Lupus nefritinde güncel tedavi

Sistemik lupus eritematoz (SLE)’ta, böbrek tutulumu, morbidite ve mortaliteyi anlamlı derecede arttıran sık ve ciddi bir komplikasyondur. Ancak böbrek tutulumunda optimal tedavi halen tartışmalıdır. Tedavi İmmünolojik ve immünolojik olmayan tedavi olarak iki grupta incelenir. İmmünolojik olmayan tedavi; antihipertansif, antiproteinürik ve antihiperlipidemik tedaviden oluşur. İmmünolojik tedavi ise 2003 yılında International Society of Nephrology/Renal Pathology Society (ISN/RPS)’in düzenlediği klasifikasyona göre başlangıç ve idame tedavi şeklinde düzenlenir. Yeni uygulanan mikofenolat mofetil (MMF) ile hem başlangıç hem de idame tedavide yüz güldürücü sonuçlar alınmaktadır. Bu yazıda yeni tedavi seçeneklerinin etkinliği, tedavide sık olarak kullanılan ilaçların etkinliğiyle birlikte tartışıldı. Sonuç olarak, ISN/RPS’deki klasifikasyona göre tedavi düzenlenmektedir. Ancak hastanın klinik ve laboratuar bulguları dikkate alınarak tedavinin şekillendirilmesi gerekmektedir.

The current treatment for SLE nephritis

Renal involvement in systemic lupus erythematosus (SLE) is a serious and common complication of the disease that significantly worsens morbidity and mortality. However, the optimal treatment of lupus nephritis remains unclear. Treatment may be divided into immunologic and non-immunologic categories. Non-immunologic treatment consists of anti-hypertensive, anti-proteinüric, and anti-hyperlipidemic options. Immunologic treatment must be designed according to the classification by International Society of Nephrology/Renal Pathology Society (ISN/RPS) in induction and remission topics. New regimens consisting mycophenolate are successful in induction and remission. The potential of other new therapeutic agents is discussed together with results of studies performed with commonly used drugs. As a conclusion, treatment must be based histological classification of ISN/RPS and individualized.

PDF

___

1. Von Feldt JM. Systemic lupus erythematosus. Recognizing its various presentations. Postgrad Med, 1995; 97: 79-86.
2. Cervera R, Khamashta MA, Font J. Systemic lupus erythematosus: clinical and immunologic patterns of disease expression incohort of 1,000 patients. The European Working Party on Systemic Lupus Erythematosus. Medicine (Baltimore), 1993; 72: 113-124.
3. Oksel,F. Sistemik lupus eritamatozis. 2002; 127-130
4. Von Feldt JM. Systemic lupus erythematosus. Recognizing its various presentations. Postgrad Med, 1995; 97: 79, 83, 86 passim.
5. Richard J, Fechally,eds. Lupus nephritis. Comprehensive Nephrology, Section: 5 glomerüler disease 2th ed.mosby. 2003; 357-371
6. Weening JJ, D'Agati VD, Schwartz MM. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol, 2004; 15:241-250.
7. Chobanian AV, Bakris GL, Black HR. The Seventh Report of the Joint National Committee on Prevention,Treatment of High Blood Pressure: the JNC 7 report. Cushman WC; Green JAMA, 2003; 21;289:2560-2572.
8. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA, 2001; 16;285:2486-2497.
9. Schwartz MM, Kawala KS, Corwin HL, et al. The prognosis of segmental glomerulonephritis in systemic lupus erythematosus. Kidney Int, 1987; 32:274-279.
10. Chi Chiu Mok MD, King Yee Ying MB, Woon Leung Ng MB. Long-term outcome of diffuse proliferative lupus glomerulonephritis treated with cyclophosphamide. Am J Med, 2006; 119:355.e25-33
11. Steinberg AD. The treatment of lupus nephritis. Kidney Int, 1986;30:769-787.
12. Steinberg AD, Steinberg SC. Long-term preservation of renal function in patients with lupus nephritis receiving treatment that includes cyclophosphamide versus those treated with prednisone only. Arthritis Rheum 1991;34:945-950.
13. Moc CC, HO CT. Treatment of diffuse proliferative lupus glomerulonephritis: a comparison of two cyclophosphamide-containing regimens. Am J Kidney Dis, 2001; 38:256-264.
14. Gourley MF, Austin HA, Scott D, et al. Methylprednisolone and cyclophosphamide, alone or in combination, in patients with lupus nephritis. A randomized, controlled trial Ann Intern Med, 1996;125-549
15. Houssiau FA, Vanconcelos C. Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Arthritis Rheum, 2002;46:2121-2131.
16. Contreras G, Pardo V. Sequential therapies for proliferative lupus nephritis. N Engl J Med, 2004;4;350:971-980.
17. Chan TM, Tse KC. Long-term study of mycophenolate mofetil as continuous induction and maintenance treatment for diffuse proliferative lupus nephritis. J Am Soc Nephrol, 2005; 16:1076-1084.
18. Austin HA, Illei GG. Membranous lupus nephritis. Lupus, 2005; 14:65-71 19. Balow JE. Austin HA 3rd. Therapy of membranous nephropathy in systemic lupus erythematosus. Semin Nephrol, 2003;23: 386-391.
20. Moroni G, Maccario M. Treatment of membranous lupus nephritis. Am J Kidney Dis 1998;31:681-686
21. Moc CC, Ying KY. Treatment of pure membranous lupus nephropathy with prednisone and azathioprine: an open-label trial. Am J Kidney Dis, 2004;43:269-276.
22. Spetie DN, Tang Y. Mycophenolate therapy of SLE membranous nephropathy. Kidney Int, 2004; 66:2411-2415
23. Looney RJ, Anolik JH, Campbell D. B cell depletion as a novel treatment for systemic lupus erythematosus: a phase I/II dose- escalation trial of rituximab. Arthritis Rheum, 2004; 50:2580-2589.
24. Leandro MJ, Edwards JC, Cambridge G, et al. An open study of B lymphocyte depletion in systemic lupus erythematosus. Arthritis and Rheumatism, 2002; 46: 2673–2677.
25. Sfikakis PP, Boletis JN, Lionaki S, et al. Remission of proliferative lupus nephritis following anti-B celltherapy is preceeded by downregulation of the T cell costimulatory molecule CD40 ligand. Arthritis and Rheumatism, 2004; 50: 227.
26. Kaufmann J, Wegener WA, Horak ID, et al. Initial clinical study of immunotherapy in SLE using epratuzumab (humanized anti-CD22 antibody). Arthritis and Rheumatism, 2004; 50: 447.
27. Anolik JH, Aringer M.New treatments for SLE: cell-depleting and anti-cytokine therapies. Best Pract Res Clin Rheumatol, 2005; 19: 859-878