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Reis-Neto ETD, Seguro LPC, Sato EI, Borba EF, Klumb EM, Costallat LTL, Medeiros MMDC, Bonfá E, Araújo NC, Appenzeller S, Montandon ACDOES, Yuki EFN, Teixeira RCDA, Telles RW, Egypto DCSD, Ribeiro FM, Gasparin AA, Junior ASDA, Neiva CLS, Calderaro DC, Monticielo OA. II Brazilian Society of Rheumatology consensus for lupus nephritis diagnosis and treatment. Adv Rheumatol 2024; 64:48. [PMID: 38890752 DOI: 10.1186/s42358-024-00386-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE To develop the second evidence-based Brazilian Society of Rheumatology consensus for diagnosis and treatment of lupus nephritis (LN). METHODS Two methodologists and 20 rheumatologists from Lupus Comittee of Brazilian Society of Rheumatology participate in the development of this guideline. Fourteen PICO questions were defined and a systematic review was performed. Eligible randomized controlled trials were analyzed regarding complete renal remission, partial renal remission, serum creatinine, proteinuria, serum creatinine doubling, progression to end-stage renal disease, renal relapse, and severe adverse events (infections and mortality). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to develop these recommendations. Recommendations required ≥82% of agreement among the voting members and were classified as strongly in favor, weakly in favor, conditional, weakly against or strongly against a particular intervention. Other aspects of LN management (diagnosis, general principles of treatment, treatment of comorbidities and refractory cases) were evaluated through literature review and expert opinion. RESULTS All SLE patients should undergo creatinine and urinalysis tests to assess renal involvement. Kidney biopsy is considered the gold standard for diagnosing LN but, if it is not available or there is a contraindication to the procedure, therapeutic decisions should be based on clinical and laboratory parameters. Fourteen recommendations were developed. Target Renal response (TRR) was defined as improvement or maintenance of renal function (±10% at baseline of treatment) combined with a decrease in 24-h proteinuria or 24-h UPCR of 25% at 3 months, a decrease of 50% at 6 months, and proteinuria < 0.8 g/24 h at 12 months. Hydroxychloroquine should be prescribed to all SLE patients, except in cases of contraindication. Glucocorticoids should be used at the lowest dose and for the minimal necessary period. In class III or IV (±V), mycophenolate (MMF), cyclophosphamide, MMF plus tacrolimus (TAC), MMF plus belimumab or TAC can be used as induction therapy. For maintenance therapy, MMF or azathioprine (AZA) are the first choice and TAC or cyclosporin or leflunomide can be used in patients who cannot use MMF or AZA. Rituximab can be prescribed in cases of refractory disease. In cases of failure in achieving TRR, it is important to assess adherence, immunosuppressant dosage, adjuvant therapy, comorbidities, and consider biopsy/rebiopsy. CONCLUSION This consensus provides evidence-based data to guide LN diagnosis and treatment, supporting the development of public and supplementary health policies in Brazil.
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Affiliation(s)
- Edgard Torres Dos Reis-Neto
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil.
| | - Luciana Parente Costa Seguro
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Emília Inoue Sato
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil
| | - Eduardo Ferreira Borba
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Evandro Mendes Klumb
- Department of Rheumatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lilian Tereza Lavras Costallat
- Division of Rheumatology, Department of Orthopedics, Rheumatology and Traumatology, Universidade Estadual de Campinas (Unicamp), Campinas, Brazil
| | | | - Eloisa Bonfá
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Nafice Costa Araújo
- Division of Rheumatology, Hospital do Servidor Público Estadual de São Paulo - Instituto de Assistência Médica ao Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Simone Appenzeller
- Division of Rheumatology, Department of Orthopedics, Rheumatology and Traumatology, Universidade Estadual de Campinas (Unicamp), Campinas, Brazil
| | | | - Emily Figueiredo Neves Yuki
- Division of Rheumatology, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | | | - Rosa Weiss Telles
- Division of Rheumatology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | | | - Francinne Machado Ribeiro
- Department of Rheumatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Andrese Aline Gasparin
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | - Antonio Silaide de Araujo Junior
- Division of Rheumatology, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/Unifesp), Otonis Street, 863, 2 Floor, Vila Clementino, São Paulo, SP, 04025-002, Brazil
| | | | - Debora Cerqueira Calderaro
- Division of Rheumatology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Odirlei Andre Monticielo
- Division of Rheumatology, Department of Internal Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
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Kostopoulou M, Mukhtyar CB, Bertsias G, Boumpas DT, Fanouriakis A. Management of systemic lupus erythematosus: a systematic literature review informing the 2023 update of the EULAR recommendations. Ann Rheum Dis 2024:ard-2023-225319. [PMID: 38777375 DOI: 10.1136/ard-2023-225319] [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: 11/27/2023] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES To analyse the new evidence (2018-2022) for the management of systemic lupus erythematosus (SLE) to inform the 2023 update of the European League Against Rheumatism (EULAR) recommendations. METHODS Systematic literature reviews were performed in the Medline and the Cochrane Library databases capturing publications from 1 January 2018 through 31 December 2022, according to the EULAR standardised operating procedures. The research questions focused on five different domains, namely the benefit/harm of SLE treatments, the benefits from the attainment of remission/low disease activity, the risk/benefit from treatment tapering/withdrawal, the management of SLE with antiphospholipid syndrome and the safety of immunisations against varicella zoster virus and SARS-CoV2 infection. A Population, Intervention, Comparison and Outcome framework was used to develop search strings for each research topic. RESULTS We identified 439 relevant articles, the majority being observational studies of low or moderate quality. High-quality randomised controlled trials (RCTs) documented the efficacy of the type 1 interferon receptor inhibitor, anifrolumab, in non-renal SLE, and belimumab and voclosporin, a novel calcineurin inhibitor, in lupus nephritis (LN), when compared with standard of care. For the treatment of specific organ manifestations outside LN, a lack of high-quality data was documented. Multiple observational studies confirmed the beneficial effects of attaining clinical remission or low disease activity, reducing the risk for multiple adverse outcomes. Two randomised trials with some concerns regarding risk of bias found higher rates of relapse in patients who discontinued glucocorticoids (GC) or immunosuppressants in SLE and LN, respectively, yet observational cohort studies suggest that treatment withdrawal might be feasible in a subset of patients. CONCLUSION Anifrolumab and belimumab achieve better disease control than standard of care in extrarenal SLE, while combination therapies with belimumab and voclosporin attained higher response rates in high-quality RCTs in LN. Remission and low disease activity are associated with favourable long-term outcomes. In patients achieving these targets, GC and immunosuppressive therapy may gradually be tapered. Cite Now.
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Affiliation(s)
- Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - George Bertsias
- Rheumatology and Clinical Immunology, University of Crete, School of Medicine, Heraklion, Greece
- Laboratory of Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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Costanzo G, Ledda AG, Sambugaro G. State of the art: the treatment of systemic lupus erythematosus. Curr Opin Allergy Clin Immunol 2024:00130832-990000000-00127. [PMID: 38788118 DOI: 10.1097/aci.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
PURPOSE OF REVIEW Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with dysregulated cells in the immune system. The disease affects organs like kidneys, nervous system, joints, and skin. To manage SLE effectively, novel treatments targeting immune system components have been developed. This review investigates the therapeutic potential of existing targeted therapies and explores future innovative approaches for well tolerated, personalized treatment. RECENT FINDINGS SLE treatment involves cytokine targets and specific immunologic pathways, with even small molecules involved. SUMMARY The advanced therapeutic options in SLE management give clinicians more tools to control disease activity according to personalized medicine.
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Affiliation(s)
- Giulia Costanzo
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Chakravarty EF, Utset T, Kamen DL, Contreras G, McCune WJ, Aranow C, Kalunian K, Massarotti E, Clowse MEB, Rovin BH, Lim SS, Majithia V, Dall'Era M, Looney RJ, Erkan D, Saxena A, Olsen NJ, Ko K, Guthridge JM, Goldmuntz E, Springer J, D'Aveta C, Keyes-Elstein L, Barry B, Pinckney A, McNamara J, James JA. Mycophenolate mofetil withdrawal in patients with systemic lupus erythematosus: a multicentre, open-label, randomised controlled trial. THE LANCET. RHEUMATOLOGY 2024; 6:e168-e177. [PMID: 38301682 PMCID: PMC10922882 DOI: 10.1016/s2665-9913(23)00320-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Mycophenolate mofetil is an immunosuppressant commonly used to treat systemic lupus erythematosus (SLE) and lupus nephritis. It is a known teratogen associated with significant toxicities, including an increased risk of infections and malignancies. Mycophenolate mofetil withdrawal is desirable once disease quiescence is reached, but the timing of when to do so and whether it provides a benefit has not been well-studied. We aimed to determine the effects of mycophenolate mofetil withdrawal on the risk of clinically significant disease reactivation in patients with quiescent SLE on long-term mycophenolate mofetil therapy. METHODS This multicenter, open-label, randomised trial was conducted in 19 centres in the USA. Eligible patients were aged between 18 and 70 years old, met the American College of Rheumatology (ACR) 1997 SLE criteria, and had a clinical SLEDAI score of less than 4 at screening. Mycophenolate mofetil therapy was required to be stable or decreasing for 2 years or more if initiated for renal indications, or for 1 year or more for non-renal indications. Participants were randomly allocated in a 1:1 ratio to a withdrawal group, who tapered off mycophenolate mofetil over 12 weeks, or a maintenance group who maintained their baseline dose (1-3g per day) for 60 weeks. Adaptive random allocation ensured groups were balanced for study site, renal versus non-renal disease, and baseline mycophenolate mofetil dose (≥2 g per day vs <2 g per day). Clinically significant disease reactivation by week 60 following random allocation, requiring increased doses or new immunosuppressive therapy was the primary endpoint, in the modified intention-to-treat population (all randomly allocated participants who began study-provided mycophenolate mofetil). Non-inferiority was evaluated using an estimation-based approach. The trial was registered at ClinicalTrials.gov (NCT01946880) and is completed. FINDINGS Between Nov 6, 2013, and April 27, 2018, 123 participants were screened, of whom 102 were randomly allocated to the maintenance group (n=50) or the withdrawal group (n=52). Of the 100 participants included in the modified intention-to-treat analysis (49 maintenance, 51 withdrawal), 84 (84%) were women, 16 (16%) were men, 40 (40%) were White, 41 (41%) were Black, and 76 (76%) had a history of lupus nephritis. The average age was 42 (SD 12·7). By week 60, nine (18%) of 51 participants in the withdrawal group had clinically significant disease reactivation, compared to five (10%) of 49 participants in the maintenance group. The risk of clinically significant disease reactivation was 11% (95% CI 5-24) in the maintenance group and 18% (10-32) in the withdrawal group. The estimated increase in the risk of clinically significant disease reactivation with mycophenolate mofetil withdrawal was 7% (one-sided upper 85% confidence limit 15%). Similar rates of adverse events were observed in the maintenance group (45 [90%] of 50 participants) and the withdrawal group (46 [88%] of 52 participants). Infections were more frequent in the mycophenolate mofetil maintenance group (32 [64%]) compared with the withdrawal group (24 [46%]). INTERPRETATIONS Mycophenolate mofetil withdrawal is not significantly inferior to mycophenolate mofetil maintenance. Estimates for the rates of disease reactivation and increases in risk with withdrawal can assist clinicians in making informed decisions on withdrawing mycophenolate mofetil in patients with stable SLE. FUNDING The National Institute of Allergy and Infectious Diseases and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Eliza F Chakravarty
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Tammy Utset
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Diane L Kamen
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - W Joseph McCune
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia Aranow
- Autoimmune and Musculoskeletal Disease, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, La Jolla, CA, USA
| | - Elena Massarotti
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Brad H Rovin
- Division of Nephrology, Ohio State University, Columbus, OH, USA
| | - S Sam Lim
- School of Medicine, Emory University, Atlanta, GA, USA
| | - Vikas Majithia
- Division of Rheumatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Maria Dall'Era
- Division of Rheumatology, Russell/Engleman Rheumatology Research Center, University of California, San Francisco, CA, USA
| | - R John Looney
- Allergy Immunology Rheumatology Division, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Nancy J Olsen
- Division of Rheumatology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Kichul Ko
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Joel M Guthridge
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA; Departments of Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ellen Goldmuntz
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | - Jessica Springer
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | | | | | - Bill Barry
- Rho Federal Systems Division, Durham, NC, USA
| | | | - James McNamara
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | - Judith A James
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA; Departments of Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Jourde-Chiche N, Chiche L. An era of immunosuppressant withdrawal in systemic lupus erythematosus: winning through weaning. THE LANCET. RHEUMATOLOGY 2024; 6:e133-e134. [PMID: 38301681 DOI: 10.1016/s2665-9913(24)00001-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/03/2024] [Indexed: 02/03/2024]
Affiliation(s)
- Noémie Jourde-Chiche
- Aix-Marseille University, C2VN, INSERM, INRAE, Marseille 13005, France; Department of Nephrology, AP-HM, CHU de la Conception, Marseille, France.
| | - Laurent Chiche
- Department of Internal Medicine, Hôpital Européen de Marseille, Marseille, France
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Nossent JC, Keen HI, Preen DB, Inderjeeth CA. Population-wide long-term study of incidence, renal failure, and mortality rates for lupus nephritis. Int J Rheum Dis 2024; 27:e15079. [PMID: 38396352 DOI: 10.1111/1756-185x.15079] [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] [Received: 10/09/2023] [Revised: 12/05/2023] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVE Given limited regional data, we investigate the state-wide epidemiology, renal and patient outcomes for lupus nephritis (LN) in Western Australia (WA). METHODS Patients hospitalized with incident SLE (≥2 diagnostic codes in the state-wide WA Health Hospital Morbidity Data Collection) in the period 1985-2015 were included (n = 1480). LN was defined by the presence of glomerulonephritis and/or raised serum creatinine. Trends over three study decades for annual incidence rate (AIR)/100.000 population, mortality (MR), and end-stage renal disease (ESRD) rates/100 person years were analyzed by least square regression and compared with a matched control group (n = 12 840). RESULTS Clinical evidence of LN developed in 366 SLE patients (25.9%) after a median disease duration of 10 months (IQR 0-101) with renal biopsy performed in 308 (84.2%). The AIR for LN (0.63/100.000) did not change significantly over time (R2 = .11, p = .85), while point prevalence reached 11.9/100.000 in 2015. ESRD developed in 14.1% (n = 54) of LN patients vs. 0.2% in non-LN SLE patients and 0.05% in controls (all p ≤ 0.01). ESRD rates increased over time in LN patients (0.4 to 0.7, R2 = .52, p = .26). The odds ratio for death was 8.81 (CI 3.78-22.9) for LN and 6.62 (CI 2.76-17.9) for non-LN SLE patients compared to controls and MR for LN patients increased over time (1.3 to 2.2, R2 = .84, p = .26). CONCLUSIONS The incidence rate of LN in WA remained unchanged over 30 years. A lack of improvement in renal failure and mortality rates illustrates the pressing need for better long-term treatment options and/or strategies in LN.
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Affiliation(s)
- Johannes C Nossent
- Department of Rheumatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Rheumatology Group, School of Medicine, University Western Australia, Crawley, Western Australia, Australia
| | - Helen I Keen
- Rheumatology Group, School of Medicine, University Western Australia, Crawley, Western Australia, Australia
- Department of Rheumatology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - David B Preen
- School of Population and Global Health, University Western Australia, Crawley, Western Australia, Australia
| | - Charles A Inderjeeth
- Department of Rheumatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- Rheumatology Group, School of Medicine, University Western Australia, Crawley, Western Australia, Australia
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Fanouriakis A, Kostopoulou M, Andersen J, Aringer M, Arnaud L, Bae SC, Boletis J, Bruce IN, Cervera R, Doria A, Dörner T, Furie RA, Gladman DD, Houssiau FA, Inês LS, Jayne D, Kouloumas M, Kovács L, Mok CC, Morand EF, Moroni G, Mosca M, Mucke J, Mukhtyar CB, Nagy G, Navarra S, Parodis I, Pego-Reigosa JM, Petri M, Pons-Estel BA, Schneider M, Smolen JS, Svenungsson E, Tanaka Y, Tektonidou MG, Teng YO, Tincani A, Vital EM, van Vollenhoven RF, Wincup C, Bertsias G, Boumpas DT. EULAR recommendations for the management of systemic lupus erythematosus: 2023 update. Ann Rheum Dis 2024; 83:15-29. [PMID: 37827694 DOI: 10.1136/ard-2023-224762] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVES To update the EULAR recommendations for the management of systemic lupus erythematosus (SLE) based on emerging new evidence. METHODS An international Task Force formed the questions for the systematic literature reviews (January 2018-December 2022), followed by formulation and finalisation of the statements after a series of meetings. A predefined voting process was applied to each overarching principle and recommendation. Levels of evidence and strengths of recommendation were assigned, and participants finally provided their level of agreement with each item. RESULTS The Task Force agreed on 5 overarching principles and 13 recommendations, concerning the use of hydroxychloroquine (HCQ), glucocorticoids (GC), immunosuppressive drugs (ISDs) (including methotrexate, mycophenolate, azathioprine, cyclophosphamide (CYC)), calcineurin inhibitors (CNIs, cyclosporine, tacrolimus, voclosporin) and biologics (belimumab, anifrolumab, rituximab). Advice is also provided on treatment strategies and targets of therapy, assessment of response, combination and sequential therapies, and tapering of therapy. HCQ is recommended for all patients with lupus at a target dose 5 mg/kg real body weight/day, considering the individual's risk for flares and retinal toxicity. GC are used as 'bridging therapy' during periods of disease activity; for maintenance treatment, they should be minimised to equal or less than 5 mg/day (prednisone equivalent) and, when possible, withdrawn. Prompt initiation of ISDs (methotrexate, azathioprine, mycophenolate) and/or biological agents (anifrolumab, belimumab) should be considered to control the disease and facilitate GC tapering/discontinuation. CYC and rituximab should be considered in organ-threatening and refractory disease, respectively. For active lupus nephritis, GC, mycophenolate or low-dose intravenous CYC are recommended as anchor drugs, and add-on therapy with belimumab or CNIs (voclosporin or tacrolimus) should be considered. Updated specific recommendations are also provided for cutaneous, neuropsychiatric and haematological disease, SLE-associated antiphospholipid syndrome, kidney protection, as well as preventative measures for infections, osteoporosis, cardiovascular disease. CONCLUSION The updated recommendations provide consensus guidance on the management of SLE, combining evidence and expert opinion.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Myrto Kostopoulou
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, INSERM UMR-S 1109, Centre National de Référence des Maladies Auto-immunes Systémiques Rares (RESO), Strasbourg, France
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Hanyang University Institute for Rheumatology Research and Hanyang Institute of Bioscience and Biotechnology, Seoul, South Korea
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Ian N Bruce
- Centre for Epidemiology Versus Arthritis, University of Manchester, Manchester, UK; National Institute for Health Research Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Thomas Dörner
- Department of Rheumatology and Clinical Immunology, Charite Universitätsmedizin Berlin; Deutsches Rheumaforschungszentrum, Berlin, Germany
| | - Richard A Furie
- Division of Rheumatology, Northwell Health, Great Neck, New York City, New York, USA
| | - Dafna D Gladman
- Lupus Program, Centre for Prognosis Studies in the Rheumatic Disease, Schroeder Arthritis Institute, Krembil Research Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Frederic A Houssiau
- Service de Rhumatologie, Cliniques Universitaires Saint-Luc and Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
| | - Luís Sousa Inês
- Department of Rheumatology, Centro Hospitalar e Universitario de Coimbra, Coimbra, Portugal; School of Health Sciences, Universidade da Beira Interior, Covilha, Portugal
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - László Kovács
- Department of Rheumatology and Immunology, Faculty of Medicine, University of Szeged, Hungary
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China
| | - Eric F Morand
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Gabriella Moroni
- Department of Biomedical Sciences Humanitas University, Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Johanna Mucke
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - György Nagy
- Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
- Department of Rheumatology and Clinical Immunology, Department of Internal Medicine and Oncology, Semmelweis University, Budapest, Hungary
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Sandra Navarra
- Section of Rheumatology, Department of Medicine, University of Santo Tomas, Manila, Philippines
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
- Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - José M Pego-Reigosa
- Rheumatology Department, Complejo Hospitalario Universitario de Vigo, IRIDIS (Investigation in Rheumatology and Immune-Mediated Diseases) - VIGO Group, Galicia Sur Health Research Institute, Vigo, Spain
| | - Michelle Petri
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Bernardo A Pons-Estel
- Grupo Oroño, Centro Regional de Enfermedades Autoinmunes y Reumáticas (GO-CREAR), Rosario, Argentina
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Düsseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Elisabet Svenungsson
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Gastroenterology, Dermatology and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, "Laiko" General Hospital, Medical School, National and Kapodistrian University of Athens, Joint Academic Rheumatology Program, Athens, Greece
| | - Yk Onno Teng
- Centre of Expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Angela Tincani
- Rheumatology and Clinical Immunology, Department of Clinical and Experimental Sciences, ASST Spedali Civili and University of Brescia, Brescia, Italy
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Chris Wincup
- Department of Rheumatology, King's College Hospital, London, UK
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Greece, University Hospital of Heraklion, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
- Joint Academic Rheumatology Program, Medical School, National and Kapodistrian University of Athens, Greece, Medical School, University of Cyprus, Nicosia, Cyprus
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8
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Parodis I, Moroni G, Calatroni M, Bellis E, Gatto M. Is per-protocol kidney biopsy required in lupus nephritis? Autoimmun Rev 2024; 23:103422. [PMID: 37633351 DOI: 10.1016/j.autrev.2023.103422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023]
Abstract
Baseline kidney biopsy is recommended in lupus nephritis (LN). Biopsy allows to classify different forms of LN and differentiate other forms of renal involvement, such as tubulo-interstitial nephritis or thrombotic microangiopathy. The indications for repeat biopsy are more controversial. Some authors feel that good clinical monitoring is sufficient to assess prognosis and make therapeutic decisions. Based on the recently demonstrated discordance between clinical and histological response, some physicians recommend per-protocol biopsies either at 6 months in stable patients to verify the response to induction therapy, or after one-to-two years to assess treatment efficacy and tune the duration of maintenance therapy. Others recommend repeating kidney biopsy in case of incomplete response or to discriminate between active and chronic lesions. By definition, a per-protocol kidney biopsy differs from a repeat biopsy in that the former is foreseen at fixed timepoints, regardless of the clinical response. Although any decision should always consider the patient's overall clinical condition, there are no doubts that repeat kidney biopsy represents a useful tool in difficult cases to evaluate treatment response, modulate treatment intensity, and predict long-term renal outcome both in quiescent lupus and during flares. How to harmonize per-protocol biopsies in the LN course remains challenging.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Medical Unit of Gastroenterology, Dermatology, and Rheumatology, Karolinska University Hospital, Stockholm, Sweden; Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy.
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Elisa Bellis
- Unit of Rheumatology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Mariele Gatto
- Unit of Rheumatology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy; Unit of Rheumatology, Department of Medicine, University of Padua, Padua, Italy
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9
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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10
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Paredes-Ruiz D, Ruiz-Irastorza G, Amoura Z. Systemic lupus erythematosus and glucocorticoids: A never-ending story? Best Pract Res Clin Rheumatol 2023; 37:101873. [PMID: 37957076 DOI: 10.1016/j.berh.2023.101873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/08/2023] [Accepted: 09/20/2023] [Indexed: 11/15/2023]
Abstract
Glucocorticoids (GCs) continue to be essential agents for the management of systemic lupus erythematosus, since there are no other drugs able to active remission of active disease so rapidly. However, their potential for causing irreversible damage greatly limit their use. Fortunately, some strategies may help take advantage of their huge anti-inflammatory power while limiting GC-induced side effects. This article reviews the pharmacological basis of GC action and their translation into the clinical ground. We also offer the practical approach for the use of GC in induction and maintenance therapy as well as the strategies for GC withdrawal of the respective practice of the authors. The three main basic principles are a) using methyl-prednisolone pulses to induce remission not only in severe disease; b) limiting initial doses of prednisone to ≤30 mg/d, with rapid tapering to ≤5 mg/d, which should be the dose for maintenance therapy; and c) individualizing the decision and the strategy to withdraw GCs. Long-term therapy with HCQ and the early introduction of immunosuppressive treatment would help achieve these objectives.
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Affiliation(s)
- Diana Paredes-Ruiz
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit. Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain; Universidad del País Vasco/Euskal Herriko Unibertsitatea, Bizkaia, Spain.
| | - Zahir Amoura
- Sorbonne Université, Faculté de Médecine, Groupement Hospitalier Pitié Salpêtrière, Centre National de Référence du Lupus Systémique, du Syndrome des Antiphospholipides et autres maladies auto-immunes, Service de Médecine Interne 2, Institut E3M, CIMI-Paris, Paris, France
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11
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Mejia-Vilet JM, Turner-Stokes T, Houssiau F, Rovin BH. Kidney involvement in systemic lupus erythematosus: From the patient assessment to a tailored treatment. Best Pract Res Clin Rheumatol 2023; 37:101925. [PMID: 38151362 DOI: 10.1016/j.berh.2023.101925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 12/10/2023] [Indexed: 12/29/2023]
Abstract
In the last few years, several studies have provided new evidence for the diagnosis, management, and follow-up of patients with lupus nephritis. Evidence showing dissociation between clinical and histological findings has prompted reevaluation of the role of the kidney biopsy as a tool for diagnosis and follow-up. In therapeutics, four immunosuppressive schemes now have supporting evidence for use as initial therapy. Current challenges include individualized selection of the best immunosuppressive regimen, an unmet need for non-invasive biomarkers of disease activity to inform treatment responses and guide subsequent therapy, holistic patient management in this complex, multisystem disease, and ultimately the development of more targeted therapies directed at specific effector pathways driving glomerular inflammation and damage in order to improve treatment response. In this communication, we review the diagnostic and therapeutic approach to lupus nephritis, as well as evaluation of response to therapy and disease control.
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Affiliation(s)
- Juan M Mejia-Vilet
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Tabitha Turner-Stokes
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom
| | - Frederic Houssiau
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Service de Rhumatologie, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University, Columbus, OH, United States.
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12
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Gopal A, Kavadichanda C, Gayathri MS, Gorijavolu M, Bairwa D, Mariaselvam CM, Srinivas BH, Thabah MM, Negi VS. Kidney histopathology in predicting flares following drug withdrawal in proliferative lupus nephritis in clinical remission. Rheumatol Int 2023:10.1007/s00296-023-05497-x. [PMID: 37987842 DOI: 10.1007/s00296-023-05497-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 10/18/2023] [Indexed: 11/22/2023]
Abstract
Residual renal histopathological activity at clinical remission in Proliferative Lupus Nephritis (PLN) can predict renal flare upon immunosuppression withdrawal. Data on the role of histological renal remission in predicting extra-renal flares is lacking. We assessed renal histopathology prior to drug withdrawal and the occurrence of renal and extra-renal flares over 52 weeks after drug withdrawal in PLN patients in long-term clinical remission. This is a subgroup analysis of a non-inferiority, open-label randomized (1:1) controlled trial. Patients with biopsy-proven Class III/IV LN in the past (biopsy 1), on immunosuppressants (IS) ≥ 3 years, in clinical remission for ≥ 1 year, on stable prednisolone dose (≤ 7.5 mg/day) plus a maintenance IS and hydroxychloroquine (HCQ) were subjected to a repeat renal biopsy (biopsy 2). Individuals with biopsy 2 having activity index (AI) < 4/24 were randomised to either prednisolone or IS withdrawal. Primary end-point was the proportion experiencing a flare [SELENA-SLEDAI flare index (SFI)] at week 52. Twenty-eight eligible patients underwent biopsy 2 and randomized to prednisolone (n = 15) and IS (n = 13) withdrawal. At biopsy 1, 12 (43%) had class III, 15 (53.5%) had class IV, and 1 (3.5%) had class III + V. At biopsy 2, PLN persisted in 4 (14.2%) while 18 (64.2%) were in histological remission (AI = 0) with 6 (21.4%) in class II. Following drug withdrawal, 9/28 (32%) had flares especially musculoskeletal (55.5%), mucocutaneous (44.4%), and renal (33.3%). Among the four persistent PLN patients, one of the two (50%) with AI = 1 had extra-renal flare while both the two with AI = 2 (100%) had renal and extra-renal flares. In those with histological remission (biopsy 2), 6/18 (66.6%) experienced extra-renal flare of whom one also had renal flare. Upon drug withdrawal, renal histopathology findings with any activity index can predict renal flare while histological remission is not enough to predict extra-renal flare, thus making it an unsuitable marker for deep SLE remission.
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Affiliation(s)
- Aishwarya Gopal
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India
| | - Chengappa Kavadichanda
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India.
| | - Mohan Sreelekha Gayathri
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India
| | - Mamatha Gorijavolu
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India
| | - Devender Bairwa
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India
- Department of Medicine, AIIMS, Bilaspur, Himachal Pradesh, India
| | - Christina Mary Mariaselvam
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India
| | | | - Molly Mary Thabah
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India
| | - Vir Singh Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Fourth Floor SSB, Puducherry, India
- Executive Director, AIIMS Bilaspur, Himachal Pradesh, India
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13
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Pennesi M, Benvenuto S. Lupus Nephritis in Children: Novel Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1841. [PMID: 37893559 PMCID: PMC10607957 DOI: 10.3390/medicina59101841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Childhood-onset systemic lupus erythematosus is an inflammatory and autoimmune condition characterized by heterogeneous multisystem involvement and a chronic course with unpredictable flares. Kidney involvement, commonly called lupus nephritis, mainly presents with immune complex-mediated glomerulonephritis and is more frequent and severe in adults. Despite a considerable improvement in long-term renal prognosis, children and adolescents with lupus nephritis still experience significant morbidity and mortality. Moreover, current literature often lacks pediatric-specific data, leading clinicians to rely exclusively on adult therapeutic approaches. This review aims to describe pediatric lupus nephritis and provide an overview of the novel perspectives on the pathogenetic mechanisms, histopathological classification, therapeutic approach, novel biomarkers, and follow-up targets in children and adolescents with lupus nephritis.
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Affiliation(s)
- Marco Pennesi
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Simone Benvenuto
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
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14
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Aguirre A, DeQuattro K, Shiboski S, Katz P, Greenlund KJ, Barbour KE, Gordon C, Lanata C, Criswell LA, Dall'Era M, Yazdany J. Medication Cost Concerns and Disparities in Patient-Reported Outcomes Among a Multiethnic Cohort of Patients With Systemic Lupus Erythematosus. J Rheumatol 2023; 50:1302-1309. [PMID: 37321640 PMCID: PMC10543599 DOI: 10.3899/jrheum.2023-0060] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE Concerns about the affordability of medications are common in systemic lupus erythematosus (SLE), but the relationship between medication cost concerns and health outcomes is poorly understood. We assessed the association of self-reported medication cost concerns and patient-reported outcomes (PROs) in a multiethnic SLE cohort. METHODS The California Lupus Epidemiology Study is a cohort of individuals with physician-confirmed SLE. Medication cost concerns were defined as having difficulties affording SLE medications, skipping doses, delaying refills, requesting lower-cost alternatives, purchasing medications outside the United States, or applying for patient assistance programs. Linear regression and mixed effects models assessed the cross-sectional and longitudinal association of medication cost concerns and PROs, respectively, adjusting for age, sex, race and ethnicity, income, principal insurance, immunomodulatory medications, and organ damage. RESULTS Of 334 participants, medication cost concerns were reported by 91 (27%). Medication cost concerns were associated with worse Systemic Lupus Activity Questionnaire (SLAQ; beta coefficient [β] 5.9, 95% CI 4.3-7.6; P < 0.001), 8-item Patient Health Questionnaire depression scale (PHQ-8; β 2.7, 95% CI 1.4-4.0; P < 0.001), and Patient-Reported Outcomes Measurement Information System (PROMIS; β for physical function -4.6, 95% CI -6.7 to -2.4; P < 0.001) scores after adjusting for covariates. Medication cost concerns were not associated with significant changes in PROs over 2-year follow-up. CONCLUSION More than a quarter of participants reported at least 1 medication cost concern, which was associated with worse PROs. Our results reveal a potentially modifiable risk factor for poor outcomes rooted in the unaffordability of SLE care.
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Affiliation(s)
- Alfredo Aguirre
- A. Aguirre, MD, M. Dall'Era, MD, J. Yazdany, MD, MPH, Division of Rheumatology, University of California, San Francisco, California;
| | - Kimberly DeQuattro
- K. DeQuattro, MD, Division of Rheumatology, University of Pennsylvania, Pennsylvania
| | - Stephen Shiboski
- S. Shiboski, PhD, Department of Epidemiology & Biostatistics, University of California, San Francisco, California
| | - Patricia Katz
- P. Katz, PhD, Department of Medicine, University of California, San Francisco, California
| | - Kurt J Greenlund
- K.J. Greenlund, PhD, Epidemiology and Surveillance Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kamil E Barbour
- K.E. Barbour, PhD, MPH, Lupus and Interstitial Cystitis Programs, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Caroline Gordon
- C. Gordon, MD, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, Alabama
| | - Cristina Lanata
- C. Lanata, MD, Genomics of Autoimmune Rheumatic Disease Section, National Human Genome Research Section, National Institutes of Health, Bethesda, Maryland
| | - Lindsey A Criswell
- L.A. Criswell, MD, MPH, DSc, Genomics of Autoimmune Rheumatic Disease Section, National Human Genome Research Section, National Institutes of Health, Bethesda, Maryland USA
| | - Maria Dall'Era
- A. Aguirre, MD, M. Dall'Era, MD, J. Yazdany, MD, MPH, Division of Rheumatology, University of California, San Francisco, California
| | - Jinoos Yazdany
- A. Aguirre, MD, M. Dall'Era, MD, J. Yazdany, MD, MPH, Division of Rheumatology, University of California, San Francisco, California
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15
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Banos A, Bertsias G. Flares in Lupus Nephritis: Risk Factors and Strategies for Their Prevention. Curr Rheumatol Rep 2023; 25:183-191. [PMID: 37452914 PMCID: PMC10504124 DOI: 10.1007/s11926-023-01109-6] [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: 06/26/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE OF REVIEW Discuss the prognostic significance of kidney flares in patients with lupus nephritis, associated risk factors, and possible preventative strategies. RECENT FINDINGS Recently performed clinical trials and observational cohort studies underscore the high frequency of relapses of kidney disease, following initial response, in patients with proliferative and/or membranous lupus nephritis. Analysis of hard disease outcomes such as progression to chronic kidney disease or end-stage kidney disease, coupled with histological findings from repeat kidney biopsy studies, have drawn attention to the importance of renal function preservation that should be pursued as early as lupus nephritis is diagnosed. In this respect, non-randomized and randomized evidence have suggested a number of factors associated with reduced risk of renal flares such as attaining a very low level of proteinuria (< 700-800 mg/24 h by 12 months), using mycophenolate over azathioprine, adding belimumab to standard therapy, maintaining immunosuppressive/biological treatment for at least 3 to 5 years, and using hydroxychloroquine. Other factors that warrant further clarification include serological activity and the use of repeat kidney biopsy to guide the intensity and duration of treatment in selected cases. The results from ongoing innovative studies integrating kidney histological and clinical outcomes, together with an expanding spectrum of therapies in lupus nephritis, are expected to facilitate individual medical care and long-term disease and patient prognosis.
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Affiliation(s)
- Aggelos Banos
- Department of Rheumatology, 'Asklepieion' General Hospital, Voula, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Center of Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation Academy of Athens, 115 27, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion and University of Crete Medical School, Voutes-Stavrakia, 71008, Heraklion, Greece.
- Institute of Molecular Biology and Biotechnology-FORTH, Heraklion, Greece.
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16
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Mok CC. Prognostic Stratification of Lupus Nephritis: The Importance of Renal Histology. J Rheumatol 2023; 50:1095-1096. [PMID: 37263655 DOI: 10.3899/jrheum.2023-0381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Chi Chiu Mok
- C.C. Mok, MD, Department of Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong Special Administrative Region, China.
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17
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Odler B, Pollheimer MJ, Kronbichler A, Säemann MD, Windpessl M, Gauckler P, Rudnicki M, Zitt E, Neumann I, Lhotta K, Eller K. [Diagnostic and therapy of lupus nephritis - 2023]. Wien Klin Wochenschr 2023; 135:675-687. [PMID: 37728652 PMCID: PMC10511585 DOI: 10.1007/s00508-023-02263-8] [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: 07/24/2023] [Indexed: 09/21/2023]
Abstract
The manuscript summarizes the consensus of the Austrian Society of Nephrology on the diagnosis and therapy of lupusnephritis, which is built on existing studies and literature. We discuss in detail the immunosuppressive treatment in proliferative forms of lupusnephritis (III and IV ± V) and in pure lupusnephritis V with nephrotic-range proteinuria. Furthermore, the supportive medication in lupusnephritis is summarized in the consensus. The figures were designed to provide the reader a guidance through the therapeutical approach in lupusnephritis for the daily practice.
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Affiliation(s)
- Balazs Odler
- Abteilung für Nephrologie, Innere Medizin, Medizinische Universität Graz, Graz, Österreich
| | | | - Andreas Kronbichler
- Department Innere Medizin 4 (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
| | - Martin Windpessl
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
- Medizinische Fakultät, JKU, Linz, Österreich
| | - Philipp Gauckler
- Department Innere Medizin 4 (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Michael Rudnicki
- Department Innere Medizin 4 (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Emanuel Zitt
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Kathrin Eller
- Abteilung für Nephrologie, Innere Medizin, Medizinische Universität Graz, Graz, Österreich.
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18
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Jourde-Chiche N, Bobot M, Burtey S, Chiche L, Daugas E. Weaning Maintenance Therapy in Lupus Nephritis: For Whom, When, and How? Kidney Int Rep 2023; 8:1481-1488. [PMID: 37547513 PMCID: PMC10403675 DOI: 10.1016/j.ekir.2023.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 04/21/2023] [Accepted: 05/16/2023] [Indexed: 08/08/2023] Open
Abstract
Lupus nephritis (LN) is one of the main determinants of the severity of systemic lupus erythematosus (SLE). LN flares can lead to organ damage with chronic kidney disease (CKD) or even end-stage kidney disease (ESKD) and impair patients' survival. The "treat-to-target" strategy, which aims at obtaining and maintaining remission or low disease activity of SLE to alleviate symptoms and prevent organ damage, also refers to the control of residual activity in the kidney. But damage in SLE can also come from treatments, and toxicities related to long-term use of treatments should be prevented. This may contribute to the frequent nonadherence in patients with SLE. The de-escalation or even weaning of treatments whenever possible, or "think-to-untreat" (T2U) strategy, is to be considered in patients with LN. This possibility of treatment weaning in LN was explored in retrospective cohorts, on the basis of long-term clinical remission. It was also proposed prospectively with a kidney-biopsy-based approach, combining clinical and pathologic remission to secure treatment weaning. The WIN-Lupus trial was the first randomized controlled trial comparing the continuation to the discontinuation of maintenance immunosuppressive therapy (IST) after 2 to 3 years in patients with LN in remission. It showed a higher risk of severe SLE flares in patients who discontinued treatment, but also a possibility of weaning without flare in some patients, who need to be better identified. We propose here a narrative review of the available literature on the weaning of treatment in LN and discuss how to secure a T2U strategy.
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Affiliation(s)
- Noémie Jourde-Chiche
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Mickaël Bobot
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
- Aix-Marseille Université, CERIMED, Marseille, France
| | - Stéphane Burtey
- Aix-Marseille Université, C2VN, INSERM, INRAE, Marseille, France
- AP-HM, CHU Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Laurent Chiche
- Hôpital Européen de Marseille, Service de Médecine interne, Marseille, France
| | - Eric Daugas
- AP-HP, Service de Néphrologie, Hôpital Bichat, Paris, France
- Université Paris Cité, INSERM U1149, Paris, France
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Kostopoulou M, Fanouriakis A, Bertsias G, Boumpas DT. Annals of the Rheumatic Diseases collection on lupus nephritis (2019-2022): novel insights and advances in therapy. Ann Rheum Dis 2023; 82:729-733. [PMID: 37094880 DOI: 10.1136/ard-2023-223880] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/17/2023] [Indexed: 04/26/2023]
Abstract
No single organ has received as much attention in systemic lupus erythematosus (SLE) as the kidneys. During the period 2019-2022, the Annals of the Rheumatic Diseases published several original papers, brief reports and letters that further elucidate the pathogenesis and advance the management of LN. A selection of representative original papers is highlighted in this review.
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Affiliation(s)
- Myrto Kostopoulou
- Rheumatology and Clinical Immunology, National and Kapodistrian University, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology, National and Kapodistrian University, Athens, Greece
- First Department of Propaedeutic Internal Medicine, National and Kapodistrian University, Athens, Greece
| | - George Bertsias
- Rheumatology, University of Crete School of Medicine, Iraklio, Greece
- Laboratory of Autoimmunity-Inflammation, Institute of Molecular Biology and Biotechnology, Heraklion, Greece
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology, National and Kapodistrian University, Athens, Greece
- Laboratory of Autoimmunity and Inflammation, Center for Clinical, Experimental Surgery and Translational Research, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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20
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Mok CC, Teng YKO, Saxena R, Tanaka Y. Treatment of lupus nephritis: consensus, evidence and perspectives. Nat Rev Rheumatol 2023; 19:227-238. [PMID: 36864291 DOI: 10.1038/s41584-023-00925-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 03/04/2023]
Abstract
Despite the continuing development of immunomodulatory agents and supportive care, the prognosis associated with lupus nephritis (LN) has not improved substantially in the past decade, with end-stage kidney disease still developing in 5-30% of patients within 10 years of LN diagnosis. Moreover, inter-ethnic variation in the tolerance of, clinical response to and level of evidence regarding various therapeutic regimens for LN has led to variation in treatment prioritization in different international recommendations. Modalities that better preserve kidney function and reduce the toxicities of concomitant glucocorticoids are unmet needs in the development of therapeutics for LN. In addition to the conventional recommended therapies for LN, there are newly approved treatments as well as investigational drugs in the pipeline, including the newer generation calcineurin inhibitors and biologic agents. In view of the heterogeneity of LN in terms of clinical presentation and prognosis, the choice of therapies depends on a number of clinical considerations. Molecular profiling, gene-signature fingerprints and urine proteomic panels might enhance the accuracy of patient stratification for treatment personalization in the future.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, China.
| | - Y K Onno Teng
- Center of Expertise for Lupus-, Vasculitis- and Complement-mediated systemic diseases, Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, Netherlands
| | - Ramesh Saxena
- Department of Internal Medicine, Division of Nephrology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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21
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[From "Treat to Target" to "Think to Untreat": Therapeutic de-implementation as a new paradigm in systemic lupus erythematosus]. Rev Med Interne 2023; 44:101-104. [PMID: 36566116 DOI: 10.1016/j.revmed.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 12/04/2022] [Indexed: 12/24/2022]
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22
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The evolving landscape of immune-mediated glomerular diseases. Nat Rev Nephrol 2023; 19:81-82. [PMID: 36517620 DOI: 10.1038/s41581-022-00666-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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23
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Absetzen der Erhaltungstherapie bei Lupusnephritis erhöht
signifikant Rezidive. AKTUEL RHEUMATOL 2023. [DOI: 10.1055/a-1950-2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Die Lupusnephritis (LN) ist eine schwere Erscheinungsform des systemischen Lupus
erythematodes (SLE). Patienten mit proliferativer LN erhalten eine
immunsuppressive Therapie (IST) zum Erreichen einer Remission und zur Vermeidung
von Rückfällen. Bislang wurde in keiner Studie prospektiv
untersucht, ob die IST bei LN abgesetzt werden kann. Jourde-Chiche et al.
untersuchten die Auswirkungen einer Beendigung der IST-Therapie nach 2–3
Jahren Therapie.
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24
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Bobot M, Jourde-Chiche N. Lupus nephritis: Is it necessary to systematically repeat kidney biopsy? Rev Med Interne 2023; 44:1-4. [PMID: 36424286 DOI: 10.1016/j.revmed.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022]
Affiliation(s)
- M Bobot
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Marseille, France; Aix-Marseille Université, C2VN, Inserm 1263, INRAE 1260, Marseille, France; CERIMED, Aix-Marseille Université, Marseille, France.
| | - N Jourde-Chiche
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Marseille, France; Aix-Marseille Université, C2VN, Inserm 1263, INRAE 1260, Marseille, France.
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