Grand Rounds | Clinician's Corner

Pharmacological Therapy of Lupus Nephritis

Derek M. Fine, MD
JAMA. 2005;293(24):3053-3060. doi:10.1001/jama.293.24.3053.
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Kidney involvement is common in systemic lupus erythematosus, occurring in up to 60% of affected adults during the course of their disease. Diffuse proliferative lupus nephritis (World Health Organization class IV), the most ominous variant, has traditionally been treated with cyclophosphamide and glucocorticoids. With cyclophosphamide, women of childbearing potential must weigh the risks of sustained amenorrhea, infertility, increased susceptibility to infection, bone marrow suppression, hemorrhagic cystitis, and malignancy against the benefits of better disease control compared with glucocorticoids alone. Because of the host of adverse effects associated with cyclophosphamide, alternative approaches to the treatment of lupus nephritis are desirable. A 31-year-old woman developed class IV lupus nephritis in the postpartum period. Seeking to preserve fertility and avoid other known toxicities of cyclophosphamide, she chose to undergo therapy with mycophenolate mofetil. In the treatment of severe lupus nephritis, mycophenolate mofetil has emerged as an alternative to cyclophosphamide, offering a major advance in the therapy of lupus nephritis.

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Figure 1. Light Microscopic Findings of Representative Glomeruli
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A, Hyperlobulated glomerulus with global involvement with endocapillary and mesangial hypercellularity with matrix expansion (white arrowheads) and wireloop lesions (black arrowheads). B, Glomerulus with global endocapillary proliferation, leukocyte influx, mesangial expansion, and crescent formation (hematoxylin-eosin stain; original magnification x 400).

Figure 2. Mrs P’s Urine Protein Changes and Glucocorticoid Tapering Over the First 9 Months of Treatment With Mycophenolate Mofetil
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