Treatment of Active Lupus Nephritis: Intravenous Immunoglobulin G Versus Cyclophosphamide or Azathioprine

Backround. To evaluate the efficacy and safety of three therapeutic regimens: CYP – cyclophosphamide with intravenous methylprednisolone (i.v.MP), AZAP azathioprine with intravenous methylprednisolone and IVIG – high doses intravenous immunoglobulin G as induction therapy in the patients with lupus nephritis (LN). Methods. 132 patients with biopsy-proven LN were studied (48 in CYP, 23 in AZAP and 61 in IVIG group). 48 out of 132 received 1000 mg cyclophosphamide every 1 weeks for a total of 4 pulses, followed by 10 pulses every 3 months, while 23 started with 2 mg/kg/day azathioprine. The cyclophosphamide or azathioprine was combined with 1000 mg i.v.MP in three consecutive days. The cycle of four pulses was repeated after 3 months (total 12 pulses). Oral prednisolone was added after i.v.MP initially 2 mg/kg/every other day for 4 weeks and thereafter tapered by 10 mg every 2 weeks to a final dose of 10 mg every other day after 6 months. IVIG was applied once a day in dose of 85 mg/kg/24 h 3 times every other day. This course was undertaken after 1-3 months. In case of a relapse the induction therapy was repeated. The regimen was advised to continue for at least 2 more years. Results. Full remission was observed in 26,52% patients and partial remission in 31,82% patients. During the first 7 years of therapy, the cumulative incidence of partial or complete renal remission was not significantly different between the treatment groups. Renal relapses occur in 25% of LN patients and more often in the AZAP group. During follow-up 11,36% patients went into end-stage renal failure or died. Conclusions. The efficacy of the induction therapy with cyclophosphamide or azathioprine and methylprednisolone is comparable with that of IVIG. IVIG appears to be a promising alternative for cyclophosphamide and azathioprine, especially in the LN patients with a strong will to conceive and with a high risk of premature ovarial failure and infections.