Immunosuppressive therapy in lupus nephritis

To evaluate the outcomes and side effects of immunosuppressive therapy in patients with lupus nephritis.

Thirty-nine patients with lupus nephritis assessed between 1988 and 1993 with a median follow-up of 46 months (range 12-60 months) were studied. Lupus nephritis was biopsy-proven in 37 patients. Patients received a median of 3 (500 mg) weekly pulses of intravenous cyclophosphamide followed either by azathioprine (n = 32) or oral cyclophosphamide (n = 7). All patients received oral prednisolone. The time from biopsy to renal insufficiency, defined by doubled serum creatinine and/or end stage renal failure, was used to assess outcome.

There were significant improvements in the median changes of all major laboratory parameters. Serum creatinine levels did not change significantly. The prednisolone dose was significantly reduced during the follow-up period.

renal function remained stable in 26 (67%) and deteriorated despite therapy in 13 (33%) patients. 6/13 (42%) of these patients had impaired renal function at the time of biopsy. The adverse effects of intravenous cyclophosphamide seen were Herpes zoster (1), transient leucopenia (2), rash (1) and fatal septicaemia (1); of azathioprine urinary infections (3), leucopenia (5), rash (1) and increased liver enzymes (1); and of oral cyclophosphamide ovarian failure (4), Herpes zoster (3), haemorrhagic cystitis (1), and fatal septicaemia (1).

Therapy with weekly low dose intravenous pulse cyclophosphamide to induce remission, followed by azathioprine appears to be useful in preserving renal function in patients with diffuse proliferative lupus nephritis. In comparison to other studies, the reduced incidence of ovarian failure using this regimen was striking.