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  • Title: What happens after complete withdrawal of therapy in patients with lupus nephritis.
    Author: Moroni G, Longhi S, Giglio E, Messa P, Ponticelli C.
    Journal: Clin Exp Rheumatol; 2013; 31(4 Suppl 78):S75-81. PubMed ID: 24129143.
    Abstract:
    OBJECTIVES: Whether and when is it possible to completely stop immunosuppression in patients with lupus nephritis is still poorly defined. METHODS: An attempt to slowly and progressively eliminate steroids and immunosuppressive drugs was tried in 73 of 161 (45.3%) patients with lupus nephritis who achieved a stable clinical remission defined as normal serum creatinine, proteinuria <0.5g/24h, inactive urine sediment, and no clinical signs of extra-renal activity of SLE for at least 12 months. RESULTS: Twenty-one out of the 73 patients (28.7%) who met the criteria for withdrawal of treatment developed flares during the phase of progressive reduction of therapy and their treatment was reinforced. Twenty patients entered remission again; the last patient was lost to follow-up at achievement of partial remission. In the other 52 of the 73 patients (71.2%), it was possible to completely withdraw treatment. Of these, 32 patients (group A) did not resume therapy for the subsequent follow-up (median 101.8 months); the other 20 patients (group B) had at least one flare, in median 37 months after withdrawing therapy, and had to be retreated. At the last observation, after a median follow-up of 286 months, 10 of these 20 patients were off therapy. At the last observation, two patients in group A and two in group B had died, no patient of group A and two of group B had developed renal insufficiency (serum creatinine 2.5 and 3 mg/dl, respectively). Compared to patients in group B, group A patients received longer treatment (98.1 vs. 31.0 months; p=0.01), had longer remission (52.8 vs. 12.0 months; p=0.000) before withdrawal of therapy, and continued chloroquine after stopping therapy (52% vs. 10%; p=0.004). In comparison to patients who never stopped therapy, patients who were able to interrupt treatment had lower risk of chronic renal insufficiency (3.8% vs. 28.4%; p=0.000), end-stage renal disease (0 vs. 12.8%; p=0.01), arterial hypertension (32.7% vs. 66.9%; p=0.000) and cardiovascular events (11.5% vs. 27.5%; p=0.04). CONCLUSIONS: Complete withdrawal of therapy is feasible in selected patients who achieved stable remission after long-term treatment. The reduction of treatment must be done in a very gradual manner, progressively and under strict medical surveillance. The withdrawal of therapy allows the patients to reduce renal and extra-renal damage accrual. Treatment with chloroquine may help to maintain remission in patients who discontinue steroids and immunosuppressive drugs.
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