Treatment of severe proliferative lupus nephritis: the current state

Opposing Roles of Tyrosine Kinase Receptors Mer and Axl Determine Clinical Outcomes in Experimental Immune-Mediated Nephritis

Glomerulonephritis is one of the most severe manifestations of systemic lupus erythematosus, with considerable morbidity and mortality. There remains a major unmet need for successful management of lupus nephritis. TAM family receptor tyrosine kinases (Mer and Axl) play an important role in the maintenance of immune homeostasis in the kidney. Mer is constitutively expressed in the glomeruli; Axl expression is inducible in glomeruli under inflammatory conditions. To investigate the distinct functions of Axl and Mer in lupus nephritis, we compared the severity of nephrotoxic serum glomerulonephritis in wild-type (WT), Axl-knockout (KO), Mer-KO, and Axl/Mer-KO mice. Mer-KO mice developed severe glomerulonephritis, with significantly decreased survival and increased blood urea nitrogen levels compared with WT mice given the same treatment. However, nephrotoxic serum-treated Axl-KO mice had significantly increased survival rates and improved renal function compared with similarly treated WT, Mer-KO, and Axl/Mer-KO mice. Interestingly, mice lacking both Axl and Mer developed kidney inflammation comparable to WT mice. Western blot analysis revealed significantly increased Stat3 phosphorylation and caspase-1 activation in the kidneys of nephritic Mer-KO mice. In contrast, Axl-deficient nephrotoxic serum-injected mice showed decreased Akt phosphorylation and Bcl-xL upregulation. Thus, the reciprocal activation of Axl and Mer receptor tyrosine kinases has a major impact on the outcome of renal inflammation.

Seronegative systemic lupus erythematosus: etiology of nephrotic syndrome and acute renal failure in early postpartum period

Systemic lupus erythematosus (SLE) is an autoimmune syndrome that occurs most commonly in women during their reproductive years. Nephritis is known to be one of the most serious complications of SLE. Lupus nephropathy is frequently associated with ANA and anti-dsDNA antibodies. Rarely, serological markers may be initially absent, and in many cases, they become positive after sometime.

We present a 28-year old, otherwise healthy female who admitted to our clinic with edema, hypertension, proteinuria and acute renal failure following her fourth delivery. Serum immunological markers were negative and renal biopsy showed histopathological changes consistent with systemic lupus erythematosus as the etiology of nephrotic syndrome. A dramatic therapeutic response was achieved by pulse steroid and cyclophosphamide treatment following oral steroid therapy.

In women with new onset nephrotic syndrome or renal function deterioration in postpartum period, even if the patient is asymptomatic or seronegative, it is crucial to exclude SLE for a rapid diagnosis and prompt treatment in the case of lupus nephritis. Renal biopsy is of diagnostic importance in such cases in which there is no other clinical, biochemical and serological evidence of the disease.

Calcineurin inhibitors may be a reasonable alternative to cyclophosphamide in the induction treatment of active lupus nephritis: A systematic review and meta-analysis

Although the accepted standard of care during the induction treatment of active lupus nephritis (LN) has been cyclophosphamide (CYC), recent trials suggest that calcineurin inhibitors (CNIs), which include cyclosporine A (CsA) and tacrolimus (TAC), may be just as, or even more, effective and less toxic than CYC. A systematic review and meta-analysis were performed to evaluate the clinical effects of CNIs on active LN compared with those of CYC. In the present study, clinical trials that compared CNIs with CYC in the induction therapy of active LN were searched in the Cochrane Library, Ovid and PubMed databases. The clinical data on renal remission and side-effects were collected and analyzed. The relative risk (RR) and 95% confidence intervals (CIs) were calculated. As a result, six controlled trials involving 265 patients were included in the meta-analysis, four of which compared TAC (treatment group) with CYC (control group), and the other two compared CsA (treatment group) with CYC (control group). CNIs were superior to CYC for higher complete remission (RR=1.56, 95% CI 1.14-2.15, Z=2.74, P=0.006) and better overall response/total remission (RR=1.23, 95% CI 1.07-1.42, Z=2.87, P=0.004) and had fewer side-effects. Among the CNIs, TAC demonstrated more favorable results than CsA. Therefore, it was concluded that CNIs may be a reasonable alternative to CYC in the induction treatment of active LN. However, large-scale, multicenter, well-designed clinical trials should be adopted to further confirm this conclusion.

Improved prognostic diagnosis of systemic lupus erythematosus in an early stage of disease by a combination of different predictive biomarkers identified by proteome analysis

Background

Since the original characterizations of the pathological features defining glomerulonephritis in systemic lupus erythematosus (SLE) were reported, numerous studies have linked the development of pathology to the abnormal expression of protein in urine. The determination of proteinuria is important and necessary; however, this alone is not predictive enough to confirm a suspected diagnosis, especially in an early state of disease when symptoms are not yet observed. Furthermore, several studies have already highlighted the pitfalls of proteinuria both as a clinical prognostic marker and as a factor predicting the progressive loss of renal function. Therefore, the identification of more accurate and predictive biomarkers is urgently needed. To address this, comparative urinary and kidney profiling was performed in the MRL-lpr/lpr mouse as a model of lupus tubulointerstitial nephritis and lupus glomerulonephritis corresponding to SLE in humans.

Results

Tamm-Horsfall glycoprotein (THG; uromodulin) and beta2-microglubulin (β2M) were identified as immune process-related molecules in the urine and kidney of the MRL-lpr/lpr mouse model. Furthermore, we show that the combinatory expression profile of THG and β2M as biomarkers, normalized by the proteinuria level, is more predictive than proteinuria determination alone. Data were confirmed by comparative urinary profiling of SLE in mice by Western blot and quantitative polymerase chain reaction (qPCR) analysis.

Conclusion

Based on our results, we are able to diagnose SLE in the MRL-lpr/lpr mouse in a very early state of disease, when the proteinuria level alone is not able to confirm a suspected diagnosis. The pre-validation of our urinary biomarkers is associated with clinical outcomes of glomerulonephritis in humans and merits additional investigation. Further conformations of our predictive biomarkers in the urine of SLE patients in the course of a clinical study are still ongoing.

A cost-utility analysis of alternative drug regimens for newly diagnosed severe lupus nephritis patients in Thailand

OBJECTIVE

The aim of this study was to assess the value of four drug regimens for newly diagnosed severe LN from a societal perspective.

METHODS

A model-based cost-utility analysis was devised to measure lifetime costs and health outcomes. Current treatment options consisting of different combinations of i.v. CYC, AZA and MMF were compared with a baseline regimen of i.v. CYC in both the induction and maintenance phases. Resource use and costs were derived from medical records reviews and databases. Event rates were elicited from randomized controlled trials. Relative treatment effects were obtained from meta-analyses. Health utilities were obtained from a real cohort of patients to estimate the outcome of quality-adjusted life years.

RESULTS

It was found that a treatment regimen that combined i.v. CYC in the induction phase with AZA in the maintenance phase was cost saving compared with the baseline regimen. Treatment with i.v. CYC in the induction phase and MMF in the maintenance phase and treatment with MMF in the induction phase and a reduced dose of the same in the maintenance phase turned out to be a negatively dominated regimen.

CONCLUSION

In the Thai context, the combination of i.v. CYC for the induction phase followed by AZA for the maintenance phase should be considered as the first-line therapy for newly diagnosed severe LN, as it seems to be the most cost-saving regimen.

Mycophenolate mofetil versus azathioprine as maintenance therapy for lupus nephritis: a meta-analysis

AIM

The options for long-term maintenance therapy in lupus nephritis (LN) remain controversial. This meta-analysis of randomized controlled trials (RCTs) assessed the prognosis and safety of mycophenolate mofetil (MMF) versus azathioprine (AZA) used as maintenance therapy for lupus nephritis.

METHODS

The data of Cochrane Library, PubMed, EMBASE were retrieved to search the studies about the RCT studies that compared MMF with AZA used as maintenance therapy for lupus nephritis. We extracted the data reflecting prognosis, which included mortality, end-stage renal failure (ESRF), renal relapse, doubling serum creatinine, and adverse effects, then further analyzed the combined results of data and calculated the relative risk (RR).

RESULTS

Four RCT studies including 328 patients were enrolled into our meta-analysis. There was no difference between the patients receiving either MMF or AZA for maintenance therapy in preventing relapse, progression to end-stage renal failure, death and doubling of serum creatinine. MMF is not superior to AZA in terms of the risks of infection and gastrointestinal upset, but fewer patients receiving MMF developed leukopenia (RR 0.12; 95% confidence interval (CI), 0.04-0.39; P = 0.0004) and amenorrhoea (RR 0.17; 95% CI, 0.04-0.72; P = 0.02) than those receiving AZA.

CONCLUSION

The current limited evidence suggests that MMF offers similar prognosis as AZA for maintenance therapy, while MMF appears safer than AZA in the treatment of lupus nephritis.

Understanding lupus nephritis: diagnosis, management, and treatment options

Systemic lupus erythematosus (SLE) predominantly affects women in their reproductive years. Renal disease (glomerulonephritis) is one of the most frequent and serious manifestations of SLE. Of the various histological types of lupus glomerulonephritis, diffuse proliferative nephritis carries the worst prognosis. Combined with high-dose prednisone, mycophenolate mofetil (MMF) has emerged as a first-line immunosuppressive treatment, although data regarding the efficacy of MMF on the long-term preservation of renal function are forthcoming. Cyclophosphamide is reserved for more severe forms of lupus nephritis, such as crescentic glomerulonephritis with rapidly deteriorating renal function, patients with significant renal function impairment at presentation, and refractory renal disease. Evidence for the calcineurin inhibitors in the treatment of lupus nephritis is weaker, and it concerns patients who are intolerant or recalcitrant to other agents. While further controlled trials are mandatory, B cell modulation therapies, such as rituximab, belimumab and epratuzumab are confined to refractory disease. Non-immunosuppressive measures, such as angiotensin-converting enzyme inhibitors, vigorous blood pressure control, prevention and treatment of hyperlipidemia and osteoporosis, are equally important.

Minimal mesangial lupus nephritis: a systematic review

OBJECTIVES

To summarize the clinical presentation, histological features, treatment, and outcome of minimal change nephropathy (MCN) in patients with systemic lupus erythematosus (SLE).

METHODS

We performed a systematic review of cases of MCN in SLE patients reported in the English literature from January 1985 to May 2009 by a Medline search.

RESULTS

The estimated prevalence of MCN in biopsy-proven lupus nephritis is 2.3% in childhood and 1.1% in adults. There are 13 individual cases (12 women, one man) of SLE-related MCN reported in the literature. The mean age of nephritis onset was 32.7 years. In six (46%) patients, MCN was the initial manifestation of SLE. All patients presented with nephrotic syndrome and two (15%) had active urinary sediments. Renal function was impaired in eight (62%) patients and six (46%) patients had active lupus serology. All patients responded promptly to high-dose glucocorticoids but four (31%) had relapse of proteinuria during their course of SLE. None of the patients developed thromboembolic or infective complications.

CONCLUSIONS

MCN is an uncommon histological class of lupus nephritis. Typically, patients present with heavy proteinuria, and transient renal dysfunction is common. The prognosis of MCN in SLE appears to be good because of its rapid response to glucocorticoids. Relapses of proteinuria may be reduced by the use of maintenance immunosuppression. Alkylating agents, calcineurin inhibitors, mycophenolate mofetil, and rituximab can be considered in glucocorticoid-dependent or refractory cases of SLE-related MCN.

Mycophenolate mofetil is as efficacious as, but safer than, cyclophosphamide in the treatment of proliferative lupus nephritis: a meta-analysis and meta-regression

OBJECTIVE

Since mycophenolate mofetil (MMF) has emerged as an immunosuppressant for treating proliferative lupus nephritis, the role of cyclophosphamide (CYC)-containing regimens is being challenged. Efficacy data from randomized controlled trials (RCTs) and previous meta-analyses comparing these two agents for treating lupus nephritis have been inconsistent as they were heterogeneous in design and of small sample size. An updated meta-analysis is therefore required.

METHODS

Publications in the English literature were searched with the keywords 'mycophenoate', 'mycophenolic', 'lupus nephritis', 'nephritis' and 'glomerulonephritis' for RCTs in electronic databases. Primary outcome was relative risk (RR) of renal remission at 6 months. Secondary outcome included RRs of mortality, development of end-stage renal failure (ESRF) and side effects. Meta-regression was performed to identify factors explaining the heterogeneity of the effect sizes.

RESULTS

Ten eligible RCTs involving 847 patients were included. MMF offers similar efficacy in inducing renal remission as CYC (RR 1.052; 95% CI 0.950, 1.166) and the risks of death (RR 0.709; 95% CI 0.373, 1.347) and ESRF (RR 0.453; 95% CI 0.183, 1.121) were comparable. Significantly fewer patients receiving MMF developed amenorrhoea (RR 0.212; 95% CI 0.094, 0.479) and leucopenia (RR 0.473; 95% CI 0.269, 0.832) while the risks of herpes infection and pneumonia tended to be lower and that of diarrhoea appeared higher in the MMF groups. Meta-regression revealed that the non-white and non-Asian ethnicities contributed significantly to the heterogeneity of the effect sizes of renal remission.

CONCLUSION

MMF offers similar efficacy in renal remission and survival as CYC. MMF appears safer than CYC in the treatment of proliferative lupus nephritis.

Semiquantitative and semi-automated morphometric evaluation of chronic lesions in renal biopsies

Chronic lesions in renal biopsies are a well recognized prognostic factor for renal diseases, including lupus nephritis. The methods used for assessment of chronic lesions are, however, largely based on semiquantitative evaluation and may lead to poor reproducibility. Interobserver variation is particularly important in lupus nephritis, in which acute and chronic lesions may occur simultaneously. In this study we tested the reproducibility of chronic lesion assessment performed by three pathologists, two with specific training in renal pathology, using 20 renal biopsies and a standard semiquantitative method. In a second experiment, we evaluated the reproducibility of chronic lesion assessment in 33 biopsies of lupus nephritis by the two nephropathologists. The semiquantitative estimated values were compared with those from a previously proposed morphometric method for quantification of chronic lesions in renal biopsies. Although correlations were observed among the estimated values, there was a wide range of variation when semiquantitative methods were used. In particular, activity and chronicity indices of lupus nephritis were poorly reproducible. In contrast, use of a morphometric score, although not eliminating interobserver variability, led to better reproducibility of estimated values than that obtained with semiquantitative methods.

Pharmacotherapy of lupus nephritis: time for a consensus?

BACKGROUND

The optimal therapy for lupus nephritis has been the subject of considerable debate.

OBJECTIVE

To provide evidence- and expert-based recommendations.

METHODS

To review the literature and the European League Against Rheumatism recommendations.

RESULTS

Risk stratification based on histological, demographical, clinical and laboratory characteristics allows the identification of patients at high risk for loss of renal function, and thus more likely to benefit from more aggressive therapy. Achieving remission within the first months of treatment, irrespective of the agent used, correlates with good long-term renal outcomes; maintenance of remission can be achieved with less toxic therapies. Aggressive management of atherosclerosis risk factors and renoprotective therapy for those patients with chronic renal disease improve long-term survival and prognosis.

[Treatment of lupus nephritis]

Lupus nephritis is a relevant source of morbidity and mortality in patients with systemic lupus erythematosus. The standard therapy of remission induction in severe lupus nephritis is based on the use of monthly intravenous cyclophosphamide. Recent data have established that the maintenance of remission in lupus nephritis can be achieved with azathioprine or mycophenolate mofetil, with less adverse effects than quarterly intravenous cyclophosphamide. In recent years, a number of controlled randomized clinical trials have been published, opening new therapeutic options in the induction of remission in lupus nephritis, such as less aggressive regimens of intravenous cyclophosphamide or mycophenolate mofetil. Further studies are needed for establishing the optimal therapy of lupus nephritis patients.

Clinical amelioration of murine lupus by a peptide based on the complementarity determining region-1 of an autoantibody and by cyclophosphamide: similarities and differences in the mechanisms of action

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by autoantibodies and systemic clinical manifestations. In this study we investigated the beneficial effects on murine lupus accomplished by a peptide based on the sequence of the complementarity-determining region 1 of an anti-DNA autoantibody (hCDR1) when given alone or in combination with cyclophosphamide (CYC), and determined the mechanisms underlying those effects. SLE-afflicted (NZB x NZW) F(1) mice were treated for 12 weeks with injections of hCDR1, CYC or a combination of both drugs. We found that hCDR1 and CYC ameliorated serological and renal manifestations of the diseased mice, down-regulated interferon-gamma and interleukin-10, and up-regulated transforming growth factor-beta. These effects were associated with an increment of naive CD4(+) cells at the expense of the number of CD4(+) cells with the memory/activated phenotype. Further, the number of CD8(+) cells in the diseased mice was increased by the two drugs, resulting in a significant decrease in the CD4 : CD8 ratio. However, whereas the frequency and activity of CD4(+) CD25(+) CD45RB(low) regulatory T cells and the expression of cytotoxic T-lymphocyte antigen 4 (CTLA-4) in CD4(+) cells were up-regulated by hCDR1 treatment, they were minimally affected following treatment with CYC. CTLA-4 played an important role in the activity of the hCDR1-induced CD4(+) CD25(+) cells as manifested by down-regulation of CD28 expression, decrease of activation-induced apoptosis, and modulation of the cytokine profile in CD4(+) CD25(-) cells derived from SLE-afflicted mice. Thus, although the two drugs have similar ameliorative effects, hCDR1 but not CYC elicits regulatory pathways that are of importance for tolerance induction in SLE.

Lupus nephritis in an Afro-Caribbean population: renal indices and clinical outcomes

In an Afro-Caribbean population, 111 new cases of systemic lupus erythematosus were diagnosed in the 10-year period from January 1995. Fifty-three cases (48%) presented with or subsequently developed lupus nephritis (SLEN). We recorded clinical characteristics and treatment outcomes of SLEN. We retrospectively categorized patients into four groups based on presence or absence of proteinuria with or without renal impairment. Group 1 (n = 15, 28%) had normal renal function (creatinine clearance (CrCl) > 70 mL/minute) with urinary protein excretion (UPE) of 0.5-3.0 g/24 hour, group 2 (n = 7, 13%) had normal renal function with UPE > 3.0 g/24 hour, group 3 (n = 9, 17%) had renal impairment (CrCl < 70 mL/minute) with UPE of 0.5-3.0 g/24 hour and group 4 (n = 22, 42%) had renal impairment with UPE > 3.0 g/24 hour. Renal biopsies were performed in 15 patients (28%). The number of treated patients in-remission decreased across the groups, from 100% in group 1 and 71% in group 2, to 33% in group 3 and 32% in group 4 (Pr < 0.001). There were 12 deaths from renal causes: none in groups 1 and 2, two (22%) from group 3 and 10 (45%) from group 4 (Pr = 0.003). In resource-poor clinical settings with limited access to histopathological services, CrCl and UPE may be useful predictors of therapeutic response and clinical outcomes in SLEN.

Treatment of Proliferative Lupus Nephritis—A Critical Approach

OBJECTIVES

To discuss the current management of proliferative lupus nephritis (PLN), with a focus on strategies to improve long-term outcome and reduce treatment toxicity while minimizing the risk of relapse.

METHODS

The literature on treatment strategies used in systemic lupus erythematosus (SLE) and PLN from 1975 to 2006, using PubMed from the National Library of Medicine, was reviewed.

RESULTS

The high efficacy of the standard therapeutic regimen of PLN, traditionally associating cyclophosphamide (CYC) with corticosteroids (CS), has markedly ameliorated the prognosis of the disease, with more than 80% of patients achieving complete or partial remission. The ameliorated renal prognosis has positively influenced the general survival rates. Ten-year survival rates now surpass 75% and continue to improve. In view of the improved survival, the major aims of treatment now include preventing long-term organ damage and minimizing treatment toxicity, which can contribute significantly to the chronic morbidity and mortality of lupus. A number of high-quality trials have been reported, making us more confident of the value of different immunosuppressive protocols, and several novel immunosuppressive drugs are still under investigation.

CONCLUSION

Recent basic and clinical research has enormously improved our understanding of the pathogenesis of SLE and has suggested new, targeted approaches to therapy. These targeted novel therapies are expected to help the patients with PLN in the next decade.

[Influence of non-complicated urinary tract infection on renal relapses in proliferative lupus nephritis]

OBJECTIVE

In patients with proliferative lupus nephritis treated with IV cyclophosphamide, analyze urinary tract infection (UTI) as a cause of treatment delay and renal relapses, compared with lupus nephritis patients without infection.

PATIENTS AND METHODS

We studied SLE patients (ACR criteria) with renal biopsy showing nephritis class IV. All patients received monthly intravenous cyclophosphamide (CYC) treatment during 6 months. Thereafter patients were assigned to 2 groups: patients who developed UTI, and those who did not; renal function tests, UTI and renal relapses were bimonthly evaluated during one year (follow-up period). To analyze data, t student test, χ(2), Fisher exact (when appropiate), and bivariate analysis, were performed.

RESULTS

We studied 50 patients, 25 with UTI (Group I) and 25 without UTI (G-II).The mean age was 30.07 ± 8.15 years, 82% were female. E. coli was the pathogen most frequently isolated (73%). UTI (G-I) was the cause for treatment delay in 19 cases (76%), compared with 3 patients (12%) in G-II whose treatment was delayed because of some other causes (severe leucopenya, hypersensibility and gastrointestinal side effects) (OR 23.22, 95% CI, 5.26-105.1; P=001). During the follow up, 90.9% of patients in G-I reached partial or complete renal remission within 3 months, but only 35% mantained remission after the year of follow up. Meanwhile, patients in G-II had complet and partial renal remission of 85% and 63%, respectively. In the first group we observed persistent albuminuria (P<05), low complement levels and high ab-dsDNA titers. Renal flares were present in 18 patients in G-I and 9 in G-II.

CONCLUSIONS

UTI in lupus nephritis patients has a negative impact. It leads to delayed CYC therapy and to a higher renal flare rate.

Emerging drug therapies for systemic lupus erythematosus

Despite the tremendous improvement in survival of systemic lupus erythematosus (SLE) in the past few decades, manifestations of the disease that are refractory to conventional therapies and treatment-related complications are still major causes of mortality and morbidity. In recent years, we have seen an explosive development of newer therapeutic modalities for various rheumatic diseases including SLE. Novel therapies for SLE should aim at targeting more specifically the immunopathogenetic pathways to achieve higher efficacy and reduce therapy related toxicities. This article reviews the emerging therapeutic modalities that have been used or are being tried in patients with SLE.

[Immunosuppresive treatment in patients with lupus glomerulonephritis. Review of adverse events]

The prognosis of lupus nephritis has improved significantly over the past few decades. This has been partly contributed to by a better understanding of the natural history of the disease, improved treatment regimens, and the use of adjunctive treatments. Despite the development of new modalities, cyclophosphamide (CYC) remains the preferred initial treatment for severe proliferative lupus nephritis. Controversies continue about the best route, dosage, and duration of CYC treatment. However, adverse events as major infections, neoplasia and permanent amenorrhea, remain as a great concern for physicians and patients. For recalcitrant disease, new immunosuppresive and immunomodulating agents, nucleoside analogues and the biological response modifiers can be considered. New treatments directed against more specific targets may theoretically be associated with higher efficacy and lower toxicity. Longterm studies are needed with new treatments to verify this assumed lower toxicity.

Sustained remission of lupus nephritis

The aim of this study was to describe the clinical course of patients with lupus nephritis (LN) who attain a sustained remission (SR) and identify predictors of SR. A retrospective study of patients with biopsy-proven LN were followed for up to 10 years. SR was defined as normal renal function, urine protein <0.5g/day, and an inactive urine sediment without significant immunosuppressive maintenance therapy for no less than three years. Control patients had LN but did not fulfill the criteria for SR. Data was collected at diagnosis of LN (T0), at onset of remission (T1), and at final follow-up (T2). A total of 35 patients were identified, 16 with a SR of LN and 19 controls, with a mean +/- SD follow-up of 126.4 +/- 8.5 months. Remission of LN was achieved following 37.7 +/- 6.8 months of therapy. At diagnosis (T0) the WHO classification of nephritis, activity and chronicity scores of renal biopsies were comparable in the two groups. At final follow-up (T2), the mean estimated creatinine clearance for the SR group was significantly higher than in controls (P = 0.009) and disease activity (SLEDAI scores) was lower (P = 0.002). Cumulative damage (SDI scores) in the SR group did not increase after patients entered remission (P = 0.250), whereas the mean SDI score in the control group increased significantly (P = 0.014) even when renal variables were excluded (P = 0.016). Multivariate analysis revealed that female gender (P = 0.023), older age (P = 0.034), higher nonrenal SLEDAI scores (P = 0.016) at the time of diagnosis of LN and absence of azathioprine (P = 0.010) were predictive of SR. It was concluded that remission of LN occurs in a substantial proportion of systemic lupus erythematosus (SLE) patients and may be sustained without maintenance immunosuppressive therapy. It is associated with a significantly slower accrual of both renal and non-renal damage over the ensuing seven years.

Basic immunosuppressive drugs outside solid organ transplantation

Immunosuppressive drugs are the backbone of solid organ transplantation. The introduction of new immunosuppressive drugs led to improved patient and organ survival rates. Nowadays, acute rejection can be reduced to a minimum. Individualization and avoidance of drug-related adverse effects became a new goal to achieve. The potency of immunosuppressive drugs makes them attractive for use in various autoimmune diseases; therefore, the experience on immunosuppressive drugs outside the field of organ transplantation is analysed in this review.

Long-term outcome of diffuse proliferative lupus glomerulonephritis treated with cyclophosphamide

PURPOSE

To report the long-term outcome of diffuse proliferative lupus nephritis (DPLN) treated with cyclophosphamide (CYC) in Chinese patients.

METHODS

Patients with biopsy-proven DPLN treated with prednisolone and CYC were identified. The long-term renal outcome and treatment-related toxicities were reported.

RESULTS

A total of 212 patients were studied (89% women; mean age 30.9 +/- 10.9 years; mean system lupus erythematosus [SLE] duration 36.7 +/- 55.1 months). At renal biopsy, 148 (70%) patients were nephrotic, and 78 (37%) had impaired serum creatinine. One hundred and three (49%) patients received daily oral CYC, whereas 109 (51%) received intravenous bolus CYC. At last dose of CYC, 126 (59%) patients responded completely, and 56 (26%) responded partially. In a logistic regression model, the cumulative CYC dose and histologic chronicity score predicted complete response. One hundred fifty-five (73%) patients received maintenance immunosuppression for at least 3 years (88% azathioprine). After a follow-up of 1873 patient-years, 66 patients experienced renal flares, 30 had doubling of serum creatinine, 18 developed end-stage renal failure, and 14 died. The renal survival rates were 88.7%, 82.8% and 70.7% at 5, 10 and 15 years, respectively. Failure to respond completely to CYC and the absence of maintenance immunosuppression were independent predictors of a poor renal outcome. Ovarian toxicity was more frequent with the oral CYC regimen. Increasing age and higher cumulative doses of CYC were independent risk factors.

CONCLUSIONS

In Chinese patients with DPLN, the cumulative dose, rather than the route of CYC administration, determines the initial treatment response and ovarian toxicity. Maintenance immunosuppression is associated with a better long-term prognosis. The oral CYC regimen is more toxic and should be reserved for high-risk patients.

Intravenous cyclophosphamide--resistant systemic lupus erythematosus in Arizona

Systemic lupus erythematosus (SLE) tends to be severe and to have a variable response in childhood. We undertook this retrospective study to assess response rates and outcome in 14 children with SLE. Mean age at onset was 12.8+/-3.1 years. Ten patients were female and 4 were male, and 12 patients (86%) were Hispanic. Creatinine clearance prior to therapy was 104+/-36 ml/min. All had hematuria and proteinuria with a protein/creatinine ratio of 3.9+/-4.8. WHO classification of renal biopsies revealed class IV in 64%, class III in 21%, and class V in 14%. Patients were treated with 6-monthly pulses of intravenous cyclophosphamide (IVCY) followed by longer-duration pulses. The mean duration of follow-up was 3.7+/-3.3 years. Of the 14 patients, 3 (21%) achieved systemic remission but all relapsed subsequently; 7 of 14 achieved renal remission, although 6 relapsed. Six (42%) had adverse outcomes, defined by death, dialysis, or need for bone marrow transplant. All 6 had failed 6 months of IVCY, suggesting that patients who demonstrate resistance to initial IVCY therapy have an unfavorable outcome and a high likelihood of complications. In summary, we report a poor response to standard therapeutic protocols with higher relapse rates, as well as significant adverse outcomes.