How long should the "maintenance treatment" of lupus kidney last?

*Only for medical professionals to read and answer the most controversial maintenance treatment time in the LN field
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The 2021 American College of Rheumatology (ACR) Annual Conference (ACR 2021) has just ended.
As an academic feast gathering the latest research and the most influential experts in the field of rheumatism and immunity, the ACR Annual Conference has always attracted the attention of clinicians at home and abroad
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On the occasion of the annual meeting, the Medical Rheumatism Channel selected 19 hottest and latest reports of ACR 2021, which were explained by 19 young members from the Rheumatology Branch of the Chinese Medical Association, in order to "spread the strongest rheumatism, Create a new academic fashion"
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At the meeting, Professor Samir Parikh lectured "How long should patients with lupus nephritis continue maintenance therapy?" "The topic of this issue is interpreted by Professor Qing Yufeng from the Affiliated Hospital of North Sichuan Medical College and takes us to "How long should the maintenance treatment of patients with lupus nephritis last?" 》What is the specific content? Let's see it together! EULAR/ERA-EDTA Lupus Nephritis (LN) maintenance treatment recommendation Professor Qing Yufeng said: Systemic lupus erythematosus (SLE) is a common systemic autoimmune disease, the kidney is the most commonly involved organ of SLE, glucocorticoids and immunity Inhibitors are the cornerstone drugs for the treatment of SLE and LN
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With the advancement of drug treatment programs, the disease has been steadily alleviated, and the patient's survival rate and long-term renal prognosis have been improved
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However, long-term use of hormones and immunosuppressants may be accompanied by serious side effects.
Therefore, when and how to stop the drug is still a controversial topic in the treatment of LN
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In 2012, the European Rheumatism Federation/European Nephrology Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) formulated a joint recommendation for LN as follows (Figure 1): If the patient’s symptoms improve after induction therapy, it is recommended Continue to use antimalarial drugs combined with immunosuppressive agents.
If disease activity needs to be controlled, use glucocorticoids; after reaching a complete clinical response, at least 3-5 years of treatment, you can try to gradually stop the treatment (discontinue glucocorticoids first), Antimalarial drugs should be used continuously for a long time; the purpose of treatment is to protect or improve renal function, and reduce proteinuria by at least 25% within 3 months, reduce by 50% at 6 months, and combine random urine protein within 12 months.
The creatinine ratio (UPCR) index is controlled below 500-700mg/g (complete clinical response)
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Figure 1: EULAR/ERA-EDTA LN guidelines.
Risk of recurrence after LN reduction and discontinuation ❶ Disease recurrence and exacerbation of kidney damage.
A single-center retrospective study included patients with LN confirmed by biopsy and followed up for at least 3 years (N=56)
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The conclusions show that from the initial diagnosis, patients who have recurred kidney disease more than 30% of the time have a significantly increased risk of developing new or progressive chronic kidney disease (CKD)
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Long-term recurrence of kidney disease is an independent predictor of the combined endpoint of new or progressive CKD (Figure 2)
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Figure 2: Disease recurrence is associated with aggravated kidney damage ❷ The recurrence rate of patients with clinical remission of LN after discontinuation of immunosuppressants.
In a study of 161 patients with LN who had reached stable clinical remission (Figure 3), there were 73 patients Gradually discontinue maintenance immunosuppressive drugs (including glucocorticoids)
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The results showed that 52/73 (71.
2%) patients were able to completely stop immunosuppressive drugs during treatment; 21/73 (28.
7%) patients had relapses during treatment withdrawal; 32/52 (61.
5%) patients were After follow-up, there were no episodes of kidney or other diseases (median 102 months); 20/52 (38.
5%) patients had at least one relapse after stopping the drug (median 286 months)
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Figure 3: Recurrence rate of patients with clinical remission of LN after discontinuation of immunosuppressants❸ Can patients in the quiescent phase of the disease successfully discontinue immunosuppressants? In a study of 102 patients with quiescent SLE who received maintenance immunosuppressants for more than 12 months: 50 patients (80% with a history of LN) continued to take immunosuppressants (MA group), 52 patients (73 % With a history of LN) gradually stopped using immunosuppressive agents (WA group) within 12 weeks
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The patients were followed up for 60 weeks, and all patients continued to use antimalarial drugs and glucocorticoids
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The results showed that the median time for the two groups to relapse in clinical significance was 38 weeks; the clinical recurrence risk increased by less than 15% within 60 weeks after stopping the drug; there was 1 case in the MA group in the British Lupus Erythematosus Assessment Group (BILAG) A Type recurrence, while there were 4 cases in the WA group
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In summary, most LN recurrences occur within 5-6 years after the start of treatment.
EULAR/ERA-EDTA recommends that after a complete clinical response is achieved, the treatment time should be maintained for ≥3-5 years; when the maintenance treatment is stopped, the goals of maintenance treatment should be considered, including Prevent recurrence, maintain normal organ function for a long time, and reduce treatment-related toxicity; it is possible for some patients to stop maintenance immunosuppressant therapy, but there is also evidence that there is a risk of LN recurrence after stopping the drug
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Expert profile Professor Qing Yufeng is a doctor of medicine, a doctoral supervisor, and the director of the Department of Rheumatology and Immunology, Affiliated Hospital of North Sichuan Medical College
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The fourteenth batch of academic and technical leaders of the Sichuan Provincial Health Commission; the young member of the Chinese Medical Association Rheumatology Branch; the young member of the Osteoporosis and Bone Mineral Disease Branch of the Chinese Medical Association; Member of the Immune Purification and Cell Therapy Group Committee of the Chinese Medical Association Internal Medicine Branch; Member of the Gout Group of the Chinese Medical Doctor Association Rheumatology and Immunology Branch; Standing Member of the Rheumatology Professional Committee of the Sichuan Medical Association; Osteoporosis and Bone Minerals of the Sichuan Medical Association Standing member of the salt disease professional committee; chairman designate of the rheumatism committee of the Nanchong Medical Association; chairman of the osteoporosis and bone mineral salt disease committee of the Nanchong Medical Association
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Published more than 100 academic papers, more than 20 papers included in SCI, won more than 10 national, provincial and ministerial level topics, won the first prize of Nanchong City Science and Technology Progress, the second prize of Science and Technology of Sichuan Medical Association, and Sichuan Medical Science and Technology One second prize for the Youth Award
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