Oral agents for maintenance

AZA or MMF ?

ALMS maintenance study

European MAINTAIN study

TAC in maintainance

Outcomes of maintenance therapy with

tacrolimus versus azathioprine for active lupus
nephritis: amulticenter randomized clinical trial
(2012)
70 pts AZA 2mg/kg/dTACT0 4-6 ng/mlPred10mg/d

2 relapse

LeucopeniamoreNo relapseNo leucopenia

After 6months

Rituximab in LN relapse

20 pts : 15 class 4, 5 class 5

12 refractory, 6 relapse, 2 first line Rx

3 received concomitant CYC during RTX Rx

10 received RTX new inj as maintenance (B cell

> 5/cmm)

Followed for median 22 months

CR or PR in 12 pts . 1 had relapse

responded to RTX

Factors predicting poor response:

Failure to achieve B cell depletion at 1 month

Hypoalbuminemia

RTX-specific human antichimeric antibodies (HACAs)

Rituximab in Severe Lupus Nephritis: Early B-Cell
Depletion Affects Long-TermRenal Outcome
RTX could be an interesting option in refractory or
relapsing LN, excludingRPGN.

Active surveillance for diagnosing flare

Early diagnosis and the initiation of

appropriateimmunosuppressive therapy

central to Mx.


How to monitor:

Measuring GFR alone : not adequate

Proteinuria : 24 hr UP vs spot uPCR

Urine for active casts : may occur 10 wks prior to

relapsediagnosis

Measuring C3, C4: drop in C4 levels predictive of

flare.

dsDNA antibodies : increasing titers

Antibody to C1q

Prediction and diagnosis of flare

Young age at onset of SLE (<30 years)

Male sex

African American ethnicity

Delay in initiation of treatment

Long time to reach remission

Low serum levels of complement C4 at the time

of response

Partial response or stabilization

High SLE disease activity score

The presence of arterial hypertension

Signs of severe SLE (CNS involvement and

leukopenia)

Treatment with low-dose immunosuppression

Novel markers predicitng relapse

Antibodies to C1q, peptide adrenomedullin

Nitrate, nitrite levels in serum

Urinary NGAL, IL6, IL8, IL10,

macrophageinflammatory protein 1, TWEAK