Cyclophosphamide and Mycophenolate Mofetil as Induction Therapy in Lupus Nephritis
Abstract
Background/Aim: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with multisystemic involvement. Almost 50 % of patients who suffer from systemic lupus erythematosus have lupus nephritis (LN) as well. Mycophenolate mofetil (MMF) or intravenous cyclophosphamide (CYC) are recommended as preferred therapy. The aim of this study was to see how MMF and CYC, when compared, are efficient in dealing with LN.
Methods: Study included 53 SLE patients with biopsy-proven class III and class IV LN. Twenty-two patients (42 %) were treated with MMF (dosage 2-3 g/day) and 31 patients (58 %) were treated with CYC (0.5 to 1.0 g/m2 in monthly pulses) in a 24-week induction study. Outcome of interest was the improvement in serum creatinine, proteinuria and creatinine clearance. Primary end point included complete renal remission defined as serum creatinine within 25 % of baseline before flare and proteinuria < 0.5 g/24 h. Secondary end point included complete renal remission in follow-up period.
Results: The results revealed that response between two groups was not notably different (χ2 = 0.151, p = 0.697). Four out of 22 patients (18.2 %) in MMF group and 7 out of 31 patients (22.6 %) in CYC group had complete renal remission. Most patients from both groups showed improvement from the clinical point of view. Secondary end point was also similar between treatment groups.
Conclusion: The study showed same efficiency between these treatment groups, MMF and CYC as induction for LN. No crucial differences were identified between MMF and CYC groups in terms of renal remission.
References
Kiriakidou M, Ching CL. Systemic Lupus Erythematosus. Ann Intern Med. 2020 Jun 2;172(11):ITC81-ITC96. doi: 10.7326/AITC202006020.
Parikh SV, Almaani S, Brodsky S, Rovin BH. Update on Lupus Nephritis: Core Curriculum 2020. Am J Kidney Dis. 2020;76(2):265–81. doi: 10.1053/j.ajkd.2019.10.017.
Danchenko N, Satia JA, Anthony MS. Epidemiology of systemic lupus erythematosus: A comparison of worldwide disease burden. Lupus. 2006;15(5):308–18. doi: 10.1191/0961203306lu2305xx.
Jorge A, Wallace ZS, Lu N, Zhang Y, Choi HK. Renal transplantation and survival among patients with lupus nephritis: a cohort study. Ann Intern Med. 2019 Feb 19;170(4):240-7. doi: 10.7326/M18-1570.
Kidney transplants in patients with lupus nephritis. Ann Intern Med. 2019 Feb 19;170(4). doi: 10.7326/P18-0022.
Goyal N, Weiner DE, Levey AS. Kidney transplantation in lupus nephritis: can we do even better? Ann Intern Med. 2019 Feb 19;170(4):266-7. doi: 10.7326/m18-3721.
Liu G, Wang H, Le J, Lan L, Xu Y, Yang Y, et al. Early-stage predictors for treatment responses in patients with active lupus nephritis. Lupus. 2019 Mar;28(3):283-9. doi: 10.1177/0961203319826703.
Slight-Webb S, Guthridge JM, Chakravarty EF, Chen H, Lu R, Macwana S, et al. Mycophenolate mofetil reduces STAT3 phosphorylation in systemic lupus erythematosus patients. JCI Insight. 2019 Jan 24;4(2). doi: 10.1172/jci.insight.124575.
Wang ZR, Ren LM, Li R, Guan X, Han QM, Liu ML, et al. [Analysis of 20-year survival rate and prognostic indicators of systemic lupus erythematosus]. Zhonghua Yi Xue Za Zhi. 2019 Jan 15;99(3):178-82. doi: 10.3760/cma.j.issn.0376-2491.2019.03.005. Chinese.
Wilson HR, Medjeral-Thomas NR, Gilmore AC, Trivedi P, Seyb K, Farzaneh-Far R, et al. Glomerular membrane attack complex is not a reliable marker of ongoing C5 activation in lupus nephritis. Kidney Int. 2019 Mar;95(3):655-65. doi: 10.1016/j.kint.2018.09.027.
Fanouriakis A, Kostopoulou M, Andersen J, Aringer M, Arnaud L, Bae SC, et al. EULAR recommendations for the management of systemic lupus erythematosus: 2023 update. Ann Rheum Dis. 2024 Jan 2;83(1):15-29. doi: 10.1136/ard-2023-224762.
Fanouriakis A, Kostopoulou M, Cheema K, Anders HJ, Aringer M, Bajema I, et al. 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 Jun;79(6):713-23. doi: 10.1136/annrheumdis-2020-216924.
Moroni G, Gatto M, Tamborini F, Quaglini S, Radice F, Saccon F, et al. Lack of EULAR/ERA-EDTA response at 1 year predicts poor long-term renal outcome in patients with lupus nephritis. Ann Rheum Dis. 2020 Aug;79(8):1077-83. doi: 10.1136/annrheumdis-2020-216965.
Chan TM, Li FK, Tang CS, Wong RW, Fang GX, Ji YL, et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferative lupus nephritis. Hong Kong-Guangzhou Nephrology Study Group. N Engl J Med. 2020;343(16):1156–62. doi: 10.1056/nejm200010193431604.
Chan TM, Tse KC, Tang CS, Mok MY, Li FK. Long-term study of mycophenolate mofetil as continuous induction and maintenance treatment for diffuse proliferative lupus nephritis. J Am Soc Nephrol 2005;16(4):1076–84. doi: 10.1681/asn.2004080686.
Ong LM, Hooi LS, Lim TO, Goh BL, Ahmad G, Ghazalli R, et al. Randomized controlled trial of pulse intravenous cyclophosphamide versus mycophenolate mofetil in the induction therapy of proliferative lupus nephritis. Nephrology (Carlton). 200;10(5):504–10. doi: 10.1111/j.1440-1797.2005.00444.x.
Hu W, Liu Z, Chen H, Tang Z, Wang Q, Shen K, et al. Mycophenolate mofetil vs cyclophosphamide therapy for patients with diffuse proliferative lupus nephritis. Chin Med J (Engl). 2002;115(5):705–9. PMID: 12133539.
Ginzler EM, Dooley MA, Aranow C, Kim MY, Buyon J, Merrill JT, et al. Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. N Engl J Med. 2005 Nov 24;353(21):2219-28. doi: 10.1056/NEJMoa043731.
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