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Optimum therapeutic approaches for lupus nephritis: what therapy and for whom?

Nature Clinical Practice Rheumatology volume 1, pages 22–30 (2005)Cite this article

Abstract

The optimum therapy for patients with lupus nephritis is a hotly debated topic. Prospective randomized studies in patients with proliferative lupus nephritis have established the superiority of cyclophosphamide to azathioprine, both of which are used in combination with corticosteroids. Although high-dose, intermittent administration of cyclophosphamide (pulse therapy) has significantly reduced the toxicity associated with this drug, premature ovarian failure and infections remain considerable problems. Short-term to intermediate-term, randomized controlled trials have shown that mycophenolate mofetil is a good option for the induction and maintenance of remission in lupus nephritis patients. Additional longer-term trials involving more patients and stricter outcomes based on renal function are needed, however, before claims that mycophenolate mofetil is superior to cyclophosphamide can be substantiated. Until such data are available, physicians caring for patients with lupus nephritis can use mycophenolate mofetil as induction or maintenance therapy for selected patients under close observation. Small noncontrolled trials with short-term follow-up suggest that up to 50% of patients who are refractory to cyclophosphamide might have a clinically significant response to rituximab, a monoclonal antibody directed against B cells.

Key Points

  • The treatment of lupus nephritis involves a period of intensive induction therapy, followed by a longer period of less intensive maintenance therapy

  • A variety of prognostic factors are used for stratification of the severity of lupus nephritis and decision-making on the basis of treatment algorithms

  • Combinations of intravenous cyclophosphamide and methylprednisolone are effective for the induction and maintenance of remission in patients with severe lupus nephritis

  • Mycophenolate mofetil is a good option for the induction and maintenance of remission in moderately severe lupus nephritis in patients who are under close observation

  • In addition to immunosuppressive therapy, aggressive treatment of hypertension and hyperlipidemia is essential

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Acknowledgements

We thank Dr Gabor Illei for critical review of the manuscript and Ms Natassa Mpizaki for assisting in the typing of the manuscript.

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Authors and Affiliations

  1. Departments of Internal Medicine and of Rheumatology, Clinical Immunology and Allergy, at the Medical School, University of Crete,

    Dimitrios T Boumpas, Prodromos Sidiropoulos & George Bertsias

  2. Faculty Member,

    Dimitrios T Boumpas, Prodromos Sidiropoulos & George Bertsias

  3. Department of Rheumatology, Clinical Immunology and Allergy, at the Medical School, University of Crete,

    Dimitrios T Boumpas, Prodromos Sidiropoulos & George Bertsias

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  1. Dimitrios T Boumpas
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  3. George Bertsias
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Correspondence to Dimitrios T Boumpas.

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Boumpas, D., Sidiropoulos, P. & Bertsias, G. Optimum therapeutic approaches for lupus nephritis: what therapy and for whom?. Nat Rev Rheumatol 1, 22–30 (2005). https://doi.org/10.1038/ncprheum0016

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