Lupus Nephritis

Abstract

SummaryLupus nephritis (LN) increases the morbidity and mortality of patients with SLE. This review compares the randomized, controlled trials that examined various maintenance regimens available to treat LN. Currently, mycophenolate mofetil (MMF) and azathioprine (AZA) are the most popular therapeutic agents used for long-term maintenance of LN. Long-term maintenance with MMF is recommended as the first choice after achieving remission with cyclophosphamide or MMF induction. MMF is effective in consolidating remission and preventing relapse and CKD in patients of diverse races and ethnicities. Long-term maintenance with AZA is the recommended second choice, especially when patients develop intolerance of or contraindications to MMF. Azathioprine is particularly effective in consolidating remission and preventing relapse and CKD in patients who receive an induction regimen of cyclophosphamide. To date, there are no data on how rapidly maintenance therapies can be withdrawn; however, it is recommended that the immunosuppressive therapy be maintained indefinitely, unless it is contraindicated, in patients at high risk for progression to CKD.

Mycophenolate as Maintenance Therapy for Lupus Nephritis with Impaired Renal Function

“…We estimated renal function in our LN patients by using the MDRD eGFR equation, as recommended by Patel et al [10]. Considering that the role of MF in long-term treatment of severe LN remains unsolved [5], we think our results are useful for clinicians.…”

“…The ALMS trial [9], which is an extended study analyzing MF as an induction treatment for LN in 227 patients of different ethnic and geographic origins, found that MMF was superior to AZA with respect to treatment failure and renal relapse (12.9 vs. 23.9%, respectively) [21]. Therefore, it can be concluded that MF should be the first choice in long-term therapy in LN, with slight superiority over AZA [5,22,23,24,25,26]. Although we did not make comparisons with other drugs in the present study, our results indicate a relatively low rate of renal flares using MF (21% at 6 months and 22% at 12 months) and a sustained renal response (68% at 6 months and 71% at 12 months), findings that are closer to those of MAINTAIN [8] than those of ALMS [9], probably because of the ethnicity of the patients included.…”

“…This large difference is probably due to the different definitions used for the diagnosis of renal flare, differences in the populations studied, and the use of different therapeutic regimens [4]. Indeed, the choice of drug to be administered for long-term maintenance therapy remains open to debate because mycophenolate (MF) or azathioprine (AZA) [5] are preferred to cyclophosphamide (CYC), whose side effects restrict long-term maintenance therapy [6,7]. According to the results of recent randomized controlled trials, MF is considered to be superior to AZA for consolidating remission and preventing relapses and progression to chronic renal failure [8,9].…”

Recomendaciones y sugerencias a 4 preguntas clave en nefropatía lúpica: Extracto de la guía de práctica clínica 2015

“…EC: 2+. -En los pacientes de alto riesgo de presentar recaída (tabla 1), se plantea prolongar el tratamiento durante más de 5 años o incluso de forma indefinida, a menos que haya contraindicación 29 . EC: 4.…”

Afectación renal en las vasculitis, el lupus eritematoso y las enfermedades sistémicas

“…Se recomienda que después del tratamiento de inducción, si ha habido respuesta, la dosis de prednisona se sitúe como máximo en 10 mg/día. A partir de este momento, la pauta de descenso debe ser más progresiva e intentar siempre conseguir la más baja posible (5 o menos mg/día) [19][20][21][22] .…”