A Comparison Between 9-Month Versus 6-Month Cyclophosphamide Induction Chemotherapy In The Management Of Lupus Nephritis In A Government Tertiary Pediatric Hospital In The Philippines.

Maria Rosario  S. Cruz,; Zarah Marie  Zamora-tan,; Mihnea Ellis  Guanzon,; Christine  Bernal,

A Comparison Between 9-Month Versus 6-Month Cyclophosphamide Induction Chemotherapy In The Management Of Lupus Nephritis In A Government Tertiary Pediatric Hospital In The Philippines.

Zarah Marie Zamora-tan | Mihnea Ellis Guanzon | Christine Bernal | Maria Rosario S. Cruz

Abstract:

BACKGROUND: Lupus nephritis is a very common complication in SLE, with clinical symptoms of renal involvement occurring in 30%-70% of patients. Outcomes in children with proliferative lupus nephritis (PLN) show 9-15% progress to end-stage renal disease (ESRD) at 5 years. OBJECTIVES: This study compared the outcome of children and adolescent patients with lupus nephritis treated with 9 month versus 6 month induction of cyclophosphamide therapy. Renal frequency and adverse effects of IV cyclophosphamide during and after induction therapy were described and determined. DESIGN: Retrospective cohort study SETTING: Tertiary hospital METHODS: Retrospective cohort study comparing 6 and 9 month protocol of IV cyclophosphamide for lupus nephritis were conducted in a government tertiary pediatric hospital in the Philippines. A total of 39 patients with lupus nephritis were gathered, 23 patients underwent 6 months and 16 patients underwent 9 months protocol. RESULTS: The comparison of two protocols in the administration of intravenous cyclophosphamide (IVCY) did not show significant difference between the two in terms of changes in GFR levels, but some evidence of a greater percent increase from baseline with the 6 months protocol post treatment were observed. Among 39 subjects, creatinine, albumin and urinalysis profile did not also differ between the two groups and levels within each group changed insignificantly over time up to 24 months. Proportion of subjects with renal flare ups, adverse effects and who expired during the study period were also essentially similar between the two groups. CONCLUSION: IV cyclophosphamide seems efficacious if given at the very beginning of the flare and at the start after patient was diagnosed with lupus nephritis. No statistically significant difference between the duration of the protocol. Renal flare ups and adverse effects of cyclophosphamide such as nausea, vomiting and headache were observed similarly between two protocols. Diligent follow up is needed for further studies and specificity of the results.

References:

De Bandt M, Goycochea MV, Meyer O, Delahousse M, Palazzo E, M’Bappe P, Kahn MF. Treatment of acute systemic lupus erythematosus with intravenous infusions of cyclophosphamide: value and limitations. Ann Med Interne (Paris). 1994;145(2):75–87.
David M, Askenazi K, Barnett M, Nymoens A, Markaroffka R, Warren A, Perez M, De Guzman M, Nitta A, Hicks J, Kale A. Outcomes of children with proliferative lupus nephritis: the role of protocol renal biopsy. Pediatr Nephrol. 2007.
Austin HA 3rd, Klippel JH, Balow JE, le Riche NG, Steinberg AD, Plotz PH, Decker JL. Therapy of lupus nephritis: controlled trial of prednisone and cytotoxic drugs. N Engl J Med. 1986;314:614–619.
Donadio JV Jr, Holley KE, Ferguson RH, Ilstrup DM. Treatment of diffuse proliferative lupus nephritis with prednisone and combined prednisone and cyclophosphamide. N Engl J Med. 1981;305:115–115.
Bogdanovic R, Nikolic V, Pasic S, Dimitrijevic J, Ljubisavljevic M, Eric-Marinkovic J, Ognjanovic M, Mlinci A, Stajic N. Lupus nephritis in childhood: a review of 53 patients followed at a single center. Pediatr Nephrol. 2004;19:36–44.
Weening JJ, D’Agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB, Balow JE, Bruijn JA, Cook T, Ferrario F, Fogo AB, Ginzler EM, Hebert L, Hill G, et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol. 2004;15:241–245.
Steinberg AD, Steinberg SC. Long-term preservation of renal function in patients with lupus nephritis receiving intermittent pulse cyclophosphamide versus those treated with prednisone only. Arthritis Rheum. 1989;32:493–500.
Tanganaratshakit K, Tanapeya-Olarn C, Tapanya-Olarn W. The efficacy of intravenous pulse cyclophosphamide in the treatment of severe lupus nephritis in children. J Med Assoc Thai. 1999;82(Suppl 1):S104–110.
Hageberg S, Lee Y, Bergman J, Mah G, Schneider R, Laskin C, Eddy A, Gladman D, Urowitz M, Hebert D, Silverman E. Long-term follow-up of childhood lupus nephritis. J Rheumatol. 2002;29:2635–2642.
Niaudet P. Treatment of lupus nephritis in children. Pediatr Nephrol. 2000;14:158–165.
McCurdy DK, Lehman TJ, Bernstein B, Hanson V, King KK, Nadorra R, Landing BH. Lupus nephritis prognostications in children. Pediatrics. 1992;89:240–246.
Yang LY, Chen WP, Lin CY. Lupus nephritis in children: a review of 167 patients. Pediatrics. 1993;93:435–440.
Barbaro G, Gusmano R, Damiano B, Albini G, Buoncompagni A, Gattorno M, Peruffo F. Childhood-onset lupus nephritis: outcome and experience of pulse intravenous cyclophosphamide therapy. J Nephrol. 2003;16:123–129.
Kessler L, et al. Predictors of relapse and first-stage kidney disease in proliferative lupus nephritis: focus on childhood/adolescents and young adults. 2009.
Arinavakul K. The outcome of proliferative lupus nephritis with pulse cyclophosphamide therapy. Arthritis Rheum. 2002;47:464–495.
Esdaile JM, Levinson C, Fedoreng W, Hayslett JP, Kashgarian M. The clinical and renal biopsy predictors of long-term outcome in lupus nephritis: a study of 87 patients and review of the literature. 1989;72(6):799–833.
Urowitz MB, Hebert D, Silverman ED, et al. Long-term outcome of childhood lupus nephritis. J Rheumatol. 2002.