Lupus Nephritis: Understanding the Paradigm for Treatment

Dr. Merrill discussed several other medications that, although they did not reach statistical significance, demonstrated trends toward efficacy when used as part of combination therapy. These included obinutuzumab, a type II, anti-CD20 monoclonal antibody, which, in the randomized, double-blind, placebo-controlled NOBILITY trial, was combined with mycophenolate mofetil in treating 125 patients with proliferative lupus nephritis and showed increased complete and partial renal responses compared to placebo.⁸

There was also discussion of an ongoing phase 3 trial of voclosporin, a novel calcineurin inhibitor.⁹ In this study of more than 350 patients with active lupus nephritis, publicly available data of the results so far have shown that combining voclosporin with mycophenolate mofetil and low-dose corticosteroids was superior to standard care for treating patients with lupus nephritis. Further information will need to be released to confirm the results, but the prospects of this medication seem potentially promising.

Future Strategies
For a condition in desperate need of additional treatment strategies to prevent progression and ultimately renal failure, the advances and thought-provoking ideas discussed by Dr. Merrill offer hopeful glimpses of the future for patients with lupus nephritis. In partnership with patients and with a clear understanding of the evolving literature, clinicians can help patients live longer, healthier lives.

Jason Liebowitz, MD, completed his fellowship in rheumatology at Johns Hopkins University, Baltimore, where he also earned his medical degree. He is currently in practice with Skylands Medical Group, N.J.

References

1. Mok CC, Kwok RC, Yip PS. Effect of renal disease on the standardized mortality ratio and life expectancy of patients with systemic lupus erythematosus. Arthritis Rheum. 2013 Aug;65(8):2154–2160.
2. Hahn BH, McMahon MA, Wilkinson A, et al. American College of Rheumatology guidelines for screening, treatment, and management of lupus nephritis. Arthritis Care Res (Hoboken). 2012 Jun;64(6):797–808.
3. Hsieh C, Chang A, Brandt D, et al. Predicting outcomes of lupus nephritis with tubulointerstitial inflammation and scarring. Arthritis Care Res (Hoboken). 2011 Jun;63(6):865–874.
4. Liu Z, Zhang H, Liu Z, et al. Multitarget therapy for induction treatment of lupus nephritis: A randomized trial. Ann Intern Med. 2015 Jan 6;162(1):18–26.
5. Rönnblom L, Leonard D. Interferon pathway in SLE: One key to unlocking the mystery of the disease. Lupus Sci Med. 2019 Aug 13;6(1):e000270.
6. An Y, Zhou Y, Bi L, et al. Combined immunosuppressive treatment (CIST) in lupus nephritis: A multicenter, randomized controlled study. Clin Rheumatol. 2019 Apr;38(4):1047–1054.
7. Rovin BH, Furie R, Latinis K, et al. Efficacy and safety of rituximab in patients with active proliferative lupus nephritis: The lupus nephritis assessment with rituximab study. Arthritis Rheum. 2012 Apr;64(4):1215–1226.
8. Furie R, Aroca G, Alvarez A, et al. A phase II randomized, double-blind, placebo-controlled study to evaluate the efficacy and safety of obinutuzumab or placebo in combination with mycophenolate mofetil in patients with active class III or IV lupus nephritis [abstract 939]. Arthritis Rheumatol. 2019;71(suppl 10).
9. Gibson K, Parikh S, Saxena A, et al. AURORA phase 3 trial demonstrates voclosporin statistical superiority over standard of care in lupus nephritis (LN) [abstract 407]. National Kidney Foundation 2020 Spring Clinical Meetings. 2020.