Background and aims Pharmacological treatments have improved survival in lupus nephritis. However, intravenous cyclophosphamide as first-line therapy has considerable toxicity and lacks evidence of efficacy to prevent end-stage kidney disease. The comparative efficacy of newer strategies compared with intravenous cyclophosphamide remains unclear.
Methods We updated a random-effects meta-analysis of randomised controlled trials on induction and maintenance therapy for proliferative lupus nephritis. Evidence quality was assessed using GRADE.
Results 59 trials (4465 participants) were eligible, including nine new trials. Compared with intravenous cyclophosphamide, mycophenolate mofetil (MMF) incurred similar risks of complete remission, mortality, or major infection, while risks of alopecia and ovarian failure were lower (Table 1) (evidence quality=moderate). There was no evidence combined MMF and tacrolimus had different effects on complete remission or major infection than intravenous cyclophosphamide (Table 1) (evidence quality=low-very low). In maintenance therapy (Table 2), MMF decreased risks of disease relapse compared to azathioprine (evidence quality=moderate), although there was no evidence of different effects between maintenance therapies on mortality, end-stage kidney disease, or major infection (evidence quality = very low –low).
Conclusions MMF is as effective as intravenous cyclophosphamide in inducing remission in patients with proliferative lupus nephritis, with lower risks of alopecia and ovarian failure, although comparative effects of treatment on end-stage kidney disease and mortality remain uncertain. MMF is the most effective maintenance treatment to prevent relapse.
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