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254 Induction and maintenance treatment of proliferative lupus nephritis: an updated cochrane review
  1. DJ Tunnicliffe1,2,
  2. SC Palmer3,
  3. JC Craig1,2,
  4. AC Webster1,2,4,
  5. LK Henderson5,
  6. P Masson1,2,6,
  7. A Tong1,2,
  8. D Singh-Grewal7,8,9,
  9. R Flanc10,
  10. MA Roberts11 and
  11. GFM Strippoli1,2,12,13
  1. 1University of Sydney, Sydney School of Public Health, Sydney, Australia
  2. 2Children’s Hospital at Westmead, Centre for Kidney Research, Sydney, Australia
  3. 3University of Otago, Department of Medicine, Christchurch, New Zealand
  4. 4Westmead Institute, Centre for Transplant and Renal Research, Sydney, Australia
  5. 5Royal Infirmary of Edinburgh, Department of Renal Medicine, Edinburgh, UK
  6. 6University of Edinburgh, Department of Medicine, University of Edinburgh, UK
  7. 7University of Sydney, Sydney Medical School, Sydney, Australia
  8. 8The University of New South Wales, Faculty of Medicine, Sydney, Australia
  9. 9Sydney Children’s Hospital Network, Department of Rheumatology, Sydney, Australia
  10. 10Monash Medical Centre, Department of Nephrology, Melbourne, Australia
  11. 11Eastern Health Clinical School- Monash University, Department of Nephrology, Box Hill- Australia, Australia
  12. 12University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
  13. 13Diaverum, Medical Scientific Office, Lund, Sweden


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).

Abstract 254 Table 1

Summary of findings for induction therapy

Abstract 254 Table 2

Summary of findings for maintenance therapy

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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