Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.


Towards the Development of Standardized Treatment Protocols for Proliferative Nephritis in Juvenile Systemic Lupus Erythematosus (jSLE).

Mina6,  Rina, Brunner5,  Hermine, Eberhard12,  B. Anne, Punaro14,  Marilynn G., Ardoin10,  Stacy P., Klein-Gitelman4,  Marisa S., Hsu13,  Joyce J.

Baylor College of Medicine, Houston, TX
Ohio State University, Columbus, OH
Robert W Johnson University, Metuchen, NJ
Schneider Children's Hospital, New Hyde Park, NY
Stanford University, Stanford, CA
Texas Scottish Rite Hospital for Children, Dallas, TX
Univ of Calif San Francisco, San Francisco, CA
University of Washington and Seattle Childerns's Hospital, Seattle, WA
Children's Hospital Los Angeles, Los Angeles, CA
Children's Hospital Montefiore, Bronx, NY
Childrens Mem Hosp/NW Univ, Chicago, IL
Cincinnati Child Hosp Med Ctr, Cincinnati, OH
Cincinnati Children's Med Ctr, Cincinnati, OH
Duke Medical Center, Durham, NC
La Rabida Children's Hospital, Chicago, IL
Lupus Foundation

Background:

There is a paucity of clinical trials (RCTs) to help guide treatment of proliferative lupus nephritis (LN) in jSLE. Comparison of outcomes resulting from standardized treatment protocols may offer an alternative to expensive RCTs for elucidating the best therapy in this population.

Objectives:

Describe current clinical practice patterns and patient-specific features that influence the management of proliferative LN in jSLE as a first step towards the development of standardized treatment protocols for LN in children.

Methods:

Based on literature review, a Delphi survey pertaining to issues in LN induction and maintenance therapy was sent to 103 members of the SLE Subcommittee of the Childhood Arthritis and Rheumatology Research Alliance. Consensus was set at 80%.

Results:

Survey response rate was 80%; most of the respondents had at least 6 years of clinical experience. The majority (79%) use cyclophosphamide according to the NIH protocol as induction therapy for Class IV LN. Mycophenolate mofetil (MMF) is less commonly used (17%) and rituximab and azathioprine were rarely prescribed for induction. The choice for induction agent is influenced by co-existent cerebritis and risk for non-adherence but not patient age, race or gender. MMF is the medication of choice for maintenance therapy. Although corticosteroids are almost universally utilized for LN therapy, there is a striking variability in the regimen (dose, route, and duration) employed. There was consensus that definitions of flare and response based on ACR/EULAR renal outcomes criteria are useful to guide treatment decisions. No consensus was reached about duration of induction or maintenance therapy; treatment adjustment for LN relapse; treatment-effects of nephrosis or persistent proteinuria, and strategies for prevention of medication side-effects. LN is typically monitored with C3/C4 levels, spot urine protein to creatinine ratio, anti-dsDNA antibody titers, GFR, and urine sediment while repeat kidney biopsy is not routine.

Conclusions:

While there is a marked variation in practice patterns among pediatric rheumatologists in the treatment of Class IV LN in jSLE, cyclophosphamide is often the preferred induction medication, and MMF is the maintenance therapy of choice. These survey responses will help guide the development of standardized treatment protocols. Based on the experience from other chronic diseases, this will allow for comparative effectiveness studies to determine the optimal therapy for LN in children, thereby leading to improved outcomes.

To cite this abstract, please use the following information:
Mina, Rina, Brunner, Hermine, Eberhard, B. Anne, Punaro, Marilynn G., Ardoin, Stacy P., Klein-Gitelman, Marisa S., et al; Towards the Development of Standardized Treatment Protocols for Proliferative Nephritis in Juvenile Systemic Lupus Erythematosus (jSLE). [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1702
DOI: 10.1002/art.29467

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