However, for this patient, he said, induction therapy should be MMF because of data showing more complications with CY in non-white patients.
Case 2: Young Asian Woman
The second case was a 26-year-old Asian woman with class IV lupus nephritis diagnosed in 1998. She was initially treated with prednisone for six months and then with AZ for four years. She relapsed and was subsequently treated with prednisone and MMF for three years, followed by another relapse. She had a repeat biopsy showing a mixed class III/V. She hopes to have children in the future.
Dr. Ginzler said that the patient should be reinduced with an increase in her steroids. “I would treat her initially at this point with the Euro-Lupus regime: six infusion low doses of IV CY. At the end of that, I would taper the steroids and return her to MMF if she changes her mind about pregnancy. If she was insistent on pregnancy, I would reluctantly go back to AZ in the dose she could tolerate.”
Dr. Houssiau agreed that the patient should be reinduced. “No drugs work better than glucocorticoids and CY if she clearly still has pregnancy wishes,” he said. But, he said, there are no sufficient data indicating use of the Euro-Lupus regime in Asian patients.
Case 3: Young Hispanic Woman
The final case considered by the panel was that of a 22-yearold Hispanic woman with class IV lupus nephritis. She was treated with 3 gm/daily of MMF for three months and had little improvement. She was then switched to monthly highdose IV CY. After three months, there was no response. She hopes to one day have children.
Dr. Dooley said that the patient is at high risk because of her age, her ethnicity, and because she presented with impaired renal function. First, she said, the physician should be certain that the lack of response is due to lupus nephritis and not to an underlying etiology related to blood pressure, blood sugar, dyslipidemia, or thrombotic thrombocytopenic purpura.
She advised that this patient should finish her six months of therapy with MMF and then transition to AZ or MMF. “Because she is a young woman, she will need longterm immunosuppression,” she said.
Kathy Holliman is a medical journalist based in New Jersey.
References
- Boumpas DT, Austin HA, Vaughn EM, et al. Controlled trial of pulse methylprednisolone versus two regimens of pulse cyclophosphamide in severe lupus nephritis. Lancet. 1992;340:741-745.
- Chan TM, Li FK, Tang CS, et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferative lupus nephritis. N Engl J Med. 2000;343:1156-1162.
- Chan TM, Tse KC, Tang CS, et al. Long-term study of mycophenolate mofetil as continuous induction and maintenance treatment for diffuse proliferative lupus nephritis. J Am Soc Nephrol. 2005;16: 1076-1084.
- Dooley MA, Hogan S, Jennette C, Falk R. Cyclophosphamide therapy for lupus nephritis: Poor renal survival in black Americans. Glomerular Disease Collaborative Network. Kidney Int. 1997;51: 1188-1195.
- Ginzler EM, Dooley MA, Aranow C, et al. Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. N Engl J Med. 2005;353:2219-2228.
- Houssiau FA, D’Cruz DP, Sangle SR, et al. Azathioprine versus mycophenolate mofetil for maintenance immunosuppression of proliferative lupus nephritis: Result of a randomized trial (MAINTAIN). #1150. Presented at the ACR/ARHP Scientific Meeting. Oct. 19, 2009. Philadelphia.
- Houssiau FA, Vasconcelos C, D’Cruz D, et al. Immunosuppressive therapy in lupus nephritis: The Euro-Lupus Nephritis Trial. A randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Arthritis Rheum. 2002;46:2121-2131.
