Study of the outcome of patients with lupus nephritis before and after induction therapy with two different immunosuppressive regimens in single Egyptian centre

Abstract

SUMMARY L upus nephritis (LN) occurs in up to 60% of adults with systemic lupus erythematosus (SLE) and predicts poor survival. The prevalence of SLE and LN and treatment response vary by age, gender, location, and race/ethnicity; LN is especially common in black and Hispanic patients in the United States (Waldman and Appel 2006). Use of intravenous cyclophosphamide (CYC) is based on studies in the 1970s and 1980s at the National Institutes of Health (NIH). Response is often slow, and treatment fails to control LN fully and is associated with increased risks for adverse effects, including gonadal toxicity.( Kuiper-Geertsma and Derksen 2003). Unlike IV CYC, MMF has not been associated with an increased risk for bladder or ovarian toxicity in LN or during long-term use after transplantation (Robson et al ,.2005). MMFwas at least as effective as IV CYC in induction treatment in previous trials in Hong Kong, Malaysia, China, and the United States. Meta-analyses of these smaller trials suggested that MMF may offer advantages over IV CYC, but they have not yet been compared in an international randomized, controlled trial (Moore and Derry, 2006). The aim of our study was to compare the outcome of Lupus Nephritis patients regarding the achievement of complete remission, partial remission or failure of therapy after 3 month of induction therapy with two different immunosuppressive regimens {CYC vs MMF}. This cross sectional study was conducted on 100 patients with proliferative L.N. recruited from the national institute of nephrology and urology Cairo, Data was retrospectively collected from the period (2010-2015). The patients were followed up for three month after induction therapy. They were divided into two main groups (Group A)48 patients that are treated with MMF and (Group B) 52 patients that received MMF. Each group was further subdivided according to response {Complete remission] proteinuria ≤0.33 g/d and serum creatinine ≤1.4 mg/dl[, Partial remission ]50% reduction in baseline proteinuria to ≤1.5 g/d and ≤25% increase in baseline creatinine [or failure of therapy)} into:- A2]no12(25%)[the part of groupA showing complete remission.A3]no8(16.6%)[the part of group A showing partial remission.A4]no28(58.3%)[the part of group A that failed to enter remission.B2]no10(19.2%)[the part of group B showing complete remission.B3]no15(28.8%)[the part of group B showing partial remission.B4]no27(51.9%)[ the part of group B that failed to enter remission. Our study showed the superiority of MMF over CYC in short term induction of remission in patients with proliferative lupus nephritis. On comparing between the two main groups regarding patients charactaristics {Table 10} there was significant difference regarding age(P value>0.01) and BMI (P value>0.01). BMI was significant as well on comparing both groups that show complete remission A2&B2 (P value 0.035 ). In comparing between the two main groups regarding Lab investigations before therapy {Table11 ,12} there was significant difference regarding e.GFR (P value 0.01)However in comparing between the 2 groups that shows complete remission A2&B2 there was no significant difference regarding e.GFR{P value >0.05} and there was only significant difference regarding ESR {P value 0.023}. The comparison between the 3 subgroups of group A {Table 15} there was significant difference between groups A2 & A4 in BMI(p value 0.03), S.albumin(p value 0.042) and 24hour protein in urine(p value 0.01) Comparison between the 3 subgroups of group B {Table16} there was significant difference between group B2&B4 regarding BMI (P value 0.003) Relation between S.creatinine and findings of renal biopsy at time of presentation in both main groups (A+B){Tables37,39} showed significant relationship between S.creatinine and presence of crescents (p value 0.005) and presence of evidence of chronic interstitial nephritis (p value 0.002) Also during exploring the relationship between Proteinuria and findings of renal biopsy at time of presentation in both main groups (A+B) {Tables38,40} there was significant relationship between proteinuria and presence of 2ndry FSGS(p value 0.008) Relation between s. creat and lab results before induction among all patients{Table 23} revealed significant relation between S.creat and HB {P value 0.016}, S.cholesterol{P value 0.03} and highly significant relation with 24hour protein in urine{0.000} However in regression analysis for factors affecting proteinuria in all patients {Table 45} there were no significant relations {P value > 0.05}.