针对无症状血清学再激活的抢先免疫抑制治疗可能减少狼疮肾炎患者的肾发作：一项队列研究。
Preemptive immunosuppressive treatment for asymptomatic serological reactivation may reduce renal flares in patients with lupus nephritis: a cohort study.
机构信息
Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong.
出版信息
Nephrol Dial Transplant. 2019 Mar 1;34(3):467-473. doi: 10.1093/ndt/gfy024.
BACKGROUND
Serological activity may precede clinical flares of lupus nephritis (LN) but the management of asymptomatic serological reactivation (ASR) remains undefined.
METHODS
We conducted a retrospective analysis of 138 episodes of ASR, which included 53 episodes in which immunosuppression was increased preemptively and 85 episodes in which treatment was unaltered. Preemptive immunosuppressive treatment comprised increasing the dose of prednisolone to ∼0.5 mg/kg/day, and in patients already on mycophenolate mofetil (MMF) or azathioprine (AZA), increasing the dose to 1.5 g/day and 100 mg/day, respectively.
RESULTS
Thirty-four episodes of renal flare occurred during follow-up (88.8 ± 77.3 and 82.8 ± 89.7 months in the preemptive group and controls, respectively), following 5 (9.4%) of preemptively treated ASR and 27 (31.8%) of untreated ASR [hazard ratio 0.3 (confidence interval 0.1-0.7), P = 0.012]. Preemptive treatment was associated with superior survival free of renal relapse (99, 92 and 90% at 6, 12 and 24 month, respectively, compared with 94, 69 and 64% in controls; P = 0.011), whereas survival rate free of extrarenal relapse was similar in the two groups. Preemptively treated patients who did not develop renal flares showed better renal function preservation (estimated glomerular filtration rate slope +0.54 ± 0.43 mL/min/1.73 m2/year, compared with -2.11 ± 0.50 and -1.00 ± 0.33 mL/min/1.73 m2/year, respectively, in controls who did and did not develop subsequent renal flares; P = 0.001 and 0.012, respectively). Preemptive treatment was associated with an increased incidence of gastrointestinal side effects attributed to MMF (P = 0.031), whereas infection rate did not differ between the two groups.
CONCLUSION
A preemptive moderate increase of immunosuppression for ASR in LN patients may reduce renal flares and confer benefit to long-term renal function.
背景
血清学活动可能先于狼疮肾炎 (LN) 的临床发作，但无症状血清学再激活 (ASR) 的管理仍未确定。
方法
我们对 138 例 ASR 发作进行了回顾性分析，其中 53 例提前增加了免疫抑制治疗，85 例未改变治疗方案。预先的免疫抑制治疗包括将泼尼松剂量增加到约 0.5mg/kg/天，对于已经接受吗替麦考酚酯 (MMF) 或硫唑嘌呤 (AZA) 治疗的患者，分别将剂量增加到 1.5g/天和 100mg/天。
结果
在随访期间（分别为 88.8±77.3 和 82.8±89.7 个月）发生了 34 例肾复发，其中 5 例（9.4%）提前治疗的 ASR 和 27 例（31.8%）未治疗的 ASR 中发生[风险比 0.3（95%置信区间 0.1-0.7），P=0.012]。预先治疗与无肾复发的生存获益相关（分别为 6、12 和 24 个月时的 99%、92%和 90%，而对照组为 94%、69%和 64%；P=0.011），而两组的无肾外复发生存率相似。未发生肾复发的预先治疗患者的肾功能保存更好（估计肾小球滤过率斜率+0.54±0.43mL/min/1.73m2/年，而对照组分别为+2.11±0.50 和+1.00±0.33mL/min/1.73m2/年；P=0.001 和 0.012）。预先治疗与 MMF 相关的胃肠道副作用发生率增加有关（P=0.031），而两组的感染率没有差异。
结论
LN 患者 ASR 时提前适度增加免疫抑制可能减少肾复发，并对长期肾功能有益。
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