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Fanouriakis A, Kostopoulou M, Cheema K, Bertsias G, Jayne D, Boumpas D. SAT0173 A SYSTEMATIC LITERATURE REVIEW INFORMING THE 2019 UPDATE OF THE JOINT EUROPEAN LEAGUE AGAINST RHEUMATISM AND EUROPEAN RENAL ASSOCIATION–EUROPEAN DIALYSIS AND TRANSPLANT ASSOCIATION (EULAR/ERA-EDTA) RECOMMENDATIONS FOR THE MANAGEMENT OF LUPUS NEPHRITIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Lupus nephritis (LN) affects ~ 40% of patients with systemic lupus erythematosus (SLE) and is associated with significant morbidity. New data has emerged since the publication of the EULAR/ERA-EDTA recommendations for the management of LN, involving a multidisciplinary panel of experts.Objectives:To analyze the current evidence, in order to inform the 2019 update of the EULAR/ERA-EDTA recommendations for the management of LN.Methods:According to the EULAR standardised operating procedures, a Medline systematic literature review (SLR) was performed, from January 2012 until 31 December 2018. The final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including the LoE of the 2012 recommendations.Results:We identified 542 relevant articles. High-quality evidence supports the use of immunosuppressive treatment for class III and IV LN (LoE 1a) there is moderate quality evidence for immunosuppression in pure class V LN, with nephrotic-range proteinuria (LoE 2b). Treatment should aim for a 25% reduction in proteinuria at 3 months, 50% at 6 months and complete renal response (< 500-700 mg/day) at 12 months (LoE 2a-2b). Strong evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) for the initial treatment of class III/IV LN (LoE 1a,Table); Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a,Table). There is little evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease due to LN, all methods of kidney replacement treatment have been used, but transplantation is accompanied by the most favourable outcomes (LoE 2b).Table.Randomized trials for induction therapy in LNConclusion:There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment. There is low quality evidence to guide treatment of class V, monitoring and optimal duration of immunosuppression.Disclosure of Interests: :Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, Myrto Kostopoulou: None declared, Kim Cheema: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim, Dimitrios Boumpas: None declared
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Fanouriakis A, Kostopoulou M, Cheema K, Anders HJ, Aringer M, Bajema I, Boletis JN, Frangou E, Houssiau F, Hollis J, Karras A, Marchiori F, Marks S, Moroni G, Mosca M, Parodis I, Praga M, Schneider M, Smolen JS, Tesar V, Trachana M, Vollenhoven RV, Voskuyl A, Teng YKO, Van Leeuw B, Bertsias G, Jayne D, Boumpas D. OP0163 2019 UPDATE OF THE JOINT EUROPEAN LEAGUE AGAINST RHEUMATISM AND EUROPEAN RENAL ASSOCIATION–EUROPEAN DIALYSIS AND TRANSPLANT ASSOCIATION (EULAR/ERA-EDTA) RECOMMENDATIONS FOR THE MANAGEMENT OF LUPUS NEPHRITIS. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.3870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Up to 40% of systemic lupus erythematosus (SLE) patients develop kidney disease, which represents a major cause of morbidity.Objectives:To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN).Methods:We followed the EULAR standardised operating procedures for the publication of treatment recommendations. Delphi-based methodology led to 15 questions for systematic literature review (SLR), which was undertaken by three fellows.Results:The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNI), and management of end-stage-kidney-disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7gr/24h with [near-]normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3g/day, or mycophenolic acid at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500mg x6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1g/24h despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations.Conclusion:The updated recommendations intend to inform rheumatologists, nephrologists, patients, national professional societies, hospital officials, social security agencies and regulators about the treatment of LN based on most recent evidence.Disclosure of Interests:Antonis Fanouriakis Paid instructor for: Paid instructor for Enorasis, Amgen, Speakers bureau: Paid speaker for Roche, Genesis Pharma, Mylan, Myrto Kostopoulou: None declared, Kim Cheema: None declared, Hans-Joachim Anders: None declared, Martin Aringer Consultant of: Boehringer Ingelheim, Roche, Speakers bureau: Boehringer Ingelheim, Roche, Ingeborg Bajema Consultant of: GSK, John N. Boletis Grant/research support from: GSK, Pfizer, Paid instructor for: GSK, Abbvie, UCB, Enorasis, Eleni Frangou: None declared, Frederic Houssiau Grant/research support from: UCB, Consultant of: GSK, Jane Hollis: None declared, Alexandre Karras: None declared, Francesca Marchiori: None declared, Stephen Marks: None declared, Gabriela Moroni: None declared, Marta Mosca: None declared, Ioannis Parodis: None declared, Manuel Praga: None declared, Matthias Schneider Grant/research support from: GSK, UCB, Abbvie, Consultant of: Abbvie, Alexion, Astra Zeneca, BMS, Boehringer Ingelheim, Gilead, Lilly, Sanofi, UCB, Speakers bureau: Abbvie, Astra Zeneca, BMS, Chugai, GSK, Lilly, Pfizer, Sanofi, Josef S. Smolen Grant/research support from: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Vladimir Tesar: None declared, Maria Trachana: None declared, Ronald van Vollenhoven Grant/research support from: AbbVie, Amgen, Arthrogen, Bristol-Myers Squibb, GlaxoSmithKline (GSK), Janssen Research & Development, LLC, Lilly, Pfizer, Roche, and UCB, Consultant of: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GSK, Janssen, Lilly, Medac, Merck, Novartis, Pfizer, Roche, UCB and Vertex, Speakers bureau: AbbVie, AstraZeneca, Biotest, Bristol-Myers Squibb, Celgene, Crescendo Bioscience, GlaxoSmithKline, Janssen, Lilly, Merck, Novartis, Pfizer, Roche, UCB, Vertex, Alexandre Voskuyl: None declared, Y.K. Onno Teng Grant/research support from: GSK, Consultant of: GSK, Aurinia Pharmaceuticals, Novartis, Bernadette van Leeuw: None declared, George Bertsias Grant/research support from: GSK, Consultant of: Novartis, David Jayne Grant/research support from: ChemoCentryx, GSK, Roche/Genentech, Sanofi-Genzyme, Consultant of: Astra-Zeneca, ChemoCentryx, GSK, InflaRx, Takeda, Insmed, Chugai, Boehringer-Ingelheim, Dimitrios Boumpas: None declared
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Dyer F, Callaghan J, Cheema K, Bott J. Ambulatory oxygen improves the effectiveness of pulmonary rehabilitation in selected patients with chronic obstructive pulmonary disease. Chron Respir Dis 2012; 9:83-91. [DOI: 10.1177/1479972312438702] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The effect of ambulatory oxygen use during pulmonary rehabilitation (PR) has not yet been clearly established, but many studies have shown benefit from oxygen acutely. Two small studies to date demonstrated no clear benefit when oxygen was used in patients who desaturated on exertion during a PR programme. One study showed the benefit of using oxygen during PR in patients who were normoxic at rest and desaturated to a minimum of 88% on exertion. We conducted a single-blind, randomised controlled trial comparing PR undertaken either with or without ambulatory oxygen, in those with demonstrable benefit from oxygen at baseline. Subjects from three PR services were recruited who, during baseline assessment, desaturated by more than 4% and to less than 90% on exertion, and walked 10% or more further with ambulatory oxygen on endurance shuttle walk test. Patients were randomised to either room air or oxygen via portable cylinder, titrated to optimise pulse oxygen saturation but up to a maximum flow rate of 6 L/min. All patients then completed a twice weekly, 6- to 7-week PR programme. Data were analysed as per protocol. Totally 51 patients completed the study. At the end of PR, both groups improved with PR, with patients in the oxygen group demonstrating a highly statistically significantly greater mean improvement in endurance walking distance than the controls, 490 m (95% confidence interval 228–750; p ≤ 0.001), as well as clinically, although not statistically, significant changes in quality of life. The use of ambulatory oxygen during a 6- to 7-week PR programme greatly improved endurance walking distance in patients who desaturated on exertion with a positive acute response to ambulatory oxygen at baseline.
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