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Tian SY, Feldman BM, Beyene J, Brown PE, Uleryk EM, Silverman ED. Immunosuppressive therapies for the induction treatment of proliferative lupus nephritis: a systematic review and network metaanalysis. J Rheumatol 2014; 41:1998-2007. [PMID: 25225281 DOI: 10.3899/jrheum.140050] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate and determine the most effective immunosuppressive therapy for the induction treatment of proliferative lupus nephritis (PLN) based on renal remission. METHODS A systematic review of randomized controlled trials was conducted. The outcomes were renal remission at 6 months: (1) normalization of serum creatinine [(sCr), or within 15% of the normal range, i.e., sCr < 132 µmol/l - creatinine remission]; and (2) proteinuric remission (prU < 0.5 g/day/1.73m(2)). A Bayesian network metaanalysis was used. RESULTS The OR (95% credible interval) of inducing an sCr remission at 6 months was 1.70 (0.51, 6.87) for mycophenolate mofetil (MMF) versus cyclophosphamide (CYC); 2.16 (0.38, 13.36) for tacrolimus (Tac) versus CYC; and 1.25 (0.13, 10.51) for Tac versus MMF. For proteinuric remission the OR was 1.46 (0.81, 3.04) for MMF versus CYC; 1.96 (0.80, 5.11) for Tac versus CYC; and 1.34 (0.43, 3.90) for Tac versus MMF. The probability (95% credible interval) of inducing a creatinine remission at 6 months was Tac 56% (19%, 88%); MMF 51% (23%, 79%); and CYC 37% (28%, 47%). The probability of inducing a proteinuric remission was Tac 41% (23%, 63%); MMF 34% (23%, 50%); CYC 26% (20%, 32%); azathioprine 10% (1%, 55%); prednisone 11% (2%, 38%). None of the results were conclusive when examined in a sensitivity analysis. CONCLUSION There is currently insufficient evidence to determine which of these immunosuppressive agents is superior. The probability of renal remission is 50% or lower at 6 months.
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Affiliation(s)
- Simon Yu Tian
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Brian M Feldman
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Joseph Beyene
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Patrick E Brown
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Elizabeth M Uleryk
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
| | - Earl D Silverman
- From the Institute of Medical Science, Faculty of Medicine, University of Toronto; Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children; Department of Pediatrics, Faculty of Medicine, University of Toronto; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto; Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, Hamilton; Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto; Cancer Care Ontario, Toronto; Hospital Library, The Hospital for Sick Children, Toronto, Ontario, Canada.S.Y. Tian's PhD research is funded in part by the Queen Elizabeth II-Edward Dunlop Foundation Scholarships in Science and Technology, administered at the University of Toronto.S.Y. Tian, MB, MSc, PhD (C), Institute of Medical Science, Faculty of Medicine, University of Toronto, and The Hospital for Sick Children; B.M. Feldman, MD, MSc, FRCPC, Professor, Institute of Health Policy, Management and Evaluation, University of Toronto, and The Hospital for Sick Children; J. Beyene, PhD, Associate Professor, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto; P.E. Brown, PhD, Associate Professor, Cancer Care Ontario, and Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Program in Population Genomics, Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University; E.M. Uleryk, MLS, Hospital Library, The Hospital for Sick Children; E.D. Silverman, MD, FRCPC, Professor, Division of Rheumatology and Program of Child Health Evaluative Sciences, The Hospital for Sick Children, and Institute of Medical Science, Department of Pediatrics, and Department of Immunology, Univer
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