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  • Review Article
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An update on the use of mycophenolate mofetil in lupus nephritis and other primary glomerular diseases

Nature Reviews Nephrology volume 5, pages 132–142 (2009)Cite this article

Abstract

Mycophenolate mofetil (MMF) has been used successfully as an immunosuppressive medication in transplantation for over a decade. Owing to its efficacy and relatively benign adverse effect profile, its use has been investigated in the treatment of several glomerular diseases, as we describe in this Review. Of these, MMF has most extensively been studied in lupus nephritis. Randomized controlled trials have documented the value of MMF in both induction and maintenance therapy for severe lupus nephritis in several different geographic and ethnic populations, and have defined its potential toxicity. In minimal-change disease, focal segmental glomerulosclerosis and membranous nephropathy, promising but limited data on MMF treatment exist from small retrospective and prospective studies. Ongoing, larger, prospective trials, such as the NIH trial in focal segmental glomerulosclerosis, might clarify the value of MMF in the treatment of this disease. The efficacy of MMF in IgA nephropathy remains unclear, despite several small, controlled trials. Conflicting results might reflect differences in the disease process, differences in MMF metabolism, or varying responses to the immunosuppressive agent in different populations. Only through large, collaborative, controlled trials will the true role of MMF be defined for each glomerular disease.

Key Points

  • Mycophenolate mofetil (MMF), when used in conjunction with corticosteroids, is effective as induction therapy for severe lupus nephritis; however, its benefits over cyclophosphamide in the treatment of crescentic lupus nephritis and in patients with very low glomerular filtration rates are unclear

  • MMF is superior to intravenous cyclophosphamide in maintenance therapy for severe lupus nephritis, but has not yet been shown to be superior to azathioprine for this indication

  • MMF has been used successfully to induce remission of the nephrotic syndrome in minimal-change disease and focal segmental glomerulosclerosis, but this finding has not yet been confirmed by any large, controlled trial

  • In membranous nephropathy, MMF seems to be as effective as several other immunosuppressive agents in inducing remission of the nephrotic syndrome, but there are concerns about a high rate of relapse on drug discontinuation

  • Despite five trials of MMF in IgA nephropathy, whether the addition of MMF is superior to use of supportive therapy alone remains unclear

  • Large, multicenter trials, similar to those performed in lupus nephritis, are needed to define the role of MMF in primary glomerular diseases

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  1. AS Appel is a Research Associate and GB Appel is a Professor of Clinical Medicine at Columbia University Medical Center, New York, NY, USA.,

    Alice S Appel & Gerald B Appel

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Correspondence to Gerald B Appel.

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GB Appel has declared associations with the following companies: Genentech, La Jolla Pharmaceutical Company and Vifor Pharma Aspreva (consultant, speakers bureau, grant/research support). AS Appel declared no competing interests.

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Appel, A., Appel, G. An update on the use of mycophenolate mofetil in lupus nephritis and other primary glomerular diseases. Nat Rev Nephrol 5, 132–142 (2009). https://doi.org/10.1038/ncpneph1036

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