1
|
Choi SJ, Ahn SM, Oh JS, Hong S, Lee CK, Yoo B, Kim YG. Initial Preserved Renal Function as a Predictor of Favorable Renal Response to Rituximab in Refractory or Relapsing Lupus Nephritis: A Single-center Cohort Study in Korea. JOURNAL OF RHEUMATIC DISEASES 2022; 29:22-32. [PMID: 37476702 PMCID: PMC10324915 DOI: 10.4078/jrd.2022.29.1.22] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/22/2021] [Accepted: 08/13/2021] [Indexed: 07/22/2023]
Abstract
OBJECTIVE Previous studies investigating the beneficial effect of rituximab on lupus nephritis (LN) reported controversial results There have been few reports of renal response to rituximab according to renal function We investigated the efficacy of rituximab in refractory/relapsing LN and the role of renal function as a predictor of renal response. METHODS From 2016 to 2019, we retrospectively reviewed 22 patients with refractory/relapsing LN receiving rituximab Renal responses (complete and partial) at 6 and 12 months were compared between normal (glomerular filtration rate [GFR]≥90 mL/min/173 m2, n=11) and decreased (GFR<90 mL/min/173 m2, n=11) GFR groups Multivariate Cox regression analysis was used to assess predictors of renal response. RESULTS At baseline, the decreased GFR group had a higher urine proteinuria to creatinine ratio (p=0008) and proportion of refractory LN (p=0010) and previous cyclophosphamide therapy (p=0035) than the normal GFR group The overall renal response rate was 455% (10 patients) at 6 months and 545% (12 patients) at 12 months Renal response rates were higher in the normal GFR group (818% and 909% at 6 and 12 months, respectively) than in the decreased GFR group (91% and 182% at 6 and 12 months, respectively; p<0001) Normal GFR and anti-La were associated with renal response to rituximab, with hazard ratios of 9256 (p=0008) and 5478 (p=0041), respectively. CONCLUSION Rituximab is an effective therapy for refractory/relapsing LN, particularly in patients with preserved renal function.
Collapse
Affiliation(s)
- Su Jin Choi
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Rheumatology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Soo Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Seon Oh
- Department of Information Medicine, Asan Medical Center, Seoul, Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
2
|
Barber MRW, Hanly JG, Su L, Urowitz MB, St Pierre Y, Romero-Diaz J, Gordon C, Bae SC, Bernatsky S, Wallace DJ, Isenberg DA, Rahman A, Ginzler EM, Petri M, Bruce IN, Fortin PR, Gladman DD, Sanchez-Guerrero J, Ramsey-Goldman R, Khamashta MA, Aranow C, Mackay M, Alarcón GS, Manzi S, Nived O, Jönsen A, Zoma AA, van Vollenhoven RF, Ramos-Casals M, Ruiz-Irastorza G, Lim SS, Kalunian KC, Inanc M, Kamen DL, Peschken CA, Jacobsen S, Askanase A, Theriault C, Farewell V, Clarke AE. Economic Evaluation of Lupus Nephritis in the Systemic Lupus International Collaborating Clinics Inception Cohort Using a Multistate Model Approach. Arthritis Care Res (Hoboken) 2018; 70:1294-1302. [PMID: 29193883 DOI: 10.1002/acr.23480] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 11/21/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Little is known about the long-term costs of lupus nephritis (LN). The costs were compared between patients with and without LN using multistate modeling. METHODS Patients from 32 centers in 11 countries were enrolled in the Systemic Lupus International Collaborating Clinics inception cohort within 15 months of diagnosis and provided annual data on renal function, hospitalizations, medications, dialysis, and selected procedures. LN was diagnosed by renal biopsy or the American College of Rheumatology classification criteria. Renal function was assessed annually using the estimated glomerular filtration rate (GFR) or estimated proteinuria. A multistate model was used to predict 10-year cumulative costs by multiplying annual costs associated with each renal state by the expected state duration. RESULTS A total of 1,545 patients participated; 89.3% were women, the mean ± age at diagnosis was 35.2 ± 13.4 years, 49% were white, and the mean followup duration was 6.3 ± 3.3 years. LN developed in 39.4% of these patients by the end of followup. Ten-year cumulative costs were greater in those with LN and an estimated glomerular filtration rate (GFR) <30 ml/minute ($310,579 2015 Canadian dollars versus $19,987 if no LN and estimated GFR >60 ml/minute) or with LN and estimated proteinuria >3 gm/day ($84,040 versus $20,499 if no LN and estimated proteinuria <0.25 gm/day). CONCLUSION Patients with estimated GFR <30 ml/minute incurred 10-year costs 15-fold higher than those with normal estimated GFR. By estimating the expected duration in each renal state and incorporating associated annual costs, disease severity at presentation can be used to anticipate future health care costs. This is critical knowledge for cost-effectiveness evaluations of novel therapies.
Collapse
Affiliation(s)
| | - John G Hanly
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Li Su
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Murray B Urowitz
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Yvan St Pierre
- Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | | | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | | | - Daniel J Wallace
- Cedars-Sinai/David Geffen School of Medicine at the University of California, Los Angeles
| | | | | | - Ellen M Ginzler
- State University of New York Downstate Medical Center, Brooklyn, New York
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian N Bruce
- Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, the University of Manchester, and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - Dafna D Gladman
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Jorge Sanchez-Guerrero
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | - Munther A Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas's Hospital, King's College London School of Medicine, London, UK
| | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, New York
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | - Susan Manzi
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | - Asad A Zoma
- Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, Scotland, UK
| | | | - Manuel Ramos-Casals
- Josep Font Autoimmune Diseases Laboratory, IDIBAPS, Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Guillermo Ruiz-Irastorza
- BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - S Sam Lim
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Soren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anca Askanase
- Hospital for Joint Diseases, New York University Seligman Center for Advanced Therapeutics, New York, New York
| | - Chris Theriault
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vernon Farewell
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | | |
Collapse
|
3
|
Tunnicliffe DJ, Palmer SC, Henderson L, Masson P, Craig JC, Tong A, Singh‐Grewal D, Flanc RS, Roberts MA, Webster AC, Strippoli GFM. Immunosuppressive treatment for proliferative lupus nephritis. Cochrane Database Syst Rev 2018; 6:CD002922. [PMID: 29957821 PMCID: PMC6513226 DOI: 10.1002/14651858.cd002922.pub4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cyclophosphamide, in combination with corticosteroids, has been first-line treatment for inducing disease remission for proliferative lupus nephritis, reducing death at five years from over 50% in the 1950s and 1960s to less than 10% in recent years. Several treatment strategies designed to improve remission rates and minimise toxicity have become available. Treatments, including mycophenolate mofetil (MMF) and calcineurin inhibitors, alone and in combination, may have equivalent or improved rates of remission, lower toxicity (less alopecia and ovarian failure) and uncertain effects on death, end-stage kidney disease (ESKD) and infection. This is an update of a Cochrane review first published in 2004 and updated in 2012. OBJECTIVES Our objective was to assess the evidence and evaluate the benefits and harms of different immunosuppressive treatments in people with biopsy-proven lupus nephritis. The following questions relating to management of proliferative lupus nephritis were addressed: 1) Are new immunosuppressive agents superior to or as effective as cyclophosphamide plus corticosteroids? 2) Which agents, dosages, routes of administration and duration of therapy should be used? 3) Which toxicities occur with the different treatment regimens? SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 2 March 2018 with support from the Cochrane Information Specialist using search terms relevant to this review. Studies in the Specialised Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any immunosuppressive treatment for biopsy-proven class III, IV, V+III and V+VI lupus nephritis in adult or paediatric patients were included. DATA COLLECTION AND ANALYSIS Data were abstracted and the risks of bias were assessed independently by two authors. Dichotomous outcomes were calculated as risk ratio (RR) and measures on continuous scales calculated as mean differences (MD) with 95% confidence intervals (CI). The primary outcomes were death (all causes) and complete disease remission for induction therapy and disease relapse for maintenance therapy. Evidence certainty was determined using GRADE. MAIN RESULTS In this review update, 26 new studies were identified, to include 74 studies involving 5175 participants overall. Twenty-nine studies included children under the age of 18 years with lupus nephritis, however only two studies exclusively examined the treatment of lupus nephritis in patients less than 18 years of age.Induction therapy Sixty-seven studies (4791 participants; median 12 months duration (range 2.5 to 48 months)) reported induction therapy. The effects of all treatment strategies on death (all causes) and ESKD were uncertain (very low certainty evidence) as this outcome occurred very infrequently. Compared with intravenous (IV) cyclophosphamide, MMF may have increased complete disease remission (RR 1.17, 95% CI 0.97 to 1.42; low certainty evidence), although the range of effects includes the possibility of little or no difference.Compared to IV cyclophosphamide, MMF is probably associated with decreased alopecia (RR 0.29, 95% CI 0.19 to 0.46; 170 less (129 less to 194 less) per 1000 people) (moderate certainty evidence), increased diarrhoea (RR 2.42, 95% CI 1.64 to 3.58; 142 more (64 more to 257 more) per 1000 people) (moderate certainty evidence) and may have made little or no difference to major infection (RR 1.02, 95% CI 0.67 to 1.54; 2 less (38 less to 62 more) per 1000 people) (low certainty evidence). It is uncertain if MMF decreased ovarian failure compared to IV cyclophosphamide because the certainty of the evidence was very low (RR 0.36, 95% CI 0.06 to 2.18; 26 less (39 less to 49 more) per 1000 people). Studies were not generally designed to measure ESKD.MMF combined with tacrolimus may have increased complete disease remission (RR 2.38, 95% CI 1.07 to 5.30; 336 more (17 to 1048 more) per 1000 people (low certainty evidence) compared with IV cyclophosphamide, however the effects on alopecia, diarrhoea, ovarian failure, and major infection remain uncertain. Compared to standard of care, the effects of biologics on most outcomes were uncertain because of low to very low certainty of evidence.Maintenance therapyNine studies (767 participants; median 30 months duration (range 6 to 63 months)) reported maintenance therapy. In maintenance therapy, disease relapse is probably increased with azathioprine compared with MMF (RR 1.75, 95% CI 1.20 to 2.55; 114 more (30 to 236 more) per 1000 people (moderate certainty evidence). Multiple other interventions were compared as maintenance therapy, but patient-outcome data were sparse leading to imprecise estimates. AUTHORS' CONCLUSIONS In this review update, studies assessing treatment for proliferative lupus nephritis were not designed to assess death (all causes) or ESKD. MMF may lead to increased complete disease remission compared with IV cyclophosphamide, with an acceptable adverse event profile, although evidence certainty was low and included the possibility of no difference. Calcineurin combined with lower dose MMF may improve induction of disease remission compared with IV cyclophosphamide, but the comparative safety profile of these therapies is uncertain. Azathioprine may increase disease relapse as maintenance therapy compared with MMF.
Collapse
Affiliation(s)
- David J Tunnicliffe
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Lorna Henderson
- NHS LothianRenal DepartmentRoyal Infirmary of EdinburghEdinburghUKEH16 4SA
| | - Philip Masson
- Royal Free London NHS Foundation TrustDepartment of Renal MedicineLondonUK
| | - Jonathan C Craig
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | - Allison Tong
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCentre for Kidney ResearchWestmeadAustralia
| | - Davinder Singh‐Grewal
- The Sydney Children's Hospitals NetworkDepartment Paediatric RheumatologyThe Children's Hospital at WestmeadCnr Hainsworth and Hawkesbury RoadsWestmeadNSWAustralia2145
| | - Robert S Flanc
- Monash Medical CentreDepartment of NephrologyClayton RdClaytonVICAustralia3168
| | - Matthew A Roberts
- Monash UniversityEastern Health Clinical SchoolBox HillVICAustralia3128
| | - Angela C Webster
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- The University of Sydney at WestmeadCentre for Transplant and Renal Research, Westmead Millennium InstituteWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- DiaverumMedical Scientific OfficeLundSweden
- Diaverum AcademyBariItaly
| | | |
Collapse
|
4
|
Hanly JG, Su L, Urowitz MB, Romero-Diaz J, Gordon C, Bae SC, Bernatsky S, Clarke AE, Wallace DJ, Merrill JT, Isenberg DA, Rahman A, Ginzler EM, Petri M, Bruce IN, Dooley MA, Fortin P, Gladman DD, Sanchez-Guerrero J, Steinsson K, Ramsey-Goldman R, Khamashta MA, Aranow C, Alarcón GS, Fessler BJ, Manzi S, Nived O, Sturfelt GK, Zoma AA, van Vollenhoven RF, Ramos-Casals M, Ruiz-Irastorza G, Lim SS, Kalunian KC, Inanc M, Kamen DL, Peschken CA, Jacobsen S, Askanase A, Theriault C, Farewell V. A Longitudinal Analysis of Outcomes of Lupus Nephritis in an International Inception Cohort Using a Multistate Model Approach. Arthritis Rheumatol 2017; 68:1932-44. [PMID: 26991067 DOI: 10.1002/art.39674] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 03/01/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To study bidirectional change and predictors of change in estimated glomerular filtration rate (GFR) and proteinuria in lupus nephritis (LN) using a multistate modeling approach. METHODS Patients in the Systemic Lupus International Collaborating Clinics inception cohort were classified annually into estimated GFR state 1 (>60 ml/minute), state 2 (30-60 ml/minute), or state 3 (<30 ml/minute) and estimated proteinuria state 1 (<0.25 gm/day), state 2 (0.25-3.0 gm/day), or state 3 (>3.0 gm/day), or end-stage renal disease (ESRD) or death. Using multistate modeling, relative transition rates between states indicated improvement and deterioration. RESULTS Of 1,826 lupus patients, 700 (38.3%) developed LN. During a mean ± SD follow-up of 5.2 ± 3.5 years, the likelihood of improvement in estimated GFR and estimated proteinuria was greater than the likelihood of deterioration. After 5 years, 62% of patients initially in estimated GFR state 3 and 11% of patients initially in estimated proteinuria state 3 transitioned to ESRD. The probability of remaining in the initial states 1, 2, and 3 was 85%, 11%, and 3%, respectively, for estimated GFR and 62%, 29%, and 4%, respectively, for estimated proteinuria. Male sex predicted improvement in estimated GFR states; older age, race/ethnicity, higher estimated proteinuria state, and higher renal biopsy chronicity scores predicted deterioration. For estimated proteinuria, race/ethnicity, earlier calendar years, damage scores without renal variables, and higher renal biopsy chronicity scores predicted deterioration; male sex, presence of lupus anticoagulant, class V nephritis, and mycophenolic acid use predicted less improvement. CONCLUSION In LN, the expected improvement or deterioration in renal outcomes can be estimated by multistate modeling and is preceded by identifiable risk factors. New therapeutic interventions for LN should meet or exceed these expectations.
Collapse
Affiliation(s)
- John G Hanly
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Li Su
- Institute of Public Health and University of Cambridge, University Forvie Site, Cambridge, UK
| | - Murray B Urowitz
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | - Caroline Gordon
- University of Birmingham, College of Medical and Dental Sciences, Birmingham, UK
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | | | | | - Daniel J Wallace
- Cedars-Sinai Medical Center and University of California, Los Angeles, David Geffen School of Medicine
| | | | | | | | - Ellen M Ginzler
- State University of New York Downstate Medical Center, Brooklyn
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian N Bruce
- Arthritis Research UK Epidemiology Unit, Manchester Academic Health Sciences Centre, University of Manchester, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, and Manchester Academic Health Science Centre, Manchester, UK
| | - M A Dooley
- University of North Carolina, Chapel Hill
| | - Paul Fortin
- Centre Hospitalier Universitaire de Québec and Université Laval, Quebec City, Canada
| | - Dafna D Gladman
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Munther A Khamashta
- The Rayne Institute, St Thomas' Hospital, King's College London School of Medicine, London, UK
| | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | | | - Susan Manzi
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ola Nived
- University Hospital Lund, Lund, Sweden
| | | | - Asad A Zoma
- Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, UK
| | | | - Manuel Ramos-Casals
- Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clínic, Barcelona, Spain
| | - Guillermo Ruiz-Irastorza
- BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - S Sam Lim
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Soren Jacobsen
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anca Askanase
- Hospital for Joint Diseases, New York University, Seligman Centre for Advanced Therapeutics, New York, New York
| | - Chris Theriault
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vernon Farewell
- Institute of Public Health and University of Cambridge, University Forvie Site, Cambridge, UK
| |
Collapse
|
5
|
Hanly JG, O'Keeffe AG, Su L, Urowitz MB, Romero-Diaz J, Gordon C, Bae SC, Bernatsky S, Clarke AE, Wallace DJ, Merrill JT, Isenberg DA, Rahman A, Ginzler EM, Fortin P, Gladman DD, Sanchez-Guerrero J, Petri M, Bruce IN, Dooley MA, Ramsey-Goldman R, Aranow C, Alarcón GS, Fessler BJ, Steinsson K, Nived O, Sturfelt GK, Manzi S, Khamashta MA, van Vollenhoven RF, Zoma AA, Ramos-Casals M, Ruiz-Irastorza G, Lim SS, Stoll T, Inanc M, Kalunian KC, Kamen DL, Maddison P, Peschken CA, Jacobsen S, Askanase A, Theriault C, Thompson K, Farewell V. The frequency and outcome of lupus nephritis: results from an international inception cohort study. Rheumatology (Oxford) 2015; 55:252-62. [PMID: 26342222 DOI: 10.1093/rheumatology/kev311] [Citation(s) in RCA: 353] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To determine nephritis outcomes in a prospective multi-ethnic/racial SLE inception cohort. METHODS Patients in the Systemic Lupus International Collaborating Clinics inception cohort (≤15 months of SLE diagnosis) were assessed annually for estimated glomerular filtration rate (eGFR), proteinuria and end-stage renal disease (ESRD). Health-related quality of life was measured by the Short Form (36 questions) health survey questionnaire (SF-36) subscales, mental and physical component summary scores. RESULTS There were 1827 patients, 89% females, mean (s.d.) age 35.1 (13.3) years. The mean (s.d.) SLE duration at enrolment was 0.5 (0.3) years and follow-up 4.6 (3.4) years. LN occurred in 700 (38.3%) patients: 566/700 (80.9%) at enrolment and 134/700 (19.1%) during follow-up. Patients with nephritis were younger, more frequently men and of African, Asian and Hispanic race/ethnicity. The estimated overall 10-year incidence of ESRD was 4.3% (95% CI: 2.8%, 5.8%), and with nephritis was 10.1% (95% CI: 6.6%, 13.6%). Patients with nephritis had a higher risk of death (HR = 2.98, 95% CI: 1.48, 5.99; P = 0.002) and those with eGFR <30 ml/min at diagnosis had lower SF-36 physical component summary scores (P < 0.01) and lower Physical function, Physical role and Bodily pain scores. Over time, patients with abnormal eGFR and proteinuria had lower SF-36 mental component summary (P ≤ 0.02) scores compared to patients with normal values. CONCLUSION LN occurred in 38.3% of SLE patients, frequently as the initial presentation, in a large multi-ethnic inception cohort. Despite current standard of care, nephritis was associated with ESRD and death, and renal insufficiency was linked to lower health-related quality of life. Further advances are required for the optimal treatment of LN.
Collapse
Affiliation(s)
- John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada,
| | - Aidan G O'Keeffe
- Department of Statistical Science, University College London, London
| | - Li Su
- MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Cambridge, UK
| | - Murray B Urowitz
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, ON, Canada
| | | | - Caroline Gordon
- Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | - Sasha Bernatsky
- Divisions of Rheumatology and Clinical Epidemiology, McGill University Health Centre
| | - Ann E Clarke
- Division of Rheumatology, University of Calgary, Alberta, Canada
| | - Daniel J Wallace
- Cedars-Sinai/David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joan T Merrill
- Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - David A Isenberg
- Centre for Rheumatology, Department of Medicine, University College London, UK
| | - Anisur Rahman
- Centre for Rheumatology, Department of Medicine, University College London, UK
| | - Ellen M Ginzler
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Paul Fortin
- Division of Rheumatology, Centre Hospitalier Universitaire de Québec et Université Laval, Quebec City, Canada
| | - Dafna D Gladman
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, ON, Canada
| | - Jorge Sanchez-Guerrero
- Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital and University of Toronto, Toronto, ON, Canada
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ian N Bruce
- Arthritis Research UK Epidemiology Unit, Institute of Inflammation and Repair, Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Mary Anne Dooley
- Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC
| | | | | | - Graciela S Alarcón
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Barri J Fessler
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kristjan Steinsson
- Center for Rheumatology Research, Landspitali University Hospital, Reykjavik, Iceland
| | - Ola Nived
- Department of Rheumatology, University Hospital Lund, Lund, Sweden
| | | | - Susan Manzi
- Division of Rheumatology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Munther A Khamashta
- Lupus Research Unit, The Rayne Institute, St Thomas' Hospital, King's College London School of Medicine, London, UK
| | | | - Asad A Zoma
- Lanarkshire Centre for Rheumatology, Hairmyres Hospital, East Kilbride, Scotland, UK
| | - Manuel Ramos-Casals
- Josep Font Autoimmune Diseases Laboratory, IDIBAPS, Department of Autoimmune Diseases, Hospital Clínic, Barcelona, Spain
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - S Sam Lim
- Emory University School of Medicine, Division of Rheumatology, Atlanta, Georgia, USA
| | - Thomas Stoll
- Kantonsspital Geissbergstr, Schaffhausen, Switzerland
| | - Murat Inanc
- Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | | | - Diane L Kamen
- Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Soren Jacobsen
- Department of Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anca Askanase
- Hospital for Joint Diseases, NYU, Seligman Centre for Advanced Therapeutics, New York, NY, USA and
| | - Chris Theriault
- Department of Medicine, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Kara Thompson
- Department of Medicine, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Vernon Farewell
- MRC Biostatistics Unit, Institute of Public Health, University Forvie Site, Cambridge, UK
| |
Collapse
|
6
|
Rivera F, Illescas ML, López-Rubio E, Fulladosa J, Poveda R, Baltar J, Fernández-Juárez G, Ballarín J, Oliet A, Vigil A, Lucas J, Sierra M, Frutos MA, García-Frías P, Ramos C, Mérida E, Praga M, Segarra A. Mycophenolate as maintenance therapy for lupus nephritis with impaired renal function. Am J Nephrol 2013; 37:509-17. [PMID: 23689615 DOI: 10.1159/000350756] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Accepted: 03/19/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mycophenolate (MF) is effective as a maintenance therapy after induction therapy in patients with lupus nephritis (LN). However, little is known about its role in patients with impaired renal function. The purpose of this study was to evaluate the efficacy and safety of MF as a maintenance therapy for LN and its association with renal function. METHODS Data were obtained for 56 Spanish patients who were receiving MF as a maintenance therapy for LN. Patients were classified into two groups according to renal function at the initiation of MF treatment: group 1 [estimated glomerular filtration rate (eGFR) ≥60 ml/min/1.73 m(2)] and group 2 (eGFR <60 ml/min/1.73 m(2)). The primary endpoints of the study were the rates of renal relapse and responses, and their relationship with baseline renal function. Secondary outcomes were the appearance of side effects during treatment. RESULTS At initiation of MF treatment, the only differences between the groups were for age, hemoglobin levels, anti-DNA antibody titer, proteinuria, and renal function. In group 1 (n = 38), the eGFR was 98 ± 34 ml/min/1.73 m(2) and in group 2 (n = 18) the eGFR was 43 ± 14 ml/min/1.73 m(2). Only 3 cases had an eGFR <30 ml/min/1.73 m(2). No significant differences were observed in the rate of relapse at 6 months (group 1: 20%; group 2: 23%) or at 12 months (group 1: 25%; group 2: 17%). Response rates were also similar in both groups. Side effects were unremarkable. CONCLUSIONS MF is effective and safe as a maintenance therapy for LN both in patients with normal renal function and in those with renal impairment.
Collapse
Affiliation(s)
- F Rivera
- Sección de Nefrología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
7
|
Henderson L, Masson P, Craig JC, Flanc RS, Roberts MA, Strippoli GFM, Webster AC. Treatment for lupus nephritis. Cochrane Database Syst Rev 2012; 12:CD002922. [PMID: 23235592 DOI: 10.1002/14651858.cd002922.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Cyclophosphamide, in combination with corticosteroids has been used to induce remission in proliferative lupus nephritis, the most common kidney manifestation of the multisystem disease, systemic lupus erythematosus. Cyclophosphamide therapy has reduced mortality from over 70% in the 1950s and 1960s to less than 10% in recent years. Cyclophosphamide combined with corticosteroids preserves kidney function but is only partially effective and may cause ovarian failure, infection and bladder toxicity. Several new agents, including mycophenolate mofetil (MMF), suggest reduced toxicity with equivalent rates of remission. This is an update of a Cochrane review first published in 2004. OBJECTIVES To assess the benefits and harms of different immunosuppressive treatments in biopsy-proven proliferative lupus nephritis. SEARCH METHODS For this update, we searched the Cochrane Renal Group's Specialised Register (up to 15 April 2012) through contact with the Trials' Search Coordinator using search terms relevant to this review. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing any treatments for biopsy-proven lupus nephritis in both adult and paediatric patients with class III, IV, V +III and V +IV lupus nephritis were included. All immunosuppressive treatments were considered. DATA COLLECTION AND ANALYSIS Data were abstracted and quality assessed independently by two authors, with differences resolved by discussion. Dichotomous outcomes were reported as risk ratio (RR) and measurements on continuous scales reported as mean differences (MD) with 95% confidence intervals (CI). MAIN RESULTS We identified 50 RCTs involving 2846 participants. Of these, 45 studies (2559 participants) investigated induction therapy, and six studies (514 participants), considered maintenance therapy.Compared with intravenous (IV) cyclophosphamide, MMF was as effective in achieving stable kidney function (5 studies, 523 participants: RR 1.05, 95% CI 0.94 to 1.18) and complete remission of proteinuria (6 studies, 686 participants: RR 1.16, 95% CI 0.85 to 1.58). No differences in mortality (7 studies, 710 participants: RR 1.02, 95% CI 0.52 to 1.98) or major infection (6 studies, 683 participants: RR 1.11, 95% CI 0.74 to 1.68) were observed. A significant reduction in ovarian failure (2 studies, 498 participants: RR 0.15, 95% CI 0.03 to 0.80) and alopecia (2 studies, 522 participants: RR 0.22, 95% CI 0.06 to 0.86) was observed with MMF. In maintenance therapy, the risk of renal relapse (3 studies, 371 participants: RR 1.83, 95% CI 1.24 to 2.71) was significantly higher with azathioprine compared with MMF. Multiple other interventions were compared but outcome data were relatively sparse. Overall study quality was variable. The internal validity of the design, conduct and analysis of the included RCTs was difficult to assess in some studies because of the omission of important methodological details. No study adequately reported all domains of the risk of bias assessment so that elements of internal bias may be present. AUTHORS' CONCLUSIONS MMF is as effective as cyclophosphamide in inducing remission in lupus nephritis, but is safer with a lower risk of ovarian failure. MMF is more effective than azathioprine in maintenance therapy for preventing relapse with no increase in clinically important side effects. Adequately powered trials with long term follow-up are required to more accurately define the risks and eventual harms of specific treatment regimens.
Collapse
Affiliation(s)
- Lorna Henderson
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead,Australia.
| | | | | | | | | | | | | |
Collapse
|
8
|
CDK-EPI equation may be the most proper formula based on creatinine in determining glomerular filtration rate in Chinese patients with chronic kidney disease. Int Urol Nephrol 2012; 45:1057-64. [DOI: 10.1007/s11255-012-0325-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Accepted: 10/24/2012] [Indexed: 10/27/2022]
|
9
|
Borchers AT, Leibushor N, Naguwa SM, Cheema GS, Shoenfeld Y, Gershwin ME. Lupus nephritis: a critical review. Autoimmun Rev 2012; 12:174-94. [PMID: 22982174 DOI: 10.1016/j.autrev.2012.08.018] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2012] [Indexed: 01/18/2023]
Abstract
Lupus nephritis remains one of the most severe manifestations of systemic lupus erythematosus associated with considerable morbidity and mortality. A better understanding of the pathogenesis of lupus nephritis is an important step in identifying more targeted and less toxic therapeutic approaches. Substantial research has helped define the pathogenetic mechanisms of renal manifestations and, in particular, the complex role of type I interferons is increasingly recognized; new insights have been gained into the contribution of immune complexes containing endogenous RNA and DNA in triggering the production of type I interferons by dendritic cells via activation of endosomal toll-like receptors. At the same time, there have been considerable advances in the treatment of lupus nephritis. Corticosteroids have long been the cornerstone of therapy, and the addition of cyclophosphamide has contributed to renal function preservation in patients with severe proliferative glomerulonephritis, though at the cost of serious adverse events. More recently, in an effort to minimize drug toxicity and achieve equal effectiveness, other immunosuppressive agents, including mycophenolate mofetil, have been introduced. Herein, we provide a detailed review of the trials that established the equivalency of these agents in the induction and/or maintenance therapy of lupus nephritis, culminating in the recent publication of new treatment guidelines by the American College of Rheumatology. Although newer biologics have been approved and continue to be a focus of research, they have, for the most part, been relatively disappointing compared to the effectiveness of biologics in other autoimmune diseases. Early diagnosis and treatment are essential for renal preservation.
Collapse
Affiliation(s)
- Andrea T Borchers
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis School of Medicine, Davis, CA 95616, United States
| | | | | | | | | | | |
Collapse
|
10
|
Rivera F, Fulladosa X, Poveda R, Frutos MA, García-Frías P, Ara J, Illescas L, López-Rubio E, Mérida E, Carreño A, Ballarín J, Fernández-Juárez G, Baltar J, Ramos C, Pons S, Oliet A, Vigil A, Praga M, Segarra A. Mycophenolate as induction therapy in lupus nephritis with renal function impairment. Am J Nephrol 2012; 35:424-33. [PMID: 22517244 DOI: 10.1159/000337916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 03/08/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mycophenolate (MF) is effective as induction therapy for lupus nephritis (LN) in patients with normal renal function; however, little is known about its role in patients with impaired renal failure. The purpose of this study was to evaluate the response to MF in LN and its association with baseline renal function. METHODS Data were obtained for 90 patients from 12 Spanish renal units who were receiving MF as induction therapy for LN. Patients were classified into 2 groups: group 1 (estimated glomerular filtration rate [eGFR] ≥60 ml/min/1.73 m(2)) and group 2 (eGFR <60 ml/min/ 1.73 m(2)). The primary outcome measure was the percentage of patients who achieved any response and its relationship with initial eGFR. The secondary outcome measures were the percentage of patients who achieved a complete response (CR) or partial response (PR) and the appearance of relapses during treatment and side effects. RESULTS At initiation of MF treatment, there were no differences in the main parameters between group 1 (n = 63; eGFR 87 ± 23 ml/min/ 1.73 m(2)) and group 2 (n = 27; eGFR 44 ± 12 ml/min/1.73 m(2)). Exposure to prednisone and MF was similar. The percentages of patients who achieved a response in groups 1 and 2 were, respectively, 69.2 and 43.8% at 6 months and 81.3 and 73.7% at 12 months. CR was more frequent in group 1, whereas PR was similar in both groups. Four patients relapsed and side effects were unremarkable. CONCLUSIONS MF is effective and safe as induction therapy for LN, and response is even achieved in patients with baseline renal impairment.
Collapse
Affiliation(s)
- F Rivera
- Hospital General de Ciudad Real, Ciudad Real, España. friverahdez @ senefro.org
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Davoudi M, Osann K, Colt HG. Validation of two instruments to assess technical bronchoscopic skill using virtual reality simulation. ACTA ACUST UNITED AC 2008; 76:92-101. [PMID: 18408359 DOI: 10.1159/000126493] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2007] [Accepted: 02/06/2008] [Indexed: 01/22/2023]
Abstract
BACKGROUND In an era of increased emphasis on patient safety and competency-based education, demonstration of significant variability in the teaching of flexible bronchoscopy has led to initiatives for new standardized curricula and assessment tools. OBJECTIVES To evaluate the efficacy of such curricula and to assess bronchoscopic skill, 2 measuring instruments have been developed: the Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) and the Bronchoscopy Step-by-Step Evaluation Tool (BSET). We studied the validity and reliability of these 2 instruments. METHODS Two independent testers simultaneously scored 22 volunteer participants at 3 levels [novice (n = 7), fellow (n = 8) and attending (n = 7)] on a virtual reality bronchoscopy simulator using the 2 instruments; each participant was tested twice, in 2 separate sessions. Intertester and test-retest reliability were analyzed with intraclass correlations (ICC); ANOVA was used to assess concurrent validity based on the subjects' expected skill level. RESULTS The ICCs between the testers were 0.98 for both the BSTAT and BSET. Comparison of the scores between the sessions showed high test-retest reliability by ICC (0.86 and 0.85 for BSTAT and BSET respectively), with a small yet statistically significant learning effect. The novice group's scores were lower than the fellows' and attendings' (p < 0.001) for both the BSTAT and BSET; the fellows' scores were consistently lower than the attendings' on both tests, yet the differences were not statistically significant. CONCLUSION This validation study of 2 objective tests of bronchoscopic skill demonstrated high reliability and concurrent validity. These instruments can now be used to evaluate the effectiveness of new competency-based bronchoscopy curricula.
Collapse
Affiliation(s)
- Mohsen Davoudi
- Medical Center, University of California, Irvine, CA 92868, USA
| | | | | |
Collapse
|