Bao H et al. (2008) Successful treatment of class V + IV lupus nephritis with multitarget therapy. J Am Soc Nephrol [doi:10.1681/ASN.2007121272]

Patients with severe lupus nephritis who have both diffuse proliferative (class IV) and membranous (class V) lesions on biopsy can be refractory to current monotherapy treatments. Bao et al. compared mycophenolate mofetil, tacrolimus and corticosteroid multitarget treatment with cyclophosphamide in patients with class V + IV lupus nephritis in order to determine an optimized immunosuppressive strategy for these individuals.

This Chinese, open-label study enrolled 40 patients with class V + IV lupus nephritis who were randomly allocated to receive induction therapy with either intravenous cyclophosphamide pulse therapy or mycophenolate mofetil and tacrolimus for 6 months, or for 9 months if complete remission was not achieved. All patients also received intravenous methylprednisolone pulse therapy for the first 3 days of the study and oral prednisone throughout.

In intention-to-treat analyses, significantly more patients in the multitarget therapy group than in the cyclophosphamide group achieved complete or partial remission at 6 months (18 [90%] vs 9 [45%]; P = 0.002) and at 9 months (19 [95%] vs 11 [55%]; P = 0.003). The overall incidence of adverse effects (e.g. gastrointestinal syndrome and leukopenia) was lower in the multitarget therapy group than in the cyclophosphamide group, although one patient in each group developed pneumonia.

The authors conclude that this multitarget therapy regimen is better at inducing remission than is intravenous cyclophosphamide in patients with both diffuse proliferative and membranous lupus nephritis. This efficacy could be due to the synchronous effects of the different components of the multitarget therapy on the different types of lesions in severe lupus nephritis.