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Papachristodoulou E, Kyttaris VC. New and emerging therapies for systemic lupus erythematosus. Clin Immunol 2024; 263:110200. [PMID: 38582250 DOI: 10.1016/j.clim.2024.110200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/23/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
Systemic Lupus Erythematosus (SLE) and lupus nephritis treatment is still based on non-specific immune suppression despite the first biological therapy for the disease having been approved more than a decade ago. Intense basic and translational research has uncovered a multitude of pathways that are actively being evaluated as treatment targets in SLE and lupus nephritis, with two new medications receiving FDA approval in the last 3 years. Herein we provide an overview of targeted therapies for SLE including medications targeting the B lymphocyte compartment, intracellular signaling, co-stimulation, and finally the interferons and other cytokines.
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Affiliation(s)
- Eleni Papachristodoulou
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Vasileios C Kyttaris
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Rovin BH, Ayoub IM, Chan TM, Liu ZH, Mejía-Vilet JM, Floege J. KDIGO 2024 Clinical Practice Guideline for the management of LUPUS NEPHRITIS. Kidney Int 2024; 105:S1-S69. [PMID: 38182286 DOI: 10.1016/j.kint.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 01/07/2024]
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Wagle Shukla A, Lunny C, Mahboob O, Khalid U, Joyce M, Jha N, Nagaraja N, Shukla AM. Tremor Induced by Cyclosporine, Tacrolimus, Sirolimus, or Everolimus: A Review of the Literature. Drugs R D 2023; 23:301-329. [PMID: 37606750 PMCID: PMC10676343 DOI: 10.1007/s40268-023-00428-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2023] [Indexed: 08/23/2023] Open
Abstract
Calcineurin inhibitors such as cyclosporine and tacrolimus are immunosuppressant drugs that are known to induce tremors. Non-calcineurin inhibitors such as sirolimus and everolimus have also reportedly been accompanied by tremors, albeit less likely. However, the prevalence rates reported in the literature are notably wide, and the risk profiles for these drug-induced tremors are less understood. We searched PubMed to extract data on the risk of tremors with these drugs when prescribed for various transplant and non-transplant indications. We ascertained whether the risk of drug-induced tremor is influenced by the underlying diagnosis, dosing formulations, drug concentrations, and blood monitoring. We extracted data on treatment strategies and outcomes for tremors. Articles were primarily screened based on English language publications, abstracts, and studies with n ≥ 5, which included case series, retrospective studies, case-controlled studies, and prospective studies. We found 81 eligible studies comprising 33 cyclosporine, 43 tacrolimus, 6 sirolimus, and 1 everolimus that discussed tremor as an adverse event. In the pooled analysis of studies with n > 100, the incidence of tremor was 17% with cyclosporine, 21.5% with tacrolimus, and 7.8% with sirolimus and everolimus together. Regarding the underlying diagnosis, tremor was more frequently reported in kidney transplant (cyclosporine 28%, tacrolimus 30.1%) and bone marrow transplant (cyclosporine 40%, tacrolimus 41.9%) patients compared with liver transplant (cyclosporine 9%, tacrolimus 11.5%) and nontransplant indications (cyclosporine 21.5%, tacrolimus 11.3%). Most studies did not report whether the risk of tremors correlated with drug concentrations in the blood. The prevalence of tremors when using the twice-daily formulation of tacrolimus was nearly the same as the once-daily formulation (17% vs 18%). Data on individual-level risk factors for tremors were lacking. Except for three studies that found some benefit to maintaining magnesium levels, there were minimal data on treatments and outcomes. A large body of data supports a substantive and wide prevalence of tremor resulting from tacrolimus use followed by cyclosporine, especially in patients receiving a kidney transplant. However, there is little reporting on the patient-related risk factors for tremor, risk relationship with drug concentrations, treatment strategies, and outcomes.
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Affiliation(s)
- Aparna Wagle Shukla
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Fixel Institute for Neurological Disorders, 3009 Williston Road, Gainesville, FL, 32608, USA.
| | - Caroline Lunny
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Fixel Institute for Neurological Disorders, 3009 Williston Road, Gainesville, FL, 32608, USA
| | - Omar Mahboob
- Florida State University Medical School, Tallahassee, FL, USA
| | - Uzair Khalid
- University of Toronto Medical School, Toronto, ON, Canada
| | - Malea Joyce
- North Florida South Georgia Veteran Healthcare System, Gainesville, FL, USA
| | - Nivedita Jha
- Department of Neurology, Tower Health, Reading Hospital, Reading, PA, USA
| | - Nandakumar Nagaraja
- Department of Neurology, Penn State University College of Medicine, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ashutosh M Shukla
- North Florida South Georgia Veteran Healthcare System, Gainesville, FL, USA
- Division of Nephrology, Department of Medicine, University of Florida, Gainesville, FL, USA
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Pennesi M, Benvenuto S. Lupus Nephritis in Children: Novel Perspectives. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1841. [PMID: 37893559 PMCID: PMC10607957 DOI: 10.3390/medicina59101841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023]
Abstract
Childhood-onset systemic lupus erythematosus is an inflammatory and autoimmune condition characterized by heterogeneous multisystem involvement and a chronic course with unpredictable flares. Kidney involvement, commonly called lupus nephritis, mainly presents with immune complex-mediated glomerulonephritis and is more frequent and severe in adults. Despite a considerable improvement in long-term renal prognosis, children and adolescents with lupus nephritis still experience significant morbidity and mortality. Moreover, current literature often lacks pediatric-specific data, leading clinicians to rely exclusively on adult therapeutic approaches. This review aims to describe pediatric lupus nephritis and provide an overview of the novel perspectives on the pathogenetic mechanisms, histopathological classification, therapeutic approach, novel biomarkers, and follow-up targets in children and adolescents with lupus nephritis.
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Affiliation(s)
- Marco Pennesi
- Institute for Maternal and Child Health IRCCS Burlo Garofolo, 34137 Trieste, Italy
| | - Simone Benvenuto
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, 34127 Trieste, Italy
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Roccatello D, Fenoglio R, Caniggia I, Kamgaing J, Naretto C, Cecchi I, Rubini E, Rossi D, De Simone E, Del Vecchio G, Cozzi M, Sciascia S. Daratumumab monotherapy for refractory lupus nephritis. Nat Med 2023; 29:2041-2047. [PMID: 37563241 PMCID: PMC10427415 DOI: 10.1038/s41591-023-02479-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 06/29/2023] [Indexed: 08/12/2023]
Abstract
Treatment-refractory lupus nephritis (LN) has a high risk of a poor outcome and is often life-threatening. Here we report a case series of six patients (one male and five females) with a median age of 41.3 years (range, 20-61 years) with refractory LN who received renal biopsies and were subsequently treated with intravenous daratumumab, an anti-CD38 monoclonal antibody (weekly for 8 weeks, followed by eight biweekly infusions and up to eight monthly infusions). One patient did not show any improvement after 6 months of therapy, and daratumumab was discontinued. In five patients, the mean disease activity, as assessed by the Systemic Lupus Erythematosus Disease Activity 2000 index, decreased from 10.8 before treatment to 3.6 at 12 months after treatment. Mean proteinuria (5.6 g per 24 h to 0.8 g per 24 h) and mean serum creatinine (2.3 mg dl-1 to 1.5 mg dl-1) also decreased after 12 months. Improvement of clinical symptoms was accompanied by seroconversion of anti-double-stranded DNA antibodies; decreases in median interferon-gamma levels, B cell maturation antigen and soluble CD163 levels; and increases in C4 and interleukin-10 levels. These data suggest that daratumumab monotherapy warrants further exploration as a potential treatment for refractory LN.
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Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy.
| | - Roberta Fenoglio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Ilaria Caniggia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Joelle Kamgaing
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Irene Cecchi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Elena Rubini
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Daniela Rossi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Emanuele De Simone
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Giulio Del Vecchio
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Martina Cozzi
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrological, Rheumatological and Rare Diseases (ERK-net, ERN-Reconnect and RITA-ERN Member) including Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), San Giovanni Bosco Hub Hospital, ASL Città di Torino and Department of Clinical and Biological Sciences of the University of Turin, Turin, Italy
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Mok CC. Combination strategies for lupus nephritis: facts and controversies. Expert Rev Clin Immunol 2023; 19:527-536. [PMID: 36927191 DOI: 10.1080/1744666x.2023.2192927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION There is an unmet need to improve the efficacy of therapeutic regimens in lupus nephritis (LN). Cocktail immunosuppressive therapy for the synergistic effect of individual drugs may enhance efficacy and enable dosage reduction. However, the potential increase in the risk of serious and opportunistic infections is a concern. Moreover, the timing of combination therapy, adoption of a step-up or step-down approach, and the choice of drugs is still controversial, partly related to the cost-effectiveness issue. AREAS COVERED Evidence of a combination of conventional, newer immunosuppressive, and biologic/targeted agents in LN. EXPERT OPINION Early combination of conventional regimens with anti-B cell activation factor (anti-BAFF) or calcineurin inhibitors (CNIs) enhances the therapeutic effect without increasing serious adverse events in LN. However, combining anti-CD20 and anti-BAFF biologics appears to be less promising from the results of clinical trials. Initial combination strategy may be more cost-effective for patients at risk of treatment failure and renal function deterioration. With the availability of more options, the treat-to-target approach in LN is increasingly feasible and further studies are needed to compare the step-up and step-down approaches in the treatment of LN.
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Affiliation(s)
- Chi Chiu Mok
- Departments of Medicine, Tuen Mun Hospital, Hong Kong, SAR, China
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Abstract
INTRODUCTION Lupus nephritis (LN) is a key predictor for kidney failure and death in patients with systemic lupus erythematosus (SLE). While conventional immunosuppressive treatments have improved the outcome of LN, novel therapies continue to emerge. These new agents target specific immune-reactive cells (B cell repertoire or T lymphocytes) and crucial cytokines/signalling pathways in LN pathogenesis. AREAS COVERED New therapeutic approaches that target specific immune-reactive cells (B cell repertoire or T lymphocytes), crucial cytokines and their signalling pathways in LN pathogenesis. EXPERT OPINION Although earlier studies of rituximab fail to show benefit, a newer generation anti-CD20 biologic, obinutuzumab, is promising in LN. Inhibition of B-cell activating factor by belimumab confers superior renal response when added to the standard of care (SOC) regimens, leading to its recent approval for LN. Therapies targeting plasma cells (proteasome inhibitors, anti-CD38) in LN are being developed. A newer generation calcineurin inhibitor, voclosporin, when combined with SOC, results in better renal responses in LN. Other innovative strategies include targeting type I interferon, co-stimulatory signals, complement cascade (anti-C5b) and intracellular proliferation signals (e.g. mTOR, JAK1/2, BTK). While these novel agents improve the short-term renal responses without increased toxicities, long-term data on disease progression and safety remain to be established. Patient stratification by clinical phenotypes, biomarkers and molecular profiles helps enhance the efficacy and cost-effectiveness of novel therapies of LN.
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Affiliation(s)
| | - Chi Chiu Mok
- Division of Rheumatology, Department of Medicine and Geriatrics, Tuen Mun Hospital, Hong Kong
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Park DJ, Joo YB, Bang SY, Lee J, Lee HS, Bae SC. Predictive Factors for Renal Response in Lupus Nephritis: A Single-center Prospective Cohort Study. JOURNAL OF RHEUMATIC DISEASES 2022; 29:223-231. [PMID: 37476428 PMCID: PMC10351413 DOI: 10.4078/jrd.22.0006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 06/01/2022] [Accepted: 06/10/2022] [Indexed: 07/22/2023]
Abstract
Objective To identify the predictive factors for renal response in patients with lupus nephritis (LN). Methods Patients and data were extracted from a prospective systemic lupus erythematosus cohort in Korea, in which clinical data were collected at 0, 3, 6, and 12 months after induction therapy. Treatment response of LN were evaluated as a complete response (CR), partial response (PR), or non-response (NR) at 3, 6, and 12 months, respectively. Predictive factors for CR at 6 months were evaluated using multivariable Poisson regression analysis. Results A total of 75 patients with LN who underwent biopsy was enrolled. The mean age at diagnosis of LN was 28.9±9.7 years, and 68 (90.7%) were female. The frequencies of classes III, IV, III+V, IV+V, and V were 20.0%, 44.0%, 16.0%, 12.0%, and 8.0%, respectively. Compared to relapsed LN, new-onset LN showed a lower percentage of glomerulosclerosis (45.5% vs. 76.2%, p=0.013). The overall proportions of CR, PR, and NR at 6 and 12 months were 52.0%, 26.7%, 21.3% and 50.7%, 24.0%, 25.3%, respectively. In multivariate analysis, age at enrollment (odds ratio [OR]=1.02, p=0.022), relapsed LN (OR=0.71, p=0.037), anti-Ro antibody (OR=0.67, p=0.014), and class III LN (OR=1.48, p=0.001) were associated with CR at 6 months. Conclusion In our prospective cohort, class III LN was a good predictive factor for CR at 6 months in patients with LN, whereas younger age, relapsed LN, and anti-Ro antibody were poor predictive factors.
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Affiliation(s)
- Dae Jin Park
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Young Bin Joo
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - So-Young Bang
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Jiyoung Lee
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Hye-Soon Lee
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
- Hanyang University Institute for Rheumatology, Seoul, Korea
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Vollbach K, Schuetz C, Hedrich CM, Speth F, Mönkemöller K, Brunner J, Neudorf U, Rietschel C, Hospach A, Kallinich T, Hinze C, Wagner N, Tönshoff B, Weber LT, Latta K, Thumfart J, Bald M, Wiemann D, Zappel H, Tenbrock K, Haffner D. Working Towards a Treat-to-Target Protocol in Juvenile Proliferative Lupus Nephritis - A Survey of Pediatric Rheumatologists and Nephrologists in Germany and Austria. Front Pediatr 2022; 10:851998. [PMID: 35529329 PMCID: PMC9072733 DOI: 10.3389/fped.2022.851998] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/07/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND To describe treatment practices for juvenile proliferative lupus nephritis (LN) class III and IV of pediatric rheumatologists and nephrologists in Germany and Austria in preparation for a treat-to-target treatment protocol in LN. METHODS Survey study by members of the Society for Pediatric and Adolescent Rheumatology (GKJR) and the German Society for Pediatric Nephrology (GPN) on diagnostics and (concomitant) therapy of LN. RESULTS Fifty-eight physicians completed the survey. Overall, there was a considerable heterogeneity regarding the suggested diagnostics and management of juvenile proliferative LN. Increased urinary protein excretion, either assessed by 24 h urine collection or spot urine (protein-creatinine ratio), and reduced estimated glomerular filtration rate were specified as important parameters for indication of kidney biopsy to diagnose proliferative LN and monitoring of therapy. Corticosteroids were generally proposed for induction and maintenance therapy, most often in conjunction with either mycophenolate mofetil (MMF) or cyclophosphamide (CP) as steroid-sparing immunosuppressants. MMF was clearly preferred over CP for induction therapy of LN class III, whereas CP and MMF were equally proposed for LN class IV. MMF was most often recommended for maintenance therapy in conjunction with oral corticosteroids and continued for at least 3 years and 1 year, respectively, after remission. Hydroxychloroquine was widely accepted as a concomitant measure followed by renin-angiotensin system inhibitors in cases of arterial hypertension and/or proteinuria. CONCLUSION The majority of pediatric rheumatologists and nephrologists in Germany and Austria propose the use of corticosteroids, most often in combination with either MMF or CP, for treatment of proliferative LN in children. The considerable heterogeneity of responses supports the need for a treat-to-target protocol for juvenile proliferative LN between pediatric rheumatologists and nephrologists.
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Affiliation(s)
- Kristina Vollbach
- Department of Pediatrics, RWTH Aachen University Hospital, Aachen, Germany
| | - Catharina Schuetz
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian M Hedrich
- Department of Pediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom.,Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Fabian Speth
- Universitätsmedizin Hamburg, Kinder- und Jugendklinik, Hamburg, Germany
| | - Kirsten Mönkemöller
- Department of Pediatrics, Kinderkrankenhaus Amsterdamer Strasse, Cologne, Germany
| | - Jürgen Brunner
- Department of Pediatrics, Pediatric Rheumatology, Medizinische Universität Innsbruck, Innsbruck, and Danube Private University, Krems an der Donau, Austria
| | - Ulrich Neudorf
- Clinic for Pediatrics III, University Hospital Essen, Essen, Germany
| | - Christoph Rietschel
- Department of Pediatric Rheumatology, Clementine Kinderhospital, Frankfurt, Germany
| | - Anton Hospach
- Center for Pediatric Rheumatology, Olgahospital, Stuttgart, Germany
| | - Tilmann Kallinich
- German Rheumatism Research Center, Leibniz Institute, Berlin, and Charité Universitätsmedizin Berlin, Pediatric Pneumology, Immunology and Critical Care Medicine and SPZ (Center for Chronically Sick Children), Berlin, Germany
| | - Claas Hinze
- Department of Pediatric Rheumatology and Immunology, University Hospital, Münster, Germany
| | - Norbert Wagner
- Department of Pediatrics, RWTH Aachen University Hospital, Aachen, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital, Heidelberg, Germany
| | - Lutz T Weber
- Division of Pediatric Nephrology, Children's and Adolescents' Hospital, University Hospital of Cologne, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Kay Latta
- Clementine Kinderhospital Frankfurt, Frankfurt, Germany
| | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Bald
- Division of Pediatric Nephrology, Olgahospital, Klinikum Stuttgart, Stuttgart, Germany
| | - Dagobert Wiemann
- Division of Pediatric Diabetology/Endocrinology, University Hospital Magdeburg, Magdeburg, Germany
| | - Hildegard Zappel
- Clinic of Pediatrics and Adolescent Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Klaus Tenbrock
- Department of Pediatrics, RWTH Aachen University Hospital, Aachen, Germany
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hanover, Germany
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Alamilla-Sanchez ME, Alcala-Salgado MA, Alonso-Bello CD, Fonseca-Gonzalez GT. Mechanism of Action and Efficacy of Immunosupressors in Lupus Nephritis. Int J Nephrol Renovasc Dis 2021; 14:441-458. [PMID: 34924767 PMCID: PMC8675090 DOI: 10.2147/ijnrd.s335371] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/16/2021] [Indexed: 11/23/2022] Open
Abstract
Approximately 70% of the patients with systemic lupus erythematosus will have clinical evidence of kidney damage during their evolution. Patients with impaired renal function at onset and those with recurrent flares have a poor prognosis. Understanding the mechanism of action of immunosuppressants is essential for proper prescription. Steroids inhibit the DNA sequence that promotes the release of inflammatory cytokines. Phosphoramide mustard, metabolite of cyclophosphamide, cross-link with the DNA, causing the aggregation of an alkyl group, causing cell death. Mycophenolate inhibits inosine monophosphate dehydrogenase, prevents de novo synthesis of guanine, inducing cell arrest in S phase. Azathioprine blocks the synthesis of purines and induces apoptosis. Calcineurin inhibitors prevent the dephosphorylation of NFAT and reduce the production of interleukin 2. Antimalarials alter the enzymatic release of lysosomes by increasing intravesicular pH. The mechanism of action of rituximab is related to complement-dependent cytotoxicity and the elimination of anti-CD20-labeled B cells. Progress in the knowledge and management of low doses of steroids may change the current paradigm and reduce the frequency of related adverse events. Mycophenolate seems to be a better choice than cyclophosphamide for induction, it is also preferred over azathioprine as a maintenance immunosuppressive agent, although azathioprine is preferred in women with a desire for conception, those pregnant, or with low resources. For treatment-resistant cases, tacrolimus, rituximab or belimumab may be effective. Ongoing clinical trials with new drugs offer promising results.
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Affiliation(s)
| | | | - Cesar D Alonso-Bello
- Department of Immunology, Centro Medico Nacional "20 de Noviembre", Mexico City, Mexico
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Yap DY, Li PH, Tang C, So BY, Kwan LP, Chan GC, Lau CS, Chan TM. Long-Term Results of Triple Immunosuppression With Tacrolimus Added to Mycophenolate and Corticosteroids in the Treatment of Lupus Nephritis. Kidney Int Rep 2021; 7:516-525. [PMID: 35257064 PMCID: PMC8897290 DOI: 10.1016/j.ekir.2021.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/01/2021] [Accepted: 12/06/2021] [Indexed: 12/14/2022] Open
Abstract
Introduction Addition of a calcineurin inhibitor (CNI) to corticosteroids and mycophenolate increased the renal response rate in lupus nephritis (LN) because of proteinuria reduction, but there is little long-term efficacy and safety data on this triple immunosuppressive regimen. Methods This is a cohort study of patients with class III/IV/V LN whose proteinuria persisted despite initial standard therapy with mycophenolate mofetil (MMF) and prednisolone (PRED), in whom tacrolimus (TAC) was added (target 12-hour trough TAC plasma levels of 4–6 μg/l). Results A total of 22 patients with LN treated with triple immunosuppression were included, with follow-up of 61.1 ± 28.1 months. Achieved trough levels of TAC and mycophenolic acid (MPA) were 3.8 to 5.7 μg/l and 1.3 to 2.1 mg/l respectively. Significant proteinuria reduction occurred after 6 months and was sustained up to 5 years. Complete response (CR) and partial response (PR) rates at 12, 24, and 36 months was 59.1%, 72.7%, and 77.3% respectively. The slope of estimated glomerular filtration rate (eGFR) over time did not change after TAC was added. A total of 7 patients (31.8%) showed progressive chronic kidney disease (CKD). Two patients reached end-stage kidney disease during follow-up. Renal survival rate at -, 3, and 5 years was 100.0%, 95.0%, and 88.7% respectively. Two patients (9.1%) had renal relapse after 8.5 ± 0.7 months. A total of 5 patients (22.7%) showed worsening of hypertension, and 3 (13.6%) had worsened hyperlipidemia. Other key adverse events included infection (n = 16, 1 in 7 patient-years) and gastrointestinal upset (n = 6). Conclusion Triple immunosuppression with the addition of TAC to mycophenolate and PRED resulted in further proteinuria reduction and sustained disease quiescence in patients with LN whose proteinuria did not respond optimally to standard therapy.
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Affiliation(s)
- Desmond Y.H. Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Colin Tang
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Benjamin Y.F. So
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Lorraine P.Y. Kwan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Gary C.W. Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Chak Sing Lau
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Tak Mao Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
- Correspondence: Tak Mao Chan, Division of Nephrology, Department of Medicine, Queen Mary Hospital, 102 Pokfulam Road, The University of Hong Kong, Hong Kong.
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12
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 656] [Impact Index Per Article: 218.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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13
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Mok CC, Hamijoyo L, Kasitanon N, Chen DY, Chen S, Yamaoka K, Oku K, Li MT, Zamora L, Bae SC, Navarra S, Morand EF, Tanaka Y. The Asia-Pacific League of Associations for Rheumatology consensus statements on the management of systemic lupus erythematosus. THE LANCET. RHEUMATOLOGY 2021; 3:e517-e531. [PMID: 38279404 DOI: 10.1016/s2665-9913(21)00009-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is prevalent in Asia and carries a variable prognosis among patients across the Asia-Pacific region, which could relate to access to health care, tolerability of medications, and adherence to therapies. Because many aspects of SLE are unique among patients from this region, the Asia-Pacific League of Associations for Rheumatology developed the first set of consensus recommendations on the management of SLE. A core panel of 13 rheumatologists drafted a set of statements through face-to-face meeting and teleconferences. A literature review was done for each statement to grade the quality of evidence and strength of recommendation. 29 independent specialists and three patients with SLE were then recruited for a modified Delphi process to establish consensus on the statements through an online voting platform. A total of 34 consensus recommendations were developed. Panellists agreed that patients with SLE should be referred to a specialist for the formulation of a treatment plan through shared decision making between patients and physicians. Remission was agreed to be the goal of therapy, but when it cannot be achieved, a low disease activity state should be aimed for. Patients should be screened for renal disease, and hydroxychloroquine is recommended for all Asian people with SLE. Major organ manifestations of SLE should be treated with induction immunosuppression and subsequently maintenance; options include cyclophosphamide, mycophenolate mofetil, azathioprine, and calcineurin inhibitors, in combination with glucocorticoids. Biologics, combination regimens, plasma exchange, and intravenous immunoglobulins should be reserved for cases of refractory or life-threatening disease. Anticoagulation therapy with warfarin is preferred to the direct oral anticoagulants for thromboembolic SLE manifestations associated with a high-risk antiphospholipid antibody profile.
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Affiliation(s)
- Chi Chiu Mok
- Division of Rheumatology, Department of Medicine, Tuen Mun Hospital, Hong Kong Special Administrative Region, China.
| | - Laniyati Hamijoyo
- Rheumatology Division, Department of Internal Medicine, Padjadjaran University, Jawa Barat, Indonesia
| | - Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Chiang Mai University, Thailand
| | - Der Yuan Chen
- Rheumatology and Immunology Centre, China Medical University, Taichung, Taiwan
| | - Sheng Chen
- Department of Rheumatology, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kunihiro Yamaoka
- Department of Rheumatology and Infectious Diseases, Kitasato University School of Medicine, Kanagawa, Japan
| | - Kenji Oku
- Department of Rheumatology, Endocrinology and Nephrology Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Meng Tao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, China; Chinese Academy of Medical Science, National Clinical Research Centre for Dermatological and Immunological Diseases, Beijing, China
| | - Leonid Zamora
- Section of Rheumatology, University of Santo Tomas, Manila, Philippines
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, South Korea
| | - Sandra Navarra
- Section of Rheumatology, University of Santo Tomas, Manila, Philippines
| | - Eric F Morand
- Centre for Inflammatory Diseases, Monash University School of Clinical Sciences, Monash Medical Centre, Melbourne, Australia
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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14
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Abstract
The recent updates on treatment recommendations for the management of systemic lupus erythematous have provided greater clarity in the way existing anti-inflammatory and immunomodulatory drugs are used, in treating disease activity, preventing flares, and reducing irreversible organ damage and toxicity arising from the treatments themselves. Novel therapies will provide more options in the armamentarium for treating this complex disease, but ongoing studies are needed to improve understanding of the optimal treatment algorithm to maintain quality of life and improve survival for patients.
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Affiliation(s)
- Alberta Y Hoi
- Centre for Inflammatory Diseases, Monash University, Victoria, Australia; Department of Rheumatology, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia
| | - Eric F Morand
- Centre for Inflammatory Diseases, Monash University, Victoria, Australia; Department of Rheumatology, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia.
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15
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Kostopoulou M, Fanouriakis A, Cheema K, Boletis J, Bertsias G, Jayne D, Boumpas DT. Management of lupus nephritis: a systematic literature review informing the 2019 update of the joint EULAR and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations. RMD Open 2021; 6:rmdopen-2020-001263. [PMID: 32699043 PMCID: PMC7425195 DOI: 10.1136/rmdopen-2020-001263] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/08/2020] [Accepted: 05/22/2020] [Indexed: 01/24/2023] Open
Abstract
Objectives To analyse the current evidence for the management of lupus nephritis (LN) informing the 2019 update of the EULAR/European Renal Association-European Dialysis and Transplant Association recommendations. Methods According to the EULAR standardised operating procedures, a PubMed systematic literature review was performed, from January 1, 2012 to December 31, 2018. Since this was an update of the 2012 recommendations, the final level of evidence (LoE) and grading of recommendations considered the total body of evidence, including literature prior to 2012. Results We identified 387 relevant articles. High-quality randomised evidence supports the use of immunosuppressive treatment for class III and class IV LN (LoE 1a), and moderate-level evidence supports the use of immunosuppressive treatment for pure class V LN with nephrotic-range proteinuria (LoE 2b). Treatment should aim for at least 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). High-quality evidence supports the use of mycophenolate mofetil/mycophenolic acid (MMF/MPA) or low-dose intravenous cyclophosphamide (CY) as initial treatment of active class III/IV LN (LoE 1a). Combination of tacrolimus with MMF/MPA and high-dose CY are alternatives in specific circumstances (LoE 1a). There is low-quality level evidence to guide optimal duration of immunosuppression in LN (LoE 3). In end-stage kidney disease, all methods of kidney replacement treatment can be used, with transplantation having the most favourable outcomes (LoE 2b). Conclusions There is high-quality evidence to guide the initial and subsequent phases of class III/IV LN treatment, but low-to-moderate quality evidence to guide treatment of class V LN, monitoring and optimal duration of immunosuppression.
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Affiliation(s)
- Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece .,Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - John Boletis
- Department of Nephrology and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, 4th Department of Internal Medicine, General University Hospital Attikon, Athens, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Joint Academic Rheumatology Program, Medical School, National and Kapodestrian University of Athens, Athens, Greece, and Medical School, University of Cyprus, Nicosia, Cyprus
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16
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2020 Chinese guidelines for the diagnosis and treatment of systemic lupus erythematosus. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2020; 1:5-23. [DOI: 10.2478/rir-2020-0009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/12/2020] [Indexed: 02/05/2023]
Abstract
Abstract
Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease that represents a prodigious challenge of diagnosis and treatment. In 2019, under the leadership of the Chinese Rheumatology Association, a multidisciplinary guideline development group was established to develop an evidence-based diagnosis and treatment guideline for patients with SLE in PR China. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to evaluate the quality of evidence and the strength of recommendations. The guideline was reported following the Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist. In this guideline, we provided recommendations for SLE classification criteria, disease activity monitoring and assessment, medication administration and considerations for SLE patients with organs and systems involved, and management of special populations such as SLE patients in the setting of pregnancy. This guideline serves as an evidence-based tool for Chinese clinicians to diagnose and treat patients with SLE.
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17
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Gao Y, Yang H, Wang Y, Tian J, Li R, Zhou X. Evaluation of the inhibitory effect of tacrolimus combined with mycophenolate mofetil on mesangial cell proliferation based on the cell cycle. Int J Mol Med 2020; 46:1582-1592. [PMID: 32945359 PMCID: PMC7447332 DOI: 10.3892/ijmm.2020.4696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022] Open
Abstract
The inhibition of mesangial cell proliferation has become an important therapy for the prevention of glomerular proliferation‑associated diseases. The combined application of immunosuppressants with multiple targets presents a novel direction in the treatment of kidney diseases. The present study was designed to explore the inhibitory effects of tacrolimus (TAC) combined with mycophenolate mofetil (MMF) on the proliferation of mesangial cells based on the cell cycle. In vitro, the levels of the proliferation index markers, Ki67 and cyclin D1, in human mesangial cells (HMCs) were determined by immunofluorescence staining and western blot analysis, respectively. In mice with lupus nephritis (LN), the proliferation of mesangial cells was determined using PAS and Masson's trichrome staining, while immunohistochemistry was used to detect Ki67 and western blot analysis was employed for the evaluation of cyclin D1 levels. The expression of platelet‑derived growth factor (PDGF), a proliferation‑associated protein, was estimated using immunohistochemistry and western blot analysis. In patients with LN, Ki67, cyclin D1 and PDGF expression was estimated by immunohistochemistry. The transforming growth factor‑β1/Smad pathway influenced by TAC and the p38 pathway influenced by MMF were also examined by western blot analysis. The results suggested that the combination of TAC and MMF at half the concentration based on the cell cycle was more effective than monotherapy in inhibiting mesangial cell proliferation in vitro and in vivo. TAC inhibited HMC proliferation by affecting the Smad2 signaling pathway. MMF inhibited HMC proliferation by affecting the p38 signaling pathway. Combined treatment with TAC and MMF significantly improved the clinical indexes of patients with LN without severe adverse effects. On the whole, the findings of the present study validate and reinforce the potential use of the combination of TAC and MMF for the treatment of mesangial proliferative diseases.
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Affiliation(s)
- Yanfang Gao
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Shanxi Provincial People's Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi 030001, P.R. China
| | - Hui Yang
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Shanxi Provincial People's Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi 030001, P.R. China
| | - Yanhong Wang
- Department of Microbiology and Immunology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Jihua Tian
- Department of Microbiology and Immunology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Rongshan Li
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Shanxi Provincial People's Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi 030001, P.R. China
| | - Xiaoshuang Zhou
- Department of Nephrology, The Affiliated People's Hospital of Shanxi Medical University, Shanxi Provincial People's Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi 030001, P.R. China
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18
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Ho RTC, Leung MH. Factors Associated with Renal Outcomes in an Inception Cohort of Biopsy-proven Lupus Nephritis Patients. JOURNAL OF CLINICAL RHEUMATOLOGY AND IMMUNOLOGY 2020. [DOI: 10.1142/s2661341720500029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective: To identify the clinical factors associated with renal response and flare in lupus nephritis (LN). Methods: All 115 patients with biopsy-proven LN diagnosed between January 2002 and June 2015 in a tertiary centre comprised of an inception cohort that was followed up until February 2017. Baseline demographic, clinical parameters, renal biopsy histology, induction and maintenance immunosuppressive therapies, complete renal response (CRR), creatinine doubling, end-stage renal disease (ESRD), renal flares and infections were retrieved and analyzed with univariate log-rank test and multivariate Cox regression. Results: At the time of the first renal biopsy, the age of patients was 38 ± 12.2 years (mean ± standard deviation), 90% female and systemic lupus erythematosus (SLE) disease duration 46 months (median); 67.0% were LN class IV or class IV + V. Patients were followed up for 104 ±49 months after biopsy. At months 3, 6, 12 and 24, a cumulative 25%, 46%, 66% and 76% of patients had achieved CRR, respectively. However, 49.5% who had CRR experienced [Formula: see text]1 infection of renal flare, with cumulative risk of 5%, 17%, 25% and 43% at year 1, 2, 3 and 5, respectively. Multivariate analysis showed that nephrotic syndrome ([Formula: see text] = 0.03) and delay of renal biopsy [Formula: see text]2 months from the onset of LN ([Formula: see text] ¡ 0.01) were negatively associated with CRR. Hydroxychloroquine use was beneficial in attaining CRR ([Formula: see text] = 0.03, hazard ratio = 1.70, 95% CI: 1.04, 2.80) and preventing renal flare ([Formula: see text] = 0.01, odds ratio = 0.51, 95% CI: 0.29, 0.88). By the end of the study, 80% of patients remained in CRR though 10.4% patients ended up in ESRD (all class IV), 8.7% died and 28.7% had [Formula: see text]1 infection episode requiring hospitalization. Conclusion: Most LN patients could achieve CRR after immunosuppressive therapy but renal flares were common over time. Infective complications were fairly frequent but the incidence of ESRD was low. The use of hydroxychloroquine was associated with better renal response and fewer flares.
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Affiliation(s)
- Roy Tsz Chung Ho
- Department of Medicine, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong, China
| | - Moon Ho Leung
- Department of Medicine, Queen Elizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong, China
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19
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Mok CC, Ho LY, Ying SKY, Leung MC, To CH, Ng WL. Long-term outcome of a randomised controlled trial comparing tacrolimus with mycophenolate mofetil as induction therapy for active lupus nephritis. Ann Rheum Dis 2020; 79:1070-1076. [PMID: 32448782 DOI: 10.1136/annrheumdis-2020-217178] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 05/02/2020] [Accepted: 05/03/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To report the 10-year outcome of lupus nephritis (LN) treated with mycophenolate mofetil (MMF) or tacrolimus (TAC) induction in a randomised controlled trial. METHODS Patients with active LN were treated with MMF or TAC combined with high-dose prednisolone. Responders were switched to azathioprine (AZA) at month 6. Clinical outcomes at 10 years (renal flares, renal function decline and mortality) were assessed. Factors affecting prognosis were studied by Cox regression. Urine protein-to-creatinine ratio (uPCr) and estimated glomerular filtration rate (eGFR) at different time points were evaluated for their prediction of a poor prognosis by receiver operating characteristic (ROC) analysis. RESULTS 150 patients were studied (age 35.5±12.8 years). Complete renal response rate was similar between MMF (59%) and TAC-treated patients (62%; p=0.71). AZA maintenance was given to 79% patients. After 118.2±42 months, proteinuric and nephritic renal flares occurred in 34% and 37% of the MMF, and 53% and 30% of the TAC groups of patients, respectively (p=0.49). The cumulative incidence of a composite outcome of ↓eGFR ≥30%, chronic kidney disease stage 4/5 or death at 10 years was 33% in both groups (p=0.90). Factors independently associated with a poor renal prognosis were first-time LN (HR 0.12 (0.031 to 0.39); p=0.01), eGFR (HR 0.98 (0.96 to 0.99); p=0.008) and no response at month 6 (HR 5.18 (1.40 to 19.1); p=0.01). ROC analysis revealed an uPCr >0.75 and eGFR of <80 mL/min at month 18 best predicted a poor renal prognosis. CONCLUSIONS Long-term data confirmed non-inferiority of TAC to MMF as induction therapy of LN. An uPCr≤0.75 and eGFR of ≥80 mL/min at month 18 best predicted a favourable 10-year outcome and may be suitable targets for induction/consolidation therapy. TRIAL REGISTRATION NUMBER NCT00371319.
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Affiliation(s)
- Chi Chiu Mok
- Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong
| | - Ling Yin Ho
- Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong
| | | | - Man Chi Leung
- Medicine, United Christian Hospital, Hong Kong, Hong Kong
| | - Chi Hung To
- Medicine, Tuen Mun Hospital, Hong Kong, Hong Kong
| | - Woon Leung Ng
- Medicine, United Christian Hospital, Hong Kong, Hong Kong
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20
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Fanouriakis A, Kostopoulou M, Cheema K, Anders HJ, Aringer M, Bajema I, Boletis J, Frangou E, Houssiau FA, Hollis J, Karras A, Marchiori F, Marks SD, Moroni G, Mosca M, Parodis I, Praga M, Schneider M, Smolen JS, Tesar V, Trachana M, van Vollenhoven RF, Voskuyl AE, Teng YKO, van Leew B, Bertsias G, Jayne D, Boumpas DT. 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; 79:713-723. [PMID: 32220834 DOI: 10.1136/annrheumdis-2020-216924] [Citation(s) in RCA: 400] [Impact Index Per Article: 100.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN). METHODS Following the EULAR standardised operating procedures, a systematic literature review was performed. Members of a multidisciplinary Task Force voted independently on their level of agreeement with the formed statements. RESULTS The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNIs) and management of end-stage kidney disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7 g/24 hours 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 2-3 g/day or mycophenolic acid (MPA) at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500 mg × 6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5 mg/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 >1 g/24 hours 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. Treatment of LN in children follows the same principles as adult disease. CONCLUSIONS We have updated the EULAR recommendations for the management of LN to facilitate homogenization of patient care.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital LMU Munich, Munich, Germany
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - John Boletis
- Nephrology Department and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Eleni Frangou
- Department of Nephrology, Limassol General Hospital, Limassol, Cyprus
| | - Frederic A Houssiau
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Jane Hollis
- Lupus nurse specialist, Addenbrooke's Hospital, Cambridge, UK
| | - Adexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Stephen D Marks
- University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Manuel Praga
- Nephrology Department, Research Institute Hospital Universitario 12 de Octubre (i+12), Department of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Duesseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Maria Trachana
- Pediatric Immunology and Rheumatology Referral Center, First Pediatric Clinic, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Y K Onno Teng
- Centre of expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece .,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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21
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Peleg Y, Bomback AS, Radhakrishnan J. The Evolving Role of Calcineurin Inhibitors in Treating Lupus Nephritis. Clin J Am Soc Nephrol 2020; 15:1066-1072. [PMID: 32152065 PMCID: PMC7341791 DOI: 10.2215/cjn.13761119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The overall kidney survival among lupus nephritis patients has improved with currently used induction immunosuppression regimens of corticosteroids and either cyclophosphamide or mycophenolate mofetil; however, there still remains a significant number of lupus nephritis patients who do not achieve remission with these regimens. Investigators have looked at other immunosuppressive regimens for lupus nephritis, and there has been interest in the use of calcineurin inhibitors in this regard. Calcineurin inhibitors are potentially an attractive option because of their established ability to inhibit T cell function, attenuate proteinuria through non-immunologic means, and their safety in pregnancy and lactation. In this review, we discuss the findings and limitations of selected trials that evaluated the use of calcineurin inhibitors in the treatment of lupus nephritis, either with corticosteroids alone or as a component of multitarget therapy when combined with mycophenolate mofetil. There may be a role for calcineurin inhibitors among patients with heavy proteinuria, as well as younger patients with refractory lupus nephritis. The multitarget therapy trials reveal higher rates of remission compared with mycophenolate mofetil alone and cyclophosphamide; however, some trials highlight the possibility of more infectious adverse events. We discuss the need for further study of calcineurin inhibitors in more diverse patient populations and the need for trials with longer follow-up with "hard" endpoints beyond proteinuria reduction, such as worsening CKD or repeat protocol biopsies, given the calcineurin inhibitors ability to reduce proteinuria non-immunologically and thus increased rate of relapse when the drug is tapered. While there may indeed be a space for calcineurin inhibitors to help increase remission rates in lupus nephritis patients, more work is needed to help address the questions the studies available to date have yet to answer.
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Affiliation(s)
- Yonatan Peleg
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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22
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Lu KL, Wu MY, Wang CH, Wang CW, Hung SI, Chung WH, Chen CB. The Role of Immune Checkpoint Receptors in Regulating Immune Reactivity in Lupus. Cells 2019; 8:E1213. [PMID: 31597242 PMCID: PMC6829486 DOI: 10.3390/cells8101213] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 09/29/2019] [Accepted: 10/03/2019] [Indexed: 12/26/2022] Open
Abstract
Immune checkpoint receptors with co-stimulatory and co-inhibitory signals are important modulators for the immune system. However, unrestricted co-stimulation and/or inadequate co-inhibition may cause breakdown of self-tolerance, leading to autoimmunity. Systemic lupus erythematosus (SLE) is a complex multi-organ disease with skewed and dysregulated immune responses interacting with genetics and the environment. The close connections between co-signaling pathways and SLE have gradually been established in past research. Also, the recent success of immune checkpoint blockade in cancer therapy illustrates the importance of the co-inhibitory receptors in cancer immunotherapy. Moreover, immune checkpoint blockade could result in substantial immune-related adverse events that mimic autoimmune diseases, including lupus. Together, immune checkpoint regulators represent viable immunotherapeutic targets for the treatment of both autoimmunity and cancer. Therefore, it appears reasonable to treat SLE by restoring the out-of-order co-signaling axis or by manipulating collateral pathways to control the pathogenic immune responses. Here, we review the current state of knowledge regarding the relationships between SLE and the co-signaling pathways of T cells, B cells, dendritic cells, and neutrophils, and highlight their potential clinical implications. Current clinical trials targeting the specific co-signaling axes involved in SLE help to advance such knowledge, but further in-depth exploration is still warranted.
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Affiliation(s)
- Kun-Lin Lu
- Chang Gung Memorial Hospital, Linkou 333, Taiwan; (K.-L.L.); (M.-Y.W.); , (C.-W.W.); (S.-I.H.)
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
| | - Ming-Ying Wu
- Chang Gung Memorial Hospital, Linkou 333, Taiwan; (K.-L.L.); (M.-Y.W.); , (C.-W.W.); (S.-I.H.)
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei 105, Taiwan
| | - Chi-Hui Wang
- Chang Gung Memorial Hospital, Linkou 333, Taiwan; (K.-L.L.); (M.-Y.W.); , (C.-W.W.); (S.-I.H.)
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei 105, Taiwan
| | - Chuang-Wei Wang
- Chang Gung Memorial Hospital, Linkou 333, Taiwan; (K.-L.L.); (M.-Y.W.); , (C.-W.W.); (S.-I.H.)
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei 105, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou 333, Taiwan
| | - Shuen-Iu Hung
- Chang Gung Memorial Hospital, Linkou 333, Taiwan; (K.-L.L.); (M.-Y.W.); , (C.-W.W.); (S.-I.H.)
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei 105, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou 333, Taiwan
| | - Wen-Hung Chung
- Chang Gung Memorial Hospital, Linkou 333, Taiwan; (K.-L.L.); (M.-Y.W.); , (C.-W.W.); (S.-I.H.)
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei 105, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung 204, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen 361000, China
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
| | - Chun-Bing Chen
- Chang Gung Memorial Hospital, Linkou 333, Taiwan; (K.-L.L.); (M.-Y.W.); , (C.-W.W.); (S.-I.H.)
- College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei 105, Taiwan
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung 204, Taiwan
- Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen 361000, China
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Kwei-Shan, Taoyuan 333, Taiwan
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23
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Bragazzi NL, Watad A, Damiani G, Adawi M, Amital H, Shoenfeld Y. Role of anti-DNA auto-antibodies as biomarkers of response to treatment in systemic lupus erythematosus patients: hypes and hopes. Insights and implications from a comprehensive review of the literature. Expert Rev Mol Diagn 2019; 19:969-978. [PMID: 31516059 DOI: 10.1080/14737159.2019.1665511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Due to the polymorphic clinical presentations and manifestations of systemic lupus erythematosus (SLE), biomarkers with enough diagnostic and prognostic value are of paramount importance. Recently, anti-double stranded DNA (anti-dsDNA) auto-antibodies have been proposed to monitor the response to different therapies. It has also been suggested that they should be employed as entry markers in trial studies. However, their clinical use remains still debated and, sometimes, controversial, due to conflicting findings reported. Areas covered: Through an extensive literature review, we evaluated changes in anti-dsDNA auto-antibodies levels before and after the administration of the treatment (either biological or non-biological). Expert opinion: Anti-dsDNA auto-antibodies related findings are still difficult to compare mainly because of the different detecting methods employed, even though in most studies included in this review a consistent decreasing pattern after the treatment seems to emerge. Hence, if properly standardized, anti-dsDNA auto-antibody profile may be a reliable biomarker to monitor the effectiveness of biologics as well as of non-biological drugs, especially if grouped in composite outcomes scores, such as the 'Lupus Multivariable Outcome Score' (LUMOS) or measured with other biomarkers, such as anti-nucleosome auto-antibodies. We recommend the assessment of anti-dsDNA auto-antibodies levels in both daily practice and research settings.
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Affiliation(s)
- Nicola Luigi Bragazzi
- Department of Mathematics and Statistics, Laboratory for Industrial and Applied Mathematics (LIAM) , Toronto , Canada
| | - Abdulla Watad
- Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel.,Department of Internal Medicine 'B', Sheba Medical Center , Ramat Gan , Israel
| | - Giovanni Damiani
- Centro Studi GISED, Young Dermatologists Italian Network , Bergamo , Italy.,Department of Biomedical, Surgical and Dental Sciences University of Milan , Milan , Italy.,Department of Dermatology, Case Western Reserve University , OH , Cleveland , USA.,Clinical Dermatology, IRCCS Istituto Ortopedico Galeazzi , Milan , Italy
| | - Mohammad Adawi
- Padeh and Ziv Hospitals, Azrieli Faculty of Medicine, Bar-Ilan University , Ramat Gan , Israel
| | - Howard Amital
- Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel.,Department of Internal Medicine 'B', Sheba Medical Center , Ramat Gan , Israel
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Tel Aviv University , Tel Aviv , Israel.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University of the Ministry of Health of the Russian Federation (Sechenov University) , Moscow , Russia.,Past incumbent of the Laura Schwarz-Kipp Chair for Research of Autoimmune Diseases, Tel Aviv University , Tel Aviv , Israel
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24
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Durcan L, O'Dwyer T, Petri M. Management strategies and future directions for systemic lupus erythematosus in adults. Lancet 2019; 393:2332-2343. [PMID: 31180030 DOI: 10.1016/s0140-6736(19)30237-5] [Citation(s) in RCA: 284] [Impact Index Per Article: 56.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 01/03/2019] [Accepted: 01/23/2019] [Indexed: 12/13/2022]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease characterised by the loss of self-tolerance and formation of nuclear autoantigens and immune complexes resulting in inflammation of multiple organs. The clinical presentation of SLE is heterogeneous, can involve one or more organs, including the skin, kidneys, joints, and nervous system, and take a chronic or relapsing and remitting disease course. SLE is most common in women and in those of non-white ethnicity. Because of the multitude of presentations, manifestations, and serological abnormalities in patients with SLE, diagnosis can be challenging. Therapeutic approaches predominantly involve immunomodulation and immunosuppression and are targeted to the specific organ manifestation, with the aim of achieving low disease activity. Despite many treatment advances and improved diagnostics, SLE continues to cause substantial morbidity and premature mortality. Current management strategies, although helpful, are limited by high failure rates and toxicity. An overreliance on corticosteroid therapy contributes to much of the long-term organ damage. In this Seminar, we outline the classification criteria for SLE, current treatment strategies and medications, the evidence supporting their use, and explore potential future therapies.
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Affiliation(s)
- Laura Durcan
- Department of Rheumatology, Beaumont Hospital, Dublin, Ireland; Department of Medicine, The Royal College of Surgeons of Ireland, Dublin, Ireland.
| | - Tom O'Dwyer
- School of Physiotherapy, Trinity College, Dublin, Ireland
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MA, USA
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25
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Fanouriakis A, Kostopoulou M, Alunno A, Aringer M, Bajema I, Boletis JN, Cervera R, Doria A, Gordon C, Govoni M, Houssiau F, Jayne D, Kouloumas M, Kuhn A, Larsen JL, Lerstrøm K, Moroni G, Mosca M, Schneider M, Smolen JS, Svenungsson E, Tesar V, Tincani A, Troldborg A, van Vollenhoven R, Wenzel J, Bertsias G, Boumpas DT. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis 2019; 78:736-745. [DOI: 10.1136/annrheumdis-2019-215089] [Citation(s) in RCA: 780] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/07/2019] [Accepted: 03/11/2019] [Indexed: 12/11/2022]
Abstract
Our objective was to update the EULAR recommendations for the management of systemic lupus erythematosus (SLE), based on emerging new evidence. We performed a systematic literature review (01/2007–12/2017), followed by modified Delphi method, to form questions, elicit expert opinions and reach consensus. Treatment in SLE aims at remission or low disease activity and prevention of flares. Hydroxychloroquine is recommended in all patients with lupus, at a dose not exceeding 5 mg/kg real body weight. During chronic maintenance treatment, glucocorticoids (GC) should be minimised to less than 7.5 mg/day (prednisone equivalent) and, when possible, withdrawn. Appropriate initiation of immunomodulatory agents (methotrexate, azathioprine, mycophenolate) can expedite the tapering/discontinuation of GC. In persistently active or flaring extrarenal disease, add-on belimumab should be considered; rituximab (RTX) may be considered in organ-threatening, refractory disease. Updated specific recommendations are also provided for cutaneous, neuropsychiatric, haematological and renal disease. Patients with SLE should be assessed for their antiphospholipid antibody status, infectious and cardiovascular diseases risk profile and preventative strategies be tailored accordingly. The updated recommendations provide physicians and patients with updated consensus guidance on the management of SLE, combining evidence-base and expert-opinion.
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26
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Gomez Mendez LM, Cascino MD, Katsumoto TR, Brakeman P, Brunetta P, Jayne D, Dall'Era M, Rovin B, Garg J. Outcome of participants with nephrotic syndrome in combined clinical trials of lupus nephritis. Lupus Sci Med 2019; 6:e000308. [PMID: 31080631 PMCID: PMC6485211 DOI: 10.1136/lupus-2018-000308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/31/2018] [Accepted: 01/06/2019] [Indexed: 12/23/2022]
Abstract
Objective The outcome of participants with nephrotic syndrome in clinical trials of lupus nephritis has not been studied in detail. Methods Collated data from two randomised controlled trials in lupus nephritis, Lupus Nephritis Assessment of Rituximab (LUNAR) and A Study to Evaluate Ocrelizumab in Patients With Nephritis due to Systemic Lupus Erythematosus (BELONG) were analysed. Nephrotic syndrome was defined as albumin <3 g/dL and urine protein/creatinine ratio ≥3.5 g/g at start of trial. Renal response was defined as a first morning urine protein/creatinine ratio ≤0.5 g/g in addition to ≤25% increase in creatinine from trial entry assessed at week 48. Logistic regression was used to evaluate the association of nephrotic syndrome with renal response while adjusting for treatment received and ACE inhibitor or angiotensin receptor blocker use. Results 28 (26%) participants with nephrotic syndrome achieved renal response as compared with 130 (52.5%) of those without (p<0.001). Having nephrotic syndrome at baseline significantly lowered the likelihood of achieving renal response (OR 0.32, 95 % CI 0.19 to 0.54, p<0.001). 125 (80%) participants achieved resolution of their nephrotic syndrome in a median time of 16 weeks. Conclusions Nephrotic syndrome at baseline decreases the likelihood of renal response at 1 year. Longer clinical trials or better short-term predictors of long-term outcomes may better assess the effect of novel therapeutic approaches on subjects with nephrotic syndrome.
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Affiliation(s)
| | - Matthew D Cascino
- Product Development Clinical Science, Genentech Inc, South San Francisco, California, USA
| | - Tamiko R Katsumoto
- Product Development Clinical Science, Genentech Inc, South San Francisco, California, USA.,Early Development, Genentech Inc, South San Francisco, CA, United States
| | - Paul Brakeman
- Department of Pediatric Nephrology, University of California San Francisco, San Francisco, California, USA
| | - Paul Brunetta
- Product Development Clinical Science, Genentech Inc, South San Francisco, California, USA
| | - David Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Maria Dall'Era
- Department of Rheumatology, University of California San Francisco, San Francisco, CA, United States
| | - Brad Rovin
- Department of Internal Medicine/Nephrology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jay Garg
- Product Development Clinical Science, Genentech Inc, South San Francisco, California, USA
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27
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Fava A, Petri M. Systemic lupus erythematosus: Diagnosis and clinical management. J Autoimmun 2019; 96:1-13. [PMID: 30448290 PMCID: PMC6310637 DOI: 10.1016/j.jaut.2018.11.001] [Citation(s) in RCA: 324] [Impact Index Per Article: 64.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 11/01/2018] [Accepted: 11/01/2018] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is a worldwide chronic autoimmune disease which may affect every organ and tissue. Genetic predisposition, environmental triggers, and the hormonal milieu, interplay in disease development and activity. Clinical manifestations and the pattern of organ involvement are widely heterogenous, reflecting the complex mosaic of disrupted molecular pathways converging into the SLE clinical phenotype. The SLE complex pathogenesis involves multiple cellular components of the innate and immune systems, presence of autoantibodies and immunocomplexes, engagement of the complement system, dysregulation of several cytokines including type I interferons, and disruption of the clearance of nucleic acids after cell death. Use of immunomodulators and immunosuppression has altered the natural course of SLE. In addition, morbidity and mortality in SLE not only derive from direct immune mediated tissue damage but also from SLE and treatment associated complications such as accelerated coronary artery disease and increased infection risk. Here, we review the diagnostic approach as well as the etiopathogenetic rationale and clinical evidence for the management of SLE. This includes 1) lifestyle changes such as avoidance of ultraviolet light; 2) prevention of comorbidities including coronary artery disease, osteoporosis, infections, and drug toxicities; 3) use of immunomodulators (i.e. hydroxychloroquine and vitamin D); and 4) immunosuppressants and targeted therapy. We also review new upcoming agents and regimens currently under study.
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Affiliation(s)
- Andrea Fava
- Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA
| | - Michelle Petri
- Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA.
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28
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Mok CC. Is Treat-to-target in Lupus Nephritis Realistic in Clinical Practice? Curr Rheumatol Rev 2018; 15:2-6. [PMID: 29623845 DOI: 10.2174/1573397114666180406100857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 02/19/2018] [Accepted: 04/01/2018] [Indexed: 11/22/2022]
Abstract
The Treat-to-Target (T2T) principle has been advocated in a number of inflammatory
and non-inflammatory medical illnesses. Tight control of disease activity has been shown to improve
the outcome of rheumatoid arthritis and psoriatic arthritis as compared to the conventional
approach. However, whether T2T can be applied to patients with lupus nephritis is still under
emerging discussion. Treatment of lupus nephritis should target at inducing and maintaining remission
of the kidney inflammation so as to preserve renal function and improve survival in the longterm.
However, there is no universal agreement on the definition of remission or low disease activity
state of nephritis, as well as the time points for switching of therapies. Moreover, despite the
availability of objective parameters for monitoring such as proteinuria and urinary sediments, differentiation
between ongoing activity and damage in some patients with persistent urinary abnormalities
remains difficult without a renal biopsy. A large number of serum and urinary biomarkers
have been tested in lupus nephritis but none of them have been validated for routine clinical use. In
real life practice, therapeutic options for lupus nephritis are limited. As patients with lupus nephritis
are more prone to infective complications, tight disease control with aggressive immunosuppressive
therapies may have safety concern. Not until the feasibility, efficacy, safety and cost-effectiveness
of T2T in lupus nephritis is confirmed by comparative trials, this approach should not be routinely
recommended with the current treatment armamentarium and monitoring regimes.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR, China
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29
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Mao Y, Yin L, Huang H, Zhou Z, Chen T, Zhou W. Addition of cyclosporine/tacrolimus for pediatric relapsed lupus nephritis during mycophenolate mofetil maintenance therapy. J Int Med Res 2018; 47:105-113. [PMID: 30208769 PMCID: PMC6384452 DOI: 10.1177/0300060518796751] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Objective We aimed to evaluate the efficacy of low-dose cyclosporine (CsA) or tacrolimus (Tac) in children with proliferative lupus nephritis (PLN) during maintenance therapy. Methods A low dose of CsA or Tac was added to 11 children who relapsed during mycophenolate mofetil (MMF) maintenance therapy. Renal remission was analyzed at 3 and 6 months, and at 1, 2, and 3 years after CsA/Tac addition. Adverse effects were recorded. Results The clinical response rates were 81.9%, 100%, 90.0%, 100%, and 100% at 3 months, 6 months, 1 year, 2 years, and 3 years after CsA/Tac addition, respectively. Complete renal remission rates were 45.5%, 45.5%, 40.0%, 44.4%, and 71.4% at 3 months, 6 months, 1 year, 2 years, and 3 years after CsA/Tac addition, respectively. None of the patients had severe adverse events. Conclusion Low-dose CsA/Tac combined with MMF shows a promising effect in renal remission with acceptable safety in children with PLN. Therefore, this combination would be a good choice for children with lupus nephritis who relapse or have suboptimal MMF maintenance therapy.
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Affiliation(s)
- Youying Mao
- Nephrology and Rheumatology Department, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lei Yin
- Nephrology and Rheumatology Department, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hua Huang
- Nephrology and Rheumatology Department, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhengyu Zhou
- Nephrology and Rheumatology Department, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Tongxin Chen
- Nephrology and Rheumatology Department, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhou
- Nephrology and Rheumatology Department, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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30
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Choi CB, Won S, Bae SC. Outcomes of multitarget therapy using mycophenolate mofetil and tacrolimus for refractory or relapsing lupus nephritis. Lupus 2018; 27:1007-1011. [DOI: 10.1177/0961203318758505] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- C-B Choi
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - S Won
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | - S-C Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
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31
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Matsuda S, Yoshida S, Nakamura E, Takeuchi T, Makino S. Refractory chronic lupus peritonitis resolved by multitargeted therapy. Lupus 2017; 27:872-874. [PMID: 29117779 DOI: 10.1177/0961203317741563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- S Matsuda
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - S Yoshida
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - E Nakamura
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - T Takeuchi
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - S Makino
- Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
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32
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Mok CC. Calcineurin inhibitors in systemic lupus erythematosus. Best Pract Res Clin Rheumatol 2017; 31:429-438. [PMID: 29224682 DOI: 10.1016/j.berh.2017.09.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/06/2017] [Accepted: 09/02/2017] [Indexed: 01/14/2023]
Abstract
The calcineurin inhibitors (CNIs) belong to a group of immunosuppressive agents that block T-cell activation through the suppression of the calcium/calcimodulin-dependent phosphatase calcineurin. Agents such as cyclosporine A (CSA) and tacrolimus (TAC) have long been used in patients with systemic lupus erythematosus (SLE). TAC is preferred to CSA in SLE because of the lower frequency of cosmetic, hypertensive and dyslipidemic adverse effects. Recent randomised controlled trials have demonstrated noninferiority of TAC to mycophenolate mofetil (MMF) or cyclophosphamide (CYC) for induction therapy of lupus nephritis. Low-dose combination of TAC and MMF has also been shown to outperform CYC pulses in inducing remission of lupus nephritis in Chinese patients. TAC does not affect fertility and is relatively safe in pregnancy. In SLE patients who are intolerant or refractory to conventional immunosuppressives, or where contraindications to other immunosuppressive agents exist, TAC is an alternative option. However, the therapeutic window of TAC is narrow, and drug level monitoring is required to ensure drug exposure and minimise toxicities. Current evidence of TAC in lupus nephritis is limited to 6 months, and its long-term safety as maintenance therapy of SLE is yet to be determined. Newer chemical analogues of CNIs, such as voclosporin, with less variable plasma concentration are being tested in lupus nephritis.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Tsing Chung Koon Road, New Territories, Hong Kong, China.
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33
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Kasitanon N, Boripatkosol P, Louthrenoo W. Response to combination of mycophenolate mofetil, cyclosporin A and corticosteroid treatment in lupus nephritis patients with persistent proteinuria. Int J Rheum Dis 2017; 21:200-207. [PMID: 28901731 DOI: 10.1111/1756-185x.13152] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To study the response of lupus nephritis (LN) patients with persistent proteinuria (≥ 1 g/day after ≥ 6 months corticosteroid and single immunosuppressant treatment, or ≥ 3 g/day after ≥ 3 months of corticosteroid and single immunosuppressant treatment) to corticosteroid combined with two immunosuppressants, and to evaluate associated factors of response within 1 year. METHOD A retrospective study of proteinuria and renal function observed in LN patients with persistent proteinuria after adding a second immunosuppressant at 3, 6, 9 and 12 months. RESULT Twenty-one LN patients (100.0% female) with persistent proteinuria were treated with corticosteroid and two immunosuppressants (mycophenolate mofetil [MMF] plus cyclosporine A [CSA]). Their mean age and duration from first immunosuppressant to initiating a combination therapy were 33.2 ± 10.2 years and 17.5 ± 15.7 months, respectively. Twelve (57.1%) patients had proteinuria levels ≥ 3 g/day. The renal pathology from 18 patients were Classes III or IV in 11 (61.1%). Fifteen patients (71.4%) responded to treatment (complete remission [CR], proteinuria ≤ 0.5 g/day, in seven patients and partial remission [PR], proteinuria reduced > 50%, in eight patients). Changing from a single immunosuppressant to combined immunosuppressants was associated with CR within 1 year (hazards ratio = 0.88; 95% CI = 0.78-0.99). Adverse events consisted of one patient with severe infection, two herpes zoster and one with transient increased serum creatinine level. CONCLUSION Approximately 70% of LN patients with persistent proteinuria responded to MMF plus CSA. However, infection should be a concern with these patients.
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Affiliation(s)
- Nuntana Kasitanon
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pornkamon Boripatkosol
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Worawit Louthrenoo
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Sakai R, Kurasawa T, Nishi E, Kondo T, Okada Y, Shibata A, Nishimura K, Chino K, Okuyama A, Takei H, Nagasawa H, Amano K. Efficacy and safety of multitarget therapy with cyclophosphamide and tacrolimus for lupus nephritis: a prospective, single-arm, single-centre, open label pilot study in Japan. Lupus 2017; 27:273-282. [DOI: 10.1177/0961203317719148] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- R Sakai
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Department of Microbiology and Immunology, Keio University, Tokyo, Japan
| | - T Kurasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - E Nishi
- Institute of Rheumatology, Zenjinkai Shimin-no-Mori Hospital, Miyazaki, Japan
| | - T Kondo
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - Y Okada
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - A Shibata
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - K Nishimura
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Division of Rheumatology, Japan Community Health Care Organization, Saitama, Japan
| | - K Chino
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - A Okuyama
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - H Takei
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
| | - H Nagasawa
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
- Nagasawa Clinic, Saitama, Japan
| | - K Amano
- Department of Rheumatology and Clinical Immunology, Saitama Medical University, Saitama, Japan
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Mok CC. Biological and targeted therapies of systemic lupus erythematosus: evidence and the state of the art. Expert Rev Clin Immunol 2017; 13:677-692. [PMID: 28443384 DOI: 10.1080/1744666x.2017.1323635] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong SAR, China
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Abstract
Systemic lupus erythematosus (SLE) continues to have important morbidity and accelerated mortality despite therapeutic advances. Targeted therapies offer the possibility of improved efficacy with fewer side effects. Current management strategies rely heavily on nonspecific immunosuppressive agents. Prednisone, in particular, is responsible for a considerable burden of later organ damage. There are a multitude of diverse mechanisms of disease activity, immunogenic abnormalities and clinical manifestations to take into consideration in SLE. Many targeted agents with robust mechanistic preclinical data and promising early phase studies have ultimately been disappointing in phase III, randomized, controlled studies. Recent efforts have focused on B-cell therapies, in particular given the success of belimumab in clinical trials, with limited success. We remain optimistic regarding other specific therapies being evaluated, including interferon-alpha blockade. It is likely that in SLE, given the heterogeneity of the population involved, precision medicine is needed, rather than expecting that any single biologic will be universally effective.
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Affiliation(s)
- L Durcan
- Division of Rheumatology, University of Washington, Seattle, WA, USA
| | - M Petri
- Division of Rheumatology, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Fernandez Nieto M, Jayne DR. Con: The use of calcineurin inhibitors in the treatment of lupus nephritis. Nephrol Dial Transplant 2016; 31:1567-71. [PMID: 27591328 DOI: 10.1093/ndt/gfw291] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 02/22/2016] [Indexed: 01/30/2023] Open
Abstract
Lupus nephritis (LN) therapy has limited efficacy due to its toxicity, and LN patients suffer high risks of renal and cardiovascular morbidity and mortality. Calcineurin inhibitors (CNIs) have been used for over >30 years in LN treatment and are an established alternative therapy for Class V nephritis, but uncertainty remains about their role in proliferative disease or in the maintenance of remission. More recently, the combination of CNIs with mycophenolate mofetil (MMF) and glucocorticoid combination therapy, 'multitarget' therapy and the use of tacrolimus as opposed to ciclosporin has received attention. Is the evidence now sufficient to support the routine use of regimens including CNIs in LN? Although CNIs appear to have similar efficacy to MMF-based regimens as induction therapy, and are comparable with azathioprine as maintenance treatment, CNI toxicities, such as new-onset hypertension, hyperglycaemia and nephrotoxicity, have been problematic. Multitarget therapy improves the rate of complete remission in short-term studies, but whether this benefit is maintained over the longer term is uncertain. However, patient tolerability is lower and the frequency of serious events is higher in multitarget versus cyclophosphamide-based regimens, and there is a paucity of evidence from non-Asian ethnic groups. CNI-based therapy is also complicated by the absence of standardized dosing and the need for drug level monitoring, as well as by pharmacogenetic differences. Also, multitarget therapy increases the complexity and the cost of treatment. There is insufficient evidence to support the routine use of CNI-based or multitarget therapy for proliferative LN. Further data on long-term renal and cardiovascular outcomes and strategies to improve tolerability and safety are required.
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Affiliation(s)
| | - David R Jayne
- Department of Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, UK
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Mok CC. Pro: The use of calcineurin inhibitors in the treatment of lupus nephritis. Nephrol Dial Transplant 2016; 31:1561-6. [PMID: 27591327 DOI: 10.1093/ndt/gfw289] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 03/19/2016] [Indexed: 12/11/2022] Open
Abstract
Renal disease in systemic lupus erythematosus (SLE) carries significant morbidity and mortality. Cyclophosphamide (CYC)- and mycophenolate mofetil (MMF)-based induction regimens are not ideal in terms of efficacy and toxicity. The adverse effects of CYC, such as infection risk, infertility, urotoxicity and oncogenicity, limit its use in lupus nephritis. Although MMF is non-inferior to CYC as induction therapy and has reduced gonadal toxicity and oncogenic potential, meta-analyses of clinical trials do not show a lower rate of infective and gastrointestinal complications. Tacrolimus (TAC) has recently been shown to have equal efficacy to either MMF or CYC for inducing remission of lupus nephritis. A low-dose combination of MMF and TAC appears to be more effective than intravenous CYC pulses in Chinese patients, and has potential to replace the more toxic CYC regimens in high-risk subgroups. TAC may be considered as another non-CYC alternative for induction therapy of lupus nephritis and in those with refractory disease or intolerance to CYC or MMF. TAC has no negative effect on fertility in younger women, and unlike MMF and CYC, it is safe in pregnancy. However, TAC has a narrow therapeutic window and drug level monitoring is required to ensure drug exposure and minimize acute toxicities. Current evidence for the efficacy of TAC in lupus nephritis is limited to 6 months and the incidence of renal flare after discontinuation of therapy or switching to azathioprine appears to be higher than other induction agents. Long-term data and the incidence of chronic nephrotoxicity of TAC as maintenance therapy in lupus nephritis are currently lacking and further prospective trials are needed to address these issues.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR, China
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Recomendaciones y sugerencias a 4 preguntas clave en nefropatía lúpica: Extracto de la guía de práctica clínica 2015. Nefrologia 2016; 36:333-8. [DOI: 10.1016/j.nefro.2016.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 12/23/2015] [Accepted: 01/14/2016] [Indexed: 11/20/2022] Open
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40
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Mok CC. Con: Cyclophosphamide for the treatment of lupus nephritis. Nephrol Dial Transplant 2016; 31:1053-7. [PMID: 27190358 DOI: 10.1093/ndt/gfw068] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 01/12/2016] [Indexed: 01/08/2023] Open
Abstract
Kidney involvement is a major determinant for morbidity and mortality in patients with systemic lupus erythematosus. The treatment target of lupus renal disease is to induce and maintain remission and to minimize disease or treatment-related comorbidities. Cyclophosphamide (CYC), in conjunction with glucocorticoids, has conventionally been used for the initial treatment of lupus nephritis. However, the major concerns of CYC are its toxicities, such as infertility, urotoxicity and oncogenicity, which are particularly relevant in women of childbearing age. As a result, maintenance therapy of lupus nephritis with an extended course of CYC pulses has largely been replaced by other immunosuppressive agents such as mycophenolate mofetil (MMF) and azathioprine. Recent randomized controlled trials have demonstrated non-inferiority of MMF to pulse CYC as induction therapy of lupus nephritis. Although MMF as induction-maintenance therapy has been increasingly used in lupus nephritis, its efficacy in the long-term preservation of renal function remains to be elucidated. MMF is not necessarily less toxic than CYC. Meta-analyses of clinical trials show similar incidence of infective complications and gastrointestinal adverse events in both MMF- and CYC-based regimens. However, considering the reduction in gonadal toxicity and the risk of oncogenicity, MMF may be used as first-line therapy of lupus nephritis. Tacrolimus (TAC) has recently been shown to be equivalent to either MMF or CYC for inducing remission of lupus nephritis and may be considered as another non-CYC alternative. Combined low-dose MMF and TAC appears to be more effective than CYC pulses in Chinese patients with lupus nephritis and has the potential to replace the more toxic CYC regimens in high-risk patients. Currently, CYC still plays an important role in the management of lupus nephritis patients with impaired or rapidly deteriorating renal function, crescentic glomerulonephritis or as salvage therapy for recalcitrant disease.
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Affiliation(s)
- Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong, SAR, China
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41
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Abstract
Renal involvement in systemic lupus erythematosus (SLE) carries substantial morbidity and mortality. Conventional immunosuppressive agents (cyclophosphamide and azathioprine) have suboptimal efficacy and substantial toxicity. Mycophenolate mofetil has emerged as an alternative agent for both induction and maintenance therapy in lupus nephritis because of its reduced gonadal toxicity, despite its failure to demonstrate superiority over cyclophosphamide in pivotal studies. The calcineurin inhibitor tacrolimus has equivalent efficacy to cyclophosphamide and mycophenolate mofetil for inducing remission of lupus nephritis. Although rituximab has shown promise in refractory lupus nephritis, combining rituximab with mycophenolate mofetil as initial therapy offers no additional benefit. Considerable interethnic variation is evident in the efficacy and tolerability of the various immunosuppressive regimens, which necessitates individualized treatment and comparison of the efficacy of new regimens across different ethnic groups. For example, low-dose combinations of tacrolimus and mycophenolate mofetil seem to be more effective than pulse cyclophosphamide as induction therapy in Chinese patients. The same regimen has also been used successfully to treat refractory proliferative and membranous lupus nephritis in patients of various ethnic groups. Finally, novel serum and urinary biomarkers are being validated for diagnosis, prognostic stratification and early recognition of flares in lupus nephritis.
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Affiliation(s)
- C C Mok
- Department of Medicine, Tuen Mun Hospital, 23 Tsing Chung Koon Road, New Territories, Hong Kong SAR, China
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43
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Abd Rahman AN, Tett SE, Abdul Gafor HA, McWhinney BC, Staatz CE. Exposure-effect relationship of mycophenolic acid and prednisolone in adult patients with lupus nephritis. Br J Clin Pharmacol 2015; 80:1064-75. [PMID: 25959850 DOI: 10.1111/bcp.12678] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/20/2015] [Accepted: 05/01/2015] [Indexed: 01/12/2023] Open
Abstract
AIMS The aim was to examine relationships between total and unbound mycophenolic acid (MPA) and prednisolone exposure and clinical outcomes in patients with lupus nephritis. METHODS Six blood samples were drawn pre- and at 1, 2, 4, 6 and 8 h post-dose and total and unbound MPA and prednisolone pre-dose (C0 ), maximum concentration (Cmax ) and area under the concentration-time curve (AUC) were determined using non-compartmental analysis in 25 patients. The analyses evaluated drug exposures in relation to treatment response since starting MPA and drug-related adverse events. RESULTS Dose-normalized AUC varied 10-, 8-, 7- and 19-fold for total MPA, unbound MPA, total prednisolone and unbound prednisolone, respectively. Median values (95% CI) of total MPA AUC(0,8 h) (21.5 [15.0, 42.0] vs. 11.2 [4.8, 30.0] mg l(-1) h, P= 0.048) and Cmax (11.9 [6.7, 26.3] vs. 6.1 [1.6, 9.2] mg l(-1) , P = 0.016) were significantly higher in responders than non-responders. Anaemia was significantly associated with higher total (37.8 [14.1, 77.5] vs. 18.5 [11.7, 32.7] mg l(-1) h, P = 0.038) and unbound MPA AUC(0,12 h) (751 [214, 830] vs. 227 [151, 389] mg l(-1) h, P = 0.004). Unbound prednisolone AUC(0,24 h) was significantly higher in patients with Cushingoid appearance (unbound: 1372 [1242, 1774] vs. 846 [528, 1049] nmol l(-1) h, P = 0.019) than in those without. Poorer treatment response was observed in patients with lowest tertile exposure to both total MPA and prednisolone as compared with patients with middle and higher tertile exposure (17% vs. 74%, P = 0.023). CONCLUSIONS This study suggests a potential role for therapeutic drug monitoring in individualizing immunosuppressant therapy in patients with lupus nephritis.
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Affiliation(s)
- Azrin N Abd Rahman
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia.,School of Pharmacy, International Islamic University of Malaysia, Kuantan, Pahang, Malaysia
| | - Susan E Tett
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
| | - Halim A Abdul Gafor
- Nephrology Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Brett C McWhinney
- Department of Chemical Pathology, Pathology Queensland, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Christine E Staatz
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
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Successful treatment with mycophenolate mofetil and tacrolimus in juvenile severe lupus nephritis. Case Rep Pediatr 2015; 2015:651803. [PMID: 25785217 PMCID: PMC4346693 DOI: 10.1155/2015/651803] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 02/03/2015] [Accepted: 02/03/2015] [Indexed: 11/17/2022] Open
Abstract
Lupus nephritis (LN) of juvenile onset often has severe disease presentation. Despite aggressive induction therapy, up to 20% of patients with LN are resistant to initial therapy and up to 44% suffer a renal relapse. However, there is no consensus on an appropriate therapeutic regimen for refractory LN. We report a 13-year-old girl with recurrent LN who was not taking her medications. At age of 11 years, she was diagnosed with LN classified as International Society of Nephrology/Renal Pathology Society (ISN/RPS) class IV G (A) + V. She was treated with prednisolone and MMF after nine methylprednisolone pulses. Nineteen months later, she was admitted to the hospital with generalized edema. Her symptoms were nephrotic syndrome and acute renal dysfunction. She received three methylprednisolone pulses for 3 days, followed by oral prednisolone and MMF. Twenty-seven days after the three methylprednisolone pulses, her acute renal dysfunction was improved, but the nephrotic syndrome was not improved. A second biopsy showed diffuse lupus nephritis classified as the predominant finding of ISN/RPS class V. We added tacrolimus to the MMF. Four months after adding tacrolimus, the nephrotic syndrome improved. We conclude that adding tacrolimus to the treatment regimen for LN resistant to MMF is effective.
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Mok CC, Ying KY, Yim CW, Siu YP, Tong KH, To CH, Ng WL. Tacrolimus versus mycophenolate mofetil for induction therapy of lupus nephritis: a randomised controlled trial and long-term follow-up. Ann Rheum Dis 2014; 75:30-6. [DOI: 10.1136/annrheumdis-2014-206456] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/07/2014] [Indexed: 12/17/2022]
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Abstract
The term refractory lupus nephritis is generally used to indicate cases that do not respond to traditional treatment. However, the clinical presentation of lupus nephritis is variable and the time to response depends on the typology of the underlying renal syndrome. The criteria and the time for response are different in lupus patients with nephritic flares, in those with nephrotic syndrome, and in those with asymptomatic renal disease. In this paper, we will focus on the clinical characteristics, the consequences, and the possible therapeutic approaches for patients with different forms of refractory lupus nephritis, defined on the basis of renal syndrome at presentation.
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Affiliation(s)
- Gabriella Moroni
- Division of Nephrology, Fondazione Ca' Granda Ospedale Maggiore IRCCS, Via Della Commenda 15-20122 Milano, Italy
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Rivera F, Mérida E, Illescas ML, López-Rubio E, Frutos MA, García-Frías P, Ramos C, Sierra M, Baltar J, Lucas J, Oliet A, Vigil A, Fernández-Juárez G, Segarra A, Praga M. Mycophenolate in refractory and relapsing lupus nephritis. Am J Nephrol 2014; 40:105-12. [PMID: 25096639 DOI: 10.1159/000365256] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/10/2014] [Indexed: 01/26/2023]
Abstract
BACKGROUND Mycophenolate (MF) is effective as induction and maintenance treatment in patients with lupus nephritis (LN). This study evaluates the efficacy and safety of MF in patients with refractory and relapsing LN. METHODS Data were retrospectively obtained for 85 patients (35 refractory and 50 relapsing) from 11 nephrology departments in Spain. The primary endpoints were the incidence and cumulative number of renal responses and relapses and their relationship with baseline clinical and analytical data. The secondary endpoint was the appearance of side effects. RESULTS The main clinical and analytical variables were similar both in refractory and relapsing LN. Most of the patients had received cyclophosphamide, and all of them switched to MF. 74 patients (87%) achieved a response (69% partial, 31% complete). Age at starting MF, gender, pathological classification, body mass index, blood pressure, baseline renal function, and proteinuria were not associated with achieving response. After stopping MF, 3 of 19 patients (15.7%) relapsed, all at 6 months of follow-up. No differences were found between clinical and analytical variables and number of relapses. Side effects were unremarkable, except for 1 patient, who died of thrombocytopenia and ovarian hemorrhage. CONCLUSIONS Switching to MF from other immunosuppressive treatments is effective and safe in refractory and relapsing LN.
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Affiliation(s)
- Francisco Rivera
- Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
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