基于环磷酰胺和霉酚酸酯的方案治疗狼疮肾炎的长期结局。
Long-term outcomes of lupus nephritis treated with regimens based on cyclophosphamide and mycophenolate mofetil.
机构信息
Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
出版信息
Lupus. 2020 Jul;29(8):845-853. doi: 10.1177/0961203320926256. Epub 2020 May 21.
INTRODUCTION
Lupus nephritis (LN) has a considerable impact on the morbidity and mortality of systemic lupus erythematosus (SLE) patients. Long-term comparative outcome data from the Indian subcontinent on treatment regimens with cyclophosphamide (CYP) and mycophenolate mofetil (MMF) are sparse. We assessed renal and patient survival for these patients in terms of the types of induction - CYP or MMF - and the two maintenance therapies - MMF or azathioprine (AZA).
METHODS
We retrospectively analysed outcomes of 100 LN patients, 67 treated with CYP (26 class III, 25 class IV, 6 class III + V and 10 class IV + V; 40 Euro lupus regimen and 27 National Institutes of Health regimen) and 33 treated with a MMF-based regimen with steroids between July 2008 and June 2018. Data regarding demographic, clinical and histopathological features and the treatment given to all patients were extracted. Outcomes between the two regimens CYP and MMF were compared in terms of remission, dialysis and patient survival.
RESULTS
The clinical characteristics were similar in both groups, except that the activity index was higher in CYP patients (6.13 ± 4.48 vs. 4.61 ± 2.80). However, the chronicity index was similar. The overall remission rate was 70% at the end of induction. The rates of complete remission, partial remission and non-responders in the CYP group were 46.2%, 23.9% and 29.9%, respectively. However, in the MMF group, the corresponding rates were 57.6%, 12.1% and 30.3%, respectively. The 1-, 2-, 3-, 4-, 5- and 10-year patient survival rates in the CYP group were 89.5%, 86.2%, 86.2%, 83.8%, 83.8% and 83.8%, respectively. In the MMF induction group, the corresponding rates were 93.9%, 93.9%, 89%, 89%, 89% and 89%, respectively. At the end of the study, rates of end-stage renal disease in the MMF group and CYP group were 7.5% and 12.1%, respectively. The death-censored and non-censored renal survival rates were also similar in the long term. With regard to maintenance therapy, 3/56 (5.3%) in the MMF group and 7/34 (20.5%) in the AZA group experienced doubling of serum creatinine ( = 0.03).
CONCLUSIONS
Long-term outcomes in terms of patient and renal survival of LN patients treated with CYP and MMF induction are similar. Doubling of serum creatinine occurred more with AZA-based maintenance therapy than with MMF-based maintenance therapy. Most deaths occurred during induction, and sepsis was the most common cause of death.
简介
狼疮肾炎（LN）对系统性红斑狼疮（SLE）患者的发病率和死亡率有相当大的影响。关于环磷酰胺（CYP）和霉酚酸酯（MMF）治疗方案的来自印度次大陆的长期比较结果数据较为稀少。我们评估了这些患者的肾脏和患者生存情况，包括诱导治疗的类型（CYP 或 MMF）和两种维持治疗（MMF 或硫唑嘌呤（AZA））。
方法
我们回顾性分析了 100 例 LN 患者的数据，其中 67 例接受 CYP 治疗（26 例 III 类，25 例 IV 类，6 例 III+V 类和 10 例 IV+V 类；40 例欧洲狼疮方案和 27 例美国国立卫生研究院方案），33 例接受 MMF 为基础的方案联合类固醇治疗。在 2008 年 7 月至 2018 年 6 月期间，提取了所有患者的人口统计学、临床和组织病理学特征以及治疗的数据。比较了 CYP 和 MMF 两种方案在缓解、透析和患者生存方面的结果。
结果
两组的临床特征相似，但 CYP 患者的活动指数较高（6.13±4.48 与 4.61±2.80）。然而，慢性指数相似。诱导结束时，总体缓解率为 70%。CYP 组完全缓解、部分缓解和无反应者的比例分别为 46.2%、23.9%和 29.9%。然而，在 MMF 组，相应的比例分别为 57.6%、12.1%和 30.3%。CYP 组的 1、2、3、4、5 和 10 年患者生存率分别为 89.5%、86.2%、86.2%、83.8%、83.8%和 83.8%。在 MMF 诱导组，相应的比例分别为 93.9%、93.9%、89%、89%、89%和 89%。在研究结束时，MMF 组和 CYP 组的终末期肾病发生率分别为 7.5%和 12.1%。长期来看，肾脏的死亡风险和非死亡风险也相似。关于维持治疗，MMF 组有 3/56（5.3%）例和 AZA 组有 7/34（20.5%）例出现血清肌酐翻倍（=0.03）。
结论
接受 CYP 和 MMF 诱导治疗的 LN 患者的长期患者和肾脏生存结果相似。基于 AZA 的维持治疗比基于 MMF 的维持治疗更易导致血清肌酐翻倍。大多数死亡发生在诱导期，感染是最常见的死亡原因。
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