Original investigation: pathogenesis and treatment of kidney disease and hypertension
Treatment of pure membranous lupus nephropathy with prednisone and azathioprine: an open-label trial

https://doi.org/10.1053/j.ajkd.2003.10.029Get rights and content

Abstract

Background: The aim of this study was to report the outcome of pure membranous lupus nephropathy treated with prednisone and azathioprine (AZA). Methods: Consecutive patients with pure membranous lupus glomerulonephritis (World Health Organization [WHO] Va and Vb) from 4 regional hospitals were recruited for an open-label treatment trial consisting of prednisone and AZA. Remission status was evaluated at 12 months. Maintenance treatment with low-dose prednisone and AZA was continued indefinitely for those who achieved remission. Factors predictive of initial renal remission and subsequent relapse were studied by statistical analyses. Results: Thirty-eight patients (31 women and 7 men) were studied. The mean age was 35.0 ± 9.2 years, and the duration of systemic lupus erythematosus was 48.5 ± 59 months. Seventeen (45%) patients had WHO class Va lupus nephritis, whereas 21 (55%) had class Vb disease. Two patients withdrew from the protocol because of idiosyncratic reactions to AZA. At 12 months, 24 (67%) patients achieved complete remission (CR), 8 (22%) achieved partial remission (PR), and 4 (11%) were treatment resistant. Patients who achieved CR or PR were maintained on low-dose prednisone and AZA. Over a mean follow-up period of 90.4 ± 59 months, 6 (19%) patients had relapse of nephritis (proteinuric flare in 4 and nephritic flare in 2). The cumulative risk of renal relapse was 12% at 36 months and 16% at 60 months. No particular clinical variables were found to predict renal remission or relapses. Over a mean follow-up of 90 months, 13% of patients had decline of creatinine clearance by 20%, but none had doubling of serum creatinine. Renal outcome was not significantly worse in patients presenting with nephrotic syndrome. Treatment generally was well tolerated. Conclusion: A combination of prednisone and AZA is reasonably effective for the initial treatment of pure membranous lupus nephritis. Severe adverse effects are uncommon. The additional efficacy of AZA in comparison with prednisone alone has to be confirmed with randomized, controlled trials.

Section snippets

Patients and methods

The Queen Mary, Tuen Mun, United Christian, and Prince Margaret Hospitals are 4 large regional hospitals in Hong Kong that serve a total population of at least 2 million. Between 1986 and 2001, consecutive patients with renal biopsy—proven pure membranous lupus glomerulonephritis (WHO Va and Vb) were recruited into an open-label treatment study consisting of prednisone and AZA. Renal biopsy samples were examined routinely by light microscopic, immunofluorescence, and electron microscopic

Results

Thirty-eight patients were studied. All were ethnic Chinese and fulfilled at least 4 of the American College of Rheumatology criteria for the classification of SLE.19 Table 1 shows their demographic and clinical manifestations at the time of renal biopsy. There were 31 women and 7 men, and the mean age was 35.0 ± 9.2 years. The mean duration of SLE was 48.5 ± 59 months. Twenty-two (58%) patients were nephrotic. Seven (18%) patients had received AZA previously because of extrarenal

Discussion

This is an open-label study of the therapeutic efficacy of prednisone and AZA in pure or minimally proliferative membranous lupus nephropathy. Our results show that a combination of prednisone and AZA is reasonably effective for the initial treatment and maintenance of pure membranous lupus nephritis. Renal remission occurred in 90% of patients in the first year of treatment. Extrarenal disease activity also improved significantly after treatment. With a mean follow-up of almost 8 years, only a

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