Treat lupus nephritis and get to know eULAR's latest recommendations!

Progress in the treatment of systemic lupus erythematosus and lupus nephritis in the second day of the European rheumatic Association (EULAR) annual meeting, a number of chapters focused on the treatment of systemic lupus erythematosus and lupus nephritis.a number of researchers from all over the world give lectures in related fields."rheumatism and nephropathy channel of medical circles" specially invited Zhou Yunshan, deputy chief physician of Rheumatology and Immunology Department of people's Hospital of Peking University, to give us a wonderful report of the meeting.1 ms. Michell A. Petri from Johns Hopkins University, USA, shared a cohort study to explore whether the plasma concentration of hydroxychloroquine is related to thrombotic events.of the 812 lupus patients enrolled, 43 (5.5%) had thrombotic events, including 3% of venous thrombosis and 2.5% of arterial thrombosis.there is a strong correlation between lupus anticoagulant positive and any thrombotic event.the results showed that the plasma concentration of hydroxychloroquine was low in patients with thrombotic events and venous thrombosis.the dosage of hydroxychloroquine (not the blood concentration) was negatively correlated with the probability of any thrombotic event and venous thrombosis.2 loqmane seridi, developed by Yang Sen, introduced the research results of predicting the efficacy of ulinuzumab in the treatment of lupus erythematosus by using baseline cytotoxic gene expression.in the phase II clinical trial, compared with placebo, ulinuzumab (anti-IL-12 / IL-23 monoclonal antibody) significantly improved the clinical and laboratory indicators of patients with mild to moderate lupus erythematosus, and the therapeutic response was related to the reduction of interferon gamma and the suppression of IL-12 / Th1 axis.therefore, the researchers hope to find some genes through transcriptomic analysis to identify lupus patients who are effective in ulinuzumab treatment.the study found that the expression of 9 kinds of cytotoxic cell related genes (PRF1, klrd1, GzmH, nkg7, gnly, fgfbp2, trgc2, tarp, trgv2) in patients with lupus erythematosus who failed to respond to ulinuzumab was lower than that in patients with lupus erythematosus and normal controls.however, there was no difference in the expression of the above genes in lupus patients with effective ulinuzumab and normal people.further experiments in vitro showed that IL-12 instead of IL-23 could stimulate the expression of the above genes, suggesting that blocking IL-12 is the main mechanism of ulinuzumab in the treatment of lupus erythematosus.3 antonis fanouriakis, from the University of Athens, Greece, brings the updated EULAR / European kidney Union - European Dialysis and transplantation Union's recommendations for the treatment of lupus nephritis in 2019.this is the first update since the last edition of the recommendations for lupus nephritis in 2012.the new recommendations suggest that the treatment goal should be to reduce urinary protein by at least 25% within 3 months, at least 50% within 6 months, and to & lt; 0.5-0.7 within 12 months, i.e. complete remission. for type III and type IV (± V) lupus nephritis, glucocorticoids combined with oral mycophenolate mofetil (MMF, 2-3g / day) or intravenous low-dose cyclophosphamide (500mg every 2 weeks, 6 times) is still recommended as the first-line treatment because of the most abundant evidence. for proteinuria at the nephrotic syndrome level, multi-target therapy (MMF 1-2g / day + calcineurin inhibitors, especially tacrolimus) can also be selected. for patients with high risk of renal failure (glomerular filtration rate is reduced or crescentic body, cellulose necrosis or severe interstitial inflammation) are at high risk of renal failure. In addition to the above treatment, intravenous high-dose cyclophosphamide (0.5-0.75g/m2 once a month for 6 months) can be considered. in order to reduce the cumulative hormone dosage, prednisone (0.3-0.5mg / kg / day) is recommended after intravenous methylprednisone (500-2500mg) at the beginning of treatment, and then reduced to ≤ 7.5mg/day within 3-6 months. Br / > if the serum creatinine level is less than 1mg, it is still recommended to use the urinary creatinine inhibitor for lupus nephritis. the first choice is MMF 2-3g / day, combined with intravenous methylprednisolone pulse therapy (total dose 500-2500mg), followed by oral prednisone (20mg / day, and reduced to ≤ 5mg / day within 3 months). simple type V lupus nephritis can also be treated with intravenous cyclophosphamide or calcineurin inhibitor alone or multi-target therapy (especially for patients with proteinuria at the level of nephrotic syndrome). maintenance treatment recommends MMF 1-2g / day or azathioprine (2mg / kg / day, especially for patients with pregnancy needs), and low-dose prednisone (2.5-5mg / day) if necessary. if complete remission is maintained within 3-5 years, hormones and immunosuppressants (hormone first, immunosuppressant later) can be gradually reduced. hydroxychloroquine should be taken for a long time. for patients with refractory lupus nephritis who can not achieve the treatment goal, it is recommended to completely re evaluate the condition, and the above-mentioned replacement regimen or rituximab (1000mg, day 1 and day 14) can be used. repeat renal biopsy should be encouraged in some cases. 4 Professor Chi Chiu Mok from Tuen Mun Hospital, Hong Kong, China, reported the results of a 10-year randomized controlled trial comparing the efficacy of tacrolimus and MMF in the induction treatment of lupus nephritis. 150 patients with type III / IV / V lupus nephritis confirmed by renal biopsy and with serum creatinine & lt; 200umol / L were randomly assigned to the treatment group (tacrolimus 0.1kg/mg/day, divided into two times, and reduced to 0.06kg/mg/day if the treatment effect is satisfactory after 3 months, the target blood concentration & gt; 5 ng / ml) or control group (2 g / day of MMF, 3 months later, if the curative effect is not satisfactory, add to 3G / day). both groups were given prednisolone 0.6mg/kg/day for 6 weeks, and then decreased by 5mg / kg to & lt; 10mg / day every week. the results showed that there was no significant difference in the complete remission rate (urinary protein / creatinine & lt; 1) and total remission rate between the two groups after 6 months of induction therapy. after azathioprine maintenance treatment, there was no difference in the total recurrence rate and nephritis recurrence rate between the two groups, but the urinary protein recurrence rate in tacrolimus group was higher than that in MMF group. some patients underwent repeated renal puncture, and there was no significant difference in pathological changes between the two groups. after 18 months of treatment, urinary protein / creatinine & gt; 0.75 or EGFR ≤ 80ml / min can predict adverse renal outcomes (4 / 5 chronic kidney disease or EGFR decrease & gt; 30%). recurrence, decreased EGFR and ineffective treatment for 6 months were independent risk factors for adverse outcomes.