Mycophenolate mofetil as the primary treatment of membranous lupus nephritis with and without concurrent proliferative disease: a retrospective study of 29 cases

Abstract

Studies of immunosuppressive therapy, particularly mycophenolate mofetil (MMF), in membranous lupus nephritis (MLN) are limited. We report on our experience with primary (first-line) MMF therapy to induce and sustain renal remission in MLN with and without a concurrent proliferative lesion. Systemic lupus erythematosus (SLE) patients were studied, retrospectively, if treated with MMF for newly diagnosed MLN. Complete remission was defined as proteinuria less than 0.5 g/24h, inactive urine sediment and normal estimated glomerular filtration rate. Response in pure MLN (Group I, n = 10) was compared with mixed MLN and proliferative lupus nephritis (Group II, n = 19). By 12 months, 4 (40%) patients in Group I and 7 (36.8%) in Group II achieved complete remission (P = 0.87). One (10%) patient in Group I and 2 (10.5%) in Group II had worsening renal disease (P = 0.97). Mean time to remission was more than seven months in both groups. The remaining patients had stable disease without improvement or worsening. Only 2 of 11 achieving initial remission had a relapse with an average of 28 months of follow-up after remission. Self-limited gastrointestinal symptoms occurred in 12 patients, none requiring withdrawal of the drug. Mycophenolate mofetil as a primary therapy in MLN was successful in inducing complete remission in about 40% of MLN, particularly in patients with mild proteinuria. However, 12 months of therapy was necessary for best outcomes. Response rate was not different in the presence or absence of a proliferative lesion. Lupus (2008) 17, 40—45.

Keywords

immunosuppressant membranous lupus nephritis mycophenolate mofetil

Get full access to this article

View all access options for this article.

References

Baldwin DS , Gluck MC , Lowenstein J. , Gallo GR Lupus nephritis. Clinical course as related to morphologic forms and their transitions. Am J Med 1977; 62: 12—30.

Appel GB , Silva FG , Pirani CL , Meltzer JI , Estes D. Renal involvement in systemic lupud erythematosus (SLE): a study of 56 patients emphasizing histologic classification. Medicine (Baltimore) 1978; 57: 371—410.

Cameron JS , Turner DR , Ogg CS et al. Systemic lupus with nephritis: a long-term study. Q J Med 1979; 48: 1—24.

Donadio JV Jr, Burgess JH , Holley KE Membranous lupus nephropathy: a clinicopathologic study. Medicine (Baltimore) 1977; 56: 527—536.

Schwartz MM , Kawala K. , Roberts JL , Humes C. , Lewis EJ Clinical and pathological features of membranous glomerulonephritis of systemic lupus erythematosus. Am J Nephrol 1984; 4: 301—311.

Schwartz MM , Lan SP , Bonsib SM , Gephardt GN , Sharma HM Clinical outcome of three discrete histologic patterns of injury in severe lupus glomerulonephritis. Am J Kidney Dis 1989; 13: 273—283.

Chan TM , Li FK , Hao WK et al. Treatment of membranous lupus nephritis with nephrotic syndrome by sequential immunosuppression. Lupus 1989 ; 8: 545—551.

Hu W. , Liu Z. , Shen S. et al. Cyclosporine A in treatment of membranous lupus nephropathy. Chin Med J (Engl) 2003; 116: 1827—1830.

Tam LS , Li EK , Szeto CC et al. Treatment of membranous lupus nephritis with prednisone, azathioprine and cyclosporin A. Lupus 2001; 10: 827—829.

10.

Chan TM , Li FK , Tang CS et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferative lupus nephritis. Hong Kong-Guangzhou Nephrology Study group. N Engl J Med 2000; 343 :1156—1162.

11.

Contreras G. , Pardo V. , Leclercq B. et al. Sequential therapies for proliferative lupus nephritis. N Engl J Med 2004; 350: 971—980.

12.

Ginzler EM , Dooley MA , Aranow C. et al. Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. N Engl J Med 2005; 353: 2219—2228.

13.

Kapitsinou PP , Boletis JN , Skopouli FN , Boki KA , Moutsopoulos HM Lupus nephritis: treatment with mycophenolate mofetil. Rheumatology 2004; 43: 377—380.

14.

Spetie DN , Tang Y. , Rovin BH et al. Mycophenolate therapy of SLE membranous nephropathy. Kidney Int 2004; 66: 2411—2415.

15.

Weening JJ , D'agati VD , Schwartz MM et al. The Classification of Glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol 2004; 15: 241—250.

16.

Levey AS , Greene T. , Kusek JW , Beck GJ A simplified equation to predict GFR from S-creatinine [abstract]. J Am Soc Nephrol 2000; 11: 155A.

17.

Petri M. , Barr SG , Buyon J. et al. RIFLE: Responder Index for Lupus Erythematosus [abstract]. Arthritis Rheum 2000; 43: S244.

18.

Sloan RP , Schwartz MM , Korbet SM , Borok RZ Long-term outcome in systemic lupus erythematosus membranous glomerulonephritis. Lupus Nephritis Collaborative Study Group. J Am Soc Nephrol 1996; 7: 299—305.

19.

Kanda H. , Kubo K. , Tateishi S. et al. Antiproteinuric effect of ARB in lupus nephritis patients with persistent proteinuria despite immunosuppressive therapy. Lupus 2005; 14: 288—292.