Clinical trials of immunosuppressive therapy in proliferative lupus nephritis Authors Ronald J Falk, MD Peter H Schur, MD Gerald B Appel, MD Section

Editor Deputy Editor Richard J Glassock, MD, MACP John P Forman, MD, MSc

All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Fev 2012. | This topic last updated: Fev 9, 2011.

INTRODUCTION The optimal treatment of lupus nephritis (LN) varies with the type of disease that is present. Immunosuppressive therapy is indicated in patients with diffuse and severe focal proliferative LN. Clinical trials of immunosuppressive therapy of proliferative LN are reviewed here. Prognostic factors and recommendations for the treatment of proliferative LN are discussed separately. (See "Therapy of diffuse or focal proliferative lupus nephritis" and "Therapy of resistant or relapsing diffuse or focal proliferative lupus nephritis".) INDUCTION THERAPY Induction therapy refers to the initial therapeutic regimen given in an attempt to produce remission of active disease. This is followed in almost all patients by maintenance therapy, usually with less toxic drugs. Cyclophosphamide versus other agents NIH trials A trial at the NIH compared three regimens in 65 patients with a mean serum creatinine of approximately 1.6 to 2.0 mg/dL (142 to 177 micromol/L): six monthly pulses of intravenous cyclophosphamide; a similar regimen followed by maintenance pulses every three months for another 24 months; and six monthly pulses of intravenous methylprednisolone (1 g/m2) without cyclophosphamide [1]. Oral prednisone was also given, beginning at a dose of 0.5 mg/kg per day and then tapering over a period of months to alternate-day maintenance therapy for control of extrarenal symptoms (minimum dose 0.25 mg/kg every other day). At follow-up of three years, the following differences were noted: The incidence of a doubling of the serum creatinine was significantly lower in the cyclophosphamide groups (25 versus 48 percent with methylprednisolone alone). The likelihood of relapse was significantly higher in the short-course (six monthly pulses) as opposed to the long-course cyclophosphamide regimen (figure 1). Although the group treated with only six monthly pulses did not do as well as those treated with more prolonged therapy, patients with relatively mild disease (serum creatinine 1.3 mg/dL [115 micromol/L] and/or protein excretion 1.0 g/day) had a favorable prognosis. One criticism of this trial is that the pulse methylprednisolone course was too short. A subsequent NIH trial in 82 patients with mostly diffuse proliferative lupus nephritis and a mean baseline serum creatinine of approximately 1.1 mg/dL (100 micromol/L) compared three regimens: one year of monthly pulse methylprednisolone (1 g/m2); pulse intravenous cyclophosphamide (0.5 to 1.0 g/m2 monthly for six months and then quarterly for at least two years); and combination therapy methylprednisolone plus cyclophosphamide [2]. All patients also received oral prednisone as in the earlier NIH study described above.

At a median follow-up of five years, the following results were reported: Remission (<10 red blood cells per high power field, no cellular casts, and proteinuria <1 g/day) occurred in 85, 62 and 29 percent of the 65 non-censored patients treated with combination therapy, cyclophosphamide alone, and methylprednisolone alone, respectively. Renal remission considering censored patients as failures occurred in 61, 48, and 26 percent, respectively. Relapse occurred in 0, 7, and 36 percent of the patients treated with combination therapy, cyclophosphamide alone, and methylprednisolone alone, respectively. Cyclophosphamide therapy was associated with a higher incidence of adverse events. Osteonecrosis occurred almost as frequently as with methylprednisolone alone, infections and amenorrhea were more frequent, and the three deaths were in the cyclophosphamide groups. (table 1). The outcomes of this cohort were further evaluated at a median follow-up of 11 years [3]. Treatment failure (defined as requiring supplemental immunosuppression, doubling of the serum creatinine, or death) was significantly less likely with combination pulse therapy or with cyclophosphamide alone than with pulse methylprednisolone alone. As an example, doubling of the serum creatinine occurred significantly less often with combination therapy (1 of 20 patients) than with cyclophosphamide alone (13 of 21) or methylprednisolone alone (15 of 24). In terms of adverse effects, avascular necrosis occurred with similar frequency in all three groups (30 to 36 percent), but osteoporosis was less frequent in the methylprednisolone group (13 percent) compared to the cyclophosphamide alone (23 percent) or combination groups (21 percent). The mortality rate was higher in the patients treated with cyclophosphamide compared to those treated with methylprednisolone alone (18 versus 4 percent). Thus, the reported benefit in terms of renal survival must be weighed against the higher mortality rate. In addition, the reported benefit of combination therapy may not be clinically applicable to all patients with diffuse proliferative lupus nephritis given study design flaws, and the relatively well preserved kidney function [4]. Dutch Working Party on SLE A randomized trial by the Dutch Working Party on Systemic Lupus Erythematosus included 87 patients with mostly class diffuse proliferative lupus nephritis who had a mean serum creatinine 1.2 mg/dL (112 micromol/L) and mean protein excretion of 4 g/day [5]. The patients were assigned to pulse cyclophosphamide (750 mg/m2 monthly for six months, then every three months for seven doses) or to azathioprine (2 mg/kg per day for two years) plus pulse methylprednisolone (1000 mg intravenously for three days, repeated at two and six weeks); all patients were treated with oral prednisone. After the initial two years, all patients were treated with azathioprine maintenance therapy (2 mg/kg per day) and 10 mg/day of prednisone for two more years, then lower doses for an additional year. During the initial two years of therapy, there were no differences between the two groups in the rate of complete and partial remissions (90 percent). However, after a median follow-up of 5.7 years, the rate of relapse was significantly lower in the cyclophosphamide group (4 versus 27 percent). Cyclophosphamide therapy was also associated with nonsignificant doubling of the serum creatinine (4 versus 16 percent) and deaths or end-stage renal disease (4 versus 11 percent). Duration of cyclophosphamide therapy The optimal duration of initial pulse cyclophosphamide therapy is not known. In the NIH trial cited above, the best long-term renal outcomes were attained with the following regimen: pulse intravenous cyclophosphamide (0.5 to 1.0 g/m2 monthly for six months and then quarterly for at least two years) combined with pulse methylprednisolone (1 g/m2 on three consecutive days the first month and then a single infusion monthly for at least one year) [2,3]. However, long courses of therapy are associated with increased toxicity. (See "General toxicity of cyclophosphamide and chlorambucil in inflammatory diseases".)

In an attempt to reduce toxicity by limiting exposure to cyclophosphamide, two other trials (the Lupus Nephritis Collaborative Study and the Euro-Lupus Nephritis Trial) have evaluated shorter courses cyclophosphamide regimens [6,7]. Lupus Nephritis Collaborative Study The Lupus Nephritis Collaborative Study attempted to control disease activity with a much shorter, and therefore less toxic, course of therapy [6]. In this study of 86 patients (40 percent with diffuse proliferative lupus, mean serum creatinine at baseline 2.0 mg/dL [188 mol/L]), oral cyclophosphamide was given for only eight weeks. Patients also received prednisone, 60 to 80 mg/day for four weeks, followed by tapering to 20 to 25 mg every other day over a period of 32 weeks. Exacerbations were treated with increasing doses of prednisone. Sixty-three of 86 enrolled patients completed at least 48 weeks of follow-up. At a mean follow-up of three years, the following results were noted: Twenty-one percent developed renal failure The likelihood of renal failure was related to kidney function at baseline and initial response. Seven and 29 percent of patients with initial serum creatinine 1.2 mg/dL or above 1.2 mg/dL (106 micromol/L) developed renal failure, respectively. Forty and 16 percent, respectively, had at least a 3 mg/dL (254 micromol/L) elevation in serum creatinine. Failure to respond to treatment within 48 weeks was associated with a higher risk of developing renal failure. The latter findings are similar to those in a preliminary report of one of the NIH studies mentioned above [1,8]. These two studies suggest that patients with diffuse proliferative lupus nephritis who have mild clinical disease might do well with relatively short-term cyclophosphamide therapy. However, as previously mentioned, a potentially important limitation of these reports is that the duration of follow-up was far too short. The initial NIH trials, for example, showed that patients treated with prednisone alone (the group with the worst outcome) did not progress to renal failure until at least five years after the institution of therapy [9,10]. Euro-Lupus Nephritis trial To better assess the long-term effect of low-dose short-term cyclophosphamide, 90 patients with proliferative lupus nephritis (two-thirds with diffuse proliferative histology) were randomly assigned either to six pulses of fixed low dose (500 mg) intravenous cyclophosphamide given every two weeks (cumulative dose of 3.0 g) or to six monthly doses of intravenous cyclophosphamide and then two quarterly pulses (0.5 g/m2 initially, with subsequent doses increased or decreased based upon white blood cell count nadir) [7].All patients also received an initial pulse of intravenous methylprednisolone (3 daily pulses of 750 mg); this was followed by oral glucocorticoids (initial dose of 0.5 mg/kg per day of prednisolone for four weeks), which was subsequently tapered to low dose maintenance therapy. Two weeks after the last cyclophosphamide infusion in both arms, azathioprine (2 mg/kg per day) was started and continued to at least month 30. At follow-up at a median of 41 months, there was no significant difference between the two arms in the rates of treatment failure (16 versus 20 percent in the high dose groups), renal remissions (71 versus 54 percent), and renal flares (27 versus 29 percent). The similarity in outcomes persisted at 10-year follow-up [11]. On multivariate analysis, a good early response to therapy was predictive of better long-term outcomes [12]. Thus, in this group of Europeans, a low dose cyclophosphamide induction regimen was as effective as a high dose regimen. However, the generalizability of these results is unclear, given that the study only enrolled Europeans without significant renal dysfunction (mean baseline serum creatinine 1.15 mg/dL [102 micromol/L]). Another strategy to reduce toxicity associated with long duration of treatment with cyclophosphamide consists of induction with short-term cyclophosphamide followed by maintenance therapy with either mycophenolate mofetil or azathioprine. (See 'Maintenance therapy' below.)

In the best comparative trial, 59 patients with lupus nephritis (12 with focal proliferative, 46 with diffuse proliferative, and 1 with membranous lupus) received induction therapy with four to a maximum of seven consecutive monthly doses of intravenous cyclophosphamide (0.5 to 1.0 g/m2) plus glucocorticoids [13]. The mean dose of prednisone (or a glucocorticoid equivalent) during induction was 0.6 mg/kg per day for three months followed by 0.3 mg/kg per day for three additional months. Over 80 percent of patients entered into remission during the induction phase. These patients were randomly assigned to one of the following therapies for two to three years: mycophenolate (500 to 3000 mg/day), azathioprine (1 to 3 mg/kg per day), or intravenous cyclophosphamide (0.5 to 1.0 g/m2 every three months). Glucocorticoids were continued during maintenance therapy at doses ranging from 0.04 to 0.20 mg/kg per day. The following results were observed at six years: Maintenance therapy with mycophenolate or azathioprine was associated with significantly lower incidence of chronic kidney disease, which was defined as a sustained increase in the serum creatinine to at least twice the lowest baseline achieved during induction therapy (5 and 5 versus 15 percent with cyclophosphamide). The relapse rate (defined as doubling of the urine protein-to-creatinine ratio or by an increase in the serum creatinine) was higher among patients who received cyclophosphamide compared to the mycophenolate. Adverse effects (including severe infections), and mortality versus that observed with long-term intravenous cyclophosphamide. Although concerns include the high rate of infections and progressive renal disease attributed to cyclophosphamide, the use of six months of monthly intravenous cyclophosphamide followed by mycophenolate or azathioprine for maintenance therapy should, at minimum, be considered an excellent therapeutic option as the induction plus maintenance regimen [14]. Mycophenolate mofetil Mycophenolate mofetil (MMF) may be an alternative to cyclophosphamide as initial therapy, particularly among patients who refuse or cannot tolerate cyclophosphamide. Several prospective trials have addressed this issue with mycophenolate being at least noninferior to cyclophosphamide [15-21]. The initial trials were small and may have been underpowered to detect a difference between the treatment regiments. A 2007 meta-analysis evaluated outcomes of 268 patients from four randomized trials [15]. Compared with cyclophosphamide, mycophenolate resulted in a significantly lower risk of failure of inducing remission (relative risk [RR] 0.70, 95% CI 0.54-0.90). Significant limitations in this analysis include the following: Studies of limited quality were included. The findings may not be generalizable, since the patients had relatively preserved renal function and a widely varying risk of remission. The initial duration of follow-up was only 6 to 12 months in the four trials, which may be too short to detect a difference in outcomes. In the NIH trials, for example, patients treated with prednisone alone had a low rate of progression to renal failure in the first five years (approximately 10 percent, similar to that with cyclophosphamide therapy) compared to 80 percent at 10 to 12 years (versus 10 percent with cyclophosphamide) [5]. Extended follow-up was provided in one of the trials, which included 42 patients at baseline and recruited 22 additional patients over time [19]. At a median follow-up of 63 months, there was no significant difference between the two groups in creatinine clearance at study end (80 mL/min), the rate of doubling of the serum creatinine (6 versus 10 percent), and the number of patients who relapsed (11 versus 9 patients). Significantly more patients on cyclophosphamide developed infections requiring hospitalization, and leukopenia, amenorrhea and death only occurred in the cyclophosphamide group. The net effect was that MMF at extended follow-up was associated with

a significant reduction in the risk of death or end-stage renal disease on extended follow-up (RR 0.44, 95% CI 0.23-0.87) [15]. In an international trial (ALMS) published after the meta-analysis and with more patients, MMF appeared to provide greater benefit than cyclophosphamide among black and Latino patients, and was comparable to monthly intravenous cyclophosphamide among white or Asian patients [21,22]. This trial compared induction therapy with the following regimens: MMF (0.5 g twice daily in week one, 1.0 g twice daily in week two, and a target of 1.5 g twice daily thereafter or, if not tolerated, 1.0 g three times to two times daily). MMF was taken before meals and with a glass of water. Monthly intravenous cyclophosphamide (0.75 g/m2 first dose, followed by five infusions of 0.5 to 1.0 g/m2). All patients were also treated with oral daily glucocorticoids (using prednisolone or an equivalent dose of another preparation). The prednisolone regimen began at a dose of 60 mg/day, tapered every two weeks by 10 mg/day until 40 mg/day was reached, followed by tapering by 5 mg/day until 10 mg/day was reached. Further tapering was allowed if the patient was stable for four weeks. The trial included 370 patients with lupus nephritis (LN): diffuse proliferative with or without membranous LN was present in 68 percent; focal proliferative with or without membranous LN in 16 percent; and pure membranous LN in 16 percent. The mean urine protein-to-creatinine ratio was 4.1 and the mean serum creatinine was 1.1 mg/dL (100 micromol/L). At 24 weeks, there was no difference between groups in the percentage of patients that achieved the primary or secondary end points. Seventy percent of patients in the MMF group had normal serum creatinine compared to 68 percent in the cyclophosphamide group. Twenty four percent of the MMF group had proteinuria less than 500 mg/day compared to 27 percent of the cyclophosphamide group. Mycophenolate appeared to provide greater benefit among black and Latino patients; among 83 such patients, 60 percent responded to MMF compared to 39 percent who responded to cyclophosphamide with an odds ratio 2.4 (95% CI, 1.1-5.4). A post hoc analysis revealed that among 131 Hispanic patients, more patients responded to MMF compared to cyclophosphamide (61 versus 39 percent with an odds ratio of 2.5 [95% CI, 1.2-5.1]). There was no difference in response rate between patients with focal or diffuse proliferative and those with membranous LN. (See "Clinical features and therapy of membranous lupus nephritis".) The rate of adverse events was not different between the two groups; 96 versus 95 percent among patients who received MMF versus cyclophosphamide, respectively. For both treatment groups, the most common types of adverse events were infections and gastrointestinal disorders. Thirteen percent of patients withdrew from treatment with MMF because of adverse events compared to seven percent who withdrew from cyclophosphamide. There were nine deaths in the MMF group and five in the cyclophosphamide group. Summary The findings from these trials suggest that an MMF regimen provides similar or perhaps greater efficacy and fewer adverse effects than a cyclophosphamide regimen, at least in patients with relatively normal kidney function and modest proteinuria [23]. The applicability of these findings to patients with more severe renal dysfunction is unknown. Furthermore, cyclophosphamide doses were not optimal in one study, and another used oral (not intravenous) cyclophosphamide. Another limitation of the above observations is the short duration of follow-up of 6 to 12 months in the four trials in the meta-analysis and the large subsequent trial [8,9]. In the NIH trials, for example, patients treated with prednisone alone had a low rate of progression to renal failure in

the first five years (approximately 10 percent, similar to that with cyclophosphamide therapy) compared to 80 percent at 10 to 12 years (versus 10 percent with cyclophosphamide) [5]. Other drugs Although not widely used, a number of other drugs have been evaluated for induction therapy in patients with lupus nephritis. These include cyclosporine, tacrolimus, azathioprine, rituximab, cladribine, total lymphoid irradiation, and cytokine-directed therapies [2435]. Data are insufficient to recommend any of these as primary therapy. Rituximab has also been used in patients with resistant disease. (See "Therapy of resistant or relapsing diffuse or focal proliferative lupus nephritis", section on 'Rituximab for cyclophosphamide and MMF resistance'.) MAINTENANCE THERAPY There are limited data regarding the relative efficacy of the different maintenance regimens [13,36,37]. Cyclophosphamide versus azathioprine or mycophenolate mofetil One trial included 59 patients with severe lupus nephritis (12 with focal proliferative, 46 with diffuse proliferative, and 1 with membranous lupus) who received induction therapy with intravenous pulse cyclophosphamide (four to seven monthly doses) plus prednisone (0.6 mg/kg per day for three months, then 0.3 mg/kg per day for three months) [13]. Subsequently, patients continued lowdose oral prednisone (0.1 to 0.2 mg/kg per day), and were randomly assigned to one of the following: MMF (500 to 3000 mg/day), azathioprine (1 to 3 mg/kg per day), or intravenous cyclophosphamide (0.5 to 1.0 g/m2 every three months). The median treatment duration was 24, 29, and 30 months for the cyclophosphamide, MMF, and azathioprine groups, respectively. The primary end points were renal and patient survival. Chronic renal failure was defined as a persistent doubling of the serum creatinine (of the lowest level attained with induction therapy) or if renal replacement therapy was required. At a median follow-up of three years, the following results were noted: With respect to the primary end points, five patients died (four and one in the cyclophosphamide and MMF groups, respectively), and five developed chronic renal failure (three in the cyclophosphamide group and one each in the azathioprine and MMF groups). Based upon a Kaplan-Meier analysis at six years, the event-free survival rate for the composite end point (patient and renal survival) was significantly higher with MMF and azathioprine (90 and 80 percent, respectively) compared to cyclophosphamide (45 percent). Seventeen patients (29 percent) had a renal relapse (eight, six, and three patients in the cyclophosphamide, azathioprine, and MMF groups, respectively). The overall relapse-free rate was significantly higher with MMF than cyclophosphamide. Compared with the other two groups, cyclophosphamide was associated with significantly more hospital days/patient-year, more infections, and a higher incidence of amenorrhea. Concerns regarding the applicability of these results include the predominance of Hispanic (49 percent) and black (46 percent) patients (who typically have a worse prognosis) and the high rate of infections attributed to cyclophosphamide [14]. Cyclosporine versus azathioprine One trial included 69 patients with diffuse proliferative or severe membranous lupus nephritis who received induction therapy with intravenous methylprednisolone (0.5 to 1 g/day for three days) and oral prednisone (1 mg/kg per day for two weeks, tapered to 0.5 mg/kg per day) plus oral cyclophosphamide (2 mg/kg per day for three months) [36]. Subsequently, patients were randomly assigned to cyclosporine (mean dose 3 mg/kg per day, adjusted to maintain trough levels 75 to 200 ng/mL) or azathioprine (2 mg/kg per day, tapered to 1.5 mg/kg per day after one month if proteinuria <1 g/day). All patients continued prednisone (tapered to 0.2 mg/kg per day by six months, and to a mean dose of 8 mg/day by 12 months). Therapy was administered for two years.

Nine patients withdrew from the study due to side effects during the second year, and an additional 12 were lost to follow-up, with a similar distribution between the two treatment groups. At four year follow-up, the following results were reported: The primary outcome of lupus flares occurred with similar frequency in the cyclosporine (five renal, two extrarenal) and azathioprine (seven renal, one extrarenal) groups. Two (cyclosporine) and three (azathioprine) flares occurred during the two years of active therapy. There was no difference in the change in creatinine clearance in the two groups. Reduction in proteinuria from >2 g/day at baseline to <0.5 g/day in both groups, but achieved earlier in the cyclosporine group (6 versus 12 months). No patient died or reached end-stage renal failure. Azathioprine versus mycophenolate mofetil Azathioprine was compared with MMF for maintenance therapy in three randomized trials [13,38,39], with MAINTAIN Nephritis and ALMS Maintenance being the largest: The MAINTAIN Nephritis Trial was a randomized open label trial that included 105 European patients (83 Caucasian) with biopsy-proven lupus nephritis and protein excretion exceeding 500 mg/day [38]. Diffuse proliferative was present in 61, focal proliferative LN in 33, and membranous LN in 11. All patients were treated with three daily 750 mg doses of intravenous methylprednisolone followed by oral glucocorticoids plus six 500 mg intravenous doses of cyclophosphamide over ten weeks. On week 12, maintenance therapy was initiated with either azathioprine (2 mg/kg per day) or MMF (2 g/day). Renal relapse was defined as one or more of the following: recurrence or development of nephrotic syndrome; a 33 percent or greater increase in serum creatinine within one month; or a threefold increase in proteinuria accompanied by hematuria. At three years, there was no significant difference between the MMF and azathioprine groups in the rate of renal relapse (19 versus 25 percent), systemic flares, or steroid withdrawal. Adverse events were similar in the two groups except for leukopenia and anemia, which occurred more frequently in the azathioprine group (14 versus 2 patients). Preliminary results from the ALMS Maintenance Trial were presented at the American Society of Nephrology meeting in November 2010 [39]. In this multinational two-phase study, 227 patients who had achieved remission with either MMF or cyclophosphamide were randomly assigned to MMF (1 g twice daily) or azathioprine (2 mg/kg per day) as maintenance therapy for 36 months. Results from the induction phase of the ALMS trial are discussed above. (See "Therapy of diffuse or focal proliferative lupus nephritis", section on 'Mycophenolate mofetil'.) Among patients who responded to induction therapy with either MMF or cyclophosphamide, treatment failure at 36 months (defined by renal relapse, the need to intensify therapy, doubling of the serum creatinine, or death) was significantly lower with MMF compared with azathioprine groups (16 versus 32 percent). The superiority of MMF was independent of the type of induction therapy, race, or region. In summary, MMF compared with azathioprine was associated with a statistically and clinically significant reduction in relapse rate in the ALMS Maintenance Trial and a nonsignificant trend toward benefit in the MAINTAIN nephritis trial. SUMMARY Induction therapy refers to the initial therapeutic regimen given in an attempt to produce remission of active disease. This is followed in almost all patients by maintenance therapy, usually with less toxic drugs. (See 'Induction therapy' above.)

 National Institutes of Health (NIH) trials demonstrated higher remission and lower relapse rates but also a higher incidence of adverse events associated with cyclophosphamide compared to methylprednisolone without cyclophosphamide. (See 'NIH trials' above.) A trial by the Dutch Working Party demonstrated lower rates of relapse, doubling of the serum creatinine, and deaths or end-stage renal disease associated with cyclophosphamide compared to azathioprine. (See 'Dutch Working Party on SLE' above.) The Lupus Nephritis Collaborative Study and the Euro-Lupus Nephritis Trial evaluated shorter courses cyclophosphamide regimens. The Euro-Lupus Nephritis Trial suggested that a low dose cyclophosphamide induction regimen was as effective as a high dose regimen. (See 'Euro-Lupus Nephritis trial' above.) Several trials have shown that mycophenolate mofetil (MMF) provides similar or perhaps greater efficacy and fewer adverse effects than cyclophosphamide, at least in patients with relatively normal kidney function and modest proteinuria, particularly among patients who refuse or cannot tolerate cyclophosphamide. Mycophenolate mofetil (MMF) may provide greater benefit than cyclophosphamide among black and Latino patients. (See 'Mycophenolate mofetil' above.) There are limited data regarding the relative efficacy of the different maintenance regimens. (See 'Maintenance therapy' above.)