25 yr old homemaker, SLE diagnosed at 14 yrs age was under Rheumatologist care, recently off Methotrexate and switched to Sulfasalazine ( she was also on Pred 10mg, HCQS 200mg BID, low dose aspirin calcium and vitamins) by her rheumatologist as she wanted to conceive (s.creat 1.1mg/dl, Lupus was stable last 3 yrs, protein creat ratio 0.15, complements normal). Now presented with flare-RPGN presentation creat 1.1 to 3 mg/dl over 2 weeks, urine active sediment, 3 gms proteinuria. Biopsy cellular crescents more than 50%, wireloops, class IV, with IV MP and MMF 1.5 gms BD, her creat started comming down to 2.2 and is asymptomatic and doing well.
In view of Bx findings of crescents would IV Cyclophosphomide -Euro lupus be a better option (especially when creatinine is improving) Vs MMF in a young lady as above . do we have strong evidence for MMF as induction agent in crescentic Class IV Lupus Nephritis
In view of Bx findings of crescents would IV Cyclophosphomide -Euro lupus be a better option (especially when creatinine is improving) Vs MMF in a young lady as above . do we have strong evidence for MMF as induction agent in crescentic Class IV Lupus Nephritis
Accepted Answer
Hi Venkat,
In some ways you have answered your own question. If the patient is responding, then the regimen is reasonable in her case. In general as well, MMF is likely equivalent to cyclophosphamide for the treatment of lupus nephritis. Having said that, some do reserve MMF more-so for cases with more benign histopathology and use cyclophosphamide for more severe cases. The evidence for this approach is not sound in my opinion - that is to say, that cyclophosphamide would be superior to MMF in more severe cases of lupus nephritis. Yet, this practice is widespread.
I include 3 references below which you are likely familiar with.
Dr. Jordan Weinstein
In some ways you have answered your own question. If the patient is responding, then the regimen is reasonable in her case. In general as well, MMF is likely equivalent to cyclophosphamide for the treatment of lupus nephritis. Having said that, some do reserve MMF more-so for cases with more benign histopathology and use cyclophosphamide for more severe cases. The evidence for this approach is not sound in my opinion - that is to say, that cyclophosphamide would be superior to MMF in more severe cases of lupus nephritis. Yet, this practice is widespread.
I include 3 references below which you are likely familiar with.
Dr. Jordan Weinstein
Dear Dr. Weinstein
Greetings !
Thank you for the prompt reply and sharing current evidence on the subject, very reassuring
....
warm regards
Venkat
Greetings !
Thank you for the prompt reply and sharing current evidence on the subject, very reassuring
....warm regards
Venkat
Accepted Answer
Hi Venkat,
In some ways you have answered your own question. If the patient is responding, then the regimen is reasonable in her case. In general as well, MMF is likely equivalent to cyclophosphamide for the treatment of lupus nephritis. Having said that, some do reserve MMF more-so for cases with more benign histopathology and use cyclophosphamide for more severe cases. The evidence for this approach is not sound in my opinion - that is to say, that cyclophosphamide would be superior to MMF in more severe cases of lupus nephritis. Yet, this practice is widespread.
I include 3 references below which you are likely familiar with.
Dr. Jordan Weinstein
In some ways you have answered your own question. If the patient is responding, then the regimen is reasonable in her case. In general as well, MMF is likely equivalent to cyclophosphamide for the treatment of lupus nephritis. Having said that, some do reserve MMF more-so for cases with more benign histopathology and use cyclophosphamide for more severe cases. The evidence for this approach is not sound in my opinion - that is to say, that cyclophosphamide would be superior to MMF in more severe cases of lupus nephritis. Yet, this practice is widespread.
I include 3 references below which you are likely familiar with.
Dr. Jordan Weinstein
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