Randomized, controlled trial of prednisone, cyclophosphamide, and cyclosporine in lupus membranous nephropathy.
Patients with lupus membranous nephropathy (LMN) are at substantial long-term risk for morbidity and mortality associated with protracted nephrotic syndrome, including ESRD. The optimal treatment for this condition is controversial. Forty-two patients with LMN participated in a randomized, controlled trial to compare adjunctive immunosuppressive drugs with prednisone alone. Adjunctive regimens included either cyclosporine (CsA) for 11 mo or alternate-month intravenous pulse cyclophosphamide (IVCY) for six doses; the control group received alternate-day prednisone alone. Median proteinuria was 5.4 g/d (range 2.7 to 15.4 g/d). We assessed the primary outcome, time to remission of proteinuria during the 12-mo protocol, by univariate survival analysis. At 1 yr, the cumulative probability of remission was 27% with prednisone, 60% with IVCY, and 83% with CsA. Although both IVCY and CsA were more effective than prednisone in inducing remissions of proteinuria, relapse of nephrotic syndrome occurred significantly more often after completion of CsA than after IVCY. By multivariate survival analysis, treatment with prednisone and high-grade proteinuria (>5 g/d) but not race or ethnicity were independently associated with a decreased probability of remission. Adverse effects during the 12-mo protocol included insulin-requiring diabetes (one with prednisone and two with CsA), pneumonia (one with prednisone and two with CsA), and localized herpes zoster (two with IVCY). In conclusion, regimens containing CsA or IVCY are each more effective than prednisone alone in inducing remission of proteinuria among patients with LMN.
Austin
Howard A
HA
Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Building 10, CRC 5-2551, Bethesda, Maryland 20892-1455, USA. howarda@bdg10.niddk.nih.gov
Illei
Gabor G
GG
Braun
Michelle J
MJ
Balow
James E
JE
D000293:Adolescent; D000328:Adult; D017668:Age of Onset; D003520:Cyclophosphamide / Q000627:therapeutic use*; D016572:Cyclosporine / Q000627:therapeutic use*; D005260:Female; D006400:Hematocrit; D006801:Humans; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D008181:Lupus Nephritis / Q000188:drug therapy* / Q000276:immunology; D008297:Male; D008875:Middle Aged; D011241:Prednisone / Q000627:therapeutic use*; D011379:Prognosis; D011507:Proteinuria / Q000188:drug therapy; D012709:Serum Albumin / Q000187:drug effects / Q000378:metabolism; D055815:Young Adult
D007166:Immunosuppressive Agents; D012709:Serum Albumin; D016572:Cyclosporine; D003520:Cyclophosphamide; D011241:Prednisone