Mycophenolate Mofetil for Remission Induction in Severe Lupus Nephritis

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Abstract
Background: Mycophenolate mofetil (MMF) is a potential alternative immunosuppressive to cyclophosphamide or azathioprine for the treatment of lupus nephritis. It has a superior toxicity profile to cyclophosphamide and is more effective than azathioprine when used in combination with cyclosporin for renal transplantation. Methods: This open label study assessed the safety and efficacy of an induction regimen of MMF and prednisolone in 24 patients, with active WHO Class III, IV or V lupus nephritis, without previous exposure to cyclophosphamide or MMF. Patients received MMF 2 g/day and a tapering dose of oral prednisolone and were followed for 12 months. Renal response was defined using the validated BILAG (British Isles Lupus Assessment Group) Index. Results: 20 patients achieved complete renal remission, 2 partial renal remission and 2 had renal disease refractory to MMF. Five patients were withdrawn, 2 for progressive renal disease, 2 for extra-renal flares and 1 following a severe infection. No patient was withdrawn for drug intolerance. There were 18 adverse events of which 10 were infections. Clinical improvement was mirrored by normalisation of complement levels and marked falls in circulating anti-double-stranded DNA antibodies. Follow-up for a mean period of 35 months documented only one episode of renal relapse which subsequently remitted with re-introduction of MMF. One patient died after 18 months’ follow-up with uterine malignancy. Conclusions: MMF with prednisolone was effective for remission induction in severe lupus nephritis and was well tolerated.