Induction and Maintenance Immunosuppression Treatment of Proliferative Lupus Nephritis: A Network Meta-analysis of Randomized Trials

Abstract

Evidence for induction therapy for lupus nephritis is inconclusive based on treatment effects on all-cause mortality, doubling of serum creatinine level, and end-stage kidney disease. MMF, calcineurin inhibitors, or their combination were most effective for inducing remission compared to IV cyclophosphamide, while conferring similar or lower treatment toxicity. MMF was the most effective maintenance therapy.

Long‐term renal outcomes in multi‐ethnic Southeast Asians with lupus nephritis: a retrospective cohort study

“…Type of induction immunosuppressant therapy was not associated with progressive CKD among our patients. This finding is in agreement with a recent meta‐analysis of 53 studies with 4222 participants, which did not find doubling of serum creatinine, ESRD or all‐cause mortality to be different in different therapies . Although not specifically evaluated in LN, protective interventions such as blood pressure control, use of renin–angiotensin–aldosterone system blockers, reduction in dietary protein and sodium and treatment of obesity, dyslipidemia and acidosis have been validated in general CKD cohorts and are relevant and important to the management of patients with LN …”

Європейські Доказові Рекомендації По Діагностиці Та Лікуванню Люпус-Нефриту У Дітей: Ініціатива SHARE

“…In addition, the recent network meta-analysis mentioned above showed that MMF was the most effective strategy to maintain remission for proliferative LN (44). Studies of proliferative LN in cSLE show similar results for MMF and AZA as in adults.…”

“…They concluded that induction treatment with MMF, CNI, or a combination thereof, when added to corticosteroids, were the most effective treatments compared to I.V. CYC (44). No RCTs have been performed in children, but the literature search yielded several observational cohort studies and case series describing treatment of class III and IV LN.…”

“…When combining the high-quality evidence from RCT for LN in adult-onset SLE with the evidence from smaller case series and observational cohort studies in cSLE, the expert group recommends MMF (1200-1800mg/m2/day, maximum 1500 mg twice daily) or I.V. CYC in combination with high-dose prednisone (1-2 mg/kg/day, maximum 60 mg/day) for induction treatment of proliferative LN in cSLE (10,(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55)(56)(57)(58)(59)(60). The dosing of I.V.…”

After 4 Decades of Lupus Nephritis Trials, Is There a “Best” Therapy?

“…4 They identified 53 studies involving 4222 participants, dividing their analyses into studies evaluating induction-phase treatment (45 trials with 3623 participants) and maintenance-phase treatment (8 trials with 599 participants). The network meta-analysis design allowed these investigators to compare multiple treatment regimens across trials based on a common comparator: intravenous (IV) cyclophosphamide for induction studies and azathioprine for maintenance studies.…”