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Induction therapy for pediatric onset class IV lupus nephritis: Mycophenolate Mofetil versus Cyclophosphamide

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Abstract

Objectives

Class IV lupus nephritis (LN) is one of the most frequent and severe types of involvement in pediatric systemic lupus erythematosus. Gold standard treatment consists of intravenous (i.v.) Cyclophosphamide (CYC) associated with corticosteroids. Recent studies in adults have shown similar efficacy of oral Mycophenolate Mofetil (MMF) with fewer adverse events. Our aim was to compare the efficacy and tolerance of CYC and MMF as induction therapy in children with class IV LN.

Methods

We conducted a retrospective study of children diagnosed with class IV LN who started oral MMF or i.v. CYC treatment at Necker Enfants Malades Hospital (Paris, France).

Results

The study included 33 patients, 17 treated with oral MMF (51%) and 16 with i.v. CYC (48%). The characteristics at treatment induction did not significantly differ between the two groups except for the neurological involvement, that was only present in the CYC group. Complete remission was obtained in 9/17 (53%) children treated with MMF versus 10/16 (71%) treated with CYC (p = 0.46). Relapse was observed in 59% of patients receiving MMF versus 50% receiving CYC (p = 0.87), after a median of 3.4 years and 4.7 years after the beginning of treatment, respectively (p = 0.41). During the 6.5 years of follow-up, we observed no significant difference regarding the number of treatment-related adverse events between the two groups (p = 0.48).

Conclusion

We report similar efficacy and tolerance of MMF or CYC as induction therapy of class IV LN in children. However, the long-term adverse events such as infertility could not be systematically evaluated in this retrospective pediatric study. Overall, however, considering the long-term safety profile reported in the literature, we suggest that MMF may be used as first-line induction therapy in LN.

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Abbreviations

ACR:

American College of Rheumatology

CYC:

Cyclophosphamide

eGFR:

Estimated glomerular filtration rate

ISN/RPS:

International Society of Nephrology/Renal Pathology Society

i.v.:

Intravenous

LN:

Lupus nephritis

MMF:

Mycophenolate mofetil

NIH:

National Institutes of Health

SAE:

Severe adverse events

SHARE:

Single Hub and Access point for pediatric Rheumatology in Europe

SLE:

Systemic lupus erythematosus

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Author notes

  1. Marwa Chbihi, Laurye-Anne Eveillard, Brigitte Bader-Meunier and Olivia Boyer contributed equally to this work.

Authors and Affiliations

  1. Pediatric Immunology-Hematology and Rheumatology Unit, Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Inserm U1163, Necker-Enfants Malades Hospital, Assistance Publique – Hôpitaux de Paris (APHP), Imagine Institute, Paris, France

    Marwa Chbihi, Pierre Quartier & Brigitte Bader-Meunier

  2. Pediatric Nephrology, Inserm U1163, MARHEA Reference Center, Imagine Institute, Paris Cité University, Necker-Enfants Malades Hospital, APHP, Paris, France

    Laurye-Anne Eveillard, Rémi Salomon, Marina Charbit, Marina Avramescu, Nathalie Biebuyck, Laurène Dehoux & Olivia Boyer

  3. Laboratory of Immunogenetics of Pediatric Autoimmune Diseases, Inserm U1163, Paris Cité University, Imagine Institute, Paris, France

    Quentin Riller

  4. Department of Pathology, Necker-Enfants Malades Hospital, APHP, Paris Cité University, Paris, France

    Romain Brousse & Jean-Paul Duong-Van-Huyen

  5. Inserm U1163, Imagine Institute, Paris Center University, Paris, France

    Nicolas Garcelon

  6. Inserm, Cordeliers Research Center, U1138, team 22, Paris Cité University, Paris, France

    Nicolas Garcelon

  7. Pediatric Nephrology, MARHEA Reference Center, Paris Cité University, Necker-Enfants Malades Hospital, AP-HP, Paris, France

    Romain Berthaud

Authors
  1. Marwa Chbihi
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Contributions

OB and BBM designed the study. LAE, MC, OB and BBM designed and created the clinical database. QR performed the statistical analysis. LAE, MC, OB and BMM analyzed and interpreted the data and drafted the article. All authors were involved in data collections, review and approval of the manuscript.

Corresponding author

Correspondence to Marwa Chbihi.

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Conflict of interest

The authors have no conflict of interest to disclose. The authors have no financial relationship relevant to this article to disclose.

Ethical statement

The study was approved by the ethical committee of Necker-Enfants Malades hospital (APHP general register Number 2020 0805180729).

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Not applicable.

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Chbihi, M., Eveillard, LA., Riller, Q. et al. Induction therapy for pediatric onset class IV lupus nephritis: Mycophenolate Mofetil versus Cyclophosphamide. J Nephrol 36, 829–839 (2023). https://doi.org/10.1007/s40620-022-01438-2

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  • DOI: https://doi.org/10.1007/s40620-022-01438-2

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