title: Moderator's view: The use of calcineurin inhibitors in the treatment of lupus nephritis.
abstract: Lupus nephritis (LN) is one of the most severe manifestations of systemic lupus erythematosus (SLE), affecting ∼50% of patients, and both renal disease and treatment-related toxicity contribute to significant morbidity and mortality. Although our understanding of the aetiopathogenesis of LN is improving, treatment still remains a challenge, with the achievement of complete remission at 1 year in <50% of patients treated with current standard of care immunosuppressive therapy; this is associated with considerable short- and long-term side effects, some of which further contribute to non-adherence. Calcineurin inhibitors (CNIs) have been successfully used in organ transplantation and there is increasing evidence that cyclosporin A (CSA), and especially tacrolimus (TAC), are also effective in the treatment of LN. Randomised controlled trials showed similar efficacy for TAC when compared with mycophenolate mofetil (MMF) and multitarget therapy, including TAC and low-dose MMF, and resulted in significantly more complete remissions and overall responses compared with intravenous cyclophosphamide (CYC). Flares are observed in up to 45% of patients with LN, and an increase in relapse rate following induction with CNIs may be an issue. Most studies on this matter have been restricted to patients from Asia, and studies in more balanced cohorts are desirable. Moreover, there is a need to understand and determine the long-term effects of CNIs on renal function, proteinuria and comorbidities, with a special focus on cardiovascular risk. In this 'Pros and Cons' debate, the potential benefits and disadvantages of CNIs in the treatment of LN will be critically highlighted.
authors: Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria.
authors: Andreas
authors: A
authors: Kronbichler
authors: vasculitis.at, Esslinggasse 18, 1010 Vienna 1010, Austria Immunologie-Zentrum Zürich, Zürich, Switzerland.
authors: Irmgard
authors: I
authors: Neumann
authors: Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria.
authors: Gert
authors: G
authors: Mayer
mesh_terms: D065095:Calcineurin Inhibitors / Q000009:adverse effects / Q000627:therapeutic use*; D002318:Cardiovascular Diseases / Q000188:drug therapy; D003520:Cyclophosphamide / Q000009:adverse effects / Q000627:therapeutic use; D016572:Cyclosporine / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D007166:Immunosuppressive Agents / Q000009:adverse effects / Q000627:therapeutic use; D008181:Lupus Nephritis / Q000188:drug therapy*; D060046:Maintenance Chemotherapy; D009173:Mycophenolic Acid / Q000009:adverse effects / Q000627:therapeutic use; D011507:Proteinuria / Q000188:drug therapy; D012307:Risk Factors; D016559:Tacrolimus / Q000009:adverse effects / Q000627:therapeutic use
chemical_list: D065095:Calcineurin Inhibitors; D007166:Immunosuppressive Agents; D016572:Cyclosporine; D003520:Cyclophosphamide; D009173:Mycophenolic Acid; D016559:Tacrolimus
keywords: calcineurin inhibitors; cyclosporin A; lupus nephritis; systemic lupus erythematosus; tacrolimus