HDCN Article Review/Hyperlink

Balow JE, Boumpas DT, Fessler BJ, Austin HA III

Management of lupus nephritis

Kidney Int (Suppl 53) (Jan) 49:S88-92 1996

Balow and his colleagues from the NIH review treatment of lupus nephritis focusing primarily on their clinical trials comparing effects of corticosteroids and cytotoxic drugs. The authors point out that the rate of renal failure may not be altered initially in patients treated with both corticosteroids and cyclophosphamide. However, with follow-up for a median duration of seven years, their studies have demonstrated the probability of developing end stage renal failure to be lower with intermittent pulse cyclophosphamide than with prednisone alone. Studies by this same group comparing only intermittent pulse-methylprednisolone with cyclophosphamide have shown that patients treated with pulse methylprednisolone only have a higher probability of doubling of their serum creatinine levels. The authors specify their preference for monthly pulses for six months followed by quarterly pulses of cyclophosphamide with maintenance treatment continued one year beyond remission.

Herpes zoster is the only major infection more likely to occur in cyclophosphamide treated patients. While ovarian failure can occur, hemorrhagic cystitis and disseminated malignancy have not been seen in patients treated with pulse cyclophosphamide at the NIH. Though the discussion of other therapeutic options is superficial, it references many recent studies. While this manuscript lacks depth, it is useful in its distillation of data from many trials and a cyclophosphamide treatment protocol that is so concise it will likely become a part of many handbooks. N. Kevin Krane, M.D.