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Randomized, Controlled Trial of Prednisone, Cyclophosphamide, and Cyclosporine in Lupus Membranous Nephropathy

Howard A. Austin, III^*, Gabor G. Illei^,, Michelle J. Braun^* and James E. Balow^*

^* National Institute of Diabetes and Digestive and Kidney Diseases, National Institute of Arthritis and Musculoskeletal and Skin Diseases, and National Institute of Dental and Craniofacial Disorders, National Institutes of Health, Bethesda, Maryland

Correspondence: Dr. Howard A. Austin, III, National Institutes of Health, Kidney Disease Section, NIDDK, Building 10, CRC 5-2551, Bethesda, MD 20892-1455. Phone: 301-435-5055; Fax: 301-480-1640; E-mail: howarda{at}bdg10.niddk.nih.gov

Received for publication June 30, 2008. Accepted for publication November 16, 2008.

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.

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				L. H. Beck Jr. and D. J. Salant Treatment of Membranous Lupus Nephritis: Where Are We Now? J. Am. Soc. Nephrol., April 1, 2009; 20(4): 690 - 691. [Full Text] [PDF]

Copyright © 2009 by the American Society of Nephrology. Online ISSN: 1533-3450 Print ISSN: 1046-6673