Bertsias George, Boumpas Dimitrios T
Department of Rheumatology, University of Crete Medical School, Heraklion, Greece.
Nat Clin Pract Rheumatol. 2008 Sep;4(9):464-72. doi: 10.1038/ncprheum0896.
The introduction of new therapeutic modalities, such as biologic agents, for the treatment of lupus nephritis has re-energized research into this disorder, enabling investigators to formulate evidence-based recommendations. Thus, it is now widely accepted that the management of lupus nephritis involves a period of intensive induction therapy, followed by a longer period of less-intensive maintenance therapy. Risk stratification, based on histologic, demographic, clinical and laboratory characteristics, allows the identification of patients at high risk of renal dysfunction, for whom aggressive therapy is likely to be the most beneficial. New studies and meta-analyses comparing mycophenolate mofetil with cyclophosphamide have confirmed the efficacy of the former for induction and maintenance therapy--particularly induction therapy, owing to its favorable toxicity profile; however, claims of efficacy superior to that of cyclophosphamide require additional documentation. Nonetheless, an increasing number of physicians use mycophenolate mofetil as induction therapy for most cases of proliferative lupus nephritis, while reserving cyclophosphamide for the most severe cases. No evidence yet indicates that mycophenolate mofetil is better than azathioprine for the maintenance of remission. For patients who relapse or who are unable to be treated with these agents, rituximab seems to offer some benefit with an acceptable toxicity profile. This article summarizes the advances in the management of lupus nephritis since our 2005 Review.
新型治疗方式的引入，如生物制剂，用于治疗狼疮性肾炎，为该疾病的研究注入了新活力，使研究人员能够制定基于证据的建议。因此，目前人们普遍认为，狼疮性肾炎的治疗包括一段强化诱导治疗期，随后是一段强度较低的维持治疗期。基于组织学、人口统计学、临床和实验室特征进行风险分层，有助于识别肾功能不全高危患者，对他们而言积极治疗可能最有益。比较霉酚酸酯与环磷酰胺的新研究和荟萃分析证实了前者在诱导和维持治疗中的疗效——特别是诱导治疗，因为其毒性特征较好；然而，其疗效优于环磷酰胺的说法还需要更多的文献证明。尽管如此，越来越多的医生将霉酚酸酯用于大多数增殖性狼疮性肾炎病例的诱导治疗，而将环磷酰胺留用于最严重的病例。尚无证据表明霉酚酸酯在维持缓解方面优于硫唑嘌呤。对于复发或无法用这些药物治疗的患者，利妥昔单抗似乎有一定益处，且毒性可接受。本文总结了自我们2005年综述以来狼疮性肾炎治疗方面的进展。
