Rheumatology Unit, Department of Medicine, University of Padova, Padua, Italy.
Division of Rheumatology, Lozano Blesa University Clinical Hospital, Zaragoza, Aragón, Spain.
Rheumatology (Oxford). 2022 Feb 2;61(2):688-695. doi: 10.1093/rheumatology/keab373.
Whether immunosuppressive therapy may be safely withdrawn in lupus nephritis (LN) is still unclear. We assessed rate and predictors of flare after IS withdrawal in patients with LN in remission.
Patients with biopsy-proven LN treated with immunosuppressants (IS) between 1980 and 2020 were considered. Remission was defined as normal serum creatinine, proteinuria <0.5 g/24 h, inactive urine sediment, and no extra-renal SLE activity on stable immunosuppressive and/or antimalarial therapy and/or prednisone ≤5mg/day. IS discontinuation was defined as the complete withdrawal of immunosuppressive therapy, flares according to SLEDAI Flare Index. Predictors of flare were analysed by multivariate logistic regression analysis.
Among 513 SLE patients included in our database, 270 had LN. Of them, 238 underwent renal biopsy and were treated with IS. Eighty-three patients (34.8%) discontinued IS, 46 (30) months after remission achievement. During a mean (s.d.) follow-up of 116.5 (78) months, 19 patients (22.9%) developed a flare (8/19 renal) and were re-treated; 14/19 (73.7%) re-achieved remission after restarting therapy. Patients treated with IS therapy for at least 3 years after remission achievement had the lowest risk of relapse (OR 0.284, 95% CI: 0.093, 0.867; P = 0.023). At multivariate analysis, antimalarial maintenance therapy (OR 0.194, 95% CI: 0.038, 0.978; P = 0.047), age at IS discontinuation (OR 0.93, 95% CI: 0.868, 0.997; P = 0.040), remission duration >3 years before IS discontinuation (OR 0.231, 95% CI: 0.058, 0.920; P = 0.038) were protective against disease flares.
Withdrawal of IS is feasible in LN patients in remission for at least 3 years and on antimalarial therapy. Patients who experience flares can re-achieve remission with an appropriate treatment.
免疫抑制治疗（IS）能否安全撤停仍不清楚。本研究评估了 LN 缓解患者中撤停 IS 后的复发率及其预测因素。
纳入 1980 年至 2020 年间接受 IS 治疗的活检证实为 LN 的患者。缓解定义为血清肌酐正常、蛋白尿<0.5 g/24 h、尿沉渣无活动、无肾脏外 SLE 活动，且稳定的免疫抑制和/或抗疟治疗及/或泼尼松≤5mg/d。IS 撤药定义为完全撤停免疫抑制剂，根据 SLEDAI 复发指数评估复发。采用多变量逻辑回归分析复发的预测因素。
在本数据库中纳入的 513 例 SLE 患者中，270 例患有 LN。其中 238 例行肾活检，并接受 IS 治疗。83 例（34.8%）患者撤停 IS，在缓解后 46（30）个月。在平均（标准差）116.5（78）个月的随访中，19 例（22.9%）患者出现复发（8/19 例为肾复发）并重新治疗；14 例（19/19，73.7%）在重新开始治疗后再次缓解。缓解后至少 3 年接受 IS 治疗的患者复发风险最低（OR 0.284，95%CI：0.093，0.867；P=0.023）。多变量分析显示，抗疟维持治疗（OR 0.194，95%CI：0.038，0.978；P=0.047）、撤药时年龄（OR 0.93，95%CI：0.868，0.997；P=0.040）、撤药前缓解持续时间>3 年（OR 0.231，95%CI：0.058，0.920；P=0.038）与疾病复发呈负相关。
缓解至少 3 年且接受抗疟治疗的 LN 患者可撤停 IS。复发患者可通过适当的治疗再次缓解。
