Περίληψη:
Background. Long-term intravenous cyclophosphamide (IVC) in combination
with corticosteroids is standard therapy for proliferative lupus
nephritis, but it has limitations. There are few data on long-term
remission rates, predictors of relapse, and the ability to achieve a
second remission with currently recommended IVC regimens.
Methods. A cohort of 85 patients with proliferative lupus
glomerulonephritis (focal N = 33, diffuse N = 52) treated with IVC was
assembled in three institutions. Timing and predictors of remission,
relapse, and re-remission were evaluated with Kaplan-Meier analyses and
Cox models.
Results. The median time to remission was 10 months, whereas an
estimated 22% of patients had not remitted after 2 years. The median
time to relapse among 63 patients who had achieved remission was 79
months. In multivariate models, adverse predictors of remission were a
delay in the initiation of therapy from the time nephritis was
clinically diagnosed [hazard ratio (HR) 0.58, P = 0.063] and a higher
amount of proteinuria (HR 0.86 per 1 g/24 hours, P = 0.014). Predictors
of earlier relapse for patients entering remission included a longer
time to remission (HR 1.029 per month, P = 0.025), a history of central
nervous system involvement (HR 8.41, P = 0.002), and World Health
Organization histology (P = 0.01). Among the 23 patients who relapsed
during follow-up, the median time to re-remission was 32 months, and
with three exceptions, all patients took substantially longer time to
remit the second time compared with their first remission (P = 0.01).
The time to re-remission was longer in patients who had taken longer to
remit the first time (HR 0.979 per month, P = 0.16), in patients who had
relapsed earlier after the first remission (HR 1.071 per month, P =
0.002), and in those with evidence of chronicity in the original kidney
biopsy (P = 0.015).
Conclusions. Prolonged courses with a cumulative risk of toxicity are
needed to achieve remission in many first-treated patients and in most
patients treated for a second time. The optimal management of patients
with identified adverse predictors of response needs further study.
Συγγραφείς:
Ioannidis, JPA
Boki, KA
Katsorida, ME
Drosos, AA and
Skopouli, FN
Boletis, JN
Moutsopoulos, HM
