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Ramasamy A, Dugyala P, Mohan C. Mobile health apps for systemic lupus erythematosus and lupus nephritis: a critical appraisal. Arthritis Res Ther 2022; 24:110. [PMID: 35568874 PMCID: PMC9107137 DOI: 10.1186/s13075-022-02791-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To critically assess the quality and functionality of the available mobile apps for systemic lupus erythematosus and lupus nephritis patients. Methods Two reviewers independently searched the App Store and Google Play Store for eligible mobile health (mHealth) apps. Two separate searches were done: one for systemic lupus erythematosus (SLE) and the other for lupus nephritis (LN). The Mobile App Rating Scale (MARS) was used to rate the quality of all selected apps. Results From the systemic lupus erythematosus screening, our search yielded 841 apps. Within these 841 apps, 17 of them were ultimately included. From the lupus nephritis screening, our search returned 1152 apps. Of the 1152 apps, 2 were ultimately included. Our search strategy included apps specifically designed for patients with SLE and LN. The MARS average of all the systemic lupus erythematosus apps was 2.7 out of 5. The MARS average of the two lupus nephritis apps was 2.6 out of 5. Conclusion Mobile health apps can serve as an effective tool for telehealth, engaging patients in self-care and for increasing the quality of life of lupus patients. While several mobile health technologies exist for patients with SLE and LN, there is still a significant need for app quality improvement and expanding the comprehensiveness of offered functions.
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Affiliation(s)
- Akshara Ramasamy
- Biomedical Engineering Department, University of Houston, 3517 Cullen Blvd., Room 2027, Houston, TX, USA
| | - Poojitha Dugyala
- Biomedical Engineering Department, University of Houston, 3517 Cullen Blvd., Room 2027, Houston, TX, USA
| | - Chandra Mohan
- Biomedical Engineering Department, University of Houston, 3517 Cullen Blvd., Room 2027, Houston, TX, USA.
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2
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Parodis I, Tamirou F, Houssiau FA. Treat-to-Target in Lupus Nephritis. What is the Role of the Repeat Kidney Biopsy? Arch Immunol Ther Exp (Warsz) 2022; 70:8. [PMID: 35147824 PMCID: PMC8837511 DOI: 10.1007/s00005-022-00646-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/12/2021] [Indexed: 01/14/2023]
Abstract
Kidney involvement, termed lupus nephritis (LN), develops in 35-60% of patients with systemic lupus erythematosus, often early during the disease course. When not treated promptly and efficiently, LN may lead to rapid and severe loss of kidney function, being the reason why it is considered one of the most severe lupus manifestations. Despite improved pharmacotherapy, 5-20% of LN patients develop end-stage kidney disease within ten years from the LN diagnosis. While the principal ground of LN therapy is prevention of renal function worsening, resembling a race against nephron loss, consensual agreement upon outcome measures and clinically meaningful short- and long-term targets of LN therapy have yet to be determined. Literature points to the importance of inclusion of tissue-based approaches in the determination of those targets, and evidence accumulates regarding the importance of per-protocol repeat kidney biopsies in the evaluation of the initial phase of therapy and prediction of long-term renal prognosis. The latter leads to the hypothesis that the information gleaned from repeat biopsies may contribute to optimised therapeutic decision making, and, therefore, increased probability to attain complete renal response in the short term, and a more favourable renal prognosis within a longer prospect. The multinational project ReBioLup was recently designed to serve as a key contributor to form evidence about the role of per-protocol repeat biopsies in a randomised fashion and aspires to unify the global LN community towards improved kidney and patient survival.
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Affiliation(s)
- Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet, and Karolinska University Hospital, 171 76, Stockholm, Sweden. .,Department of Rheumatology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Farah Tamirou
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Rheumatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Frédéric A Houssiau
- Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium.,Rheumatology Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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3
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Abstract
Progressive glomerular damage can occur as a result of various etiologic factors including infections, medications, diseases, and autoimmune disorders. This article discusses the clinical management of the leading conditions associated with glomerular disease, including glomerulosclerosis, diabetic nephropathy, focal segmental glomerulosclerosis, and membranous nephropathy. Glomerular damage and disease progression may lead to end stage renal disease. Clinical management is individualized, as based on causative factors and clinical manifestations, with the overall goal of limiting glomerular damage. Collaborative and comprehensive care is imperative to improving patient outcomes.
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Affiliation(s)
- Patty Orr
- School of Nursing, Austin Peay State University, PO Box 4658, Clarksville, TN 37044, USA
| | - Bettina Cobb Shank
- School of Nursing, Austin Peay State University, PO Box 4658, Clarksville, TN 37044, USA.
| | - Shondell Hickson
- School of Nursing, Austin Peay State University, PO Box 4658, Clarksville, TN 37044, USA
| | - Jennifer Cooke
- School of Nursing, Austin Peay State University, PO Box 4658, Clarksville, TN 37044, USA
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4
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Höllriegl W, Bauer A, Baumgartner B, Dietrich B, Douillard P, Kerschbaumer RJ, Höbarth G, McKee JS, Schinagl A, Tam FWK, Thiele M, Weber A, Wolfsegger M, Turecek M, Muchitsch EM, Scheiflinger F, Glantschnig H. Pharmacokinetics, disease-modifying activity, and safety of an experimental therapeutic targeting an immunological isoform of macrophage migration inhibitory factor, in rat glomerulonephritis. Eur J Pharmacol 2018; 820:206-216. [PMID: 29274331 DOI: 10.1016/j.ejphar.2017.12.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 01/09/2023]
Abstract
New therapeutic agents are needed to overcome the toxicity and suboptimal efficacy observed in current treatment of glomerulonephritis (GN). BaxB01 is a fully human monoclonal antibody targeting a disease-related immunologically distinct isoform of Macrophage migration Inhibitory Factor (MIF), designated oxidized MIF (oxMIF) and locally expressed in inflammatory conditions. We report the pharmacokinetic profile of BaxB01, and its dose and exposure-related disease-modifying activity in experimentally induced rat GN. BaxB01 bound to rat oxMIF with high affinity and reduced rat macrophage migration in vitro. After intravenous administration in rats, BaxB01 demonstrated favorable pharmacokinetics, with a half-life of up to nine days. Disease modification was dose-related (≥ 10mg/kg) as demonstrated by significantly reduced proteinuria and diminished histopathological glomerular crescent formation. Importantly, a single dose was sufficient to establish an exposure-related, anti-inflammatory milieu via amelioration of glomerular cellular inflammation. Pharmacodynamic modeling corroborated these findings, consistently predicting plasma exposures that were effective in attenuating both anti-inflammatory activity and reducing loss of kidney function. This pharmacologic benefit on glomerular function and structure was sustained during established disease, while correlation analyses confirmed a link between the antibody's anti-inflammatory activity and reduced crescent formation in individual rats. Finally, safety assessment in rats showed that the experimental therapeutic was well tolerated without signs of systemic toxicity or negative impact on kidney function. These data define therapeutically relevant exposures correlated with mechanism-based activity in GN, while toxicological evaluation suggests a large therapeutic index and provides evidence for achieving safe and effective exposure to a MIF isoform-directed therapeutic in nephritis-associated disease.
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Affiliation(s)
- Werner Höllriegl
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Alexander Bauer
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Bernhard Baumgartner
- Research & Development, Baxter Healthcare Corporation, One Baxter Parkway, Deerfield, IL 60015, United States
| | - Barbara Dietrich
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Patrice Douillard
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | | | - Gerald Höbarth
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Jeffrey S McKee
- Research & Development, Baxter Healthcare Corporation, One Baxter Parkway, Deerfield, IL 60015, United States
| | - Alexander Schinagl
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Frederick W K Tam
- Imperial College Renal and Transplant Centre, Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0NN, UK
| | - Michael Thiele
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Alfred Weber
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Martin Wolfsegger
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Marietta Turecek
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | - Eva-Maria Muchitsch
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria
| | | | - Helmut Glantschnig
- Research & Nonclinical Development, Shire, Industriestrasse 67, A-1220 Vienna, Austria.
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5
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Qu H, Shewchuk RM, Alarcón G, Fraenkel L, Leong A, Dall'Era M, Yazdany J, Singh JA. Mapping Perceptions of Lupus Medication Decision-Making Facilitators: The Importance of Patient Context. Arthritis Care Res (Hoboken) 2017; 68:1787-1794. [PMID: 27059939 DOI: 10.1002/acr.22904] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 03/13/2016] [Accepted: 03/29/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Numerous factors can impede or facilitate patients' medication decision-making and adherence to physicians' recommendations. Little is known about how patients and physicians jointly view issues that affect the decision-making process. Our objective was to derive an empirical framework of patient-identified facilitators to lupus medication decision-making from key stakeholders (including 15 physicians, 5 patients/patient advocates, and 8 medical professionals) using a patient-centered cognitive mapping approach. METHODS We used nominal group patient panels to identify facilitators to lupus treatment decision-making. Stakeholders independently sorted the identified facilitators (n = 98) based on their similarities and rated the importance of each facilitator in patient decision-making. Data were analyzed using multidimensional scaling and hierarchical cluster analysis. RESULTS A cognitive map was derived that represents an empirical framework of facilitators for lupus treatment decisions from multiple stakeholders' perspectives. The facilitator clusters were 1) hope for a normal/healthy life, 2) understand benefits and effectiveness of taking medications, 3) desire to minimize side effects, 4) medication-related data, 5) medication effectiveness for "me," 6) family focus, 7) confidence in physician, 8) medication research, 9) reassurance about medication, and 10) medication economics. CONCLUSION Consideration of how different stakeholders perceive the relative importance of lupus medication decision-making clusters is an important step toward improving patient-physician communication and effective shared decision-making. The empirically derived framework of medication decision-making facilitators can be used as a guide to develop a lupus decision aid that focuses on improving physician-patient communication.
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Affiliation(s)
| | | | | | - Liana Fraenkel
- Yale University School of Medicine, New Haven, Connecticut
| | - Amye Leong
- Healthy Motivation, Santa Barbara, California
| | | | | | - Jasvinder A Singh
- Birmingham VA Medical Center and University of Alabama at Birmingham, and Mayo Clinic College of Medicine, Rochester, Minnesota
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6
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Barbour S, Lo C, Espino-Hernandez G, Sajjadi S, Feehally J, Klarenbach S, Gill J. The population-level costs of immunosuppression medications for the treatment of glomerulonephritis are increasing over time due to changing patterns of practice. Nephrol Dial Transplant 2017; 33:626-634. [DOI: 10.1093/ndt/gfx185] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 04/10/2017] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sean Barbour
- Department of Medicine, BC Provincial Renal Agency, Vancouver, BC, Canada
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcomes Research, St Paul’s Hospital, Vancouver, BC, Canada
| | - Clifford Lo
- Department of Medicine, BC Provincial Renal Agency, Vancouver, BC, Canada
| | | | - Sharareh Sajjadi
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - John Feehally
- Department of Medicine, The John Walls Renal Unit, Leicester General Hospital, Leicester, UK
| | - Scott Klarenbach
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jagbir Gill
- Department of Medicine, BC Provincial Renal Agency, Vancouver, BC, Canada
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
- Centre for Health Evaluation and Outcomes Research, St Paul’s Hospital, Vancouver, BC, Canada
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7
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Tesar V. Moderator's view: Cyclophosphamide in lupus nephritis. Nephrol Dial Transplant 2016; 31:1058-61. [PMID: 27190357 DOI: 10.1093/ndt/gfw067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 03/07/2016] [Indexed: 01/18/2023] Open
Abstract
Mycophenolate mofetil was recently accepted as the effective induction treatment of lupus nephritis, with the potential to replace cyclophosphamide or at least expand our therapeutic armamentarium in patients with this lifelong disease often requiring repeated induction treatment of its relapses. Compared with cyclophosphamide, mycophenolate may be more effective in black patients, and the risk of gonadotoxicity may be significantly lower in mycophenolate-treated subjects. However, experience with mycophenolate in severe lupus nephritis is still limited and we also have insufficient data on the long-term outcome of mycophenolate-treated patients. Treatment with mycophenolate is more expensive than with cyclophosphamide, which may limit its use, especially in low- and middle-income countries. The efficacy of mycophenolate mofetil may be more dependent on the patient's compliance compared with intravenous cyclophosphamide pulses. Low-dose cyclophosphamide remains an effective and relatively safe induction treatment of active lupus nephritis, but to decrease its cumulative toxicity, repeated exposure to cyclophosphamide in relapsing patients should be (if possible) avoided.
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Affiliation(s)
- Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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8
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Kamen DL, Zollars ES. Corticosteroids in Lupus Nephritis and Central Nervous System Lupus. Rheum Dis Clin North Am 2016; 42:63-73, viii. [DOI: 10.1016/j.rdc.2015.08.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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9
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Imran TF, Yick F, Verma S, Estiverne C, Ogbonnaya-Odor C, Thiruvarudsothy S, Reddi AS, Kothari N. Lupus nephritis: an update. Clin Exp Nephrol 2015; 20:1-13. [PMID: 26471017 DOI: 10.1007/s10157-015-1179-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 10/02/2015] [Indexed: 01/06/2023]
Abstract
Lupus nephritis (LN) is an inflammatory condition of the kidneys that encompasses various patterns of renal disease including glomerular and tubulointerstitial pathology. It is a major predictor of poor prognosis in patients with systemic lupus erythematosus (SLE). Genetic factors, including several predisposing loci, and environmental factors, such as EBV and ultraviolet light, have been implicated in the pathogenesis. It carries a high morbidity and mortality if left untreated. Renal biopsy findings are utilized to guide treatment. Optimizing risk factors such as proteinuria and hypertension with renin-angiotensin receptor blockade is crucial. Immunosuppressive therapy is recommended for patients with focal or diffuse proliferative lupus nephritis (Class III or IV) disease, and certain patients with membranous LN (Class V) disease. Over the past decade, immunosuppressive therapies have significantly improved long-term outcomes, but the optimal therapy for LN remains to be elucidated. Cyclophosphamide-based regimens, given concomitantly with corticosteroids, have improved survival significantly. Even though many patients achieve remission, the risk of relapse remains considerably high. Other treatments include hydroxychloroquine, mycofenolate mofetil, and biologic therapies such as Belimumab, Rituximab, and Abatacept. In this paper, we provide a review of LN, including pathogenesis, classification, and clinical manifestations. We will focus, though, on discussion of the established as well as emerging therapies for patients with proliferative and membranous lupus nephritis.
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Affiliation(s)
- Tasnim F Imran
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA.
| | - Frederick Yick
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Suneet Verma
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA.,Division of Nephrology, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Christopher Estiverne
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Chinonye Ogbonnaya-Odor
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Srikanth Thiruvarudsothy
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Alluru S Reddi
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA.,Division of Nephrology, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
| | - Neil Kothari
- Department of Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, 185 South Orange Avenue, Newark, NJ, 07103, USA
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10
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Mak A, Tay SH. Outcome of lupus glomerulonephritis: the role of prospective observational cohort studies. Rheumatology (Oxford) 2015; 55:195-6. [PMID: 26342225 DOI: 10.1093/rheumatology/kev220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Anselm Mak
- Division of Rheumatology, University Medicine Cluster, National University Health System and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Sen Hee Tay
- Division of Rheumatology, University Medicine Cluster, National University Health System and Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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11
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Tselios K, Sarantopoulos A, Gkougkourelas I, Papagianni A, Boura P. Increase of peripheral T regulatory cells during remission induction with cyclophosphamide in active systemic lupus erythematosus. Int J Rheum Dis 2015; 17:790-5. [PMID: 25430593 DOI: 10.1111/1756-185x.12500] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Cyclophosphamide efficacy in lupus nephritis (LN) and neuropsychiatric systemic lupus erythematosus (NPSLE) is probably mediated by a non-specific ablation of reactive lymphocytes. However, little is known in regard to its effect on T regulatory cells (Tregs) in such patients, which was the aim of this study. PATIENTS AND METHODS Ten Caucasian lupus patients were included, six with LN classes IV-V (mean age 33.8 ± 8.8 years) and four with NPSLE (mean age 35.5 ± 8.8 years, clinical manifestations: 1/4 acute confusional state, 1/4 psychosis, 2/4 refractory seizures). Cyclophosphamide was administered at monthly pulses (500 mg/m(2) /month for 6 months); doses of other administered drugs, including steroids, remained stable or lower. CD4(+) CD25(high) FOXP3(+) Tregs were assessed by flow-cytometry at baseline and before every subsequent pulse and 3-6 months after the final pulse. Disease activity was assessed by SLE Disease Activity Index (SLEDAI). RESULTS In LN patients, Tregs were significantly increased even after the fourth pulse (0.54 ± 0.20% vs. 1.24 ± 0.29%, P < 0.001). Likewise, in NPSLE, Tregs were significantly expanded after the fourth pulse (0.57 ± 0.23% vs. 1.41 ± 0.28%, P < 0.001). SLEDAI was significantly reduced in all patients. CONCLUSIONS Cyclophosphamide pulse therapy was associated with a significant increase of the CD4(+) CD25(high) FOXP3(+) Tregs in patients with active LN and NPSLE. This effect is probably indirect and may partially explain the beneficial role of cyclophosphamide in such cases.
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Affiliation(s)
- Konstantinos Tselios
- Clinical Immunology Unit, 2nd Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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12
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Tian SY, Feldman BM, Beyene J, Brown PE, Uleryk EM, Silverman ED. Immunosuppressive Therapies for the Maintenance Treatment of Proliferative Lupus Nephritis: A Systematic Review and Network Metaanalysis. J Rheumatol 2015; 42:1392-400. [DOI: 10.3899/jrheum.141650] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2015] [Indexed: 01/20/2023]
Abstract
Objective.To determine the most effective immunosuppressive therapy for the longterm management of proliferative lupus nephritis (PLN) based on the outcome of renal failure.Methods.A systematic review of randomized controlled trials (RCT) was conducted. MEDLINE and EMBASE were searched. RCT designed to examine the maintenance treatment effectiveness of immunosuppressive agents for PLN were included. A Bayesian network metaanalysis of 2-arm and 3-arm trials was used. A skeptical prior assumption was used in sensitivity analysis. Four immunosuppressive agents were evaluated: cyclophosphamide (CYC), azathioprine (AZA), mycophenolate mofetil (MMF), and prednisone alone. The outcome of interest was renal failure during the study period, defined by serum creatinine (sCr) > 256µmol/l, doubling of sCr from baseline, and/or endstage renal disease.Results.The OR (95% credible interval) of developing renal failure at 2–3 years was 0.72 (0.11, 4.49) for AZA versus CYC, 0.32 (0.04, 2.25) for MMF versus CYC, 2.40 (0.22, 36.94) for prednisone alone versus CYC, and 0.45 (0.11, 1.48) for MMF versus AZA. The probability (95% credible interval) of developing renal failure at 2 years as expected for each agent was 6% (0.7%, 24%) for MMF, 12% (2%, 37%) for AZA, 16% (5%, 33%) for CYC, and 31% (5%, 81%) for prednisone alone. After applying a skeptical prior in the Bayesian analysis, there was no evidence of benefit for 1 therapy over another.Conclusion.Although the data suggest that MMF may be superior to other treatments for the maintenance treatment of PLN, the evidence is not conclusive.
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13
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Tamirou F, D'Cruz D, Sangle S, Remy P, Vasconcelos C, Fiehn C, Ayala Guttierez MDM, Gilboe IM, Tektonidou M, Blockmans D, Ravelingien I, le Guern V, Depresseux G, Guillevin L, Cervera R, Houssiau FA. Long-term follow-up of the MAINTAIN Nephritis Trial, comparing azathioprine and mycophenolate mofetil as maintenance therapy of lupus nephritis. Ann Rheum Dis 2015; 75:526-31. [PMID: 25757867 PMCID: PMC4789692 DOI: 10.1136/annrheumdis-2014-206897] [Citation(s) in RCA: 119] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 12/15/2014] [Indexed: 01/28/2023]
Abstract
Objective To report the 10-year follow-up of the MAINTAIN Nephritis Trial comparing azathioprine (AZA) and mycophenolate mofetil (MMF) as maintenance therapy of proliferative lupus nephritis, and to test different definitions of early response as predictors of long-term renal outcome. Methods In 2014, data on survival, kidney function, 24 h proteinuria, renal flares and other outcomes were collected for the 105 patients randomised between 2002 and 2006, except in 13 lost to follow-up. Results Death (2 and 3 in the AZA and MMF groups, respectively) and end-stage renal disease (1 and 3, respectively) were rare events. Time to renal flare (22 and 19 flares in AZA and MMF groups, respectively) did not differ between AZA and MMF patients. Patients with good long-term renal outcome had a much more stringent early decrease of 24 h proteinuria compared with patients with poor outcome. The positive predictive value of a 24 h proteinuria <0.5 g/day at 3 months, 6 months and 12 months for a good long-term renal outcome was excellent (between 89% and 92%). Inclusion of renal function and urinalysis in the early response criteria did not impact the value of early proteinuria decrease as long-term prognostic marker. Conclusions The long-term follow-up data of the MAINTAIN Nephritis Trial do not indicate that MMF is superior to AZA as maintenance therapy in a Caucasian population suffering from proliferative lupus nephritis. Moreover, we confirm the excellent positive predictive value of an early proteinuria decrease for long-term renal outcome. Trial registration number NCT00204022.
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Affiliation(s)
- Farah Tamirou
- Rheumatology Department, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - David D'Cruz
- Louise Coote Lupus Unit, St Thomas' Hospital, London, UK
| | - Shirish Sangle
- Louise Coote Lupus Unit, St Thomas' Hospital, London, UK
| | - Philippe Remy
- Nephrology Department, Hôpital Henri Mondor, Créteil, France
| | - Carlos Vasconcelos
- Clinical Immunology Unit, Hospital Santo Antonio, ICBAS, Porto, Portugal
| | | | | | | | - Maria Tektonidou
- First Department of Internal Medicine, National University of Athens, Athens, Greece
| | - Daniel Blockmans
- General Internal Medicine Department, UZ Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | | | | | - Geneviève Depresseux
- Rheumatology Department, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Loïc Guillevin
- General Internal Medicine Department, Hôpital Cochin, Paris, France
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Catalonia, Spain
| | - Frédéric A Houssiau
- Rheumatology Department, Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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14
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Zickert A, Amoudruz P, Sundström Y, Rönnelid J, Malmström V, Gunnarsson I. IL-17 and IL-23 in lupus nephritis - association to histopathology and response to treatment. BMC Immunol 2015; 16:7. [PMID: 25887118 PMCID: PMC4326189 DOI: 10.1186/s12865-015-0070-7] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 01/29/2015] [Indexed: 11/15/2022] Open
Abstract
Background Recent studies indicate a central role for the IL-23/IL-17 axis in the pathogenesis of lupus nephritis (LN) but the importance in the context of treatment outcome is unknown. We studied various cytokines, including the IL-23/IL-17 axis, in association to histopathology and response to therapy. Methods Fifty-two patients with active LN were included. Renal biopsies were performed at baseline and after immunosuppressive treatment. Serum levels of TNF-α, IFN-γ, IL-6, IL-10, IL-17, IL-23 and TGF-β were analysed at both biopsy occasions and in 13 healthy controls. IL-17 expression in renal tissue was assessed by immunohistochemistry. Biopsies were evaluated regarding WHO-classification and renal disease activity was estimated using the BILAG-index. Improvement of 2 grades in renal BILAG was regarded complete response, and 1 grade partial response. Results At baseline, all patients had high disease activity (BILAG A/B). Baseline levels of IL-6, IL-10, IL-17, IL-23 (p < 0.001) and IFN-γ (p = 0.03) were increased in patients vs. controls. In contrast, TGF-β was lower in patients compared to controls (p < 0.001). Baseline levels of IL-17 were higher in patients with persisting active nephritis (WHO III, IV, V) after treatment, i.e. a poor histological response, vs. WHO I-II (p < 0.03). At follow-up, IL-23 were higher in BILAG-non-responders vs. responders (p < 0.05). Immunostaining of renal tissue revealed IL-17 expression in inflammatory infiltrates. Conclusions High baseline IL-17 predicted an unfavourable histopathological response, and BILAG-non-responders had high IL-23, indicating that that a subset of LN-patients has a Th-17 phenotype that may influence response to treatment and could be evaluated as a biomarker for poor therapeutic response.
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Affiliation(s)
- Agneta Zickert
- Department of Medicine, Unit of Rheumatology, Karolinska University Hospital, Karolinska Institute, SE-171 76, Stockholm, Sweden.
| | - Petra Amoudruz
- Department of Medicine, Unit of Rheumatology, Karolinska University Hospital, Karolinska Institute, SE-171 76, Stockholm, Sweden.
| | - Yvonne Sundström
- Department of Medicine, Unit of Rheumatology, Karolinska University Hospital, Karolinska Institute, SE-171 76, Stockholm, Sweden.
| | - Johan Rönnelid
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.
| | - Vivianne Malmström
- Department of Medicine, Unit of Rheumatology, Karolinska University Hospital, Karolinska Institute, SE-171 76, Stockholm, Sweden.
| | - Iva Gunnarsson
- Department of Medicine, Unit of Rheumatology, Karolinska University Hospital, Karolinska Institute, SE-171 76, Stockholm, Sweden.
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Zickert A, Sundelin B, Svenungsson E, Gunnarsson I. Role of early repeated renal biopsies in lupus nephritis. Lupus Sci Med 2014; 1:e000018. [PMID: 25379188 PMCID: PMC4213828 DOI: 10.1136/lupus-2014-000018] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 07/02/2014] [Accepted: 07/10/2014] [Indexed: 12/31/2022]
Abstract
Objectives A renal biopsy is generally recommended for diagnosis and is necessary for classification of lupus nephritis (LN), but second biopsies after immunosuppressive therapy are seldom a routine procedure. We investigated how repeat biopsies contribute to the evaluation of treatment response and long-term outcome in LN. Methods Sixty-seven patients with active LN were included. Renal biopsies were performed at diagnosis and after standard induction immunosuppressive therapy in all patients (median 8 months), regardless of clinical outcome. Biopsies were evaluated according to the International Society of Nephrology/Renal Pathology Society classification. Clinical response was defined as complete (CR), partial (PR) or non-response (NR) according to recent definitions. Histological response (HR) was defined as Class I, II or III/IV-C on repeat biopsies. Long-term renal outcome was determined in 55 patients after a median of 10 years. Results CR was demonstrated in 25%, PR in 27% and NR in 48% of patients. HR was shown in 42% and histopathological non-response (HNR) in 58% of patients. Twenty-nine per cent of CR and 61% of patients with PR had active lesions on repeat biopsies, that is, were HNR. Poor long-term renal outcome was associated with high chronicity index at repeated biopsies, but not with clinical or histological response. Conclusions Despite apparent clinical response to immunosuppressive therapy, repeated biopsies revealed persisting active nephritis in almost half of the patients, thus providing additional information to clinical response criteria. Repeated renal biopsies may be a tool to improve the evaluation of treatment response in LN.
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Affiliation(s)
- A Zickert
- Department of Medicine, Unit of Rheumatology , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
| | - B Sundelin
- Department of Pathology and Cytology , Karolinska University Hospital, Karolinska Institute , Stockholm, Sweden
| | - E Svenungsson
- Department of Medicine, Unit of Rheumatology , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
| | - I Gunnarsson
- Department of Medicine, Unit of Rheumatology , Karolinska University Hospital, Karolinska Institute , Stockholm , Sweden
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Zirkzee EJM, Ndosi ME, Vliet Vlieland TPM, Meesters JJL. Measuring educational needs among patients with systemic lupus erythematosus (SLE) using the Dutch version of the Educational Needs Assessment Tool (D-ENAT). Lupus 2014; 23:1370-6. [PMID: 25059487 DOI: 10.1177/0961203314544188] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The Educational Needs Assessment Tool (ENAT) was developed in the United Kingdom (UK) to systematically assess the educational needs of patients with rheumatic diseases. The aim of the present study was to describe the educational needs of Dutch patients with systemic lupus erythematosus (SLE) by means of a Dutch version of the ENAT (D-ENAT). METHODS The D-ENAT was sent to a random sample of 244 SLE patients registered at the outpatient clinic of a university hospital. D-ENAT consists of 39 items in seven domains. The D-ENAT domain scores range from 0-16 to 0-28 (higher scoring equals higher educational needs) depending of the number of items in the domain. A total D-ENAT score (0-156) is calculated by summing all 39 items. In addition, age, disease duration, gender, educational level, present information need (yes/no) and the extent of information need (1-4: nothing-everything) were recorded. Univariate regression analysis was used to examine the D-ENAT's potential determinants. RESULTS The response rate was 122 out of 244 (50%). The mean (% of maximum score) educational needs scores were 56% for 'D-ENAT total score', 62% for 'Self-help measures', 60% for 'Disease process', 58% for 'Feelings', 56% for 'Treatments', 50% for 'Movement', 49% for 'Support systems' and 46% for 'Managing pain'. Being female was significantly associated with higher scoring on the D-ENAT total score (β 23.0; 95% CI 5.9, 40.3). CONCLUSION SLE patients demonstrated substantial educational needs, especially in the domains: 'Self-help measures', 'Disease process' and 'Feelings'. The validity and practical applicability of the D-ENAT to make an inventory of SLE patients' educational needs requires further investigation.
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Affiliation(s)
- E J M Zirkzee
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - M E Ndosi
- School of Healthcare, University of Leeds, Leeds, United Kingdom
| | - T P M Vliet Vlieland
- Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden Sophia Rehabilitation Center, The Hague, The Netherlands Rijnlands Rehabilitation Center, Leiden, The Netherlands
| | - J J L Meesters
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands Department of Orthopaedics, Rehabilitation and Physical Therapy, Leiden University Medical Center, Leiden Sophia Rehabilitation Center, The Hague, The Netherlands
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Lehman TJA, Singh C, Ramanathan A, Alperin R, Adams A, Barinstein L, Moorthy N. Prolonged improvement of childhood onset systemic lupus erythematosus following systematic administration of rituximab and cyclophosphamide. Pediatr Rheumatol Online J 2014; 12:3. [PMID: 24423147 PMCID: PMC3896732 DOI: 10.1186/1546-0096-12-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 01/06/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although the combination of cyclophosphamide and rituximab has been utilized in case reports, there are no previous reports of the long term outcome of SLE treated systematically with this regimen. We report a pilot study to evaluate the efficacy of a systematically administered course of rituximab and cyclophosphamide over an eighteen month period to provide sustained improvement in childhood onset systemic lupus erythematosus (SLE). FINDINGS Twelve patients with childhood onset lupus nephritis or corticosteroid resistant SLE received systematic treatment with a combination of rituximab (750 mg/M2 up to 1 gram) and cyclophosphamide (750 mg/M2: no patient exceeded 1.8 M2). Two administrations of rituximab and cyclophosphamide, two weeks apart, were administered at the start of study, six months later, and eighteen months later. Clinical data were collected and analyzed after sixty months of follow up. There was sustained improvement in all clinical parameters with a dramatic reduction in both mean SLEDAI score (10.1 to 1 at one year and 0 at five years p<0.005) and mean daily prednisone dosage (29.7 mg/day to 12.7 by one year and 7.0 mg/day at five years p<0.005), with sustained improvement in mean C3 (55.5 mg/ml to 113 at one year and 107.5 at five years p<0.001) which was maintained through sixty months of follow up. Serum immunoglobulin levels were transiently depressed but mean values were within the normal range for both IgG and IgM at one and five years. Few complications were observed (two episodes of febrile neutropenia during the first year of treatment were the only serious adverse events) and patients routinely reported sustained wellbeing. CONCLUSIONS This pilot study demonstrates that a systematically administered course of rituximab and cyclophosphamide over an eighteen month period provided sustained relief for patients with childhood onset SLE which was maintained over a sixty month period, while minimizing the need for corticosteroids, without excessive toxicity.
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Affiliation(s)
- Thomas JA Lehman
- Hospital for Special Surgery, Weil Cornell Medical College, New York, NY, USA
| | - Chahait Singh
- Hospital for Special Surgery, Weil Cornell Medical College, New York, NY, USA
| | - Anusha Ramanathan
- Hospital for Special Surgery, Weil Cornell Medical College, New York, NY, USA
| | - Risa Alperin
- Hospital for Special Surgery, Weil Cornell Medical College, New York, NY, USA
| | - Alexa Adams
- Hospital for Special Surgery, Weil Cornell Medical College, New York, NY, USA
| | - Laura Barinstein
- Hospital for Special Surgery, Weil Cornell Medical College, New York, NY, USA
| | - Nandini Moorthy
- Rutgers University, Robert Wood Johnson Medical School, New Brunswick, New Brunswick, NJ, USA
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18
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Calvo-Alén J, Silva-Fernández L, Úcar-Angulo E, Pego-Reigosa JM, Olivé A, Martínez-Fernández C, Martínez-Taboada V, Marenco JL, Loza E, López-Longo J, Gómez-Reino JJ, Galindo-Izquierdo M, Fernández-Nebro A, Cuadrado MJ, Aguirre-Zamorano MÁ, Zea-Mendoza A, Rúa-Figueroa Í. SER Consensus Statement on the Use of Biologic Therapy for Systemic Lupus Erythematosus. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.reumae.2013.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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19
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Consenso de la Sociedad Española de Reumatología sobre el uso de terapias biológicas en el lupus eritematoso sistémico. ACTA ACUST UNITED AC 2013; 9:281-96. [DOI: 10.1016/j.reuma.2013.04.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 04/03/2013] [Indexed: 12/23/2022]
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20
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Abstract
Lupus nephritis is a common complication of systemic lupus erythematosus in children and adolescents. This article reviews the clinical relevance of lupus nephritis and its current treatment. The reader is introduced to novel biomarkers that are expected to improve the management of lupus nephritis in the future, and support the testing of novel medication regimens.
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Affiliation(s)
- Michael Bennett
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, University of Cincinnati, MC 7022, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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21
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Korbet SM, Lewis EJ. Severe lupus nephritis: the predictive value of a >=50% reduction in proteinuria at 6 months. Nephrol Dial Transplant 2013; 28:2313-8. [DOI: 10.1093/ndt/gft201] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Abstract
The aim of this review is to briefly explore how steroids came to be a presumed adjunct to all treatment regimens for lupus nephritis, despite being the main cause of long term damage among patients with lupus and despite increasingly effective alternative agents. I then go on to compare and contrast how differently immunosuppression regimens have developed in the world of solid organ transplantation. Almost from the start of transplantation a clear goal was to develop steroid sparing regimens – and now units such as our own routinely use induction with a biological, a single week of steroids and then monotherapy with tacrolimus. There has been a clear trend of using biologicals as induction agents and less immunosuppression in the long run but with improved outcomes. The drive has not been the same in lupus nephritis despite there being almost no evidence to support the use of steroids and certainly nothing to suggest correct dosage and timing. Rituximab, a B cell depleting antibody, offers great promise as a treatment agent despite the negative randomised control LUNAR trial. I briefly review our own data, demonstrating that early use of rituximab in lupus nephritis allows omission of oral steroids with excellent rates of remission (complete and partial). I review why the LUNAR trial should not discourage the use of rituximab. Finally, I introduce the RITUXILUP trial, a multicentre randomised controlled trial we are developing to formally evaluate our oral steroid avoiding regimen against a standard treatment regimen of mycophenolate mofetil and steroids. We have to follow the lead of our transplant colleagues and challenge the assumption that the future for lupus nephritis cannot be steroid free.
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Affiliation(s)
- L Lightstone
- Imperial College NHS Healthcare Trust Lupus Centre, Hammersmith Hospital, London, UK
- Section of Renal Medicine, Department of Medicine, Imperial College London, London, UK
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23
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Chakravarty EF, Michaud K, Katz R, Wolfe F. Increased incidence of herpes zoster among patients with systemic lupus erythematosus. Lupus 2012; 22:238-44. [PMID: 23257402 DOI: 10.1177/0961203312470186] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Herpes zoster (HZ) is the painful reactivation of latent varicella zoster virus infection. The incidence of HZ may be increased in some autoimmune diseases, including systemic lupus erythematosus (SLE). We examined the incidence and risk factors for HZ in a prospective cohort of patients with physician-diagnosed SLE compared to those diagnosed with non-inflammatory musculoskeletal conditions (MSK). After excluding participants with a history of prior HZ at enrollment, we followed 1485 SLE patients and 2775 MSK with semi-annual mailed questionnaires for incident HZ between 2001 and 2010. Age-adjusted incidences were calculated for each group and Cox proportional hazard models were used to identify predictors of HZ. Zostavax® vaccination rates were compared between groups. Participants had a mean age of 60 years at enrollment, with 13.9 years of disease. SLE patients had more HZ at all ages, with an age-adjusted incidence of 12.0/1000 person-years compared to MSK (8.7/1000 person-years) and a hazard ratio of 1.7 (95% CI 1.08-2.71) for SLE. Increasing age and reduced functional status were independent predictors of HZ. In SLE, prednisone and mycophenolate mofetil use conferred additional risk. SLE had the lowest HZ vaccination rates among age-eligible subjects.
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Affiliation(s)
- E F Chakravarty
- Division of Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, USA.
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Baqai T, Ioannou Y. Comparison of juvenile and adult onset systemic lupus erythematosus. Br J Hosp Med (Lond) 2012; 73:558-63. [DOI: 10.12968/hmed.2012.73.10.558] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Yiannis Ioannou
- Clinical Senior Lecturer and Honorary Consultant in Rheumatology in the Centre for Rheumatology Research, Rayne Institute, University College London, London WC1E 6JF
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