title: Treatment of membranous lupus nephritis with nephrotic syndrome by sequential immunosuppression.
abstract: The optimal therapy for pure membranous lupus nephritis (MLN) with nephrotic syndrome remains controversial. While the risk of progressive renal deterioration may be small, persistent heavy proteinuria leads to the complications of oedema, hypoalbuminaemia, hyperlipidaemia, hypercoagulability, and venous thrombosis. We examined prospectively the efficacy and tolerability of a sequential immunosuppressive regimen in a cohort of 20 patients with nephrotic syndrome due to pure MLN (WHO Class Va and Vb). Initial therapy comprised prednisolone (0.8 mg/kg/d p.o.) and cyclophosphamide (2-2. 5 mg/kg/d p.o.). Prednisolone dosage was gradually tapered to 10 mg/d at 6 months, when cyclophosphamide was replaced by azathioprine (2 mg/kg/d p.o.) as maintenance therapy. Within 12 months of therapy 11(55%) patients had complete remission (CR), 7(35%) patients achieved partial remission (PR) (proteinuria reduced from 6.2+/-4.0 to 2.0+/-1.7 g/24 h, P<0.01), and 2 patients failed to respond. Improvements in proteinuria and serum albumin level were observed after 3-6 months of treatment. Non-responders had lower baseline serum albumin compared to complete responders. Renal function remained stable during follow-up for 73.5+/-48.9 months. 8 patients had disease relapse at 47+/-15 months. Early complications (</=12 months) included herpes zoster (40%), minor respiratory or urinary tract infections (25%), mild leukopenia (15%), and transient amenorrhea (14.3%). 4 of the 20 patients developed pulmonary tuberculosis during follow-up, at 35+/-24 months after the diagnosis of MLN. 8 patients had hyperlipidaemia. Haemorrhagic cystitis, permanent amenorrhea, vascular complications, and mortality were not observed. We conclude that this sequential immunosuppressive regimen is effective in 90% of patients with MLN and heavy proteinuria. Prudent consideration of the benefits and potential side-effects is required to determine the optimal management for individual patients.
authors.affiliation: Division of Nephrology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China.
authors.forename: T M
authors.initials: TM
authors.lastname: Chan
authors.forename: F K
authors.initials: FK
authors.lastname: Li
authors.forename: W K
authors.initials: WK
authors.lastname: Hao
authors.forename: K W
authors.initials: KW
authors.lastname: Chan
authors.forename: S L
authors.initials: SL
authors.lastname: Lui
authors.forename: S
authors.initials: S
authors.lastname: Tang
authors.forename: K N
authors.initials: KN
authors.lastname: Lai
mesh_terms: D000328:Adult; D000505:Alopecia / Q000139:chemically induced; D000893:Anti-Inflammatory Agents / Q000008:administration & dosage / Q000009:adverse effects; D001379:Azathioprine / Q000008:administration & dosage* / Q000009:adverse effects; D015331:Cohort Studies; D003520:Cyclophosphamide / Q000008:administration & dosage* / Q000009:adverse effects; D004359:Drug Therapy, Combination; D005260:Female; D006562:Herpes Zoster / Q000139:chemically induced; D006723:Hong Kong; D006801:Humans; D007165:Immunosuppression Therapy / Q000009:adverse effects; D007166:Immunosuppressive Agents / Q000008:administration & dosage* / Q000009:adverse effects; D008181:Lupus Nephritis / Q000150:complications / Q000188:drug therapy* / Q000821:virology; D008297:Male; D008875:Middle Aged; D009404:Nephrotic Syndrome / Q000150:complications / Q000188:drug therapy*; D011241:Prednisone / Q000008:administration & dosage / Q000009:adverse effects; D011446:Prospective Studies; D011507:Proteinuria / Q000188:drug therapy / Q000209:etiology; D012141:Respiratory Tract Infections / Q000139:chemically induced; D012709:Serum Albumin; D016896:Treatment Outcome; D014552:Urinary Tract Infections / Q000139:chemically induced
chemical_list: D000893:Anti-Inflammatory Agents; D007166:Immunosuppressive Agents; D012709:Serum Albumin; D003520:Cyclophosphamide; D001379:Azathioprine; D011241:Prednisone