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Saiteja P, Deepthi B, Krishnasamy S, Sravani M, Krishnamurthy S. Intravenous cyclophosphamide therapy in children with calcineurin inhibitor-resistant steroid-resistant nephrotic syndrome in a resource-limited setting. Pediatr Nephrol 2024; 39:1149-1160. [PMID: 37947902 DOI: 10.1007/s00467-023-06187-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/01/2023] [Accepted: 09/26/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND In pediatric steroid-resistant nephrotic syndrome (SRNS), calcineurin inhibitors (CNIs) are recommended as first-line therapy, with efficacy ranging between 60 and 80%, implying a substantial proportion will exhibit CNI resistance. Which alternate immunosuppressive therapy should be used in non-genetic pediatric SRNS exhibiting CNI resistance is especially relevant in low- to middle-income countries (LMIC), where the prohibitive costs of certain drugs such as monoclonal antibodies often determine therapy choice. METHODS The primary objective was to assess the efficacy of intravenous cyclophosphamide in a proportion of children aged 1-18 years with CNI-resistant SRNS with a complete response (CR) or partial response (PR) at 6 months from commencement of pulse therapy. The secondary objectives were to assess the proportion and profile of infections and adverse effects. RESULTS Of 90 children with idiopathic SRNS presenting between January 2013 and December 2022, 29 (32.2%) had CNI resistance and were enrolled. They were administered monthly intravenous cyclophosphamide pulses (6 pulses). Median (IQR) duration of follow-up was 48 (29.5, 63.5) months. At the end of 6 months of cyclophosphamide therapy, 13 (44.8%) attained CR and 4 (13.8%) attained PR, with an overall cyclophosphamide success rate of 58.6%. The efficacy of intravenous cyclophosphamide was higher in secondary (9/10; 90%) versus primary CNI resistance (8/19; 42.1%) (p = 0.029). Three children (3/29; 10.3%) developed systemic infections within 12 months of initiation of cyclophosphamide therapy, similar to the rate of systemic infections among children receiving CNI for SRNS management (6/41; 14.6%) (p = 0.85). CONCLUSIONS It is prudent to try intravenous cyclophosphamide in CNI-resistant SRNS in LMIC, given the reasonable cost and good efficacy rates (58.6%).
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Affiliation(s)
- Paraselli Saiteja
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Bobbity Deepthi
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Sudarsan Krishnasamy
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Madhileti Sravani
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India
| | - Sriram Krishnamurthy
- Pediatric Nephrology Services, Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, 605006, India.
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Sofue H, Kida T, Hirano A, Omura S, Kadoya M, Nakagomi D, Abe Y, Takizawa N, Nomura A, Kukida Y, Kondo N, Yamano Y, Yanagida T, Endo K, Hirata S, Matsui K, Takeuchi T, Ichinose K, Kato M, Yanai R, Matsuo Y, Shimojima Y, Nishioka R, Okazaki R, Takata T, Ito T, Moriyama M, Takatani A, Miyawaki Y, Ito-Ihara T, Yajima N, Kawaguchi T, Fujioka K, Fujii W, Seno T, Wada M, Kohno M, Kawahito Y. Optimal Dose of Intravenous Cyclophosphamide during remission induction therapy in ANCA-associated vasculitis: a retrospective cohort study of J-CANVAS. Mod Rheumatol 2023:road099. [PMID: 37801552 DOI: 10.1093/mr/road099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/19/2023] [Accepted: 10/02/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVES To identify the optimal dose of intravenous cyclophosphamide (IVCY) for induction therapy for anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV). METHODS We retrospectively assessed patients with AAV who received IVCY every 2-3 weeks during the remission induction phase. The associations of the IVCY dose with infection-free survival and relapse-free survival were analysed using a Cox regression model. We compared patients in three categories: very low-dose (VLD), low-dose (LD), and conventional dose (CD) (<7.5 mg/kg, 7.5-12.5 mg/kg, and >12.5 mg/kg, respectively). The non-linear association between IVCY dose and the outcomes were also evaluated. RESULTS Of the 80 patients (median age 72 years), 12, 42, and 26 underwent the VLD, LD, and CD regimens, respectively, of whom 4, 3, and 7 developed infection or died. The adjusted hazard ratios for infection or death were 4.3 (95% confidence interval (CI) 0.94-19.8) for VLD and 5.1 (95% CI 1.21-21.3) for CD, compared with LD. We found the hazard ratio for infection or death increased when the initial IVCY dose exceeded 9 mg/kg. Relapse-free survival did not differ clearly. CONCLUSION Low-dose IVCY (7.5-12.5 mg/kg) may result in fewer infections and similar relapse rates compared with the conventional regimen (>12.5 mg/kg).
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Affiliation(s)
- Hideaki Sofue
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Kida
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Aiko Hirano
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Omura
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masatoshi Kadoya
- Center for Rheumatic Disease, Japanese Red Cross Society Kyoto Daiichi Hospital, Kyoto, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Yoshiyuki Abe
- Department of Internal Medicine and Rheumatology, Juntendo University, Tokyo, Japan
| | - Naoho Takizawa
- Department of Rheumatology, Chubu Rosai Hospital, Nagoya, Japan
| | - Atsushi Nomura
- Immuno-Rheumatology Center, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Kukida
- Department of Rheumatology, Japanese Red Cross Society Kyoto Daini Hospital, Kyoto, Japan
| | - Naoya Kondo
- Department of Nephrology, Kyoto Katsura Hospital, Kyoto, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Aichi, Japan
| | - Takuya Yanagida
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
- Department of Hematology and Rheumatology, Kagoshima University Hospital, Kagoshima, Japan
| | - Koji Endo
- Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kiyoshi Matsui
- Department of Diabetes, Endocrinology and Clinical Immunology, Hyogo Medical University School of Medicine, Hyogo, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine (IV), Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
- Department of Rheumatology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Masaru Kato
- Department of Rheumatology, Endocrinology and Nephrology, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Ryo Yanai
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yusuke Matsuo
- Department of Rheumatology, Tokyo Kyosai Hospital, Tokyo, Japan
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yasuhiro Shimojima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Ryota Okazaki
- Division of Respiratory Medicine and Rheumatology, Department of Multidisciplinary Internal Medicine, Faculty of Medicine, Tottori University, Yonago, Japan
| | - Tomoaki Takata
- Division of Gastroenterology and Nephrology, Tottori University, Yonago, Japan
| | - Takafumi Ito
- Division of Nephrology, Shimane University Hospital, Shimane, Japan
| | - Mayuko Moriyama
- Department of Rheumatology, Shimane University Faculty of Medicine, Shimane, Japan
| | - Ayuko Takatani
- Rheumatic Disease Center, Sasebo Chuo Hospital, Nagasaki, Japan
| | - Yoshia Miyawaki
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiko Ito-Ihara
- The Clinical and Translational Research Center, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nobuyuki Yajima
- Division of Rheumatology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
- Center for Innovative Research for Communities and Clinical Excellence, Fukushima Medical University, Fukushima, Japan
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Kazuki Fujioka
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Wataru Fujii
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takahiro Seno
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Makoto Wada
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masataka Kohno
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yutaka Kawahito
- Inflammation and Immunology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Ștefan G, Zugravu A, Stancu S. Intravenous cyclophosphamide as an alternative to the oral cyclophosphamide modified Ponticelli regimen for high-risk PLA2R-positive membranous nephropathy. J Nephrol 2023; 36:293-295. [PMID: 35960429 DOI: 10.1007/s40620-022-01426-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 07/29/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Gabriel Ștefan
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
- "Dr. Carol Davila" Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.
| | - Adrian Zugravu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- "Dr. Carol Davila" Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania
| | - Simona Stancu
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- "Dr. Carol Davila" Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania
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Iwata S, Okada M, Suemori K, Teraoka M, Yamada H, Ishizaki J, Matsumoto T, Hato N. The hearing prognosis of otitis media with ANCA-associated vasculitis. Auris Nasus Larynx 2020; 48:377-382. [PMID: 32951931 DOI: 10.1016/j.anl.2020.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/10/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The concept of otitis media with ANCA-associated vasculitis (OMAAV) was recently proposed by the study group of the Japan Otological Society. However, information remains limited regarding the hearing outcome of OMAAV. Thus, we investigated this issue in this study. METHODS We retrospectively examined 50 ears from 32 patients diagnosed with OMAAV at our hospital between 2010 and 2019. We collected the results of pure tone audiometry (PTA) at diagnosis and changes in PTA threshold after treatment, serological findings including ANCA type, titer, soluble interleukin-2 receptor (sIL2R), and C-reactive protein, organs involved at initial diagnosis, treatment, and disease relapse from medical records. According to the hearing outcome, patients were divided into two groups: good prognosis and poor prognosis groups. We investigated the clinical features, treatment, and changes in PTA between the groups. RESULTS Age, sex, ANCA negativity, and the use of intravenous cyclophosphamide (IVCY) were significantly related to hearing prognosis of OMAAV, while other organs involved at diagnosis, serological findings, and relapse rate were not significantly associated with hearing outcome. Hearing level at diagnosis was significantly better in good prognosis group, while air-bone gap (ABG) was not significantly different between the groups. The air conduction (AC), bone conduction (BC), and ABG were significantly improved in the good prognosis group. However, ABG was not improved in the poor prognosis group, while AC and BC were significantly improved. The AC hearing level at diagnosis (58.5 dB) and hearing gain at 2 weeks after treatment (12.5 dB) were suggested as good indicators for predicting the hearing outcome of OMAAV. CONCLUSION Younger age, male sex, shorter period from onset to diagnosis, the use of IVCY, and better hearing threshold at diagnosis were the good prognostic factors of the hearing outcome of OMAAV. These results suggest that earlier diagnosis of OMAAV might be needed for better hearing outcome, and the use of IVCY may be recommended for the treatment of OMAAV patients.
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Affiliation(s)
- Shinji Iwata
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Masahiro Okada
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan.
| | - Koichiro Suemori
- Department of Hematology, Clinical Immunology and Infectious Disease, Ehime University Graduate School of Medicine, Toon, Japan
| | - Masato Teraoka
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Hiroyuki Yamada
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Jun Ishizaki
- Department of Hematology, Clinical Immunology and Infectious Disease, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takuya Matsumoto
- Department of Hematology, Clinical Immunology and Infectious Disease, Ehime University Graduate School of Medicine, Toon, Japan
| | - Naohito Hato
- Department of Otolaryngology, Head and Neck Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime 791-0295, Japan
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Shibata Y, Fukuoka K, Yokota R, Lee H, Sayo H, Ikegaya N, Mori K, Yamamoto J, Isomura A, Nagahama K, Shimoyamada H, Kawakami T, Komagata Y, Kaname S. Nephrotic syndrome due to minimal-change disease superimposed on anti-glomerular basement membrane antibody positive glomerulonephritis; a case report. BMC Nephrol 2020; 21:283. [PMID: 32680573 PMCID: PMC7368767 DOI: 10.1186/s12882-020-01947-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022] Open
Abstract
Background The prognosis for renal function in anti-GBM glomerulonephritis (anti-GBM GN) is extremely poor, and when renal impairment progresses severely, it is difficult to expect improvement. In addition, it is also known that once the disease activity can be controlled by aggressive treatment, its recurrence is rare. We experienced an anti-GBM GN that improved from severe renal dysfunction and relapsed. A possible cause was the superimpose of nephrotic syndrome due to minimal change disease (MCD). Case presentation A 30-year-old man was admitted to our hospital because of general malaise, fever, oliguria and renal dysfunction. The patient’s laboratory data showed serum creatinine as high as 6.6 mg/dl, and severe inflammation (C-reactive protein 20.6 mg/dl). Anti-glomerular basement membrane antibody (anti-GBM Ab) was detected in his serum, which led to the diagnosis of anti-GBM GN. Treatment was initiated with high-dose glucocorticoid (GC) and plasma exchange therapy (PE), and the patient’s renal function and oliguria improved rapidly and he was discharged 40 days after admission. Renal biopsy findings showed cellular crescents associated with linear IgG depositions along the glomerular tufts compatible with anti-GBM GN, but only about one-third of the glomeruli was involved, suggesting that it still remains an early stage of the disease. However, 2 months after discharge, he had a relapse and was readmitted due to severe proteinuria with positive anti-GBM Ab. On the second admission, after high-dose GC and PE combined with intravenous cyclophosphamide, and remission was achieved. Despite the relatively minor renal biopsy findings, the patient showed rapid renal dysfunction and relatively rapid improvement with our treatment. Electron microscopy of the renal biopsy tissue showed significant foot process effacement on podocytes in the apparently normal glomeruli, without electron dense deposits. Conclusion On the basis of clinical course and renal pathology, it is suggested that the present case was a rare complication of an early stage of anti-GBM GN and minimal change nephrotic syndrome. Although the simultaneous development of anti-GBM GN and MCD with anti-GBM antibody is unclear, it might have been precipitated by influenza infection or some unknown factor.
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Affiliation(s)
- Yuko Shibata
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Kazuhito Fukuoka
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan.
| | - Riyo Yokota
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Heryon Lee
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Hikaru Sayo
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Noriko Ikegaya
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Kiyotaka Mori
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Jin Yamamoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Aya Isomura
- Department of Pathology, Kyorin University Hospital, Tokyo, Japan
| | | | | | - Takahisa Kawakami
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Yoshinori Komagata
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
| | - Shinya Kaname
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, 6-20-2, Mitaka-shi, Tokyo, 181-8611, Japan
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Sigdel MR, Kafle MP, Shah DS. Outcome of low dose cyclophosphamide for induction phase treatment of lupus nephritis, a single center study. BMC Nephrol 2016; 17:145. [PMID: 27717323 PMCID: PMC5055665 DOI: 10.1186/s12882-016-0361-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/29/2016] [Indexed: 12/26/2022] Open
Abstract
Background The current standard for induction phase treatment of lupus nephritis is steroid combined with mycophenolate mofetil or pulse intravenous cyclophosphamide (IVC). The lowest dose of IVC recommended for induction therapy is that used in the Euro-Lupus Trial. It is not known whether same cumulative dose of IVC would be effective when given over six months. Methods We carried out a prospective, observational study on 41 patients of biopsy-proven lupus nephritis (class III, IV, V or mixed). For induction, patients received six pulses of monthly IVC (500 mg each), along with steroid. Patients were followed up monthly until one month beyond completion of the sixth pulse. The outcomes assessed were complete remission (proteinuria < 200 mg/day or urine albumin nil with serum albumin >35 gm/L, stable estimated glomerular filtration rate (eGFR) if normal at baseline or increase in eGFR by 25 % if abnormal at baseline and normal urinary sediment), response (complete or partial remissions), complications of therapy and death. Results Twenty two patients (53.7 %) had class IV nephritis. Eighteen patients (43.9 %) achieved complete remission, 16 (39.0 %) achieved partial remission, yielding an overall response rate of 82.9 %. Nephrotic range proteinuria (UTP ≥ 3 g/day) and severe hypoalbuminemia (serum albumin < 20 g/L) at baseline influenced remission (p <0.05). Infection, seen in 12 patients (29.3 %), was the most common complication. Four deaths (9.6 %) were observed, all due to infection. Conclusions For induction phase treatment, Nepalese patients with lupus nephritis responded favorably to steroid and low dose IVC of 3 grams given as six monthly pulses.
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Affiliation(s)
- Mahesh R Sigdel
- Department of Nephrology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal.
| | - Mukunda P Kafle
- Department of Nephrology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Dibya Singh Shah
- Department of Nephrology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
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Kizawa T, Nozawa T, Kikuchi M, Nagahama K, Okudela K, Miyamae T, Imagawa T, Nakamura T, Mori M, Yokota S, Tsutsumi H. Mycophenolate mofetil as maintenance therapy for childhood-onset systemic lupus erythematosus patients with severe lupus nephritis. Mod Rheumatol 2014; 25:210-4. [PMID: 25159157 DOI: 10.3109/14397595.2014.950810] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We evaluated histological changes occurring in renal biopsy specimens, between the time before initial induction therapy and after 12 months' maintenance therapy, as well as changes in laboratory parameters, SLE disease activity (SLEDAI), and dosage of corticosteroid (CS) in childhood-onset systemic lupus erythematosus (SLE) patients treated with mycophenolate mofetil (MMF). METHODS A retrospective analysis was performed on nine patients diagnosed with childhood-onset SLE and lupus nephritis. They were treated with pulsed mPSL and intravenous cyclophosphamide as induction therapy and MMF (500-1500 mg/day) plus CS as maintenance therapy. Renal biopsy was performed before the initial induction therapy and after 12 months' maintenance therapy. RESULTS Pathological findings at second biopsy were improved in eight of nine patients (89%). The findings of SLEDAI, urinalysis, and blood tests also showed improvement. CS doses could be tapered satisfactorily. Adverse events were observed in two patients. No patients treated with MMF experienced any disease flares during maintenance therapy. CONCLUSIONS MMF as maintenance therapy might be useful in that not only the histological findings of lupus nephritis were improved, but also CS doses could be beneficially tapered. Nonetheless, this is a retrospective report of only nine cases and further prospective multicenter studies are necessary.
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Affiliation(s)
- Toshitaka Kizawa
- Department of Pediatrics, Yokohama City University School of Medicine , Yokohama , Japan
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Kishi N, Suga K, Matsuura S, Kinoshita Y, Urushihara M, Kondo S, Kitano E, Hatanaka M, Kitamura H, Sato T, Maeda A, Kagami S. A case of infantile systemic lupus erythematosus with severe lupus nephritis and EBV infection. CEN Case Rep 2013; 2:190-193. [PMID: 28509290 DOI: 10.1007/s13730-013-0062-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Accepted: 01/07/2013] [Indexed: 11/30/2022] Open
Abstract
Infantile systemic lupus erythematosus (iSLE) is extremely rare. Patients with iSLE usually become severely unwell and have poor prognosis. Epstein-Barr virus (EBV) infection has been implicated in the development of SLE in both adults and children. Recently, we experienced a case of iSLE with severe lupus nephritis (LN) and EBV infection. A 14-month-old Japanese boy was diagnosed with iSLE according to the American Rheumatism Association criteria. Renal biopsy showed LN classified as International Society of Nephrology/Renal Pathology Society class IV-G (A), and liver biopsy showed lupus hepatitis. Steroid pulse treatment resulted in improvement of the levels of serological markers of SLE such as double-stranded DNA and complement, but his proteinuria worsened and he developed acute nephritic-nephrotic syndrome. Monthly intravenous cyclophosphamide (IVCY) therapy dramatically reduced his proteinuria and led to complete remission (urinary protein/creatinine ratio <0.1 mg/mg), with gradual improvement in levels of serological markers. EBV antibody titers and EBV polymerase chain reaction (PCR) of peripheral blood lymphocytes suggested that the onset of iSLE might have been associated with EBV infection. At his 2-year follow-up visit, he was healthy and remained in complete remission. We conclude that IVCY treatment might be well tolerated and effective in cases of iSLE. EBV infection might play an important role in the pathogenesis of iSLE.
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Affiliation(s)
- Natsuko Kishi
- Department of Pediatrics, Institution of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Kenichi Suga
- Department of Pediatrics, Institution of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan. .,Department of Pediatrics, Tokushima Prefectural Central Hospital, 10-3 Kuramotocho-1 chome, Tokushima, 770-8539, Japan.
| | - Sato Matsuura
- Department of Pediatrics, Institution of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Yukiko Kinoshita
- Department of Pediatrics, Institution of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Maki Urushihara
- Department of Pediatrics, Institution of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Shuji Kondo
- Department of Pediatrics, Institution of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
| | - Etsuko Kitano
- Department of Medical Technology, Kobe Tokiwa University, Kobe, Japan
| | - Michiyo Hatanaka
- Department of Medical Technology, Kobe Tokiwa University, Kobe, Japan
| | - Hajime Kitamura
- Department of Nutritional Sciences for Well-being, Kansai University of Welfare Sciences, Kashiwara, Japan
| | - Tetsuya Sato
- Department of Pediatrics, Kochi Medical School, Kochi, Japan
| | - Akihiko Maeda
- Department of Pediatrics, Kochi Prefectural Hatakenmin Hospital, Kochi, Japan
| | - Shoji Kagami
- Department of Pediatrics, Institution of Health Biosciences, The University of Tokushima Graduate School, Tokushima, Japan
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