Department of Nephrology, 1st School of Medicine and General University Hospital, Charles University, U Nemocnice 2, 128 08 Prague 2, Czech Republic.
Nat Rev Nephrol. 2011 Feb;7(2):96-109. doi: 10.1038/nrneph.2010.170. Epub 2010 Dec 21.
Proliferative lupus nephritis is the most severe form of lupus nephritis. Outcomes of this disease are affected by ethnicity, clinical characteristics, irreversible damage on renal biopsy, initial response to treatment and future disease course (for example, the occurrence of renal flares). Initial intensive (induction) treatment of proliferative lupus nephritis is aimed at achieving remission, but optimal duration and intensity are not well defined. A combination of intravenous cyclophosphamide and corticosteroids have been shown to decrease the risk of end-stage renal disease, but are associated with substantial acute toxic effects (such as infections) and chronic toxic effects (such as ovarian failure). In white populations, low-dose cyclophosphamide is a reasonable alternative to high-dose cyclophosphamide as it is similarly effective and associated with less toxicity. Mycophenolate mofetil is as effective as high-dose intravenous cyclophosphamide in terms of inducing remission and similar in terms of safety. Although most patients respond to induction treatment, remission is often only achieved after patients are switched to maintenance treatment. As maintenance treatment, mycophenolate mofetil is superior to azathioprine and azathioprine is similarly effective to ciclosporin in terms of prevention or reducing the risk of relapse. Rituximab should be reserved for patients with refractory disease. Treatment of lupus nephritis should be individually tailored to patients, with more aggressive therapy reserved for patients at high risk of renal dysfunction and progression of renal disease.
增生性狼疮肾炎是狼疮肾炎中最严重的一种。这种疾病的结局受种族、临床特征、肾活检的不可逆损伤、初始治疗反应和未来疾病过程（如肾复发）的影响。增生性狼疮肾炎的初始强化（诱导）治疗旨在实现缓解，但最佳持续时间和强度尚未明确。静脉注射环磷酰胺和皮质类固醇的联合应用已被证明可降低终末期肾病的风险，但会引起严重的急性毒性（如感染）和慢性毒性（如卵巢功能衰竭）。在白人人群中，低剂量环磷酰胺是高剂量环磷酰胺的合理替代方案，因为它同样有效，且毒性较小。霉酚酸酯在诱导缓解方面与高剂量静脉注射环磷酰胺同样有效，安全性也相似。尽管大多数患者对诱导治疗有反应，但在患者转为维持治疗后，通常才能达到缓解。在维持治疗中，霉酚酸酯优于硫唑嘌呤，而硫唑嘌呤在预防或降低复发风险方面与环孢素的效果相似。利妥昔单抗应留作难治性疾病的患者使用。狼疮肾炎的治疗应根据患者个体情况进行调整，对于肾功能障碍和肾脏疾病进展风险较高的患者，应采用更积极的治疗方法。
