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Li K, Yu Y, Gao Y, Zhao F, Liang Z, Gao J. Comparative Effectiveness of Rituximab and Common Induction Therapies for Lupus Nephritis: A Systematic Review and Network Meta-Analysis. Front Immunol 2022; 13:859380. [PMID: 35444666 PMCID: PMC9013779 DOI: 10.3389/fimmu.2022.859380] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Objective This study aimed to compare the efficacy and safety (infection events) between rituximab (RTX), tacrolimus (TAC), mycophenolate mofetil (MMF), and cyclophosphamide (CYC) as induction therapies in lupus nephritis (LN). Methods Electronic databases, including PubMed, EMBASE, and the Cochrane Library, were searched from inception up to December 9, 2021. Bayesian network meta-analysis was used to combine the direct and indirect evidence of different drugs for LN patients. The pooled relative effects were shown using odds ratios (ORs) and 95% credible intervals (CrIs). Results Nineteen studies (1,566 patients) met the inclusion criteria and were selected in the present study. The network meta-analysis reported that no statistically significant differences were found in partial remission (PR) and infection among the four drugs. RTX showed a significantly higher complete remission (CR) than MMF (OR = 2.60, 95% CrI = 1.00–7.10) and seemed to be more effective than CYC (OR = 4.20, 95% CrI = 1.70–14.00). MMF had a better CR than CYC (OR = 1.60, 95% CrI = 1.00–3.20). TAC presented a better overall response than CYC (OR = 3.70, 95% CrI = 1.20–12.00). Regarding CR and overall response, the maximum surface under the cumulative ranking curve (SUCRA) values were 96.94% for RTX and 80.15% for TAC. The maximum SUCRA value of infection reaction was 74.98% for RTX and the minimum value was 30.17% for TAC, respectively. Conclusions RTX and TAC were the most effective drugs for induction remission in LN. Among the four drugs, TAC had the lowest probability of infection, and RTX showed the highest probability of experiencing an infection. This meta-analysis could not conclude about other adverse events.
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Shin JI, Li H, Park S, Yang JW, Lee KH, Jo Y, Park S, Oh J, Kim H, An HJ, Jeong G, Jung H, Lee HJ, Kim JS, Nam SW, Koyanagi A, Jacob L, Hwang J, Yon DK, Lee SW, Tizaoui K, Kronbichler A, Kim JH, Smith L. Induction and Maintenance Treatment of Lupus Nephritis: A Comprehensive Review of Meta-Analyses. J Clin Med 2022; 11:jcm11020343. [PMID: 35054037 PMCID: PMC8780781 DOI: 10.3390/jcm11020343] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/16/2021] [Accepted: 12/18/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Lupus nephritis (LN) is present in over 50% of patients with systemic lupus erythematosus (SLE) which is managed with immunosuppressive and immunomodulatory therapies. However, several novel therapeutic approaches for LN are under investigation due to the adverse effects spectrum of conventional therapy; Methods: We performed a comprehensive review of meta-analyses aggregating the comparative efficacies of various pharmacotherapies for LN. We conducted a literature search and retrieved a total of 23 meta-analyses and network meta-analyses for summarization. Pharmacotherapies were evaluated across six major outcomes: remission, relapse, mortality, end stage kidney disease (ESKD) progression, infection, and malignancy. RESULT Calcineurin inhibitors (CNI), particularly tacrolimus (TAC), in combination with glucocorticoids (GC) outperformed cyclophosphamide (CPA) with GC in the rate of remission, either complete or partial remission, and in terms of infectious complications. In maintenance therapy, MMF was superior to azathioprine (AZA) as the MMF-treated patients had lower relapse rate. INTERPRETATION This review aggregates evidence of therapy for clinicians and sheds light on comparative efficacies of alternative LN treatments. As more promising agents are entering the market, such as voclosporin, belimumab, and obinutuzumab, LN management might undergo significant changes during the next years.
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Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
| | - Han Li
- University of Florida College of Medicine, Gainesville, FL 32610, USA;
| | - Seoyeon Park
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Jae Won Yang
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (J.W.Y.); (J.S.K.)
| | - Keum Hwa Lee
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
| | - Yongsuk Jo
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Seongeun Park
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Jungmin Oh
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Hansol Kim
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Hyo Jin An
- Yonsei University College of Medicine, Seoul 03722, Korea; (S.P.); (Y.J.); (S.P.); (J.O.); (H.K.); (H.J.A.)
| | - Gahee Jeong
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Haerang Jung
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Hyun Jung Lee
- Ewha Womans University College of Medicine, Seoul 07804, Korea; (G.J.); (H.J.); (H.J.L.)
| | - Jae Seok Kim
- Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea; (J.W.Y.); (J.S.K.)
| | - Seoung Wan Nam
- Department of Rheumatology, Yonsei University Wonju College of Medicine, Wonju 26426, Korea;
| | - Ai Koyanagi
- Research and Development Unit, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, 08830 Barcelona, Spain; (A.K.); (L.J.)
- Catalan Institution for Research and Advanced Studies, Pg. Lluis Companys 23, 08010 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental, 78019 Madrid, Spain
| | - Louis Jacob
- Research and Development Unit, Parc Sanitari Sant Joan de Deu, Sant Boi de Llobregat, 08830 Barcelona, Spain; (A.K.); (L.J.)
- Centro de Investigación Biomédica en Red de Salud Mental, 78019 Madrid, Spain
- Faculty of Medicine, University of Versailles Saint-Quentin-en-Yvelines, 78000 Montigny-le-Bretonneux, France
| | - Jimin Hwang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Dong Keon Yon
- Medical Science Research Institute, Kyung Hee University College of Medicine, Seoul 02447, Korea;
| | - Seung-Won Lee
- Department of Data Science, Sejong University College of Software Convergence, Sungkyunkwan University School of Medicine, Seoul 05006, Korea;
| | - Kalthoum Tizaoui
- Laboratory of Microorganisms and Active Biomolecules, Sciences Faculty of Tunis, University Tunis El Manar, Tunis 1068, Tunisia;
| | | | - Ji Hong Kim
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea; (J.I.S.); (K.H.L.)
- Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 26426, Korea
- Correspondence:
| | - Lee Smith
- Centre for Health, Performance, and Wellbeing, Anglia Ruskin University, Cambridge CB1 1PT, UK;
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Ponticelli C, Reggiani F, Moroni G. Old and New Calcineurin Inhibitors in Lupus Nephritis. J Clin Med 2021; 10:jcm10214832. [PMID: 34768354 PMCID: PMC8584552 DOI: 10.3390/jcm10214832] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 12/27/2022] Open
Abstract
Calcineurin inhibitors (CNIs) are drugs that inhibit calcineurin, a key phosphatase that dephosphorylates a transcription factor called the nuclear factor of activated T cells (NFAT), allowing its translocation into the nucleus of quiescent T cells. In the nucleus, NFAT activates interleukin 2, which stimulates the proliferation and differentiation of T-cells. CNIs can also stabilize the actin cytoskeleton of podocytes reducing proteinuria. Thanks to these characteristics, CNIs have been often used in the treatment of autoimmune diseases. However, the therapeutic index of CNIs is narrow, and their interactions with other drugs can increase toxicity or reduce efficacy. In lupus nephritis, cyclosporine and tacrolimus have been used both in induction and maintenance therapies. Observational studies and randomized controlled trials showed that both cyclosporine and tacrolimus can increase efficacy. Tolerance is satisfactory if low doses are used and the patient is carefully monitored. More recently, a new CNI, called voclosporin (VCS), has been approved by the Food and Drug Administration for use in lupus nephritis. VCS offers potential advantages over other CNIs. In two large multiethnic trials, VCS was not associated with adverse renal and metabolic events and obtained positive results despite a novel and rapid corticosteroid tapering regime.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology Division, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Francesco Reggiani
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy; (F.R.); (G.M.)
| | - Gabriella Moroni
- Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, via Manzoni 56, 20089 Milan, Italy; (F.R.); (G.M.)
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Kostopoulou M, Fanouriakis A, Cheema K, Boletis J, Bertsias G, Jayne D, Boumpas DT. Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations. RMD Open 2021; 6:rmdopen-2020-001263. [PMID: 32699043 PMCID: PMC7425195 DOI: 10.1136/rmdopen-2020-001263] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/08/2020] [Accepted: 05/22/2020] [Indexed: 01/24/2023] Open
Abstract
Objectives To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations. Methods According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012. Results We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (<500–700 mg/day) at 12 months (LoE 2a-2b). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b). Conclusions There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.
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Affiliation(s)
- Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece .,Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, Athens, Greece, and Medical School, University of Cyprus, Nicosia, Cyprus
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Tanaka Y, O'Neill S, Li M, Tsai IC, Yang YW. Systemic Lupus Erythematosus: Targeted literature review of the epidemiology, current treatment and disease burden in the Asia Pacific region. Arthritis Care Res (Hoboken) 2020; 74:187-198. [PMID: 32841537 DOI: 10.1002/acr.24431] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 07/09/2020] [Accepted: 08/18/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To understand the epidemiology, current treatment and disease burden of systemic lupus erythematosus (SLE) in the Asia Pacific region (APAC). METHODS A targeted literature review of published evidence on SLE in APAC was conducted, using the MEDLINE® database (2008-2018), conference proceedings and other supplementary sources. RESULTS The review identified 70 studies conducted in China (n=15), Japan (n=13), Taiwan (n=12), Korea (n=9), Australia (n=7), Hong Kong (n=6), Singapore (n=4), and multiple places within the APAC region (n=4). Incidence rates (per 100,000 per year) ranged from 0.9-8.4, while prevalence rates ranged from 3.7-127 (per 100,000); however, recent data was limited. Asian SLE patients were reported to have higher disease severity, activity (higher SLE disease activity index scores) and organ damage accrual; along with increased morbidity, mortality, and susceptibility to renal involvement compared with other ethnicities in APAC. The risk of developing SLE is higher in the Asian population. Routinely used SLE therapies included belimumab, hydroxychloroquine, cyclophosphamide, tacrolimus, azathioprine, mycophenolate mofetil, and corticosteroids; however, prescribing patterns varied across the region. Increased disease activity was associated with high economic burden and poor quality of life for SLE patients in APAC. CONCLUSION SLE remains a disease with a significant unmet medical need for an innovative therapy that is well-tolerated and effective for patients in APAC. Further evidence is required to better characterize the disease and fully capture the burden and impact of SLE in APAC. This review has highlighted where there is a paucity of data from patients across the APAC region.
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Affiliation(s)
- Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Sean O'Neill
- Department of Rheumatology, Royal North Shore Hospital, Northern Clinical School, University of Sydney, St Leonards, New South Wales, Australia
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, National Clinical Research Center for Immunologic Diseases, Ministry of Science & Technology, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - I-Ching Tsai
- Janssen: Pharmaceutical Companies of Johnson & Johnson, 11F, No.2, Sec.3, Minsheng East Rd, Taipei City, Taiwan
| | - Ya-Wen Yang
- Janssen Global Services, LLC, Horsham, PA, USA
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Ponticelli C, Doria A, Moroni G. Renal disorders in rheumatologic diseases: the spectrum is changing (Part 1: connective tissue diseases). J Nephrol 2020; 34:1069-1080. [PMID: 32529559 DOI: 10.1007/s40620-020-00772-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/03/2020] [Indexed: 01/15/2023]
Abstract
The kidney is frequently involved by autoimmune rheumatic diseases. The renal manifestations may be variable, ranging from asymptomatic proteinuria and microscopic haematuria to nephrotic syndrome and rapidly progressive glomerulonephritis or vasculitis. In a number of cases the kidney involvement is related to the treatment of the original disease and may represent a major cause of morbidity and mortality. Thus, it is important for nephrologists and rheumatologists to remember that dysfunction of the kidney may be part of the primary systemic disorder or consequence of its pharmacotherapy. In the first part of this review we will analyse the kidney involvement in four autoimmune connective tissue diseases: systemic lupus erythematosus, Sjögren syndrome, polymyositis/dermatomyositis, and systemic sclerosis. Renal disease is common in lupus and is a main cause of morbidity and mortality. About 10% of patients with Sjögren syndrome may present interstitial nephritis or, more rarely, glomerulonephritis. Myoglobinuria and acute kidney injury is a frequent complication of polymyositis. Renal disease is one of the most serious complications of systemic sclerosis and may present with a dramatic renal crisis, characterized by malignant hypertension, oligo-anuria, and microangiopathic thrombocytopenic anaemia.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, IRCCS Ospedale Maggiore Milano, Via Ampere 126, 20131, Milano, Italy.
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Gabriella Moroni
- Division of Nephrology, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Milano, Italy
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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.
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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
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Wilson PC, Kashgarian M, Moeckel G. Interstitial inflammation and interstitial fibrosis and tubular atrophy predict renal survival in lupus nephritis. Clin Kidney J 2017; 11:207-218. [PMID: 29644061 PMCID: PMC5888814 DOI: 10.1093/ckj/sfx093] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 07/19/2017] [Indexed: 11/14/2022] Open
Abstract
Background This study examines the effect of interstitial inflammation and interstitial fibrosis and tubular atrophy on renal survival in lupus nephritis. Methods Baseline characteristics, initial (n = 301) and repeat biopsies (n = 94) and clinical outcomes for patients with biopsy-proven lupus nephritis from 1998 to 2014 were retrospectively collected from the medical record. Clinical and morphologic variables were evaluated using a Cox proportional hazards model and multiple imputation to address missing data. Renal survival was defined as the time from initial biopsy to end-stage renal disease [estimated glomerular filtration rate (eGFR) <15 mL/min/1.73 m2], dialysis or transplant. Results A total of 218 patients had follow-up and Class IV had worse renal survival, especially in patients with active and chronic glomerular lesions {relative to non-IV; Class IV-A: hazard ratio [HR] 0.92 [95% confidence interval (CI) 0.41–2.04], Class IV-AC: HR 5.02 [95% CI 2.70–9.36]}. Interstitial inflammation grade [relative to interstitial inflammation <5%; interstitial inflammation 5–25%: HR 2.36 (95% CI 1.13–4.91), interstitial inflammation 25–50%: HR 3.84 (95% CI 1.53–9.62), interstitial inflammation >50%: HR 7.67 (95% CI 3.75–15.67)] and increased interstitial fibrosis and tubular atrophy (IFTA) category [relative to IFTA <5%; IFTA 5–25%: HR 3.93 (95% CI 1.58–9.75), IFTA 25–50%: HR 4.01 (95% CI 1.37–11.70), IFTA >50%: HR 13.99 (95% CI 4.91–39.83)] predicted worse renal survival among all patients and those with Class IV on initial and repeat biopsy (n = 94) in a dose-dependent manner. Interstitial inflammation grade and IFTA category were significant predictors of renal survival in a multivariable model adjusted for age, gender, race, ethnicity and serum creatinine. Conclusions Interstitial inflammation and IFTA independently affect renal survival and grading these lesions stratifies risk within the International Society of Nephrology and Renal Pathology Society classification of lupus nephritis.
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Affiliation(s)
- Parker C Wilson
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Michael Kashgarian
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
| | - Gilbert Moeckel
- Department of Pathology, Yale University School of Medicine, New Haven, CT, USA
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Chen Y, Sun J, Zou K, Yang Y, Liu G. Treatment for lupus nephritis: an overview of systematic reviews and meta-analyses. Rheumatol Int 2017; 37:1089-1099. [DOI: 10.1007/s00296-017-3733-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 05/04/2017] [Indexed: 12/29/2022]
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10
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Fernandez Nieto M, Jayne DR. Con: The use of calcineurin inhibitors in the treatment of lupus nephritis. Nephrol Dial Transplant 2016; 31:1567-71. [PMID: 27591328 DOI: 10.1093/ndt/gfw291] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 02/22/2016] [Indexed: 01/30/2023] Open
Abstract
Lupus nephritis (LN) therapy has limited efficacy due to its toxicity, and LN patients suffer high risks of renal and cardiovascular morbidity and mortality. Calcineurin inhibitors (CNIs) have been used for over >30 years in LN treatment and are an established alternative therapy for Class V nephritis, but uncertainty remains about their role in proliferative disease or in the maintenance of remission. More recently, the combination of CNIs with mycophenolate mofetil (MMF) and glucocorticoid combination therapy, 'multitarget' therapy and the use of tacrolimus as opposed to ciclosporin has received attention. Is the evidence now sufficient to support the routine use of regimens including CNIs in LN? Although CNIs appear to have similar efficacy to MMF-based regimens as induction therapy, and are comparable with azathioprine as maintenance treatment, CNI toxicities, such as new-onset hypertension, hyperglycaemia and nephrotoxicity, have been problematic. Multitarget therapy improves the rate of complete remission in short-term studies, but whether this benefit is maintained over the longer term is uncertain. However, patient tolerability is lower and the frequency of serious events is higher in multitarget versus cyclophosphamide-based regimens, and there is a paucity of evidence from non-Asian ethnic groups. CNI-based therapy is also complicated by the absence of standardized dosing and the need for drug level monitoring, as well as by pharmacogenetic differences. Also, multitarget therapy increases the complexity and the cost of treatment. There is insufficient evidence to support the routine use of CNI-based or multitarget therapy for proliferative LN. Further data on long-term renal and cardiovascular outcomes and strategies to improve tolerability and safety are required.
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Affiliation(s)
| | - David R Jayne
- Department of Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, UK
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Trujillo-Martín MM, Rúa-Figueroa Fernández de Larrinoa I, Ruíz-Irastorza G, Pego-Reigosa JM, Sabio Sánchez JM, Serrano-Aguilar P. [Clinical practice guidelines for systemic lupus erythematosus: Recommendations for general clinical management]. Med Clin (Barc) 2016; 146:413.e1-14. [PMID: 26975887 DOI: 10.1016/j.medcli.2016.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/13/2016] [Accepted: 01/21/2016] [Indexed: 12/22/2022]
Abstract
Systemic lupus erythematosus (SLE) is a complex rheumatic multisystemic disease of autoimmune origin with significant potential morbidity and mortality. It is one of the most common autoimmune diseases with an estimated prevalence of 20-150 cases per 100,000 inhabitants. The clinical spectrum of SLE is wide and variable both in clinical manifestations and severity. This prompted the Spanish Ministry of Health, Social Services and Equality to promote and fund the development of a clinical practice guideline (CPG) for the clinical care of SLE patients within the Programme of CPG in the National Health System which coordinates GuiaSalud. This CPG is is intended as the reference tool in the Spanish National Health System in order to support the comprehensive clinical management of people with SLE by all health professionals involved, regardless of specialty and level of care, helping to standardize and improve the quality of clinical decisions in our context in order to improve the health outcomes of the people affected. The purpose of this document is to present and discuss the rationale of the recommendations on the general management of SLE, specifically, clinical follow-up, general therapeutic approach, healthy lifestyles, photoprotection, and training programmes for patients. These recommendations are based on the best available scientific evidence, on discussion and the consensus of expert groups.
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Affiliation(s)
- María M Trujillo-Martín
- Fundación Canaria de Investigación Sanitaria (FUNCANIS), La laguna, Santa Cruz de Tenerife, España; Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, España
| | | | - Guillermo Ruíz-Irastorza
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital Universitario Cruces, Barakaldo, Vizcaya, España
| | - José María Pego-Reigosa
- Servicio de Reumatología, Hospital Meixoeiro, Vigo, España; IRIDIS (Investigation in Rheumatology and Immuno-Mediated Diseases) Group, Instituto de Investigación Biomédica (IBI) de Vigo, Pontevedra y Ourense, España
| | | | - Pedro Serrano-Aguilar
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, España; Servicio de Evaluación y Planificación (SESCS), Servicio Canario de la Salud, Santa Cruz de Tenerife, España
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12
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Zhang X, Ji L, Yang L, Tang X, Qin W. The effect of calcineurin inhibitors in the induction and maintenance treatment of lupus nephritis: a systematic review and meta-analysis. Int Urol Nephrol 2016; 48:731-43. [DOI: 10.1007/s11255-015-1201-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/23/2015] [Indexed: 02/06/2023]
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13
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Lin CT, Liu XN, Xu HL, Sui HY. Menstrual Disturbances in Premenopausal Women with End-Stage Renal Disease: A Cross-Sectional Study. Med Princ Pract 2016; 25:260-5. [PMID: 26907185 PMCID: PMC5588400 DOI: 10.1159/000444879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 02/22/2016] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To evaluate menstrual disturbances and sex hormonal status in premenopausal women with end-stage renal disease (ESRD). SUBJECTS AND METHODS The study consisted of 184 patients with ESRD treated with one of four treatment modalities (46/modality): conventional hemodialysis (CHD), continuous ambulatory peritoneal dialysis (CAPD), nocturnal hemodialysis (NHD) and renal transplantation (RT). Blood samples were collected to determine sex hormone levels. Sociodemographic and clinical data were collected from medical records. A questionnaire was administered to analyze menstrual patterns, and the final analysis included 46, 43, 40 and 36 patients in the CHD, CAPD, NHD and RT groups, respectively. RESULTS The overall prevalence of menstrual disturbances was 64.2% for all four treatment modalities (RT: 50%; NHD: 55%; CAPD: 72.1%, and CHD: 76.1%). Serum prolactin levels were significantly lower (p < 0.01) in the NHD (25.1 ± 10.9 ng/ml) and RT (13.4 ± 5.1 ng/ml) groups than in the CHD group (55.2 ± 10.8 ng/ml). Serum progesterone levels were significantly higher (p < 0.01) in the NHD (25.7 ± 8.3 nmol/l) and RT (30.1 ± 5.9 nmol/l) groups than in the CHD group (17.7 ± 7.3 nmol/l). Moreover, the hormonal status (follicle-stimulating hormone, luteinizing hormone and testosterone) was much closer to normal in the NHD and RT groups compared to the other two groups. CONCLUSIONS In this study, successful transplantation and NHD partially improved the symptoms of menstrual disturbances. Therefore, we recommend that further studies are necessary to confirm our finding in ESRD patients.
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Affiliation(s)
- Chong-Ting Lin
- Department of Hemodialysis Room, Yantai Hospital of Traditional Chinese Medicine, Yantai, China
| | - Xi-Ning Liu
- Department of Hemodialysis Room, Yantai Hospital of Traditional Chinese Medicine, Yantai, China
| | - Hong-Lei Xu
- Department of Hemodialysis Room, Yantai Hospital of Traditional Chinese Medicine, Yantai, China
| | - Hui-Yan Sui
- Department of Radiology, Yantai Hospital of Traditional Chinese Medicine, Yantai, China
- *Hui-Yan Sui, Department of Radiology, Yantai Hospital of Traditional Chinese Medicine, No. 39 Xingfu Road, Zhifu District, Yantai 264000 (PR China), E-Mail
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Imran TF, Yick F, Verma S, Estiverne C, Ogbonnaya-Odor C, Thiruvarudsothy S, Reddi AS, Kothari N. Lupus nephritis: an update. Clin Exp Nephrol 2015; 20:1-13. [PMID: 26471017 DOI: 10.1007/s10157-015-1179-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 10/02/2015] [Indexed: 01/06/2023]
Abstract
Lupus nephritis (LN) is an inflammatory condition of the kidneys that encompasses various patterns of renal disease including glomerular and tubulointerstitial pathology. It is a major predictor of poor prognosis in patients with systemic lupus erythematosus (SLE). Genetic factors, including several predisposing loci, and environmental factors, such as EBV and ultraviolet light, have been implicated in the pathogenesis. It carries a high morbidity and mortality if left untreated. Renal biopsy findings are utilized to guide treatment. Optimizing risk factors such as proteinuria and hypertension with renin-angiotensin receptor blockade is crucial. Immunosuppressive therapy is recommended for patients with focal or diffuse proliferative lupus nephritis (Class III or IV) disease, and certain patients with membranous LN (Class V) disease. Over the past decade, immunosuppressive therapies have significantly improved long-term outcomes, but the optimal therapy for LN remains to be elucidated. Cyclophosphamide-based regimens, given concomitantly with corticosteroids, have improved survival significantly. Even though many patients achieve remission, the risk of relapse remains considerably high. Other treatments include hydroxychloroquine, mycofenolate mofetil, and biologic therapies such as Belimumab, Rituximab, and Abatacept. In this paper, we provide a review of LN, including pathogenesis, classification, and clinical manifestations. We will focus, though, on discussion of the established as well as emerging therapies for patients with proliferative and membranous lupus nephritis.
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Affiliation(s)
- Tasnim F Imran
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA.
| | - Frederick Yick
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Suneet Verma
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA.,Division of Nephrology, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Christopher Estiverne
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Chinonye Ogbonnaya-Odor
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Srikanth Thiruvarudsothy
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Alluru S Reddi
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA.,Division of Nephrology, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Neil Kothari
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
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Kansal A, Tripathi D, Rai MK, Agarwal V. Persistent expression and function of P-glycoprotein on peripheral blood lymphocytes identifies corticosteroid resistance in patients with systemic lupus erythematosus. Clin Rheumatol 2015; 35:341-9. [PMID: 26415739 DOI: 10.1007/s10067-015-3079-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/15/2015] [Accepted: 09/17/2015] [Indexed: 12/18/2022]
Abstract
Corticosteroids (CS) are the mainstay of treatment in systemic lupus erythematosus (SLE) patients. However, some patients have poor response to CS treatment. Among the multiple mechanisms of CS resistance, overexpression of P-glycoprotein (P-gp) on peripheral blood lymphocytes (PBL) may be one of them as this result in efflux of CS from lymphocytes. Thus, we evaluated the role of P-gp protein on PBLs in patients with SLE in its response to CS therapy. SLE patients (n = 42) (fulfilling ACR revised criteria) who were naïve to CS and immunosuppressive drugs were enrolled. Disease activity was assessed using SLE disease activity index (SLEDAI) and expression, and function of P-gp was evaluated by flow cytometry at baseline and after 3 months of therapy with CS. At 3 months, patients with SLEDAI >4 and SLEDAI ≤4 were grouped as nonresponders and responders, respectively. P-gp expression was significantly increased on PBLs of SLE patients as compared to healthy controls (p < 0.001). P-gp expression and function correlated with SLEDAI (r = 0.49, p = 0.005; and r = 0.49, p = 0.001, respectively). P-gp expression and function were not different in responders and nonresponders at baseline. However, at 3 months of CS therapy, P-gp expression and function decreased in responders (p < 0.001 and p < 0.005, respectively), whereas in nonresponders, it remained unchanged. Persistent overexpression and activity of P-gp are associated with poor response to CS in CS naïve patients of SLE.
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Affiliation(s)
- Amit Kansal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Deepak Tripathi
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Mohit K Rai
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of medical Sciences, Raebareli Road, Lucknow, 226014, India.
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Lee YH, Song GG. Relative efficacy and safety of tacrolimus, mycophenolate mofetil, and cyclophosphamide as induction therapy for lupus nephritis: a Bayesian network meta-analysis of randomized controlled trials. Lupus 2015; 24:1520-8. [PMID: 26162684 DOI: 10.1177/0961203315595131] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 06/12/2015] [Indexed: 01/08/2023]
Abstract
AIMS This study aimed to assess the relative efficacy and safety of tacrolimus, mycophenolate mofetil (MMF) and cyclophosphamide (CYC) as induction therapy for lupus nephritis. METHODS Randomized controlled trials (RCTs) examining the efficacy and safety of tacrolimus, MMF and CYC for induction therapy in patients with lupus nephritis were included. We performed a Bayesian random-effects network meta-analysis to combine direct and indirect evidence from the RCTs. RESULTS Nine RCTs including 972 patients met the inclusion criteria and pair-wise comparisons were performed, including 11 direct comparisons. Tacrolimus showed a significantly higher overall response rate (complete remission plus partial remission) than CYC (OR 2.35, 95% confidence interval (CI) 1.03-5.45), and was more efficacious than MMF (OR 1.60, 95% CI 0.70-3.57). MMF was superior to CYC in terms of overall response (OR 1.45, 95% CI 0.96-2.42). Ranking probability based on the surface under the cumulative ranking curve (SUCRA) indicated that tacrolimus had the highest probability of being the best treatment for achieving the overall response (SUCRA = 0.9321), followed by MMF (SUCRA = 0.5385) and CYC (SUCRA = 0.0294). In terms of safety, tacrolimus showed the highest probability of decreasing the risk of serious infections (SUCRA = 0.9253), followed by MMF (SUCRA = 0.4027) and CYC (SUCRA = 0.1720). CONCLUSIONS Tacrolimus was the most efficacious induction treatment for patients with lupus nephritis, and had the highest probability of decreasing the risk of serious infections. Higher remission rates combined with a more favorable safety profile suggest that MMF is superior to CYC as induction treatment in these patients.
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Affiliation(s)
- Y H Lee
- Division of Rheumatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - G G Song
- Division of Rheumatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Thanou A, Merrill J. T Cell Targeted Therapies in Lupus: Do They Make Sense? CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2015. [DOI: 10.1007/s40674-014-0008-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Yang M, Li M, He W, Wang B, Gu Y. Calcineurin inhibitors may be a reasonable alternative to cyclophosphamide in the induction treatment of active lupus nephritis: A systematic review and meta-analysis. Exp Ther Med 2014; 7:1663-1670. [PMID: 24926363 PMCID: PMC4043578 DOI: 10.3892/etm.2014.1669] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 03/21/2014] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Min Yang
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P.R. China
| | - Min Li
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P.R. China
| | - Wei He
- Department of Gastroenterology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P.R. China
| | - Bin Wang
- Department of Nephrology, The Third Affiliated Hospital of Soochow University, Changzhou, Jiangsu 213000, P.R. China
| | - Yong Gu
- Division of Nephrology, Huashan Hospital and Institute of Nephrology, Fudan University, Shanghai 200040, P.R. China
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Ugarte-Gil MF, Alarcón GS. Systemic lupus erythematosus: a therapeutic challenge for the XXI century. Clin Rheumatol 2014; 33:441-50. [PMID: 24577816 DOI: 10.1007/s10067-014-2531-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 02/09/2014] [Accepted: 02/09/2014] [Indexed: 11/28/2022]
Abstract
Despite significant advances in our understanding of the pathogenesis of systemic lupus erythematosus (SLE), there are only a few drugs approved by the regulatory agencies across the world for the treatment of these patients; in fact, many of the compounds subjected to clinical trials have failed in achieving their primary endpoints. Current therapeutic options include antimalarials which should be used in all SLE patients unless they are strongly contraindicated, glucocorticoids which should be used at the lowest possible dose and for the shortest possible time, and immunosuppressive drugs which should be used judiciously, mainly in patients with severe organ involvements or receiving high doses of steroids to control their disease. Despite improvement on the survival of SLE patients, damage accrual has not varied over the last few decades, reflecting a gap between these therapeutic options and the expectations of these patients and their treating physicians. Biologic compounds can be used in some refractory cases. However, their cost is of great concern for both the patients and the health system. Cost is of special importance in low-income countries, because low-income SLE patients tend to experience a more severe disease having an overall worse prognosis which is compounded by their limited access to the health system. Although a treatment to target based on defined molecular pathways for specific disease subsets is appealing, this is not yet a reality. This review addressed current therapeutic options for SLE patients and the state of the art of investigational drugs targeting pathogenic pathways identified in these patients.
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Affiliation(s)
- Manuel F Ugarte-Gil
- Servicio de Reumatología, Hospital Nacional Guillermo Almenara Irigoyen, EsSalud, Lima, Perú,
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Treatment of systemic lupus erythematosus: new therapeutic avenues and blind alleys. Nat Rev Rheumatol 2013; 10:23-34. [DOI: 10.1038/nrrheum.2013.145] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abud-Mendoza C. Lupus nephritis: advances in the knowledge of its immunopathogenesis without the expected therapeutic success? REUMATOLOGIA CLINICA 2013; 9:77-79. [PMID: 23465964 DOI: 10.1016/j.reuma.2013.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 02/04/2013] [Accepted: 02/06/2013] [Indexed: 06/01/2023]
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