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Ten Common Mistakes in The Management of Lupus Nephritis. 2014
Ten Common Mistakes in The Management of Lupus Nephritis. 2014
idney involvement in systemic lupus erythematosus (SLE) can range from mild to severe and
occurs in 50%-70% of patients with lupus.1-3 Despite
advances in therapy, morbidity and mortality remain
high. In some studies, lupus nephritis leads to endstage renal failure in 17%-25% of patients4-6 and also
is associated with increased mortality.7,8 There are
some common misconceptions that are widely held
and may compromise optimal therapy of these
patients. If these misconception or myths are
addressed, we believe the outcome of these patients
might improve. These comments are based on our
experience over the past quarter century dealing with
a diverse ethnic lupus population in academically
based multidisciplinary lupus clinics in Toronto.
The following are the 10 most common mistakes
we have observed surrounding the management of
patients with lupus nephritis (Box 1).
Study
Therapy
(wk)
Age (y)
Race (%)
Baseline SCr
(mg/dL)
24-h Urine
Protein (g/d)
Intervention (n)
Outcome
Ginzler15
(2005)
140
24
31.5 6 9.5
White, 17;
black, 56.5;
Asian, 5.5;
Hispanic, 20;
other, 1
1.07 6 0.50
4.25 6 3.3
MMF group:
CR, 22.5%;
PR, 29.6%; I
V CYC group:
CR, 5.8%;
PR, 24.6%
Appel14
(2009;
ALMS)
370
24
31.9 6 10.7
White, 39.7;
Asian, 33.2;
other, 27
1.13 6 0.90
4.1 6 3.7
Primary efficacy
end point
achieveda in
56.2% of MMF
group; 53% of
IV CYC group
Table 1. Two Large Studies Comparing MMF Versus IV Cyclophosphamide for Induction Treatment of Lupus Nephritis
669
prednisone tablets are taken). With the start of corticosteroid therapy, there is almost always a gratifying
improvement in hemoglobin level and lupus-related
serologic test results, much before improvements
in urinary indexes. If there is no change in hemoglobin
level early or in double-stranded DNA titers and complement levels within 3-4 months, nonadherence
should be considered. The otherwise excellent KDIGO
guidelines discuss switching therapies for treatment
failure without addressing the possibility of nonadherence as the cause.20
ACKNOWLEDGEMENTS
Support: None.
Financial Disclosure: Dr Silverman is a consultant for Eli Lilly
and Glaxo Smith Kline. The remaining authors declare that they
have no relevant nancial interests.
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REFERENCES
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Am J Kidney Dis. 2014;63(4):667-676
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