A Cochrane review [Abstract] 1 included 74 studies with a total of 5 175 subjects witj biopsy-proven proliferative lupus nephritis. Twenty-nine studies included adults and children (< 18 years), 29 studies included only adults, 2 only children, and 14 studies did not specify the age of the participants. Sixty-seven studies (n=4 791) investigated induction therapy, and 9 studies (n=767) considered maintenance therapy.
In induction therapy, mycophenolate mofetil (MMF) dosed at 2 g to 3 g daily tended to increase complete remission compared to IV cyclophosphamide, although the difference was not statistically significant. MMF was as effective as IV cyclophosphamide in preventing death or end-stage kidney disease, inducing partial renal remission, and achieving stable kidney function (RR 1.05, 95% CI 0.94 to 1.17), with reduced risk of alopecia, similar risks of major infection and ovarian failure, but with increased risk of diarrhea (Table T1).MMF combined with tacrolimus increased complete disease remission (RR 2.38, 95% CI 1.07 to 5.30; 2 studies, n=402) compared with IV cyclophosphamide. The effects of biologics on most outcomes were uncertain compared to standard care.
| Outcome | Participants (studies) | Illustrative comparative risks (95% CI) | Relative effect (95% CI) | |
|---|---|---|---|---|
| Assumed risk (CYC) | Corresponding risk (MMF) | |||
| Death Follow up: mean 24 weeks | 826 (8) | 40 per 1000 | 53 per 1000 (29 to 98) | RR 1.12 (0.61 to 2.06) |
| Complete renal remission Follow up: mean 24 weeks | 828 (8) | 222 per 1000 | 260 per 1000 (216 to 316) | RR 1.17 (0.97 to 1.42) |
| Partial renal remission Follow-up: mean 24 weeks | 868 (9) | 415 per 1000 | 423 per 1000 (369 to 490) | RR 1.02 (0.89 to 1.18) |
| ESKD Follow-up: mean 32 weeks | 231 (3) | 85 per 1000 | 61 per 1000 (23 to 157) | RR 0.71 (0.27 to 1.84) |
| Major infection Follow-up: mean 24 weeks | 699 (6) | 114 per 1000 | 116 per 1000 (76 to 175) | RR 1.02 (0.67 to 1.54) |
| Ovarian failure | 539 (3) | 41 per 1000 | 15 per 1000 (2 to 90) | RR 0.36(0.06 to 2.18) |
| Alopecia Follow-up: mean 24 weeks | 622 (3) | 239 per 1000 | 69 per 1000 (45 to 110) | RR 0.29 (0.19 to 0.46) |
| Diarrhoea Follow-up: mean 24 weeks | 609 (4) | 100 per 1000 | 241 per 1000 (163 to 357) | RR 2.42 (1.64 to 3.58) |
In maintenance therapy, the risk of renal relapse (RR 1.75, 95% CI 1.20 to 2.55; 4 studies, n=452) was significantly higher with azathioprine compared with MMF. Multiple other interventions were compared but outcome data were relatively sparse.
Comment: The quality of evidence is downgraded by imprecise results (few outcome events and wide confidence intervals).
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