HDCN Article Review/Hyperlink

Bansal VK, Beto JA

Treatment of lupus nephritis: a meta-analysis of clinical trials

Am J Kidney Dis (Feb) 29:193-199 1997

Bansal and Beto conducted a MEDLINE search of all prospective controlled clinical trials of treatment of SLE (defined using Am Rheum Assoc criteria) between 1970 and 1995.

They found 19 studies with more than one year of follow up and performed a meta-analysis looking specifically at ESRD and total mortality as outcome measures. From each study, it was determined whether patients were treated with oral prednisone alone, or in combination with azathioprine or cyclophosphamide (orally or intravenously). Intravenous methylprednisolone was not included. Data were pooled to compare treatment efficacy between oral prednisone and all other immunosuppressive agents, and treatment efficacy of all agents with one another. The clinical effectiveness was calculated as absolute risk differences and number needed to treat.

The authors found that all oral and IV immunosuppressive agents in conjunction with oral prednisone were statistically more effective than oral prednisone alone in reducing both total mortality and end stage renal disease. The authors point out that no clear superiority of any single immunosuppressive agent or combination was demonstrated, and specifically they could not demonstrate that intravenous cyclophosphamide offered specific advantage over oral immunosuppressive agents with regards to their outcome measures. Histologic criteria were not used as indicators in the study.

In conclusion, oral prednisone in combination with immunosuppressive therapy is more effective in reducing either mortality or end stage renal disease in patients with lupus nephritis when compared to prednisone alone, though the optimal treatment regimen could not be demonstrated from this study. While this study demonstrates the importance of combining prednisone with immunosuppressive therapy for long term outcome, other studies which have already been published and those underway at the NIH are helping to elucidate the most effective treatment regimens. This meta-analysis illustrates the difficulty in evaluating different clinical trials in the treatment of lupus nephritis because of lack of standardization of treatment protocols. (N. Kevin Krane, M.D., Tulane University)

The abstract of this paper is available from the AJKD online at this site.