thrombocytopenia, and a variety of neurologic abnormalities. The purpose of this document is to examine potential pregnancy complications and to provide recommendations on treatment and management of systemic lupus erythematosus during pregnancy. The following are the Society for Maternal-Fetal Medicine recommendations: (1) we recommend low-dose aspirin beginning at 12 weeks of gestation until delivery in patients with systemic lupus erythematosus to decrease the occurrence of preeclampsia (GRADE 1B); (2) we recommend that all patients with systemic lupus erythematosus, other than those with quiescent disease, either continue or initiate hydroxychloroquine (HCQ) in pregnancy (GRADE 1B); (3) we suggest that for all other patients with quiescent disease activity who are not taking HCQ or other medications, it is reasonable to engage in shared decision-making regarding whether to initiate new therapy with this medication in consultation with the patient's rheumatologist (GRADE 2B); (4) we recommend that prolonged use (>48 hours) of nonsteroidal antiinflammatory drugs (NSAIDs) generally be avoided during pregnancy (GRADE 1A); (5) we recommend that COX-2 inhibitors and full-dose aspirin be avoided during pregnancy (GRADE 1B); (6) we recommend discontinuing methotrexate 1-3 months and mycophenolate mofetil/mycophenolic acid at least 6 weeks before attempting pregnancy (GRADE 1A); (7) we suggest the decision to initiate, continue, or discontinue biologics in pregnancy be made in collaboration with a rheumatologist and be individualized to the patient (GRADE 2C); (8) we suggest treatment with a combination of prophylactic unfractionated or low-molecular-weight heparin and low-dose aspirin for patients without a previous thrombotic event who meet obstetrical criteria for antiphospholipid syndrome (APS) (GRADE 2B); (9) we recommend therapeutic unfractionated or low-molecular-weight heparin for patients with a history of thrombosis and antiphospholipid (aPL) antibodies (GRADE 1B); (10) we suggest treatment with low-dose aspirin alone in patients with systemic lupus erythematosus and antiphospholipid antibodies without clinical events meeting criteria for antiphospholipid syndrome (GRADE 2C); (11) we recommend that steroids not be routinely used for the treatment of fetal heart block due to anti-Sjögren's-syndrome-related antigen A or B (anti-SSA/SSB) antibodies given their unproven benefit and the known risks for both the pregnant patient and fetus (GRADE 1C); (12) we recommend that serial fetal echocardiograms for assessment of the PR interval not be routinely performed in patients with anti-SSA/SSB antibodies outside of a clinical trial setting (GRADE 1B); (13) we recommend that patients with systemic lupus erythematosus undergo prepregnancy counseling with both maternal-fetal medicine and rheumatology specialists that includes a discussion regarding maternal and fetal risks (GRADE 1C); (14) we recommend that pregnancy be generally discouraged in patients with severe maternal risk, including patients with active nephritis; severe pulmonary, cardiac, renal, or neurologic disease; recent stroke; or pulmonary hypertension (GRADE 1C); (15) we recommend antenatal testing and serial growth scans in pregnant patients with systemic lupus erythematosus because of the increased risk of fetal growth restriction (FGR) and stillbirth (GRADE 1B); and (16) we recommend adherence to the Centers for Disease Control and Prevention medical eligibility criteria for contraceptive use in patients with systemic lupus erythematosus (GRADE 1B).
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El Miedany Y, Kamel NS, Abu-Zaid MH, El Hadidi K, Mahmoud GA, Sarhan E, El Gaafary M, Abdel-Nasser A, Abualfadl EM, Azim AA, Fathi NA, Mokbel A, Hassan W, Tabra SAA, Eissa M, Mortada M, Fouad NA, Elnemr R, Mansour AE, Elaraby I, Medhat BM, Mohamed SS, Abdelradi ER, Ibrahim RA, Saber S. Egyptian evidence-based consensus on clinical practice recommendations for the management of lupus nephritis. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2022. [DOI: 10.1186/s43166-022-00146-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Lupus nephritis (LN) affects a substantial number of the patients living with Systemic lupus erythematosus (SLE), representing a major cause of morbidity and mortality. Patients with lupus nephritis should be referred to a lupus nephritis expert who can confirm the diagnosis, assess the level of disease activity, and offer guidance on treatment and monitoring of the disease, as well as its consequences and side effects. The aim of this guideline was to develop recommendations for the management of adult lupus patients, including lupus nephritis diagnosis, assessment, and monitoring.
Nineteen key clinical questions were identified by scientific committee according to the Patient/Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. Literature review team performed a systematic review to summarize evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for LN. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A 2-round Delphi process was conducted with 24 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.
Results
An online questionnaire was sent to an expert panel who participated in the two rounds (response rate 100%). At the end of round 2, a total of 19 recommendation items, categorized into 11 sections to address the main LN categories, were obtained. The percentage of those who agreed with the recommendations (ranks 7–9) ranged from 90.5 to 100%. The phrasing of all 19 clinical standards identified by the scientific committee was agreed upon (i.e., 75% of respondents strongly agreed or agreed).
Conclusion
These recommendations provide an updated consensus on the pharmacological treatment of lupus nephritis and strategies to reach optimal treat to target outcomes in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient situation.
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Cajamarca-Barón J, Buitrago-Bohórquez J, Orozco JEM, Segura O, Guavita-Navarro D, Gallego-Cardona L, Cubides H, Arredondo AM, Escobar A, Rojas-Villarraga A. Efficacy and safety of intravenous immunoglobulin in patients with lupus nephritis: A systematic review of the literature. Clin Exp Rheumatol 2022; 21:103182. [PMID: 36028194 DOI: 10.1016/j.autrev.2022.103182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/18/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND OBJECTIVE Intravenous immunoglobulin (IVIg) is an anti-inflammatory drug with an unclear role in the treatment of patients with lupus nephritis (LN). This systematic review evaluates the evidence for IVIg in the care of patients with LN. METHODOLOGY A systematic search was done in the PubMed, EMBASE, BVS and OVID databases - All EBM Reviews following the PRISMA methodology (registration in PROSPERO CRD42021236662). The variables were extracted: indications for use, dosage, partial or complete response, adverse reactions, initiation of renal replacement therapy, reduction of proteinuria, and mortality. The quality assessment was done with the "The Joanna Briggs Institute (JBI) Critical Appraisal tools for use in Systematic Reviews Checklist". In addition, synthesis reports were prepared through the Synthesis Without Meta-analysis - SWiM guide. RESULTS A total of 2328 articles were obtained (28 were considered for inclusion). When the studies were evaluated, IVIg therapy was found to be between 60% to 70% effective (except for patients with class V LN) with overall responses (complete + partial) even for patients who are refractory to first line treatment. Normalization (<0.5 g) of nephrotic proteinuria occurred in 24% of cases with infrequent adverse events and a mortality plus dialysis composite of 11.5% and 24.1% (most representative study). CONCLUSION In patients with LN refractory to conventional treatment or co-infection situations, the reported data seem to demonstrate effectiveness of IVIg therapy. There are few adverse reactions and caution is exercised when using it on patients with class V NL. However, given the lack of controlled studies with long-term follow-up, these data should be interpreted cautiously thus encouraging the development of high-quality RCTs.
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Affiliation(s)
- Jairo Cajamarca-Barón
- Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia.
| | - Jhon Buitrago-Bohórquez
- Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia
| | - José Emmanuel Mendoza Orozco
- Internal Medicine, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Bogotá, Colombia, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia.
| | - Omar Segura
- Research Institute, Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Bogotá, Colombia, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia.
| | - Diana Guavita-Navarro
- Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia
| | - Laura Gallego-Cardona
- Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia
| | - Hector Cubides
- Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia
| | - Ana María Arredondo
- Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia
| | - Alejandro Escobar
- Fundación Universitaria de Ciencias de la Salud (FUCS), Hospital San José, Cra 19 No. 8A - 32, 111411 Bogotá, Colombia
| | - Adriana Rojas-Villarraga
- Research Institute, Fundación Universitaria de Ciencias de la Salud (FUCS), Cra 19 No. 8A - 32, 111411 Bogotá, Colombia.
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10
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Botero B JD, Bernal-Macías S, Celis P CA, Lasso A JI, Rodríguez J, Arias Álvarez L, Gonzalez C, Contreras KM, Fernández-Ávila DG. Systemic lupus erythematosus/ANCA-associated vasculitis overlap: An explanation for atypical lupus manifestation. Lupus 2022; 31:495-499. [PMID: 35244473 DOI: 10.1177/09612033221084519] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The coexistence of systemic lupus erythematosus (SLE) and ANCA-associated vasculitis (AAV) as an overlapping syndrome is not common. Here, we report a case of a 33-year-old woman, with recent SLE diagnosis due to skin, kidney, articular, and immunologic compromise, in whom a chest CT scan showed bilateral nodules, consolidations, and tree-in-bud pattern; thoracoscopic lung biopsy revealed diffuse non-caseating granulomas, without other features of sarcoid, organizing pneumonia, or hypersensitivity pneumonitis with high positive p-ANCA titers. Overlap between SLE and AAV was a possible explanation for lupus granulomatous pneumonitis, and for this reason, a multidisciplinary meeting was held to evaluate complex patients with interstitial lung diseases patients.
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Affiliation(s)
- Juan D Botero B
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Internal Medicine Specialist and Pulmonologist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
| | - Santiago Bernal-Macías
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Internal Medicine Specialist and Rheumatologist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
| | - Carlos A Celis P
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Internal Medicine Specialist and Pulmonologist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
| | - Javier I Lasso A
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Internal Medicine Specialist and Pulmonologist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
| | - Jorge Rodríguez
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Pathology Specialist and Lung Pathology Specialist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
| | - Liliana Arias Álvarez
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Radiologist and Body Images Specialist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
| | - Catalina Gonzalez
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Internal Medicine Specialist and Pulmonologist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
| | - Kateir M Contreras
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Internal Medicine Specialist and Nephrologist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
| | - Daniel G Fernández-Ávila
- Faculty of Medicine, 27964Pontificia Universidad Javeriana, Bogotá, DC, Colombia.,Internal Medicine Specialist and Rheumatologist, 173049Hospital Universitario San Ignacio, Bogotá, DC, Colombia
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11
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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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12
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Petrou P. A Systematic Review of the Economic Evaluations of Belimumab in Systemic Lupus Erythematosus. Value Health Reg Issues 2021; 27:32-40. [PMID: 34784546 DOI: 10.1016/j.vhri.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/24/2021] [Accepted: 06/20/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Systemic lupus erythematosus is a heterogeneous, multisystem autoimmune disease. These attributes cause lupus to be a challenging condition to adequately manage, which is further aggravated by the lack of treatment modalities. Belimumab is a full human monoclonal antibody, and its safety and efficacy in lupus management have been demonstrated in a number of randomized clinical trials. However, these gains come at a high cost in an era that is demarcated by soaring pharmaceutical expenditure. Therefore, the objective of this paper is to critically assess the economic evaluations of belimumab. METHODS A systematic review was performed for economic evaluations of belimumab and the retrieved studies were assessed with the quality of health economic studies questionnaire. RESULTS A total of 3 studies and 5 abstracts were retrieved. Belimumab demonstrated a consistent favorable economic profile across Spain, Italy, Portugal, Greece, Hong Kong, Canada, and Greece. The sensitivity analyses revealed that the effectiveness of treatment and the discontinuation rate had the greatest effect on the outcome. CONCLUSION Current data underscore a favorable cost-effectiveness ratio of belimumab in the treatment of systemic lupus erythematosus. Results are consistent across Spain, Italy, Portugal, Greece, Hong Kong, Canada, and Greece, countries for which an economic evaluation was available. Nevertheless, the low number of assessments, along with concerns regarding its long-term effectiveness, underpin areas that necessitate further research.
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Affiliation(s)
- Panagiotis Petrou
- Pharmacoepidemiology-Pharmacovigilance, Pharmacy School, School of Sciences and Engineering, University of Nicosia and Health Insurance Organization, Nicosia, Cyprus.
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13
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Huang MX, Wang CY, Guo JY, Li JH, Li XH, Zhang JA, Yu JB. Pharmacotherapy for Behçet's Disease and the Risk of Malignancy. Front Pharmacol 2021; 12:661150. [PMID: 34354582 PMCID: PMC8329246 DOI: 10.3389/fphar.2021.661150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 07/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Behçet’s disease (BD) is associated with an increased risk of cancer. Few reports have been published on the relationship between drug exposure and the risk of cancer in patients with BD. Herein, we explored the relationship between pharmacologic interventions for BD and the risk of cancer. Methods: we carried out a retrospective nested case-control study in a cohort of BD patients from attending our institution. Among 1,148 patients, 22 cancer patients were individually 1:2 matched to 44 cancer-free controls. The following biochemical indicators were evaluated: routine blood analysis, liver and kidney function tests, inflammatory indexes, blood gas analysis, blood electrolyte and previous pharmacologic interventions to manage BD including systemic glucocorticoids, methotrexate, cyclosporine-A, azathioprine, cyclophosphamide (CYC), and thalidomide, which are considered the primary medicines used for the management of BD. Results: Among the 22 BD patients with cancers, myelodysplastic syndrome (MDS) (22.72%) was the most common type. Furthermore, CYC administration was significantly higher in BD patients with cancer compared with the cancer-free matched control group. Further, we observed that complement 4 (C4) (odds ratio [OR] = 0.0001, 95% confidence interval [CI]: 0.001–0.065) and hemoglobin (Hb) (OR = 0.891, 95% CI: 0.795–0.998) levels were independent protective factors for predicting cancer risk in BD patients on multivariate analyses. Conclusion: Our study revealed that CYC was associated with a high risk of cancer in BD patients. Furthermore, C4 and Hb are independent protective factors for oncogenesis in BD patients. These findings may provide references and suggestions for clinicians to select appropriate treatments and for the early recognition of high-risk patients to reduce cancer incidence in BD patients.
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Affiliation(s)
- Mao-Xin Huang
- Department of Dermatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cai-Yun Wang
- Department of Dermatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jin-Yan Guo
- Department of Rheumatism, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jian-Hao Li
- Department of Infection, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao-Hong Li
- Department of Dermatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiang-An Zhang
- Department of Dermatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jian-Bin Yu
- Department of Dermatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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14
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Gurcan M, Esatoglu SN, Hamuryudan V, Saygin D, Ugurlu S, Seyahi E, Melikoglu M, Fresko I, Yurdakul S, Yazici H, Hatemi G. Long term follow-up of Behçet's syndrome patients treated with cyclophosphamide. Rheumatology (Oxford) 2021; 59:2264-2271. [PMID: 31840168 DOI: 10.1093/rheumatology/kez598] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 10/31/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES CYC remains an important treatment option for Behçet's syndrome (BS) patients with life-threatening manifestations. However, adverse events may occur with CYC and this has led to increased use of biologic agents in other vasculitides. We investigated short and long term adverse events associated with CYC use in BS patients. METHODS We conducted a retrospective chart review of all BS patients treated with CYC between 1972 and 2006. Patients were called in and a standard form was used for collecting demographic characteristics, indication for CYC, its cumulative dose and short term adverse events, defined as those causing discontinuation of CYC, hospitalization and/or death, long term adverse events, including infertility and malignancy, and outcome. RESULTS Of 5790 BS patients, 198 (3.4%) had used at least one dose of CYC. Main indications were vascular or neurological involvement. After a median follow-up of 17 years, 52 (26%) patients had died, 113 (57%) could be contacted, and 33 (17%) were lost to follow-up. Vascular involvement was the leading cause of death (n = 27). Seventeen (9%) patients experienced short term adverse events with haemorrhagic cystitis being the most common. After a median follow-up of 25 years (interquartile range: 15-26 years), 17 malignancies occurred in 15 (8%) patients. Infertility was experienced by 26 (30%) patients. CONCLUSION Long term adverse events such as malignancy and infertility were major problems in our BS patients treated with CYC. These results underline the need for safer treatment modalities that are at least as effective as CYC.
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Affiliation(s)
- Mert Gurcan
- Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sinem Nihal Esatoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Vedat Hamuryudan
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Didem Saygin
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Serdal Ugurlu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Emire Seyahi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Melike Melikoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Izzet Fresko
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sebahattin Yurdakul
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hasan Yazici
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
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15
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Farah RI, Shahin NA, Alawneh M, Adwan M. Rapidly progressive glomerulonephritis due to systemic lupus erythematosus and ANCA-associated vasculitis overlap. Lupus 2020; 29:983-986. [PMID: 32316845 DOI: 10.1177/0961203320920368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Systemic lupus erythematosus (SLE) and ANCA-associated vasculitis (AAV) are different autoimmune diseases. While vasculitis can be seen in the SLE clinical course as a secondary phenomenon, and may indicate a severe disease, primary vasculitis such as AAV rarely occurs in association with SLE. We present a 44-year-old woman who presented with rapidly progressive glomerulonephritis which was histologically identified as a combination of crescentic and lupus nephritis in the presence of myeloperoxidase ANCA antibody. The frequency of this association is very rare. The clinical, histological and immunological features are different in SLE/AAV overlap syndrome and need different treatment options, which may include rituximab, to achieve complete recovery. Since SLE/AAV overlap can be serious at presentation, the physician must be aware of this syndrome.
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Affiliation(s)
- Randa I Farah
- Nephrology Division, Internal Medicine Department, School of Medicine, The University of Jordan, Amman, Jordan
| | - Nisreen Abu Shahin
- Department of Pathology and Microbiology and Forensic Medicine, School of Medicine, The University of Jordan, Amman, Jordan
| | - Mohannad Alawneh
- Internal Medicine Department, School of Medicine, The University of Jordan, Amman, Jordan
| | - Marwan Adwan
- Rheumatology Division, Internal Medicine Department, School of Medicine, The University of Jordan, Amman Jordan
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16
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Nechifor G, Totu EE, Nechifor AC, Constantin L, Constantin AM, Cărăuşu ME, Isildak I. Added value recyclability of glass fiber waste as photo-oxidation catalyst for toxic cytostatic micropollutants. Sci Rep 2020; 10:136. [PMID: 31924816 PMCID: PMC6954219 DOI: 10.1038/s41598-019-56836-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/17/2019] [Indexed: 02/05/2023] Open
Abstract
There is an increased interest in recycling valuable waste materials for usage in procedures with high added values. Silica microparticles are involved in the processes of catalysis, separation, immobilization of complexants, biologically active compounds, and different nanospecies, responding to restrictive requirements for selectivity of various chemical and biochemical processes. This paper presents the surface modification of accessible and dimensionally controlled recycled silica microfiber with titanium dioxide. Strong base species in organic solvents: methoxide, ethoxide, propoxide, and potassium butoxide in corresponding alcohol, activated the glass microfibres with 12-13 µm diameter. In the photo-oxidation process of a toxic micro-pollutant, cyclophosphamide, the new composite material successfully proved photocatalytic effectiveness. The present work fulfills simultaneously two specific objectives related to the efforts directed towards a sustainable environment and circular economy: recycling of optical glass microfibers resulted as waste from the industry, and their usage for the photo-oxidation of highly toxic emerging micro-pollutants.
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Affiliation(s)
- Gheorghe Nechifor
- Faculty of Applied Chemistry and Material Science, Polytechnic University of Bucharest, 060042, Bucharest, Romania
| | - Eugenia Eftimie Totu
- Faculty of Applied Chemistry and Material Science, Polytechnic University of Bucharest, 060042, Bucharest, Romania.
| | - Aurelia Cristina Nechifor
- Faculty of Applied Chemistry and Material Science, Polytechnic University of Bucharest, 060042, Bucharest, Romania
| | - Lucian Constantin
- National Research and Development Institute for Industrial Ecology - ECOIND Bucharest, 71-73 Drumul Podul Dambovitei Str., 060652, Bucharest, Romania
| | - Alina Mirela Constantin
- National Research and Development Institute for Industrial Ecology - ECOIND Bucharest, 71-73 Drumul Podul Dambovitei Str., 060652, Bucharest, Romania
| | - Mihaela Elena Cărăuşu
- Department of Public Health and Management, Faculty of Dental Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115, Iasi, Romania
| | - Ibrahim Isildak
- Department of Bioengineering, Faculty of Chemical and Metallurgical Engineering, Yildiz Technical University, 34210, Esenler-Istanbul, Turkey
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17
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Li J, Chen X, Qu Y. Effects of cyclophosphamide combined with prednisone on TNF-α expression in treatment of patients with interstitial lung disease. Exp Ther Med 2019; 18:4443-4449. [PMID: 31777548 PMCID: PMC6862246 DOI: 10.3892/etm.2019.8099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 08/06/2019] [Indexed: 12/25/2022] Open
Abstract
Effects of cyclophosphamide combined with prednisone on TNF-α expression in the treatment of patients with interstitial lung disease (ILD), and its clinical significance were investigated. A prospective analysis was performed on 198 patients with ILD in Jinan Central Hospital Affiliated to Shandong University from January 2010 to December 2017. Among them, 101 patients treated with cyclophosphamide combined with prednisone were assigned in the combined treatment group, and 97 patients treated with prednisone alone in the control group. Patients in the two groups were compared in terms of lung function, St. George's Respiratory Questionnaire (SGRQ) score, clinical efficacy, adverse reactions and TNF-α expression levels before and after treatment. After treatment, the patients in the combined treatment group had significantly higher forced vital capacity (FVC) and forced expiratory volume in first second (FEV1) compared with the control group, but significantly lower diffusing capacity of lung for carbon monoxide (DLCO) and DLCO% (P<0.05). In both groups, patients after treatment had higher FVC and FEV1, but lower DLCO and DLCO% (P<0.05), compared with before treatment, while SGRQ score before treatment was higher than that after treatment (P<0.05). Compared with control group, the combined treatment group had significantly more patients with complete remission (CR) and higher total effective rate, however less patients with stable disease (SD) (P<0.05). Patients with adverse reactions in the combined treatment group were less than those in the control group (P<0.05). After treatment, TNF-α expression level in the combined treatment group was significantly lower than that in the control group (P<0.05), and TNF-α expression before treatment was higher than that after treatment in both groups (P<0.05). In conclusion, cyclophosphamide combined with prednisone is effective and safe in the treatment of ILD without severe adverse reactions, reducing TNF-α expression level, and therefore is worthy of clinical application.
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Affiliation(s)
- Jun Li
- Department of Respiratory Medicine, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong 250014, P.R. China
| | - Xiuling Chen
- Department of Gynaecology and Obstetrics, First People's Hospital of Jinan, Jinan, Shandong 250014, P.R. China
| | - Yunping Qu
- Department of Stomatology, First People's Hospital of Jinan, Jinan, Shandong 250014, P.R. China
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18
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Romão VC, Fonseca JE. Major Challenges in Rheumatology: Will We Ever Treat Smarter, Instead of Just Harder? Front Med (Lausanne) 2019; 6:144. [PMID: 31294026 PMCID: PMC6606708 DOI: 10.3389/fmed.2019.00144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 06/10/2019] [Indexed: 12/17/2022] Open
Affiliation(s)
- Vasco C Romão
- Department of Rheumatology, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - João Eurico Fonseca
- Department of Rheumatology, Centro Hospitalar Universitário Lisboa Norte, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
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19
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Efficacy of mycophenolate mofetil in Japanese patients with systemic lupus erythematosus. Clin Rheumatol 2019; 38:1571-1578. [PMID: 30778862 DOI: 10.1007/s10067-019-04473-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/29/2019] [Accepted: 02/07/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To assess the renal and non-renal efficacy of mycophenolate mofetil (MMF) in Japanese patients with systemic lupus erythematosus (SLE). METHODS We conducted a retrospective study to assess the renal and non-renal efficacies of MMF in Japanese patients with systemic lupus erythematosus (SLE). We analyzed 14 patients with lupus nephritis (LN) who were given MMF, and 13 patients who received monthly intravenous cyclophosphamide (IVCY) as induction therapy, and a further 19 patients without LN who were treated with MMF, and 13 patients who took tacrolimus (TAC) to reduce glucocorticoid dosages. We assessed the therapeutic effects of each therapeutic regime on renal and non-renal disease manifestations over a six-month period after treatment initiation. RESULTS Median urine protein to creatinine ratios in the MMF and IVCY groups significantly decreased from 2.2 to 0.7 g/gCr and from 3.3 to 0.5 g/gCr, respectively. Significant improvements in serum immunological variables (serum complements C3 and C4 and the anti-double stranded DNA antibody) and reductions in the SLE disease activity index (SLEDAI) and daily prednisolone dosages were observed in each group with LN. MMF and TAC significantly improved SLEDAI and serum immunological variables and reduced daily prednisolone dosages in patients without LN. CONCLUSION The present results demonstrated that MMF might be an effective treatment for renal and non-renal manifestations in Japanese patients with SLE and has potential as a good therapeutic alternative and steroid-sparing agent.
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Martínez T, Garcia-Robledo JE, Plata I, Urbano MA, Posso-Osorio I, Rios-Serna LJ, Barrera MC, Tobón GJ. Mechanisms of action and historical facts on the use of intravenous immunoglobulins in systemic lupus erythematosus. Autoimmun Rev 2019; 18:279-286. [PMID: 30639648 DOI: 10.1016/j.autrev.2018.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/14/2018] [Indexed: 12/29/2022]
Abstract
The current existing therapies for severe cases of systemic lupus erythematosus (SLE) patients are still limited. Intravenous immunoglobulin (IVIGs), which are purified from the plasma of thousands of healthy human donors, have been profiled as efficacious and life-saving options for SLE patients refractory to conventional therapy. The specific mechanism of action by which IVIGs generate immunomodulation in SLE is not currently understood. In this manuscript, we reviewed some of the hypothesis that have been postulated to explain the IVIG effects, including those on T and B cell intracellular signalling and activation, as well as the interferon signalling pathways involved in the detection of nucleic acids and the defective removal of immune complexes and debris.
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Affiliation(s)
- Tatiana Martínez
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina traslacional. Fundación Valle del Lili, Univesidad Icesi, Colombia
| | | | - Ilich Plata
- Medical School, Universidad Icesi, Cali, Colombia
| | | | - Ivan Posso-Osorio
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina traslacional. Fundación Valle del Lili, Univesidad Icesi, Colombia
| | - Lady J Rios-Serna
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina traslacional. Fundación Valle del Lili, Univesidad Icesi, Colombia
| | - María Claudia Barrera
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina traslacional. Fundación Valle del Lili, Univesidad Icesi, Colombia
| | - Gabriel J Tobón
- GIRAT: Grupo de Investigación en Reumatología, Autoinmunidad y Medicina traslacional. Fundación Valle del Lili, Univesidad Icesi, Colombia; Laboratory of immunology, Fundación Valle del Lili, Cali, Colombia.
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Fava A, Petri M. Systemic lupus erythematosus: Diagnosis and clinical management. J Autoimmun 2019; 96:1-13. [PMID: 30448290 PMCID: PMC6310637 DOI: 10.1016/j.jaut.2018.11.001] [Citation(s) in RCA: 347] [Impact Index Per Article: 69.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is a worldwide chronic autoimmune disease which may affect every organ and tissue. Genetic predisposition, environmental triggers, and the hormonal milieu, interplay in disease development and activity. Clinical manifestations and the pattern of organ involvement are widely heterogenous, reflecting the complex mosaic of disrupted molecular pathways converging into the SLE clinical phenotype. The SLE complex pathogenesis involves multiple cellular components of the innate and immune systems, presence of autoantibodies and immunocomplexes, engagement of the complement system, dysregulation of several cytokines including type I interferons, and disruption of the clearance of nucleic acids after cell death. Use of immunomodulators and immunosuppression has altered the natural course of SLE. In addition, morbidity and mortality in SLE not only derive from direct immune mediated tissue damage but also from SLE and treatment associated complications such as accelerated coronary artery disease and increased infection risk. Here, we review the diagnostic approach as well as the etiopathogenetic rationale and clinical evidence for the management of SLE. This includes 1) lifestyle changes such as avoidance of ultraviolet light; 2) prevention of comorbidities including coronary artery disease, osteoporosis, infections, and drug toxicities; 3) use of immunomodulators (i.e. hydroxychloroquine and vitamin D); and 4) immunosuppressants and targeted therapy. We also review new upcoming agents and regimens currently under study.
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Affiliation(s)
- Andrea Fava
- Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA
| | - Michelle Petri
- Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA.
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Han Y, Ma FY, Di Paolo J, Nikolic-Paterson DJ. An inhibitor of spleen tyrosine kinase suppresses experimental crescentic glomerulonephritis. Int J Immunopathol Pharmacol 2018; 32:2058738418783404. [PMID: 29923438 PMCID: PMC6024518 DOI: 10.1177/2058738418783404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Non-selective inhibitors of spleen tyrosine kinase (SYK) efficiently suppress
disease in T cell-dependent models of crescentic glomerulonephritis. However,
the therapeutic potential of selective SYK inhibitors in this disease has not
been established. In addition, we lack knowledge regarding SYK expression in
non-myeloid cells in glomerulonephritis. We addressed these two issues in a rat
model of nephrotoxic serum nephritis (NTN) using a SYK inhibitor, GS-492429.
Disease was induced in Sprague-Dawley rats (Study 1) or Wistar-Kyoto (WKY) rats
(Study 2) by immunization with sheep IgG and administration of sheep anti-rat
nephrotoxic serum. Animals were untreated or received GS-492429 (30 mg/kg/bid)
or vehicle treatment from 2 h before nephrotoxic serum injection until being
killed 3 or 24 h later (Study 1) or 14 days later (Study 2). Two-colour confocal
microscopy found that SYK expression in NTN kidney was restricted to myeloid
cells and platelets, with no evidence of SYK expression by T cells, mesangial
cells, podocytes or tubular epithelial cells. In Study 1, GS-492429 treatment
significantly reduced glomerular neutrophil and macrophage infiltration, with
protection from glomerular thrombosis and proteinuria. In Study 2, GS-492429
treatment reduced glomerular crescent formation by 70% on day 14 NTN in
conjunction with reduced glomerular thrombosis, glomerulosclerosis and tubular
damage. This was accompanied by a marked reduction in markers of inflammation
(CCL2, TNF-α, NOS2, MMP-12). Importantly, the protective effects of GS-492429
were independent of T cell infiltration and activation and independent of
JAK/STAT3 signalling. In conclusion, this study demonstrates that a SYK
inhibitor can suppress the development of crescentic glomerulonephritis through
effects upon myeloid cells and platelets.
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Affiliation(s)
- Yingjie Han
- 1 Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia.,2 Monash University Centre for Inflammatory Diseases, Monash Medical Centre, Clayton, VIC, Australia
| | - Frank Y Ma
- 1 Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia.,2 Monash University Centre for Inflammatory Diseases, Monash Medical Centre, Clayton, VIC, Australia
| | | | - David J Nikolic-Paterson
- 1 Department of Nephrology, Monash Medical Centre, Clayton, VIC, Australia.,2 Monash University Centre for Inflammatory Diseases, Monash Medical Centre, Clayton, VIC, Australia
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Mesnyankina AA, Solovyev SK, Aseeva EA, Nasonov EL. THE EFFICIENCY OF BIOLOGICAL THERAPY AND THE FEATURES OF HUMORAL IMMUNITY IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS. ACTA ACUST UNITED AC 2018. [DOI: 10.14412/1995-4484-2018-302-309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Objective: to investigate the effect of various biological agents (BAs), including combined treatment with rituximab (RTM) and belimumab (BLM), on the activity of systemic lupus erythematosus (SLE) and to evaluate their efficacy and impact on some parameters of humoral immunity.Subjects and methods. BAs were prescribed to 54 patients with a reliable diagnosis of SLE with high and medium activity according to SLEDAI-2K; 40 of them received RTM, 7 – BLM; 7 – combined therapy with RTM and BLM. Clinical and laboratory examinations were made in all the patients at the time of their inclusion and then every 3 months during a year. The results were assessed using SLEDAI-2K, BILAG index, Lupus Erythematosus National Assessment (SELENA)-SLEDAI Flare index (SFI) (a moderate, severe exacerbation), and SLE Responder Index (SRI).Results and discussion. At 3, 6, and 12 months after start of therapy, the use of BAs in all the patients resulted in a disease activity reduction. It was statistically significant (p < 0.00001) in the RTM group; and no statistical analysis was carried out in the BLM and RTM+BLM groups due to the small numbers of patients. At the same time, there was a progressive decrease in the levels of anti-double-stranded DNA (ds-DNA) antibodies (Abs) and an increase in the concentration of the complement fractions C3 and C4 in the RTM and RTM+BLM groups (p < 0.05) at one-year follow-up. After 12 months of therapy with BAs, there was a decrease in IgG (p < 0.02) and IgM (p < 0.03) levels; but overall it remained within the reference ranges. Prior to therapy, irreversible organ damages were recorded in 23 (42.6%) of the 54 patients. The increased damage index at 12 month was observed only in patients receiving RTM, which is probably due to the use of higher-dose glucocorticoids.Conclusion. All three methods of therapy with BAs in SLE patients demonstrated good efficiency shown as a significant decrease in clinical and laboratory activity measures that were assessed by SLEDAI-2K and the levels of anti-ds-DNA and complement components C3 and C4. The decrease in immunoglobulin levels did not go beyond the reference values. Therapy with BLM and RTM+BLM allowed for managing patients with the low and average doses of oral glucocorticoids, which contributed to the reduction of not only the activity, but also risk of irreversible organ damages.
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Tian M, Song X, Dong L, Xin X, Dong J. Systematic evaluation of different doses of cyclophosphamide induction therapy for lupus nephritis. Medicine (Baltimore) 2017; 96:e9408. [PMID: 29390559 PMCID: PMC5758261 DOI: 10.1097/md.0000000000009408] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE This study systemically evaluated the efficacy and safety of intermittent intravenous pulse therapy with different doses of cyclophosphamide (CTX) for the treatment of lupus nephritis (LN). METHODS We screened the Chinese Journal Full-text Database (CNKI, 1994-present), China Biology Medicine (CBMdisc, 1978-present), VIP Database for Chinese Technical Periodicals (1989-present), PubMed (1948-present), MEDLINE (Ovid SP, 1946-present), Embase (1947-present), and the Cochrane controlled trials register (13, 2017). Literature reports were selected according to the inclusion and exclusion criteria, effective data were extracted, research quality was evaluated, and RevMan5.2 was used for meta-analysis. RESULTS Seven randomized controlled studies were included, consisting of 655 patients. The meta-analysis results showed no significant differences between the low- and high-dose cyclophosphamide groups in partial, complete, and total remission rates as well Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Furthermore, there were no significant differences between the 2 groups in hematologic toxicity and gastrointestinal reaction, but the risk of infection (risk ratio [RR] = 0.74, 95% confidence interval [CI], 0.56-0.98, total effect inspection Z = 2.12, P = .03), and menstrual disorder (RR = 0.46, 95% CI, 0.31-0.69, total effect inspection Z = 3.83, P = .0001) decreased in the low-dose cyclophosphamide group. CONCLUSIONS There was no obvious difference between the low- and high-dose cyclophosphamide groups in efficacy in the treatment of lupus nephritis, but the risk of infection and menstrual disorder significantly decreased in the low-dose group.
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Affiliation(s)
- Ming Tian
- Department of Nephrology, Puai Hospital
| | | | | | - Xing Xin
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R.China
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Momtaz M, Fayed A, Wadie M, Gamal SM, Ghoniem SA, Sobhy N, Kamal Elden NM, Hamza WM. Retrospective analysis of nephritis response and renal outcome in a cohort of 928 Egyptian lupus nephritis patients: a university hospital experience. Lupus 2017; 26:1564-1570. [DOI: 10.1177/0961203317716320] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Aim We aim to describe the pattern of response to treatment in a cohort of Egyptian lupus nephritis (LN) patients and to define variable prognostic factors. Methods We retrospectively analyzed records of 928 systemic lupus erythematosus (SLE) patients (898 females, 30 males) with biopsy-confirmed LN seen between 2006 and 2012 at Cairo University hospitals. Results Our study involved 928 SLE patients with a mean age of 26.25 ± 6.487 years, mean LN duration at time of renal biopsy 6.48 ± 4.27 months, mean SLEDAI 28.22 ± 11.7, and mean follow-up duration of 44.14 ± 17.34 months. Induction treatment achieved remission in 683 patients. Remission was achieved in all 32 patients with class II LN, compared to 651/896 (72.7%) patients in classes III, IV, and V. Induction by intravenous (IV) cyclophosphamide achieved response in 435/575 (75.7%) patients, while induction by mycophenolate mofetil (MMF) resulted in response in 216/321 (67.3%) patients ( p = 0.0068). Nephritic flares were least observed when MMF was used for maintenance (30/239 (12.6%) patients), compared to 71/365 patients (19.5%) ( p = 0.0266) when azathioprine (AZA) was used, and 22/79 patients (27.8%) ( p = 0.002) with IV cyclophosphamide. Class IV LN, high chronicity index, presence of crescents, and interstitial fibrosis in biopsies were all associated with chronic kidney disease (CKD) development eventually ( p < 0.001, p = 0.005, p = 0.012, and p = 0.031, respectively). By the end of the study duration, 305 (32.7%) patients had CKD. Logistic regression detected that high baseline serum creatinine, failure to achieve remission, hypertension, and nephritic flare were the main risk factors for poor renal outcome ( p < 0.001, p < 0.001, p = 0.004, and p < 0.001, respectively). The 5 years’ mortality was 69 (7.4%) patients with sepsis being the main cause of death. Conclusion IV cyclophosphamide superseded as induction treatment, while MMF was the best maintenance treatment. High serum creatinine, hypertension, and nephritic flare were the main risk factors for poor renal outcome.
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Affiliation(s)
- M Momtaz
- Department of Internal Medicine, Cairo University Hospital, Cairo, Egypt
| | - A Fayed
- Department of Internal Medicine, Cairo University Hospital, Cairo, Egypt
| | - M Wadie
- Department of Internal Medicine, Cairo University Hospital, Cairo, Egypt
| | - S M Gamal
- Rheumatology and Rehabilitation Department, Cairo University Hospital, Cairo, Egypt
| | - S A Ghoniem
- Rheumatology and Rehabilitation Department, Cairo University Hospital, Cairo, Egypt
| | - N Sobhy
- Rheumatology and Rehabilitation Department, Cairo University Hospital, Cairo, Egypt
| | - N M Kamal Elden
- Public Health Department, Cairo University Hospital, Cairo, Egypt
| | - W M Hamza
- Pathology Department, Cairo University Hospital, Cairo, Egypt
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Sakai R, Kurasawa T, Nishi E, Kondo T, Okada Y, Shibata A, Nishimura K, Chino K, Okuyama A, Takei H, Nagasawa H, Amano K. Efficacy and safety of multitarget therapy with cyclophosphamide and tacrolimus for lupus nephritis: a prospective, single-arm, single-centre, open label pilot study in Japan. Lupus 2017; 27:273-282. [DOI: 10.1177/0961203317719148] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- R Sakai
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Department of Microbiology and Immunology, Keio University, Tokyo, Japan
| | - T Kurasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - E Nishi
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - T Kondo
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - Y Okada
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - A Shibata
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - K Nishimura
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Division of Rheumatology, Japan Community Health Care Organization, Saitama, Japan
| | - K Chino
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - A Okuyama
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - H Takei
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - H Nagasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Nagasawa Clinic, Saitama, Japan
| | - K Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
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Margery-Muir AA, Bundell C, Nelson D, Groth DM, Wetherall JD. Gender balance in patients with systemic lupus erythematosus. Autoimmun Rev 2017; 16:258-268. [DOI: 10.1016/j.autrev.2017.01.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 11/16/2016] [Indexed: 12/19/2022]
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Mok CC. Pro: The use of calcineurin inhibitors in the treatment of lupus nephritis. Nephrol Dial Transplant 2016; 31:1561-6. [PMID: 27591327 DOI: 10.1093/ndt/gfw289] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 03/19/2016] [Indexed: 12/11/2022] Open
Abstract
Renal disease in systemic lupus erythematosus (SLE) carries significant morbidity and mortality. Cyclophosphamide (CYC)- and mycophenolate mofetil (MMF)-based induction regimens are not ideal in terms of efficacy and toxicity. The adverse effects of CYC, such as infection risk, infertility, urotoxicity and oncogenicity, limit its use in lupus nephritis. Although MMF is non-inferior to CYC as induction therapy and has reduced gonadal toxicity and oncogenic potential, meta-analyses of clinical trials do not show a lower rate of infective and gastrointestinal complications. Tacrolimus (TAC) has recently been shown to have equal efficacy to either MMF or CYC for inducing remission of lupus nephritis. A low-dose combination of MMF and TAC appears to be more effective than intravenous CYC pulses in Chinese patients, and has potential to replace the more toxic CYC regimens in high-risk subgroups. TAC may be considered as another non-CYC alternative for induction therapy of lupus nephritis and in those with refractory disease or intolerance to CYC or MMF. TAC has no negative effect on fertility in younger women, and unlike MMF and CYC, it is safe in pregnancy. However, TAC has a narrow therapeutic window and drug level monitoring is required to ensure drug exposure and minimize acute toxicities. Current evidence for the efficacy of TAC in lupus nephritis is limited to 6 months and the incidence of renal flare after discontinuation of therapy or switching to azathioprine appears to be higher than other induction agents. Long-term data and the incidence of chronic nephrotoxicity of TAC as maintenance therapy in lupus nephritis are currently lacking and further prospective trials are needed to address these issues.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR, China
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