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Athanassiou P, Athanassiou L. Current Treatment Approach, Emerging Therapies and New Horizons in Systemic Lupus Erythematosus. Life (Basel) 2023; 13:1496. [PMID: 37511872 PMCID: PMC10381582 DOI: 10.3390/life13071496] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 06/18/2023] [Accepted: 06/30/2023] [Indexed: 07/30/2023] Open
Abstract
Systemic lupus erythematosus (SLE), the prototype of systemic autoimmune diseases is characterized by extreme heterogeneity with a variable clinical course. Renal involvement may be observed and affects the outcome. Hydroxychloroquine should be administered to every lupus patient irrespective of organ involvement. Conventional immunosuppressive therapy includes corticosteroids, methotrexate, cyclophosphamide, mycophenolate mofetil, azathioprine, cyclosporine and tacrolimus. However, despite conventional immunosuppressive treatment, flares occur and broad immunosuppression is accompanied by multiple side effects. Flare occurrence, target organ involvement, side effects of broad immunosuppression and increased knowledge of the pathogenetic mechanisms involved in SLE pathogenesis as well as the availability of biologic agents has led to the application of biologic agents in SLE management. Biologic agents targeting various pathogenetic paths have been applied. B cell targeting agents have been used successfully. Belimumab, a B cell targeting agent, has been approved for the treatment of SLE. Rituximab, an anti-CD20 targeting agent is also used in SLE. Anifrolumab, an interferon I receptor-targeting agent has beneficial effects on SLE. In conclusion, biologic treatment is applied in SLE and should be further evaluated with the aim of a good treatment response and a significant improvement in quality of life.
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Affiliation(s)
| | - Lambros Athanassiou
- Department of Rheumatology, Asclepeion Hospital, Voula, GR16673 Athens, Greece
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Hailu GMT, Hussen SU, Getachew S, Berha AB. Management practice and treatment outcomes of adult patients with Lupus Nephritis at the Renal Clinic of St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. BMC Nephrol 2022; 23:214. [PMID: 35715762 PMCID: PMC9206350 DOI: 10.1186/s12882-022-02846-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/08/2022] [Indexed: 12/01/2022] Open
Abstract
Background Lupus nephritis (LN) is the most common severe complication of systemic lupus erythematosus (SLE) which results in high morbidity and mortality. Up to 60% of adult patients with SLE develop the renal disease with different severity. Even with potent anti-inflammatory and immunosuppressive therapies, many LN patients still progress to chronic kidney disease or end-stage renal disease. Thus, this study aimed to assess the management practice, treatment outcomes and to identify the associated factors of poor renal outcome in adult LN patients at the renal clinic of St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. Methods A retrospective cross-sectional study design was used to collect the data using an abstraction tool from patients’ records. The Kidney Disease Improving Global Outcomes (KDIGO) criteria were used to diagnose LN among SLE patients. Logistic regression was used to determine crude and adjusted odds ratio and a p-value of < 0.05 was considered statistically significant. Ethical approval was obtained from the ethical review committee of the School of Pharmacy, Addis Ababa University and institutional review board of St. Paul’s Hospital Millennium Medical College. Results Out of 168 study participants enrolled from September 1, 2016 to October 30, 2020, a total of 114 adult LN patients were included for final analysis. The mean (± SD) age of the LN patients at onset was 29.10 ± 9.67 years and 99 (86.8%) of all the patients were females. More than three-fourths (78.9%) of the LN patients had a good prognosis. However, 24 (21.1%) of the patients who didn’t achieve complete or partial remission had a poor prognosis. A kidney biopsy was done for 71 patients at initial presentation with class IV and III as the commonest class. The commonly prescribed immunosuppressive medications were cyclophosphamide as induction therapy in 67 (58.7%) and mycophenolate mofetil (MMF) as maintenance therapy in 76 (66.7%). Gastrointestinal intolerances like abdominal pain, nausea, or diarrhea from MMF were the most common 27(31.2%) treatment-related adverse events reported. Acute kidney injury (AKI) at onset (AOR = 4.83, P = 0.026), high serum creatinine (SCr) at six months (AOR = 0.12, P = 0.003), no response at six months to attain complete remission (AOR = 0.05, P = 0.041) and presence of flare (AOR = 0.04, P = 0.004) were predictors poor treatment outcomes. Conclusion Despite good response with the present immunosuppressive regimens, relapse, treatment-related complications and adverse events are major problems that require close monitoring. The results and identified gaps of this study are used as an input to improve the management practice of LN in the study setting. Overall, this study is comparable with other findings and strengthen the present available literatures. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02846-z.
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Affiliation(s)
- Gebre-Mariam Tsegay Hailu
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Shemsu Umer Hussen
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Seifemichael Getachew
- Department of Internal Medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Alemseged Beyene Berha
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
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Noone DG, Silverman ED. Treatment of Childhood-onset Proliferative Lupus Nephritis in the 21st Century: A Call to Catch Up With the Evidence. J Rheumatol Suppl 2022; 49:552-554. [PMID: 35365579 DOI: 10.3899/jrheum.220196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Proliferative lupus nephritis (PLN) is associated with significant morbidity, mortality, and kidney failure, especially in childhood-onset PLN (cPLN). Therefore, it is important to treat it promptly and aggressively, while being cognizant of the risk-benefit ratio and side effects of therapies.
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Affiliation(s)
- Damien G Noone
- D. Noone, MB BCh BAO, MSc, Division of Nephrology, The Hospital for Sick Children, and Associate Professor, Department of Paediatrics, University of Toronto; E.D. Silverman, MD, FRCPC, Division of Rheumatology, The Hospital for Sick Children, Senior Associate Scientist, Physiology & Experimental Medicine Program, SickKids Research Institute, and Professor of Paediatrics and Immunology, University of Toronto, Toronto, Ontario, Canada. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. E.D. Silverman, The Hospital for Sick Children, Division of Rheumatology, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
| | - Earl D Silverman
- D. Noone, MB BCh BAO, MSc, Division of Nephrology, The Hospital for Sick Children, and Associate Professor, Department of Paediatrics, University of Toronto; E.D. Silverman, MD, FRCPC, Division of Rheumatology, The Hospital for Sick Children, Senior Associate Scientist, Physiology & Experimental Medicine Program, SickKids Research Institute, and Professor of Paediatrics and Immunology, University of Toronto, Toronto, Ontario, Canada. The authors declare no conflicts of interest relevant to this article. Address correspondence to Dr. E.D. Silverman, The Hospital for Sick Children, Division of Rheumatology, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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Bankole AA, Nwaonu JN. The Shifting Landscape of Lupus Nephritis Management: A Review. Cureus 2022; 14:e20950. [PMID: 35154930 PMCID: PMC8815326 DOI: 10.7759/cureus.20950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 11/09/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is commonly the first autoimmune disease that comes to mind for most people when rheumatology is mentioned. It remains an enigma that many of us, including patients and healthcare providers, do not fully understand. Although an ancient disease, it still remains difficult to both diagnose and treat. Historically, there has always been a paucity of therapeutic interventions for SLE as a whole. One of the most distressing manifestations for the patient and diagnostic and therapeutically challenging aspects of SLE is lupus nephritis (LN). There has historically been some difficultly in the development of LN drugs that provide significant therapeutic benefits while having an acceptable side-effect profile. This difficulty led to decades in which no drugs were approved for LN. With a better understanding of the pathogenesis of SLE and LN and improvement in trial design, great therapeutic strides have recently been made. The immunosuppressive landscape of LN has changed recently with the approval of two newer agents as well as a number of promising trials in LN. With the increased number of therapeutic agents (both immunosuppressive and non-immunosuppressive), the clinical question is how and when to use these medications, and, more importantly, which agents to use first. With the increased number of agents, the answers to these questions are becoming more difficult to answer. The purpose of the paper is to review updates in LN diagnosis and management.
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Timlin H, Hardenbergh D, Fine D, Monroy-Trujillo JM, Haque U, Adler B, Vaidya D, Geetha D. The Effect of Mycophenolate Mofetil as First-Line Therapy on the Timing of Urine Protein-to-Creatinine Ratio Reduction in Immunosuppressant-Naive Patients With Lupus Nephritis at a Single Center. J Clin Rheumatol 2022; 28:e141-e144. [PMID: 33394827 DOI: 10.1097/rhu.0000000000001656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND/OBJECTIVES Early response to immunosuppressive therapy predicts good renal outcome in lupus nephritis (LN). The purpose of this study was to assess the effect of mycophenolate mofetil (MMF) on the timing of urine protein-to-creatinine ratio reaching 200 mg or less after starting MMF as initial therapy for class III, IV, or V in immunosuppressant-naive patients with LN. METHODS Patients who had a diagnosis of biopsy-proven LN were included in this cohort study. The initial dose of MMF was 1000 mg twice daily. If no improvement, it was increased to 1500 mg twice daily after 1 month. For statistical analysis, exact binomial distribution 95% confidence intervals were calculated. RESULTS Nine patients were identified. There were 3 patients with class III, 3 with class IV, 1 with class III to V, 1 with class II to V, and 1 with class V lupus nephritis. The majority were African Americans (70%). At baseline, proteinuria ranged between 0.41 and 4 g, and 88% had normal estimated glomerular filtration rate. Forty-four percent of patients reached 0.28 g of proteinuria within 8 weeks of starting MMF (95% confidence interval, 14%-79%), all of which maintained the same level of response and normal estimated glomerular filtration rate at 12 months. Thirty-three percent of patients achieved the American College of Rheumatology complete response at 8 weeks. CONCLUSIONS This study demonstrates that only a minority of immunosuppressant-naive LN patients achieved the American College of Rheumatology complete response at 8 weeks after initiation of MMF. A rapid decline in the proteinuria to 0.28 g within the first 8 weeks of the treatment correlated strongly with achieving the same level of response at 12 months.
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Affiliation(s)
| | | | | | | | | | | | - Dhananjay Vaidya
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Kuzuya K, Morita T, Kumanogoh A. Efficacy of mycophenolate mofetil as a remission induction therapy in antineutrophil cytoplasmic antibody: associated vasculitis-a meta-analysis. RMD Open 2021; 6:rmdopen-2020-001195. [PMID: 32371435 PMCID: PMC7299518 DOI: 10.1136/rmdopen-2020-001195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/25/2020] [Accepted: 03/29/2020] [Indexed: 01/01/2023] Open
Abstract
Objectives A few studies on antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) treatments have shown the therapeutic efficacy of mycophenolate mofetil (MMF). However, the therapeutic efficacy of MMF compared with that of cyclophosphamide (CYC) in patients with AAV has not been established. We conducted a systematic review and meta-analysis to assess the efficacy of MMF as a remission induction therapy in patients with AAV comparing it with the efficacy of CYC. Methods We searched randomised controlled trials (RCTs) comparing the efficacy of MMF with that of CYC in patients with AAV on three different websites: PubMed, Cochrane Library and Google Scholar. We compared the difference in the relative risk (RR) of each outcome based on a Mantel-Haenszel random-effects model. Results We analysed data from four RCTs with 300 patients for the study. The 6-month remission rate (RR 1.09, 95% CI 0.86 to 1.38, p=0.48), the 6-month ANCA negativity (RR 1.31, 95% CI 0.91 to 1.90, p=0.15) and the long-term relapse rate (RR 1.36, 95% CI 0.80 to 2.31, p=0.26) were all similar between the two treatments. The rates of death, infection and leucopenia were also similar between the two groups (RR 1.05, 95% CI 0.40 to 2.74, p=0.93; RR 1.26, 95% CI 0.79 to 2.01, p=0.33; RR 0.45, 95% CI 0.16 to 1.32, p=0.15, respectively). Conclusions We found no difference between the therapeutic efficacy of MMF and that of CYC in patients with AAV. MMF may be an alternative remission induction therapy in patients with non-life-threatening AAV.
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Affiliation(s)
- Kentaro Kuzuya
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takayoshi Morita
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan .,Laboratory of Immunopathology, World Premier International Immunology Frontier Research Center, Suita, Japan
| | - Atsushi Kumanogoh
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan.,Laboratory of Immunopathology, World Premier International Immunology Frontier Research Center, Suita, Japan.,Integrated Frontier Research for Medical Science Division, Institute for Open and Transdisciplinary Research Initiatives, Osaka University, Suita, Japan
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7
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Legendre P, Blanchet B, Porcher R, Bérezné A, Allard M, London J, Terrier B, Cohen P, Le Jeunne C, Mouthon L. Mycophenolic acid drug monitoring in patients with systemic sclerosis associated with diffuse skin and/or pulmonary involvement: A monocentric and retrospective French study. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2021; 6:87-95. [PMID: 35382246 PMCID: PMC8922638 DOI: 10.1177/2397198320944342] [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: 01/02/2020] [Accepted: 06/24/2020] [Indexed: 11/10/2023]
Abstract
OBJECTIVE To explore pharmacokinetic/pharmacodynamic relationship between mycophenolic acid area under the curve and clinical response at 1 year on skin involvement or interstitial lung disease in patients with systemic sclerosis. METHOD Retrospective, monocentric study based on French Scleroderma Database in patients receiving mycophenolate mofetil who experienced a limited sampling strategy to estimate individual mycophenolic acid area under the curve plus two pulmonary function tests and skin evaluation after 1 month and 1 year. Efficacy criterions were variations of modified Rodnan skin score, forced vital capacity, and diffusing lung capacity for carbon monoxide at 1 year. RESULTS We included 52 patients; mean age was 49 years (range 17-79), and 36 (69%) were females. Fifty patients (96%) had skin sclerosis, 39 (75%) had diffuse skin involvement with a median modified Rodnan skin score of 14 (0-38). Thirty-eight (76%) had interstitial lung disease, with median forced vital capacity and diffusing lung capacity for carbon monoxide of 81% (37-127) and 56% (28-103) from predicted values, respectively. Twenty-five (51%) patients had pulmonary fibrosis. Mycophenolate mofetil was given for 10 months (0-173) at a median dose of 2000 mg/day (500-3000). In the entire population, no relationship was found between area under the curve and modified Rodnan skin score (p = 0.085), forced vital capacity (p = 0.80), or diffusing lung capacity for carbon monoxide (p = 0.72) variations at 1 year. CONCLUSION In this retrospective study, we failed to document any relationship between mycophenolic acid area under the curve and skin involvement or interstitial lung disease evolution. Routine monitoring of mycophenolic acid in systemic sclerosis patients treated with mycophenolate mofetil cannot be recommended based on our results.
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Affiliation(s)
- Paul Legendre
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Benoit Blanchet
- UF de Pharmacocinétique et Pharmacochimie, Hôpital Cochin, AP-HP, Paris, France
- UMR8638 CNRS, Pharmacy UFR, University of Paris Descartes, PRES Sorbonne Paris Cité, Paris, France
- RAPIDEM (Research on Autoimmune Disease for Personalized Medicine), Paris, France
| | - Raphael Porcher
- Centre d'Epidémiologie Clinique, Hôpital Hôtel-Dieu, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Descartes, Paris, France
| | - Alice Bérezné
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Marie Allard
- UF de Pharmacocinétique et Pharmacochimie, Hôpital Cochin, AP-HP, Paris, France
| | - Jonathan London
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Benjamin Terrier
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- RAPIDEM (Research on Autoimmune Disease for Personalized Medicine), Paris, France
| | - Pascal Cohen
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Claire Le Jeunne
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Luc Mouthon
- Service de Médecine Interne, Hôpital Cochin, Centre de Référence pour les Maladies Systémiques Autoimmunes Rares d'Ile de France, DHU Authors, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Institut Cochin, INSERM U1016, CNRS UMR 8104, Université Paris Descartes, Paris, France
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Abstract
Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease with exocrine gland dysfunction and multi-organ involvement. Currently, there is an increasing trend toward non-steroid therapy for the treatment of autoimmune diseases. Some biological agents or immunosuppressive drugs may be the ideal choices. In real-world practice, as patients have severe systemic complications or organ damage, they will have a bad prognosis even if they are treated with high-dose steroids and strong immunosuppressive drugs. However, if we can start early intervention and prevent progressive development in advance, the patient may have a good prognosis. Mycophenolate is an immunosuppressive drug with minor side effects. Here, we conduct a systemic review and find supporting evidence that patients with pSS benefit from early mycophenolate therapy. Mycophenolate may be the first-line treatment for pSS patients in the future.
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Affiliation(s)
- Weiqian Chen
- Division of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jin Lin
- Division of Rheumatology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Abstract
Systemic lupus erythematosus is the most characteristic of auto-immune disorders that can lead to tissue damage in many organs, including kidney. Lupus nephritis occurs in 10 to 40% of lupus patients. Its clinical hallmark is the appearance of a proteinuria as soon as a 0.5 g/g or 0.5 g/d threshold, which calls for a renal histological evaluation in order to determine the lupus nephritis severity and the need for specific therapy. More than half of renal biopsies lead to the diagnosis of active lupus nephritis-class III or class IV A according to the ISN/RPS classification-that are the most severe in regards to renal prognosis and mortality. Their treatment aims to their clinical remission and to the prevention of relapse with minimal adverse effects for eventually the preservation of renal function, the prevention of other irreversible damage, and the reduction of risk of death. The remission is obtained through induction therapies of which the association of high dose steroids and cyclophosphamide is the most experienced. When this association must be challenged by the prevention of side-effect, in particular infertility, mycophenolate can be given instead of cyclophosphamide. Maintenance therapy, for the prevention of relapse, consists in mycophenolate or in azathioprine, mycophenolate being the most efficient however associated with a high risk of teratogenicity. Withdrawal of maintenance therapy is possible after two to three years in absence of high risk factors of relapse of lupus nephritis, however a reliable assessment of the risk of relapse is still lacking. Only pure membranous lupus nephritis (pure class V) associated with high level proteinuria requires specific therapies that usually associates steroids and an immunosuppressive drug. However, their choice hierarchy and even the use of less immunosuppressive strategies remain to be determined in terms of benefice over risk ratios. In spite of its trigger effect on lupus activity, pregnancy can be safe and successful if scheduled in the lowest risk periods with close multidisciplinary monitoring before, during and after. When necessary, renal replacement therapy does not require specific adaptation, renal transplantation is the best option when possible, as early as possible.
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Affiliation(s)
- Quentin Raimbourg
- Service de néphrologie, hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris cedex 18, France; Université Paris Diderot, 5, rue Thomas-Mann, 75013 Paris, France; Inserm U1149, Département hospitalo-universitaire (DHU) Fibrosis-Inflammation-Remodeling (FIRE), 16, rue Henri Huchard, 75890 Paris cedex 18, France
| | - Éric Daugas
- Service de néphrologie, hôpital Bichat, 46, rue Henri-Huchard, 75877 Paris cedex 18, France; Université Paris Diderot, 5, rue Thomas-Mann, 75013 Paris, France; Inserm U1149, Département hospitalo-universitaire (DHU) Fibrosis-Inflammation-Remodeling (FIRE), 16, rue Henri Huchard, 75890 Paris cedex 18, France.
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10
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Choi SE, Park DJ, Kang JH, Lee KE, Xu H, Lee JS, Choi YD, Lee SS. Comparison of Renal Responses to Cyclophosphamide and Mycophenolate Mofetil used as Induction Therapies in Korean Patients with Lupus Nephritis. JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.1.57] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Sung-Eun Choi
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, Gwangju, Korea
| | - Dong-Jin Park
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, Gwangju, Korea
| | - Ji-Hyoun Kang
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, Gwangju, Korea
| | - Kyung-Eun Lee
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, Gwangju, Korea
| | - Haimuzi Xu
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, Gwangju, Korea
| | - Ji Shin Lee
- Department of Pathology, Chonnam National University Medical School & Hospital, Gwangju, Korea
| | - Yoo-Duk Choi
- Department of Pathology, Chonnam National University Medical School & Hospital, Gwangju, Korea
| | - Shin-Seok Lee
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School & Hospital, Gwangju, Korea
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11
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Basu N, Karabayas M, Pusey C. Prognosis and future developments in vasculitis. Best Pract Res Clin Rheumatol 2018; 32:148-165. [PMID: 30526894 DOI: 10.1016/j.berh.2018.08.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 08/07/2018] [Accepted: 08/24/2018] [Indexed: 12/11/2022]
Abstract
The prognosis of ANCA-associated vasculitis has been transformed in recent years. Once it was a set of invariably acute and fatal conditions, but these disorders are currently considered to be chronic diseases. This change is largely attributable to earlier diagnosis and the careful application of immunotherapeutics. However, patients still experience premature mortality, relapse, comorbid ill health and poor quality of life. Mortality rates in large-vessel vasculitis are not comparable; however, morbidity and poor patient outcomes prevail. Toxicity secondary to glucocorticoids represents a common driver of poor outcomes across systemic vasculitis. The main thrust of future treatment strategies is to reduce if not eliminate exposure to these agents.
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Affiliation(s)
- N Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, United Kingdom.
| | - M Karabayas
- Department of Rheumatology, NHS Grampian, United Kingdom
| | - C Pusey
- Department of Medicine, Imperial College London, United Kingdom
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12
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Sedhain A, Hada R, Agrawal RK, Bhattarai GR, Baral A. Low dose mycophenolate mofetil versus cyclophosphamide in the induction therapy of lupus nephritis in Nepalese population: a randomized control trial. BMC Nephrol 2018; 19:175. [PMID: 29996800 PMCID: PMC6042432 DOI: 10.1186/s12882-018-0973-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 06/27/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND The management of proliferative lupus nephritis (LN) comprises timely and coordinated immunosuppressive therapy. This study aimed to evaluate and compare the effectiveness and safety profile of low dose mycophenolate mofetil (MMF) and cyclophosphamide (CYC) in induction therapy of LN in Nepalese population. METHODS We conducted a prospective, open-label, randomized trial over a period of one and half years. Forty-nine patients with class III to V lupus nephritis were enrolled, out of which 42 patients (21 in each group) could complete the study. CYC was given intravenously as a monthly pulse and MMF was administered orally in the tablet form in the maximum daily dose of 1.5 g in two divided doses. RESULTS The mean age of the patients was 25.43 ± 10.17 years with female to male ratio of 7.3:1. Mean baseline serum creatinine was 1.58 ± 1.38 mg/dL and eGFR was 62.38 ± 26.76 ml/min/1.73m2. Mean 24-h urinary protein was 4.35 ± 3.71 g per 1.73 m2 body surface area. At 6 months, serum creatinine (mg/dL) decreased from 1.73 to 0.96 in CYC and from 1.24 to 0.91 in the MMF group with improvement in eGFR (ml/min/1.73 m2) from 60.33 to 88.52 in CYC and from 64.42 to 89.09 in MMF group. Twenty-four-hour urinary protein (gm/1.73m2) reduced from 4.47 to 0.94 in CYC and from 4.5 to 0.62 in the MMF group. Primary end point was achieved in higher percentage of patients with MMF than CYC (28.6% vs. 19%) while equal proportion of patients (67% in each group) achieved secondary end point in both groups. Number of non-responders was higher in CYC group than in the MMF group (14.3% vs. 4.8%). There was no difference in the rate of achievement of secondary end point in both CYC and MMF groups (3.16 vs. 3.05 months). The occurrence of adverse events was higher in the CYC than in MMF group (56 vs. 15 events). CONCLUSION Present study has concluded that MMF, used in relatively lower dose, is equally effective in inducing remission with reduction of proteinuria and improvement of kidney function with lesser adverse events than CYC in the induction therapy of proliferative lupus nephritis. TRIAL REGISTRATION Retrospectively registered to ClinicalTrials.gov PRS. NCT03200002 (Registered date: June 28, 2017).
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Affiliation(s)
- Arun Sedhain
- Nephrology Unit, Department of Medicine, Chitwan Medical College, Bharatpur, Chitwan, Nepal.
| | - Rajani Hada
- Department of Nephrology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal
| | - Rajendra K Agrawal
- Department of Nephrology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal
| | - Gandhi R Bhattarai
- OptumInsight, Product Engineering and Data Solutions, Rocky Hill, CT, 06067, USA
| | - Anil Baral
- Department of Nephrology, National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal
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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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Jin SY, Huang DL, Dang XQ, Yi ZW. Lupus glomerulonephritis in 788 Chinese children: a multi-centre clinical and histopathological analysis based on 549 renal biopsies. Paediatr Int Child Health 2017; 37:286-291. [PMID: 28463080 DOI: 10.1080/20469047.2017.1309337] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND System lupus erythematosus (SLE) is a severe multisystem autoimmune disease. OBJECTIVE To describe the clinical and pathological features, treatment, and renal outcome in children under 18 years with lupus nephritis (LN). METHODS The study was undertaken by a questionnaire completed in 26 Grade 3A hospitals' paediatric renal units in China. The study comprised 788 children (619 girls, 169 boys) diagnosed with SLE by the American College of Rheumatology criteria (1997) during 2005-2010. Results of renal biopsies were classified according to the guidelines of The International Association of Nephrology and the Renal Pathology Society (2003). Guidelines by the Chinese Society of Paediatric Nephrology were applied for the diagnosis and treatment (for trial implementation) in 2010 to determine inclusion. The data included the prevalence of acute kidney injury (AKI), SLE disease activity index (SLEDAI), renal histopathology and the induction of therapy mode. RESULTS The mean (SD) age of onset of SLE was 10.9 (2.90) years (range 1-18) and at diagnosis was 11.3 (2.9) years. The mean (SD) SLEDAI score was 13.5 (5.53). The clinical classification was as follows: about 36 (4.6%) patients had isolated haematuria, 99 (12.6%) isolated proteinuria, 60 (7.6%) isolated haematuria and proteinuria, 157 (19.9%) acute glomerulonephritis, 392 (49.7%) nephrotic syndrome, 20 (2.5%) rapidly progressive glomerulonephritis, 15 (1.9%) chronic nephritis, 2 (0.3%) tubule-interstitial damage and 7 (0.9%) subclinical LN. A total of 549 children (69.7%) underwent renal biopsy. The most frequent renal histopathological findings of LN were Class IV, followed by Class II and Class V + IV. There were no significant differences between the age groups in either renal pathological types or prognosis. In 242 (30.7%) patients, LN was complicated by AKI. Those with AKI had an older mean (SD) age at onset than the non-AKI patients [11.5 (2.8) years vs 10.7 (2.9) years, respectively, p < 0.0001] and a higher SLEDAI score [14.3 (5.8) vs 13.1 (5.4), respectively, p = 0.003]. In the induction phase, cyclophosphamide (CTX) and mycophenolate mofetil (MMF) were equally effective in the patients with the same pathological type. Follow-up records were only available for 482 (61.2%) patients, with a mean (SD) follow-up time of 21.5 (18.4) months. Six of the 35 patients who deteriorated required dialysis and seven died. CONCLUSION In LN, AKI is a risk factor for poor outcome. Owing to different times of onset and remission, the pathological types of LN cannot be estimated by clinical manifestation alone, and therefore renal biopsy should be undertaken in all LN children with AKI. In the induction phase, there was no significant difference in efficacy between CTX and MMF. Follow-up of children with LN in China needs to be improved.
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Affiliation(s)
- Si-Yan Jin
- a Division of Paediatric Nephrology, Department of Paediatrics , Central South University , Changsha , P. R. China
| | - Dan-Lin Huang
- a Division of Paediatric Nephrology, Department of Paediatrics , Central South University , Changsha , P. R. China
| | - Xi-Qiang Dang
- a Division of Paediatric Nephrology, Department of Paediatrics , Central South University , Changsha , P. R. China
| | - Zhu-Wen Yi
- a Division of Paediatric Nephrology, Department of Paediatrics , Central South University , Changsha , P. R. China
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Basu B, Roy B, Babu BG. Efficacy and safety of rituximab in comparison with common induction therapies in pediatric active lupus nephritis. Pediatr Nephrol 2017; 32:1013-1021. [PMID: 28191596 DOI: 10.1007/s00467-017-3583-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 12/21/2016] [Accepted: 12/21/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Childhood-onset lupus nephritis (LN) is one of the most severe manifestations of systemic lupus erythematosus (SLE). Despite treatment-related toxicities, cyclophosphamide (CYC) and glucocorticoid-based treatment protocols are still considered standard therapy in managing this multisystem disorder. An effective and safe alternative induction regimen is needed. METHODS Forty-four pediatric patients with active LN aged 3.5-13.8 (median 8.4) years, of whom 32 entered the study at diagnosis of SLE, were followed over 36 months. Induction therapy consisted of methylprednisolone pulses followed by either rituximab (RTX) (n = 17), mycophenolate mofetil (MMF) (n = 12) or pulse-CYC (n = 15), with tapering dose of prednisolone orally. MMF was added as maintenance immunosuppressant (800 mg/m2 daily) in all children from the third month onward. RESULTS Flare-free survival was significantly higher at 36 months with RTX compared with MMF and CYC (100% for RTX vs. 83% for MMF. and 53% for CYC, p = 0·006). Twelve patients (76.5%) achieved complete remission with RTX compared with five (41.7%) and seven (46.7%) with MMF and CYC, respectively, at last follow-up. Requirement of mean daily dosage of prednisone was significantly lower in RTX group [p = 0.005 (RTX vs MMF); 0.0001 (RTX vs CYC) at 36 months] compared with other groups after the 3-month follow-up. In comparison with few minor adverse events in the other two cohorts, several serious adverse events occurred in the CYC group. CONCLUSIONS Efficacy and medium-term safety of RTX induction followed by MMF maintenance therapy in inducing and maintaining remission among children with LN were evident in this study.
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Affiliation(s)
- Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, NRS Medical College & Hospital, Kolkata, 700014, West Bengal, India.
| | - Birendranath Roy
- Department of Pediatrics, NRS Medical College & Hospital, Kolkata, India
| | - Binu George Babu
- Division of Pediatric Nephrology, Department of Pediatrics, NRS Medical College & Hospital, Kolkata, India.,Department of Pediatrics, Caritas Hospital, Kerala, India
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16
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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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17
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Chowdhary VR. Broad Concepts in Management of Systemic Lupus Erythematosus. Mayo Clin Proc 2017; 92:744-761. [PMID: 28473038 DOI: 10.1016/j.mayocp.2017.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/18/2017] [Accepted: 02/16/2017] [Indexed: 12/14/2022]
Abstract
Systemic lupus erythematosus is a multisystem autoimmune disease with protean manifestation. Although commonly seen in young women, it can affect men as well as elderly patients. Approach to treatment is multidisciplinary, involves defining the extent of organ involvement, and distinguishing between active manifestations and damage. The mainstay of therapy is judicious use of immunosuppressive medications. Long-term follow-up to address morbidity arising from treatment complications, disease damage, and increased cardiovascular risk is essential.
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Affiliation(s)
- Vaidehi R Chowdhary
- Division of Rheumatology, Department of Medicine, Mayo Clinic, Rochester MN.
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18
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Pakfetrat M, Malekmakan L, Kamranpour M, Tadayon T. A five consecutive years' study of renal function outcome among biopsy proven lupus nephritis patients in Southern Iran. Lupus 2017; 26:1082-1088. [PMID: 28420065 DOI: 10.1177/0961203317696588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Lupus nephritis (LN) is one of the most common complications of systemic lupus erythematous (SLE) responsible for an increase in mortality and morbidity. This study was conducted to evaluate the outcome for LN patients and factors that correlate with their outcome. Materials and methods We included 80 patients with proved LN and more than three-years follow up at Shiraz University of Medical Sciences. We prepared a data gathering sheet for each patient and extracted the data from patients' file records which existed in the hospital. Results The mean age of patients was 36.6 ± 10.6 years, and 88.3% of patients were women. Men develop remission less than women (three men (33.3%) vs 49 women (72.1%), p = 0.014). Chronic kidney disease (GFR < 60) developed in 14.2% of our patients, and 7.8% progressed to end stage renal disease (ESRD). We found a significant relation between initial creatinine (Cr), GFR, and urine 24 hour protein with developing ESRD ( p = 0.002, 0.039, < 0.001, respectively). Also we found that hypertensive patients are at risk of developing ESRD 0.4 times more than normotensive patients ( p = 0.047, CI: 0.131-0.985). Lack of remission was significantly associated with ESRD progression ( p = 0.025). Conclusion There is a strong agreement among studies that initial Cr, hypertension and lack of remission are associated with poor outcome in LN patients. As a result we must observe hypertensive patients and patients with increased Cr more carefully. Also, we should consider changing treatment in patients who do not develop remission. In spite of dominancy of women in SLE, men are likely to have poorer outcomes.
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Affiliation(s)
- M Pakfetrat
- 1 Department of Internal Medicine, Shiraz Nephro Urology Research Center, Shiraz University of Medical Sciences, Iran
| | - L Malekmakan
- 2 Shiraz Nephro Urology Research Center, Shiraz University of Medical Sciences, Iran
| | - M Kamranpour
- 1 Department of Internal Medicine, Shiraz Nephro Urology Research Center, Shiraz University of Medical Sciences, Iran
| | - T Tadayon
- 2 Shiraz Nephro Urology Research Center, Shiraz University of Medical Sciences, Iran
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19
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Kuhn A, Aberer E, Bata-Csörgő Z, Caproni M, Dreher A, Frances C, Gläser R, Klötgen HW, Landmann A, Marinovic B, Nyberg F, Olteanu R, Ranki A, Szepietowski JC, Volc-Platzer B. S2k guideline for treatment of cutaneous lupus erythematosus - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2016; 31:389-404. [PMID: 27859683 DOI: 10.1111/jdv.14053] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/26/2016] [Indexed: 12/31/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is a rare inflammatory autoimmune disease with heterogeneous clinical manifestations. To date, no therapeutic agents have been licensed specifically for patients with this disease entity, and topical and systemic drugs are mostly used 'off-label'. The aim of the present guideline was to achieve a broad consensus on treatment strategies for patients with CLE by a European subcommittee, guided by the European Dermatology Forum (EDF) and supported by the European Academy of Dermatology and Venereology (EADV). In total, 16 European participants were included in this project and agreed on all recommendations. Topical corticosteroids remain the mainstay of treatment for localized CLE, and further topical agents, such as calcineurin inhibitors, are listed as alternative first-line or second-line topical therapeutic option. Antimalarials are recommended as first-line and long-term systemic treatment in all CLE patients with severe and/or widespread skin lesions, particularly in patients with a high risk of scarring and/or the development of systemic disease. In addition to antimalarials, systemic corticosteroids are recommended as first-line treatment in highly active and/or severe CLE. Second- and third-line systemic treatments include methotrexate, retinoids, dapsone and mycophenolate mofetil or mycophenolate acid, respectively. Thalidomide should only be used in selected therapy-refractory CLE patients, preferably in addition to antimalarials. Several new therapeutic options, such as B-cell- or interferon α-targeted agents, need to be further evaluated in clinical trials to assess their efficacy and safety in the treatment of patients with CLE.
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Affiliation(s)
- A Kuhn
- Interdisciplinary Center for Clinical Trials (IZKS), University Medical Center Mainz, Mainz, Germany.,Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg, Germany
| | - E Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Z Bata-Csörgő
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - M Caproni
- Department of Medical and Surgical Critical Care Section of Dermatology, University of Florence, Florence, Italy
| | - A Dreher
- Evidence-Based Medicine Frankfurt, Institute for General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Paris, France
| | - R Gläser
- Department of Dermatology, Venerology and Allergology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - H-W Klötgen
- Department of Dermatology, Inselspital Bern - University Hospital, Bern, Switzerland
| | - A Landmann
- Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg, Germany
| | - B Marinovic
- Department of Dermatology and Venereology, University Hospital Center Zagreb and School of Medicine University of Zagreb, Zagreb, Croatia
| | - F Nyberg
- Institution for Clinical Sciences, Unit for Dermatology, Karolinska Institutet at Danderyd Hospital (KIDS), Stockholm, Sweden
| | - R Olteanu
- Department of Dermatology, Colentina Clinical Hospital, Bucharest, Romania
| | - A Ranki
- Department of Skin and allergic diseases, Inflammation Center, Helsinki University Central Hospital, Helsinki, Finland
| | - J C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - B Volc-Platzer
- Department of Dermatology, Donauspital, University affiliated Hospital, Vienna, Austria
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20
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Sigdel MR, Kafle MP, Shah DS. Outcome of low dose cyclophosphamide for induction phase treatment of lupus nephritis, a single center study. BMC Nephrol 2016; 17:145. [PMID: 27717323 PMCID: PMC5055665 DOI: 10.1186/s12882-016-0361-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/29/2016] [Indexed: 12/26/2022] Open
Abstract
Background The current standard for induction phase treatment of lupus nephritis is steroid combined with mycophenolate mofetil or pulse intravenous cyclophosphamide (IVC). The lowest dose of IVC recommended for induction therapy is that used in the Euro-Lupus Trial. It is not known whether same cumulative dose of IVC would be effective when given over six months. Methods We carried out a prospective, observational study on 41 patients of biopsy-proven lupus nephritis (class III, IV, V or mixed). For induction, patients received six pulses of monthly IVC (500 mg each), along with steroid. Patients were followed up monthly until one month beyond completion of the sixth pulse. The outcomes assessed were complete remission (proteinuria < 200 mg/day or urine albumin nil with serum albumin >35 gm/L, stable estimated glomerular filtration rate (eGFR) if normal at baseline or increase in eGFR by 25 % if abnormal at baseline and normal urinary sediment), response (complete or partial remissions), complications of therapy and death. Results Twenty two patients (53.7 %) had class IV nephritis. Eighteen patients (43.9 %) achieved complete remission, 16 (39.0 %) achieved partial remission, yielding an overall response rate of 82.9 %. Nephrotic range proteinuria (UTP ≥ 3 g/day) and severe hypoalbuminemia (serum albumin < 20 g/L) at baseline influenced remission (p <0.05). Infection, seen in 12 patients (29.3 %), was the most common complication. Four deaths (9.6 %) were observed, all due to infection. Conclusions For induction phase treatment, Nepalese patients with lupus nephritis responded favorably to steroid and low dose IVC of 3 grams given as six monthly pulses.
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Affiliation(s)
- Mahesh R Sigdel
- Department of Nephrology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
| | - Mukunda P Kafle
- Department of Nephrology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Dibya Singh Shah
- Department of Nephrology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Mahieu MA, Strand V, Simon LS, Lipsky PE, Ramsey-Goldman R. A critical review of clinical trials in systemic lupus erythematosus. Lupus 2016; 25:1122-40. [PMID: 27497257 PMCID: PMC4978143 DOI: 10.1177/0961203316652492] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
One challenge in caring for patients with systemic lupus erythematosus (SLE) is a paucity of approved therapeutics for treatment of the diverse disease manifestations. In the last 60 years, only one drug, belimumab, has been approved for SLE treatment. Critical evaluation of investigator initiated and pharma-sponsored randomized controlled trials (RCTs) highlights barriers to successful drug development in SLE, including disease heterogeneity, inadequate trial size or duration, insufficient dose finding before initiation of large trials, handling of background medications, and choice of primary endpoint. Herein we examine lessons learned from landmark SLE RCTs and subsequent advances in trial design, as well as discuss efforts to address limitations in current SLE outcome measures that will improve detection of true therapeutic responses in future RCTs.
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Affiliation(s)
- M A Mahieu
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - V Strand
- Division of Immunology/Rheumatology, Stanford University School of Medicine, Palo Alto, USA
| | | | - P E Lipsky
- AMPEL BioSolutions, Charlottesville, USA
| | - R Ramsey-Goldman
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, USA
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22
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Comparison of low-dose intravenous cyclophosphamide with oral mycophenolate mofetil in the treatment of lupus nephritis. Kidney Int 2016; 89:235-42. [DOI: 10.1038/ki.2015.318] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/04/2015] [Accepted: 08/20/2015] [Indexed: 02/06/2023]
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23
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Danafar H, Hamidi M. Simple and Sensitive High-Performance Liquid Chromatography (HPLC) Method with UV Detection for Mycophenolic Acid Assay in Human Plasma. Application to a Bioequivalence Study. Adv Pharm Bull 2015; 5:563-8. [PMID: 26819930 DOI: 10.15171/apb.2015.076] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Revised: 09/01/2015] [Accepted: 09/11/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE A simple and available reversed-phase high performance liquid chromatography (HPLC) method with UV detection has been developed and validated for mycophenolic acid (MPA) assay in human plasma. METHODS MPA was extracted from plasma with protein precipitation method by acetonitrile: percholeric acid: methanol (75:5:20 v/v/v). The drug separation was achieved using a C8 analytical column and a mobile phase of 0.1M triethylammonium phosphate (pH=5.4)-acetonitril (65:35, v/v), with a flow rate of 1.5 ml/min. The detection wavelength was 304 nm. Limit of detection (LOD) of the method was determined as the lowest MPA concentration producing a signal-to-noise (S/N) ratio of about 3. Limit of quantitation (LOQ) was determined as the lowest MPA concentration capable of being quantitated with enough accuracy and precision. RESULTS The method showed significant linear response-concentration relationship throughout the MPA concentration range of 0.2-10 µg/ml. A typical linear regression equation of the method was: y = 8.5523 x + 0.094, with x and y representing MPA concentration (in µg/ml) and peak height respectively, and the regression coefficient (r) of 0.9816. The average within-run and between-run variations of 7.81 and 4.78 percent. The average drug recovery from plasma was 95.24 percent throughout the linear concentration range. The limits of detection (LOD) and quantitation (LOQ) of the method were 0.05 and 0.2 µg/ml, respectively. The practical applicability of the method was proven throughout a bioequivalence study. CONCLUSION The results showed the acceptable degree of linearity, sensitivity, precision, accuracy and recovery for the method. The method was used successfully for quantitation of MPA in plasma samples of healthy volunteers throughout a bioequivalence study.
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Affiliation(s)
- Hossein Danafar
- Department of Medicinal Chemistry, School of Pharmacy, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mehrdad Hamidi
- Department of Pharmaceutics, School of Pharmacy, Zanjan University of Medical Sciences, Zanjan, Iran
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Chou HH, Chen MJ, Chiou YY. Enteric-coated mycophenolate sodium in pediatric lupus nephritis: a retrospective cohort study. Clin Exp Nephrol 2015; 20:628-636. [DOI: 10.1007/s10157-015-1171-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 09/22/2015] [Indexed: 02/04/2023]
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25
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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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Rezaieyazdi Z, Tavakoli T, Khajehdaluee M, Honarmand S. Efficacy of long-term maintenance therapy with mycophenolate mofetil in lupus nephritis. SPRINGERPLUS 2014; 3:638. [PMID: 25392806 PMCID: PMC4227986 DOI: 10.1186/2193-1801-3-638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 09/29/2014] [Indexed: 01/09/2023]
Abstract
Background Mycophenolate mofetil (MMF) has long been used to manage lupus nephritis. Despite research on its long-term efficacy, it is still warranted to conduct further investigation regarding its indications, safety and outcome. This study was intended to evaluate our proposed protocol in maintenance therapy with MMF. Twenty-four lupus nephritis patients were registered prior to their receiving 3–6 month induction therapy with monthly iv pulses of cyclophosphamide (CYC), followed by 24 month maintenance therapy using MMF and steroid. We defined end points as achievement of complete and partial remission, relapse, refractory to therapy as well as end stage renal disease (ESRD) and death. Friedman and repeated measurement tests were used to assess the effect of treatment on parameters over time. Complete renal remission was achieved in 79.16% until the end of the last follow up with an average period of 12.45 ± 7.37 months since treatment commenced. Significant statistical differences were seen regarding proteinuria, hematuria, leukocyturia, plasma creatinine, C3, C4 before and after therapy (P < 0.05): plasma creatinine and proteinurea falling from 0.96 ± 0.65 to 0.75 ± 0.19 mg/dl (P < 0.14) and from 1.64 ± 1.12 to 0.27 ± 0.60 gr/24 h (P < 0.001). By the end of 24-month, 95.8% of patients had been in remission. Four episodes of relapse ended in remission followed by retreatment. No life-threatening side effects were observed in 66.6% of patients with fourteen cases of infection (58.3%). None of them developed ESRD. Maintenance therapy with MMF was shown to yield favorable outcome with minimal complications, in treating lupus nephritis (IRCT2012071710313N1).
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Affiliation(s)
- Zahra Rezaieyazdi
- Rheumatic Diseases Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Tahmine Tavakoli
- Internal Medicine, Brigand University of Medical Sciences, Brigand, Iran
| | | | - Shahram Honarmand
- Rheumatic Diseases Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Jones RB, Walsh M, Chaudhry AN, Smith KGC, Jayne DRW. Randomized trial of enteric-coated mycophenolate sodium versus mycophenolate mofetil in multi-system autoimmune disease. Clin Kidney J 2014; 7:562-8. [PMID: 25859373 PMCID: PMC4389135 DOI: 10.1093/ckj/sfu096] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2014] [Accepted: 08/19/2014] [Indexed: 12/13/2022] Open
Abstract
Background The use of mycophenolate mofetil (MMF) in autoimmune disease is often limited by adverse effects. In this single-centre, open label, parallel design study, we investigated whether enteric-coated mycophenolate sodium (MS) is better tolerated and therefore more efficacious than MMF in primary systemic vasculitis (PSV) and systemic lupus erythematosus (SLE). Methods Forty patients with vasculitis or systemic lupus erythematosus (SLE) due to commence MMF for active disease or remission maintenance were randomized to receive either 1440 mg/day MS or 2000 mg/day MMF (18 PSV, 2 SLE per group) in addition to corticosteroids. Random allocation was performed by minimization for age, diagnosis and renal function using a computer algorithm. Twenty-five were treated for active disease (5 first-line therapy, 20 salvage therapy) and 15 for remission maintenance. The composite primary end point was treatment failure and/or drug intolerance over 12 months. Treatment failure was defined as failure to achieve remission by 6 months or disease relapse and treatment intolerance was defined as inability to tolerate and maintain the target dose of MS or MMF within 12 months. Results Forty patients were included in the analyses. MS was associated with a lower primary end point rate [hazard ratio (HR) 0.37; 95% CI 0.17–0.80; P = 0.012] (11/20, 55% patients) compared with MMF (17/20, 85% patients). Treatment failure alone was less common in the MS group (HR 0.28; 95% CI 0.095–0.82; P = 0.020), although drug intolerance did not differ between groups (HR 0.53; 95% CI 0.20–1.42; P = 0.21). Despite randomization, patients in the MMF group may have had a higher baseline risk for treatment failure; more MMF patients had refractory disease and granulomatosis with polyangiitis (Wegener's). A glomerular filtration rate (GFR) ≤40 mL/min was associated with intolerance. Serious adverse events were common (55% MMF and 45% MS patients). Conclusions No differences in treatment tolerance were observed between the MS and MMF groups. Despite similar treatment intolerance, MS was associated with improved efficacy in PSV and SLE compared with MMF. However, baseline group imbalances in factors potentially affecting remission and relapse may have influenced the results. Treatment intolerance was common and strongly associated with low GFR. Further treatment trials are warranted to investigate the effect of GFR on mycophenolic acid pharmacokinetics and clinical outcomes (ISRCTN83027184; EUDRACT 2005-002207-16; Funding Novartis UK).
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Affiliation(s)
- Rachel B Jones
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK
| | - Michael Walsh
- Departments of Medicine and Clinical Epidemiology & Biostatistics , McMaster University , Hamilton, Canada
| | - Afzal N Chaudhry
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK
| | - Kenneth G C Smith
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK ; Cambridge Institute of Medical Research , University of Cambridge School of Clinical Medicine , Cambridge , UK ; Department of Medicine , University of Cambridge School of Clinical Medicine , Cambridge , UK
| | - David R W Jayne
- Vasculitis and Lupus Clinic , Addenbrooke's Hospital , Cambridge , UK ; Department of Medicine , University of Cambridge School of Clinical Medicine , Cambridge , UK
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Chaigne B, Gatault P, Darrouzain F, Barbet C, Degenne D, François M, Szymanski P, Rabot N, Golea G, Diot E, Maillot F, Lebranchu Y, Nivet H, Paintaud G, Halimi JM, Guillevin L, Büchler M. Mycophenolate mofetil in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis: a prospective pharmacokinetics and clinical study. Clin Exp Immunol 2014; 176:172-9. [PMID: 24304103 DOI: 10.1111/cei.12246] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2013] [Indexed: 12/13/2022] Open
Abstract
Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) treatment strategy is based on immunosuppressive agents. Little information is available concerning mycophenolic acid (MPA) and the area under the curve (AUC) in patients treated for AAV. We evaluated the variations in pharmacokinetics for MPA in patients with AAV and the relationship between MPA-AUC and markers of the disease. MPA blood concentrations were measured through the enzyme-multiplied immunotechnique (C(0), C(30), C(1), C(2), C(3), C(4), C(6) and C(9)) to determine the AUC. Eighteen patients were included in the study. The median (range) MPA AUC(0-12) was 50·55 (30·9-105·4) mg/h/l. The highest coefficient of determination between MPA AUC and single concentrations was observed with C(3) (P < 0·0001) and C(2) (P < 0·0001) and with C(4) (P < 0·0005) or C(0) (P < 0·001). Using linear regression, the best estimation of MPA AUC was provided by a model including C(30), C(2) and C(4): AUC = 8·5 + 0·77 C(30) + 4·0 C(2) + 1·7 C(4) (P < 0·0001). Moreover, there was a significant relationship between MPA AUC(0-12) and lymphocyte count (P < 0·01), especially CD19 (P < 0·005), CD8 (P < 0·05) and CD56 (P < 0·05). Our results confirm the interindividual variability of MPA AUC in patients treated with MMF in AAV and support a personalized therapy according to blood levels of MPA.
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Affiliation(s)
- B Chaigne
- Department of Immunology and Nephrology, Tours University Hospital, Tours, France; Department of Internal Medicine, Tours University Hospital, Tours, France; Université François Rabelais, Tours, France
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Tazi Mezalek Z, Bono W. Challenges for lupus management in emerging countries. Presse Med 2014; 43:e209-20. [PMID: 24857588 DOI: 10.1016/j.lpm.2014.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 04/03/2014] [Indexed: 12/23/2022] Open
Abstract
In emerging countries, systemic lupus erythematosus (SLE) has been associated with several unfavorable outcomes including disease activity, damage accrual, work disability and mortality. Poor socioeconomic status (SES) and lack of access to healthcare, especially in medically underserved communities, may be responsible for many of the observed disparities. Diagnostic delay of SLE or for severe organ damages (renal involvement) have a negative impact on those adverse outcomes in lupus patients who either belong to minority groups or live in emerging countries. Longitudinal and observational prospective studies and registries may help to identify the factors that influence poor SLE outcomes in emerging countries. Infection is an important cause of mortality and morbidity in SLE, particularly in low SES patients and tuberculosis appears to be frequent in SLE patients living in endemic areas (mainly emerging countries). Thus, tuberculosis screening should be systematically performed and prophylaxis discussed for patients from these areas. SLE treatment in the developing world is restricted by the availability and cost of some immunosuppressive drugs. Moreover, poor adherence has been associated to bad outcomes in lupus patients with a higher risk of flares, morbidity, hospitalization, and poor renal prognosis. Low education and the lack of money are identified as the main barrier to improve lupus prognosis. Newer therapeutic agents and new protocols had contributed to improve survival in SLE. The use of corticoid-sparing agents (hydroxychloroquine, methotrexate, azathioprine and mycophenolate mofetif) is one of the most useful strategy; availability of inexpensive generics may help to optimize access to these medications.
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Affiliation(s)
- Zoubida Tazi Mezalek
- Université Mohamed V Souissi, Faculté de médecine et de pharmacie, 10000 Rabat, Morocco; Ibn Sina University Hospital, internal medicine department, 10000 Rabat, Morocco.
| | - Wafaa Bono
- Hassan II University Hospital, internal medicine and immunology Clinic, Fès, Morocco
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Takahashi S, Hiromura K, Sakurai N, Matsumoto T, Ikeuchi H, Maeshima A, Kaneko Y, Kuroiwa T, Nojima Y. Efficacy and safety of tacrolimus for induction therapy in patients with active lupus nephritis. Mod Rheumatol 2014. [DOI: 10.3109/s10165-010-0398-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Satoshi Takahashi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
| | - Keiju Hiromura
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
| | - Noriyuki Sakurai
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
| | - Takayuki Matsumoto
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
| | - Hidekazu Ikeuchi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
| | - Akito Maeshima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
| | - Yoriaki Kaneko
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
| | - Takashi Kuroiwa
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
| | - Yoshihisa Nojima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
3-39-22 Showa, Maebashi 371-8511, Japan
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Ikeuchi H, Hiromura K, Takahashi S, Mishima K, Sakurai N, Sakairi T, Kaneko Y, Maeshima A, Kuroiwa T, Nojima Y. Efficacy and safety of multi-target therapy using a combination of tacrolimus, mycophenolate mofetil and a steroid in patients with active lupus nephritis. Mod Rheumatol 2013; 24:618-25. [DOI: 10.3109/14397595.2013.844397] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hidekazu Ikeuchi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Keiju Hiromura
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Satoshi Takahashi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Keiichiro Mishima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Noriyuki Sakurai
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Toru Sakairi
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Yoriaki Kaneko
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Akito Maeshima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Takashi Kuroiwa
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
| | - Yoshihisa Nojima
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine,
Maebashi, Japan
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32
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Treatment strategies for vasculitis that affects the nervous system. Drug Discov Today 2013; 18:818-35. [DOI: 10.1016/j.drudis.2013.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 05/08/2013] [Accepted: 05/15/2013] [Indexed: 01/04/2023]
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Mysler EF, Spindler AJ, Guzman R, Bijl M, Jayne D, Furie RA, Houssiau FA, Drappa J, Close D, Maciuca R, Rao K, Shahdad S, Brunetta P. Efficacy and Safety of Ocrelizumab in Active Proliferative Lupus Nephritis: Results From a Randomized, Double-Blind, Phase III Study. ACTA ACUST UNITED AC 2013; 65:2368-79. [DOI: 10.1002/art.38037] [Citation(s) in RCA: 210] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 05/23/2013] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | - Marc Bijl
- Martini Hospital; Groningen The Netherlands
| | | | | | - Frédéric A. Houssiau
- Cliniques Universitaires Saint-Luc, Université Catholique de Louvain; Brussels Belgium
| | - Jorn Drappa
- Genentech, Inc.; South San Francisco California
| | | | | | - Kajal Rao
- Comprehensive Kidney Care; Chicago Illinois
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Hogan JJ, Bomback AS. Mycophenolate Mofetil in Severe Lupus Nephritis: Should Post Hoc Analyses Change Treatment Patterns? Am J Kidney Dis 2013; 61:692-3. [DOI: 10.1053/j.ajkd.2013.02.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 02/11/2013] [Indexed: 11/11/2022]
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Walsh M, Solomons N, Lisk L, Jayne DR. Mycophenolate Mofetil or Intravenous Cyclophosphamide for Lupus Nephritis With Poor Kidney Function: A Subgroup Analysis of the Aspreva Lupus Management Study. Am J Kidney Dis 2013; 61:710-5. [DOI: 10.1053/j.ajkd.2012.11.042] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 11/07/2012] [Indexed: 12/15/2022]
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Abstract
Lupus nephritis (LN) is more common and severe in childhood-onset systemic lupus erythematosus (SLE) than in adults. It is one of the major causes of acute kidney injury (AKI) and chronic kidney disease (CKD) in children. Steroid therapy has been used as the first-line treatment for SLE since 1970, and has improved the survival of SLE patients from ∼ 50% to >80%. Over the years many immunosuppressive drugs, including pulse methylprednisolone, oral cyclophosphamide, pulse intravenous cyclophosphamide, mycophenolate mofitil, rituximab, and tacrolimus, have been combined with prednisolone, further improving survival rates to 90%-95%. However, the effectiveness of these drugs is still uncertain, as most seem very good in the beginning, but in studies examining longer-term follow-up the remission of disease does not remain. Fatal infection is still a major complication of aggressive chemotherapy, and the potential benefits as well as adverse events from each drug need to be considered. Induction of remission is the major aim of therapy, with safe and effective maintenance therapy for long-term remission. The survival rates of many published studies vary widely because of differences in patients and treatment modalities, severity of disease, renal histopathology, racial factors, and duration of follow-up. Finding the optimal treatment for SLE and related co-morbidities is highly challenging, and will likely involve a complex combination of different drugs for different patients in the search for giving them an opportunity to be free from this debilitating disease.
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Affiliation(s)
- P Vachvanichsanong
- Department of Pediatrics, Prince of Songkla University, Songkla 90110,Thailand.
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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.
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Affiliation(s)
- Lorna Henderson
- Centre for Transplant and Renal Research, Westmead Millennium Institute, The University of Sydney at Westmead, Westmead,Australia.
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Liu LL, Jiang Y, Wang LN, Yao L, Li ZL. Efficacy and safety of mycophenolate mofetil versus cyclophosphamide for induction therapy of lupus nephritis: a meta-analysis of randomized controlled trials. Drugs 2012; 72:1521-33. [PMID: 22818016 DOI: 10.2165/11635030-000000000-00000] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Whether mycophenolate mofetil is superior to cyclophosphamide as induction therapy for lupus nephritis (LN) remains controversial. OBJECTIVE Our objective was to investigate the efficacy and safety of mycophenolate mofetil compared with cyclophosphamide as induction therapy for LN patients. METHODS Randomized controlled trials (RCTs) on humans were identified in searches of PubMed/MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (all to 1 December 2011). Studies that compared the efficacy and safety between mycophenolate mofetil and cyclophosphamide as induction therapy in LN patients were selected. Methodological quality of the included trials was assessed according to Cochrane criteria and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The fixed effects model was applied for pooling where there was no significant heterogeneity, otherwise the random effects model (Dersimonian and Laird method) was performed. RESULTS Seven trials were identified, including 725 patients. The Dersimonian and Laird method was applied for renal remission in the presence of significant heterogeneity, and no statistically significant differences were distinguished between mycophenolate mofetil and cyclophosphamide. To explore the possible source of heterogeneity, meta-regression was performed. It was suggested that no obvious study- or patient-level factors could explain interstudy heterogeneity with statistical significance. Among all these factors, the mode of administration of cyclophosphamide could explain most of the heterogeneity, although the coefficient was insignificant. Therefore, we performed a sensitivity analysis by excluding the trial in which cyclophosphamide was administered orally instead of intravenously, which suggested that mycophenolate mofetil was more effective than intravenous cyclophosphamide for inducing complete remission (relative risk [RR] 1.72; 95% CI 1.17, 2.55; p = 0.006) and complete or partial remission (RR 1.18; 95% CI 1.04, 1.35; p = 0.01). In addition, mycophenolate mofetil was superior to cyclophosphamide for significantly reducing end-stage renal disease (ESRD) or death (RR 0.64; 95% CI 0.41, 0.98; p = 0.04). For the safety comparison, lower risks of leukopenia, amenorrhoea and alopecia, and a higher risk of diarrhoea were found with mycophenolate mofetil. No statistical differences in infection and gastrointestinal symptoms were distinguished between mycophenolate mofetil and cyclophosphamide. The relatively small number and the open-label fashion of eligible RCTs may limit the value of our meta-analysis. CONCLUSIONS Mycophenolate mofetil is superior to intravenous cyclophosphamide for inducing renal remission, and has a significant advantage over cyclophosphamide for reducing ESRD or death. Furthermore, mycophenolate mofetil has lower risks of leukopenia, amenorrhoea and alopecia, but a higher risk of diarrhoea than cyclophosphamide. However, our conclusions need to be proved further in larger well designed trials.
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Affiliation(s)
- Lin-Lin Liu
- Department of Nephrology, The First Hospital of China Medical University, Shen Yang, Peoples Republic of China
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Henderson LK, Masson P, Craig JC, Roberts MA, Flanc RS, Strippoli GFM, Webster AC. Induction and maintenance treatment of proliferative lupus nephritis: a meta-analysis of randomized controlled trials. Am J Kidney Dis 2012. [PMID: 23182601 DOI: 10.1053/j.ajkd.2012.08.041] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Lupus nephritis accounts for ~1% of patients starting dialysis therapy. Treatment regimens combining cyclophosphamide with steroids preserve kidney function but have significant side effects. Newer immunosuppressive agents may have improved toxicity profiles. STUDY DESIGN Systematic review and random-effects meta-analysis, searching MEDLINE (1966 to April 2012), EMBASE (1988-2011), and the Cochrane Renal Group Specialised Register. SETTING & POPULATION Patients with biopsy-proven proliferative lupus nephritis (classes III, IV, V+III, and V+IV). SELECTION CRITERIA Randomized controlled trials. INTERVENTION Immunosuppressive treatment regimens used for induction and maintenance therapy of lupus nephritis. OUTCOMES Mortality, renal remission and relapse, doubling of creatinine level, proteinuria, incidence of end-stage kidney disease, ovarian failure, alopecia, leukopenia, infections, diarrhea, vomiting, malignancy, and bladder toxicity. RESULTS 45 trials (2,559 participants) of induction therapy and 6 (514 participants) of maintenance therapy were included. In induction regimens comparing mycophenolate mofetil (MMF) with intravenous cyclophosphamide, there was no significant difference in mortality (7 studies, 710 patients; risk ratio [RR], 1.02; 95% CI, 0.52-1.98), incidence of end-stage kidney disease (3 studies, 231 patients; RR, 0.71; 95% CI, 0.27-1.84), complete renal remission (6 studies, 686 patients; RR, 1.39; 95% CI, 0.99-1.95), and renal relapse (1 study, 140 patients; RR, 0.97; 95% CI, 0.39-2.44). MMF-treated patients had significantly lower risks of ovarian failure (2 studies, 498 patients; RR, 0.15; 95% CI, 0.03-0.80) and alopecia (2 studies, 522 patients; RR, 0.22; 95% CI, 0.06-0.86). In maintenance therapy comparing azathioprine with MMF, the risk of renal relapse was significantly higher (3 studies, 371 patients; RR, 1.83; 95% CI, 1.24-2.71). LIMITATIONS Heterogeneity in interventions and definitions of remission and lack of long-term outcome reporting. CONCLUSIONS MMF is as effective as cyclophosphamide in achieving 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 difference in clinically important side effects.
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Affiliation(s)
- Lorna K Henderson
- Cochrane Renal Group, Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia.
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Should mycophenolate mofetil replace cyclophosphamide as first-line therapy for severe lupus nephritis? Kidney Int 2012; 82:1256-60. [PMID: 22648298 DOI: 10.1038/ki.2012.203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Available treatments for severe (class III, IV, and V) lupus nephritis (LN) have expanded greatly over the last 40 years. In the 1970s and 1980s, cyclophosphamide (CYC), in combination with glucocorticoids, gained favor as induction and maintenance therapy for severe LN. However, the adverse event profile of CYC led to the search for other medications for severe LN. Beginning in the late 1990 s, mycophenolate mofetil (MMF) was introduced as induction and maintenance therapy for severe LN. This review discusses the clinical trial results, pharmacology, cost-effectiveness, and adverse effect profiles of CYC compared to MMF for induction and maintenance therapy for severe LN. The authors conclude that MMF should be considered first-line induction and maintenance treatment therapy for severe LN, although CYC may have a place under specific clinical and economic circumstances.
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Abstract
Immunotherapy has been used for the treatment of renal diseases for a long time, and there has been significant progress in such treatment. This review focuses on the use of immunotherapy for the treatment of glomerular diseases. The use of immunosuppression in the treatment of minimal change disease, membranous nephropathy, primary focal segmental glomerulosclerosis, lupus nephritis, immunoglobulin-A nephropathy, antineutrophil cytoplasmic antibody-associated disease, and anti-glomerular basement membrane disease is discussed.
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Affiliation(s)
- Ajay Kher
- The Transplant Institute, Beth Israel Deaconess Medical Center, 110 Francis Street, 7th Floor, Boston, MA 02215, USA.
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Ruiz-Irastorza G, Espinosa G, Frutos MA, Jiménez Alonso J, Praga M, Pallarés L, Rivera F, Robles Marhuenda Á, Segarra A, Quereda C. [Diagnosis and treatment of lupus nephritis]. Rev Clin Esp 2012; 212:147.e1-30. [PMID: 22361331 DOI: 10.1016/j.rce.2012.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- G Ruiz-Irastorza
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital Universitario Cruces, UPV/EHU, Barakaldo, Bizkaia, España.
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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.
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Affiliation(s)
- F Rivera
- Hospital General de Ciudad Real, Ciudad Real, España. friverahdez @ senefro.org
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Ostalska-Nowicka D, Malinska A, Silska M, Perek B, Zachwieja J, Nowicki M. Mycophenolate mofetil (MMF) treatment efficacy in children with primary and secondary glomerulonephritis. Arch Med Sci 2011; 7:1042-8. [PMID: 22328889 PMCID: PMC3264998 DOI: 10.5114/aoms.2011.26618] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 05/10/2011] [Accepted: 09/25/2011] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The aim of our study was to analyse the efficacy and safety of mycophenolate mofetil (MMF) as part of the complex immunosuppressive therapy in children with different types of primary and secondary glomerulonephritis, who were not eligible for the standard treatment routine suggested by evidence-based guidelines. MATERIAL AND METHODS The study group comprised 85 children with proteinuric glomerulopathies hospitalized between 2007 and 2010, who were non-responders to immunosuppressive therapy. The dose of MMF was established as 1 g/m(2)/24 h. Remission was defined as negative proteinuria in three consecutive urinalyses. RESULTS The patients were divided into 4 groups: idiopathic nephrotic syndrome (n = 35), primary glomerulonephritis (n = 15), auto-antibody associated glomerulonephritis (n = 20) and lupus nephropathy (LN, n = 15). Ten patients from the first group (29%) and 5 patients each from the second and third group (34% and 25% respectively) did not respond to MMF therapy. On the other hand, all the children diagnosed with LN have reached clinical and biochemical remission. CONCLUSIONS Alternative rescue MMF therapy should always be taken into consideration in proteinuric patients who are non-responders to steroids, cyclosporine A and cyclophosphamide in whom the initial glomerular filtration rate is higher than 60 ml/min/1.73m(2). It is recommended that MMF be administered as part of the standard treatment regimen in patients diagnosed with lupus nephropathy. In these groups of patients, the potent benefits of this therapy are higher than expected side-effects.
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Affiliation(s)
- Danuta Ostalska-Nowicka
- Department of Paediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poland
| | - Agnieszka Malinska
- Department of Histology and Embryology, Poznan University of Medical Sciences, Poland
| | - Magdalena Silska
- Department of Paediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poland
| | - Bartlomiej Perek
- Department of Cardiac Surgery, Poznan University of Medical Sciences, Poland
| | - Jacek Zachwieja
- Department of Paediatric Cardiology and Nephrology, Poznan University of Medical Sciences, Poland
| | - Michal Nowicki
- Department of Histology and Embryology, Poznan University of Medical Sciences, Poland
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Opastirakul S, Chartapisak W. Pulse cyclophosphamide induction treatment in Thai children with diffuse proliferative lupus nephritis. Nephrology (Carlton) 2011; 17:269-73. [PMID: 22181066 DOI: 10.1111/j.1440-1797.2011.01554.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To report the effectiveness of pulse cyclophosphamide induction therapy and to identify predictors for unresponsiveness to treatment in Thai children. METHODS Children with biopsy-proven diffuse proliferative lupus nephritis admitted to Chiang Mai University hospital between 2001 and 2006 were retrospectively studied. Patients received a test dose of 750 mg/m(2) at the first month followed by six cycles of monthly cyclophosphamide (IVCY) at a dose of 1 g/m(2) (maximum 1 g) as induction therapy. Responsiveness to treatment, defined as urinary protein to creatinine ratio of less than 0.3 with normalization of C3 level and clinical remission, was assessed at the end of the induction period. Gender, age at onset, duration of disease before treatment, hypertension, clinical nephrotic syndrome, amount of proteinuria, serum creatinine, creatinine clearance, serum C3 level and crescentic formation were compared between responsive and nonresponsive groups. Maintenance therapy with quarterly pulse IVCY or Azathioprine or Mycophenolate mofetil was given for 18-24 months after remission. RESULTS Twenty nine patients with a mean age of 10.3 ± 2.6 years were studied. Hypertension, microscopic haematuria and nephrotic-range proteinuria were seen in 66%, 86% and 60% of the patients, respectively. Forty-one per cent of biopsies showed cellular or fibrocellular crescents. Twenty patients (69%) achieved remission at the end of induction therapy. There were no significant differences in all parameters studied between responsive and nonresponsive groups. The relapse rate after maintenance therapy was 58.8%. CONCLUSION Our results show that pulse cyclophosphamide is an effective regimen for induction therapy in children with diffuse proliferative glomerulonephritis. No definite predictor for unresponsiveness was detected in this study.
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Affiliation(s)
- Sauwalak Opastirakul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
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Kuhn A, Ruland V, Bonsmann G. Cutaneous lupus erythematosus: Update of therapeutic options. J Am Acad Dermatol 2011; 65:e195-213. [DOI: 10.1016/j.jaad.2010.06.017] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 05/28/2010] [Accepted: 06/04/2010] [Indexed: 12/23/2022]
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Zeher M, Doria A, Lan J, Aroca G, Jayne D, Boletis I, Hiepe F, Prestele H, Bernhardt P, Amoura Z. Efficacy and safety of enteric-coated mycophenolate sodium in combination with two glucocorticoid regimens for the treatment of active lupus nephritis. Lupus 2011; 20:1484-93. [DOI: 10.1177/0961203311418269] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Mycophenolic acid, in combination with glucocorticoids, has been shown in a series of trials to be safe and effective for treatment of lupus nephritis. Regimens that permit glucocorticoid dose reduction without loss of efficacy would be advantageous. MyLupus was a 24-week, multicentre, open-label, study in patients with active proliferative lupus nephritis treated with enteric-coated mycophenolate sodium (EC-MPS), randomized to standard-dose ( n = 42) or reduced-dose ( n = 39) glucocorticoids. Complete response at week 24, the primary endpoint, was achieved in 19.8% (16/81) of patients (19.0% standard-dose, 20.5% reduced-dose; lower limit of 97.5% CI for the difference −15.9%, p = 0.098, i.e. non-inferiority was not shown). Partial response occurred in 42.0% of patients (34/81). From baseline to week 24, the mean global British Isles Lupus Assessment Group (BILAG) score decreased from 14.0 ± 5.4 to 5.0 ± 3.8 ( p < 0.001). The incidence of adverse events was 80.2% (65/81), most frequently gastrointestinal complications (31/81, 38.3%). Infections were reported in 57.1% and 35.9% of standard- and reduced-dose glucocorticoid patients, respectively ( p = 0.056), with herpes zoster in 16.7% and 0% ( p = 0.012). Three patients discontinued study medication due to adverse events. This exploratory study suggests that EC-MPS may facilitate glucocorticoid reduction without loss of efficacy in patients with active lupus nephritis, but results require confirmation in a controlled, longer-term study versus the current standard of care.
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Affiliation(s)
- M Zeher
- Institute for Internal Medicine, Debrecen, Hungary
| | - A Doria
- Division of Rheumatology, Department of Clinical and Experimental Medicine, University of Padova, Padova, Italy
| | - J Lan
- Taichung Veterans General Hospital, Taichung, Taiwan, Republic of China
| | - G Aroca
- Clínica de la Costa, Barranquilla, Colombia
| | - D Jayne
- Addenbrooke's Hospital, Cambridge, UK
| | | | - F Hiepe
- Charité University Medicine, Berlin, Germany
| | | | | | - Z Amoura
- Pitie-Salpetriere Hospital, French National Reference Centre for SLE, Paris, France
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Eckstein C, Saidha S, Levy M. A differential diagnosis of central nervous system demyelination: beyond multiple sclerosis. J Neurol 2011; 259:801-16. [DOI: 10.1007/s00415-011-6240-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 08/28/2011] [Accepted: 08/30/2011] [Indexed: 12/12/2022]
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Abstract
Lupus nephritis is a complication of systemic lupus erythematosus, which has significant morbidity and mortality. The accepted standard of treatment for severe lupus nephritis is cyclophosphamide for induction of remission. This has significant adverse effects including severe infection and amenorrhea. In addition, although cyclophosphamide induces remission, long-term mortality does not seem to be altered. Mycophenolate mofetil (MMF) is an immunosuppressive agent originally used in solid organ transplantation, which has been compared with cyclophosphamide in trials for lupus nephritis. Randomized trials with MMF have been relatively small, although pooled data seem to suggest that it is at least as effective as cyclophosphamide in inducing remission. In addition, MMF has also been associated with a reduced risk of infection and amenorrhea, although this finding is not universal. MMF appears to be associated with more diarrhea compared with cyclophosphamide. MMF is likely to be a useful treatment for lupus nephritis, although available trial data are limited due to the small size of previous studies. A large trial (the Aspreva Lupus Management Study) is currently underway to attempt to establish the place of MMF in treatment of lupus nephritis.
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Abstract
PURPOSE OF REVIEW Recurrent glomerulonephritis is the third most common cause of graft failure, ranking only behind immunologic rejection and death with a functioning graft. Knowledge of the rates and timing of recurrent glomerular disease are important in counseling potential transplant recipients and preventive and therapeutic treatment strategies are necessary for those patients at risk. RECENT FINDINGS Large observational studies that have analyzed posttransplant biopsies have confirmed the high rates of glomerular disease recurrence in renal allografts. Newer immunosuppressive protocols over the past 10 years have not affected the rate of disease recurrence or graft loss. There is emerging evidence that rituximab may be efficacious in treating recurrent membranous nephropathy and focal segmental glomerulosclerosis; however, larger clinical trials are warranted. SUMMARY Recurrent glomerulonephritis is an important determinant of long-term outcomes after transplantation, requiring appropriate counseling to potential transplant recipients. Currently, there are no proven strategies to prevent recurrent glomerulonephritis in renal transplant recipients. Despite the high rates of recurrent disease, long-term graft survival is still very good and transplantation remains the best treatment option for patients with end-stage renal disease from primary glomerulonephritis.
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