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Wang CS, Sadun RE, Zhou W, Miller KR, Pyle L, Ardoin SP, Bacha C, Hause E, Hui-Yuen J, Ling N, Pereira M, Riebschleger M, Rouster-Stevens K, Sarkissian A, Shalen J, Soulsby W, Twilt M, Wu EY, Lewandowski LB, Wenderfer SE, Cooper JC. Renal Response Outcomes of the EuroLupus and National Institutes of Health Cyclophosphamide Dosing Regimens in Childhood-Onset Proliferative Lupus Nephritis. Arthritis Rheumatol 2024; 76:469-478. [PMID: 37800549 DOI: 10.1002/art.42725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 09/07/2023] [Accepted: 09/27/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE We compared clinical characteristics and renal response in patients with childhood-onset proliferative lupus nephritis (LN) treated with the EuroLupus versus National Institutes of Health (NIH) cyclophosphamide (CYC) regimen. METHODS A retrospective cohort study was conducted at 11 pediatric centers in North America that reported using both CYC regimens. Data were extracted from the electronic medical record at baseline and 3, 6, and 12 months after treatment initiation with CYC. To evaluate the adjusted association between CYC regimen (EuroLupus vs NIH) and renal response over time, generalized estimating equations with a logit link were used. An interaction between time and CYC regimen was included, and a contrast between CYC regimens at 12 months was used to evaluate the primary outcome. RESULTS One hundred forty-five patients (58 EuroLupus, 87 NIH) were included. EuroLupus patients were on average older at the start of current CYC therapy, had longer disease duration, and more commonly had relapsed or refractory LN compared with the NIH group. After multivariable adjustment, there was no significant association between CYC regimen and achieving complete renal response at 12 months (odds ratio [OR] of response for the EuroLupus regimen, reference NIH regimen: 0.76; 95% confidence interval [CI] 0.29-1.98). There was also no significant association between CYC regimen and achieving at least a partial renal response at 12 months (OR 1.35, 95% CI 0.57-3.19). CONCLUSION Our study failed to demonstrate a benefit of the NIH regimen over the EuroLupus CYC regimen in childhood-onset proliferative LN. However, future prospective outcome studies are needed.
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Affiliation(s)
| | | | - Wenru Zhou
- University of Colorado Anschutz Medical Campus, Aurora
| | | | - Laura Pyle
- University of Colorado Anschutz Medical Campus, Aurora
| | | | | | - Emily Hause
- University of Minnesota Masonic Children's Hospital, Minneapolis
| | - Joyce Hui-Yuen
- Cohen Children's Medical Center, New Hyde Park, New York
| | | | - Maria Pereira
- Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | | | - Kelly Rouster-Stevens
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | | | - Julia Shalen
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Marinka Twilt
- Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Laura B Lewandowski
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
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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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Zhang S, Chen Y, Chen X, Zhao Y, Zeng X, Zhang F, Wang L, Li M. Treatment of refractory lupus nephritis using leflunomide: A prospective study. Front Immunol 2023; 14:1133183. [PMID: 37006280 PMCID: PMC10065288 DOI: 10.3389/fimmu.2023.1133183] [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: 12/28/2022] [Accepted: 02/28/2023] [Indexed: 03/19/2023] Open
Abstract
IntroductionThe condition of refractory lupus nephritis (LN) negatively affects the prognosis and life expectancy of the patients, posing a challenge to manage in clinical. This interventional study evaluated the efficacy as well as safety of leflunomide in patients with refractory LN.MethodsTwenty patients with refractory LN were enrolled in this study. A daily dose of 20–40 mg of leflunomide was given to the patients orally. Meanwhile, immunosuppressives were withdrawn, and corticosteroids were gradually tapered. There was an average follow-up period of 3, 6, and 12 months for most patients while some were observed for as long as 24 months. We recorded biochemical parameters and side effects. We calculated the response rate using intention-to-treat analysis.ResultsEighteen patients (90%) completed the study. At 3 months, 80% (16/20) of the patients achieved more than a 25% decrease in 24-hour urine protein quantity. At 6 months, three patients (15%) achieved a partial response, and five patients (25%) achieved a complete response. However, by 12 months and 24 months, the complete response rate dropped to 15% and 20%, respectively. The objective responses were 30% (6/20), 40% (8/20), 40% (8/20), and 30% (6/20) at 3, 6, 12, and 24 months, respectively. Two patients withdrew from the study due to developing cytopenia and leucopenia.ConclusionIn patients diagnosed with refractory LN, our study shows that leflunomide could be a promising treatment option owing to its response rate and safety profile.
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Affiliation(s)
- Shuo Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yiran Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xin Chen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Zhao
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Li Wang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- *Correspondence: Li Wang, ; Mengtao Li,
| | - Mengtao Li
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, National Clinical Research Center for Dermatologic and Immunologic Diseases, Ministry of Science and Technology, State Key Laboratory of Complex Severe and Rare Diseases, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- *Correspondence: Li Wang, ; Mengtao Li,
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Li C, Han Y, Zhang L, Chen Z, Jin M, Sun S. Endocapillary hypercellularity levels are associated with early complete remission in children with class IV lupus nephritis as the initial presentation of SLE. BMC Nephrol 2022; 23:296. [PMID: 36008770 PMCID: PMC9413905 DOI: 10.1186/s12882-022-02921-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background Endocapillary hypercellularity (ECHC) is commonly seen in class IV lupus nephritis (LN), the most common and severe LN in children. Factors influencing early complete remission (CR) in pediatric class IV LN have been poorly described. We investigated the relationship between ECHC levels and early CR in pediatric class IV LN. Methods Patients with newly, simultaneously diagnosed systemic lupus erythematosus (SLE) and class IV LN by renal biopsy from 2012 to 2021 were studied. In this retrospective study, two pathologists who were blind to clinical information reviewed all pathological data retrospectively and classified glomerular lesions according to the revised criteria of the International Society of Nephrology and the Renal Pathology Society (ISN/RPS). The demographics, baseline clinical characteristics, laboratory parameters, renal histopathological findings, treatment regimen and CR at 6 months after immunosuppressive therapy were analyzed. ECHC was categorized as: > 50% (group A), 25–50% (group B) and < 25% (group C). CR was defined as absence of clinical symptoms, 24-hour urinary protein < 0.15 g, and normal levels of serum creatinine and albumin. Results Sixty-four patients were identified: 23, 15 and 26 in groups A, B and C, respectively. Group A had significantly higher levels of D-dimer, urine protein, and SLE disease activity index (SLEDAI) than groups B and C. Group C had a markedly higher estimated glomerular filtration rate (eGFR) than groups A and B. A substantially greater proportion of patients in group A had glomerular microthrombi and basement membrane thickening than in groups B and C. At 6 months post treatment, CR was achieved in 19 (82.6%), 5 (33.3%) and 11 (42.3%) in groups A, B and C, respectively (p < 0.05, group A vs groups B and C). Multiple logistic regression analysis revealed that ECHC and urine protein levels were significantly associated with CR. Conclusion ECHC and urine protein levels may be valuable biomarkers for predicting early CR in pediatric class IV LN.
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Affiliation(s)
- Chunzhen Li
- Department of Pediatrics, Hebei Medical University, Shijiazhuang, China.,Department of Pediatric Nephrology and Immunology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Yanan Han
- Department of Pediatric Nephrology and Immunology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Lili Zhang
- Department of Pathology, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Zhiguo Chen
- Department of Pediatric Thoracic Surgery, Children's Hospital of Hebei Province, Shijiazhuang, China
| | - Mei Jin
- Department of Pediatric Neurology, Children's Hospital of Hebei Province, 133 Jianhua South Street, Shijiazhuang, 050031, Hebei Province, China
| | - Suzhen Sun
- Department of Pediatrics, Hebei Medical University, Shijiazhuang, China. .,Department of Pediatric Neurology, Children's Hospital of Hebei Province, 133 Jianhua South Street, Shijiazhuang, 050031, Hebei Province, China.
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Role of clinicopathological features for the early prediction of prognosis in lupus nephritis. Immunol Res 2021; 69:285-294. [PMID: 33954909 DOI: 10.1007/s12026-021-09201-8] [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: 11/29/2020] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
Ambiguities remain regarding the role of clinicopathological characteristics in the early prediction of the prognosis of lupus nephritis (LN). Systemic lupus erythematosus (SLE) patients who completed routine follow-up were identified and retrospectively reviewed for eligible cases. Poor prognosis was defined as all-cause mortality or a persistent decrease of eGFR greater than half the baseline level or progression to end-stage renal disease (ESRD). An optimal Cox regression model was constructed for the early prediction of a poor prognosis for LN. Among the 2163 SLE patients, 376 eligible LN cases were enrolled in the study, with a median follow-up time of 55 [27.0, 87.0] months. The male-to-female ratio was 1:7.2, and 37 patients (9.8%) progressed to the composite endpoint. The ISN/RPS class was significantly associated with proteinuria levels (P-value < 0.001), and class IV/IV + V patients, but not class V patients, had the most severe proteinuria. Our optimal multivariate Cox regression model indicated that sex, ISN/RPS class, tubular atrophy/interstitial fibrosis, serum albumin, tertiles of proteinuria, and their interaction were independently associated with a poor prognosis. ROC analysis and external validation demonstrated that our model was efficient and robust for distinguishing LN patients with a poor prognosis. Our study constructed a robust and early predictive model for convenience in clinical practice to identify poor prognosis in LN patients. We found a significant interaction effect between proteinuria and serum albumin for the prediction of poor prognosis. LN patients with low-level proteinuria and hypoalbuminemia exhibit an increased hazard of progression to poor outcomes.
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Abstract
PURPOSE OF REVIEW Update on the diagnosis, treatment, and monitoring of lupus nephritis. RECENT FINDINGS The recent criteria enable the earlier classification of lupus nephritis based on kidney biopsy and compatible serology. Treatment of active nephritis includes low-dose intravenous cyclophosphamide or mycophenolate, followed by maintenance immunosuppression. Recent trials have suggested superiority of regimens combining mycophenolate with either calcineurin inhibitor or belimumab, although their long-term benefit/risk ratio has not been determined. Encouraging results with novel anti-CD20 antibodies confirm the effectiveness of B cell depletion. Achievement of low-grade proteinuria (< 700-800 mg/24 h) at 12-month post-induction is linked to favorable long-term outcomes and could be considered in a treat-to-target strategy. Also, repeat kidney biopsy can guide the duration of maintenance immunosuppression. Lupus nephritis has increased cardiovascular disease burden necessitating risk-reduction strategies. An expanding spectrum of therapies coupled with ongoing basic/translational research can lead to individualized medical care and improved outcomes in lupus nephritis.
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Affiliation(s)
- Myrto Kostopoulou
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Christina Adamichou
- 4th Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, 71008 Voutes-Stavrakia, Heraklion, Greece
| | - George Bertsias
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, 71008 Voutes-Stavrakia, Heraklion, Greece.
- Laboratory of Rheumatology, Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology-FORTH, Heraklion, Greece.
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