A combination of cyclophosphamide or azathioprine with steroids can improve kidney function in people with severe lupus nephritis

Flanc RS, Roberts MA, Strippoli GFM, Chadban SJ, Kerr PG, Atkins RC

Published Online:

January 21, 2009

Lupus nephritis is an inflammation of the kidneys caused by lupus. Lupus (systemic lupus erythematosus - SLE) is a disease of the immune system that usually affects women. The person produces antibodies against various components of their cells, particularly DNA. Some develop kidney disease or failure. The review found that adding cyclophosphamide or azathioprine to steroids has better results than steroids alone. This combination of drugs improves the functioning of the kidneys but has not been shown to reduce kidney failure. More research is needed to refine the use of these treatments and find new drugs. Cyclophosphamide may lead to infertility.

Abstract (click to read)

Background:

Lupus nephritis is the renal manifestation of systemic lupus erythematosus (SLE) - a disease mainly affecting young women with substantial morbidity and mortality. It is classified by the World Health Organization (WHO) criteria I - VI based on histology. WHO Class IV is a diffuse proliferative glomerulonephritis which has the worst prognosis without treatment, with a reported 17% five year survival in the era 1953-1969. This survival was 82% in the early 1990's and continues to improve. An important factor behind this has been the use of cytotoxics such as cyclophosphamide in addition to steroids.

Objectives:

To assess the benefits and harms of different treatments in biopsy-proven proliferative lupus nephritis (LN).

Search strategy:

We searched the Cochrane Renal Group's specialised register (January 2003), the Cochrane Central Register of Randomised Controlled Trials (CENTRAL - The Cochrane Library issue 1, 2003), MEDLINE (1966 - 31 January 2003), EMBASE (1980 - 31 January 2003) and handsearched reference lists of retrieved articles.

Selection criteria:

Randomised controlled trials (RCTs) and quasi-RCTs comparing treatments for PLN in both adult and paediatric patients with Class III, IV , Vc, Vd lupus nephritis were included. All treatments were considered.

Data collection and analysis:

Data was extracted and quality assessed independently by two reviewers, with differences resolved by discussion. Dichotomous outcomes are reported as risk ratio (RR) and measurements on continuous scales are reported as mean differences (MD) with 95% confidence intervals. Subgroup analysis by study quality, drug type and drug route have been performed where possible to explore reasons for heterogeneity.

Main results:

Of 920 articles identified, 25 were RCTs suitable for inclusion, which enrolled 915 patients. The majority compared cyclophosphamide or azathioprine plus steroids versus steroids alone. Cyclophosphamide plus steroids reduced the risk of doubling of serum creatinine (RR 0.59, 95% CI 0.40 to 0.88) compared to steroids alone but had no impact on mortality (RR 0.98, 95% CI 0.53 to 1.82). The risk of ovarian failure was significantly increased (RR 2.18, 95% CI 1.10 to 4.34). Azathioprine plus steroids reduced the risk of all cause mortality compared to steroids alone (RR 0.60, 95% CI 0.36 to 0.99), but did not alter renal outcomes. Neither therapy was associated with increased risk of major infection.

No benefit was found with addition of plasma exchange to cyclophosphamide or azathioprine plus steroids for mortality ( RR 0.71, 95% CI 0.50 to 1.02), doubling of serum creatinine (RR 0.17, 95% CI 0.02 to 1.26) or end-stage renal failure (RR 1.24, 95% CI 0.60 to 2.57). There was also no increased risk of major infection (RR 0.69 , 95% CI 0.35 to 1.37) .

Authors' conclusions:

Until future RCTs of newer agents are completed, the current use of cyclophosphamide combined with steroids remains the best option to preserve renal function in proliferative LN. The smallest effective dose and shortest duration of treatment should be used to minimise gonadal toxicity, without compromising efficacy.

This record should be cited as:

Flanc RS, Roberts MA, Strippoli GFM, Chadban SJ, Kerr PG, Atkins RC. Treatment for lupus nephritis. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002922. DOI: 10.1002/14651858.CD002922.pub2

Assessed as up to date:

November 4, 2003

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Primary Review Group:

Renal Group

Health topics:

Kidney disease > Chronic kidney disease > Glomerular disease

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

A combination of cyclophosphamide or azathioprine with steroids can improve kidney function in people with severe lupus nephritis

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