Arthritis & Rheumatism, Volume 63,
November 2011 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Chicago, Illinois November 4-9, 2011.


Developing Consensus Treatment Plans for Proliferative Nephritis in Juvenile Systemic Lupus Erythematosus: Maintenance Therapy.

Mina1,  Rina, Brunner2,  Hermine, Eberhard3,  B. Anne, Punaro4,  Marilynn G., Ardoin5,  Stacy P., Klein-Gitelman6,  Marisa, Moorthy7,  Lakshmi N.

Cincinnati Children's Med Ctr, Cincinnati, OH
Seattle Children's Hospital, Seattle, WA
Baylor College of Medicine, Houston, TX
Stanford University, Palo Alto, CA
University of Chicago Hospital, Chicago, IL
The Hospital for Sick Children, Toronto, ON
Childrens Hosp & Regional Med, Seattle, WA
Children's Hospital Montefiore, Bronx, NY
UC San Francisco, San Francisco, CA
Cincinnati Children's Hospital Medical Center, Cincinnati, OH
Cohen Children's Hospital Medical Center, New Hyde Park, NY
Texas Scottish Rite Hospital, Dallas, TX
Ohio State University, Columbus, OH
Children's Memorial Hospital, Chicago, IL
Robert Wood Johnson Medical School-UMDNJ, New Brunswick, NJ
Children's Hosp Los Angeles, Los Angeles, CA
Children's Hospital Boston, Boston, MA

Background/Purpose:

The Childhood Arthritis and Rheumatology Research Alliance Lupus (CARRA)-Systemic Lupus Erythematosus (SLE) Committee is developing consensus treatment plans (CTPs) for proliferative lupus nephritis (LN) in juvenile SLE (jSLE) to guide therapy and to serve as the basis for future comparative effectiveness studies. The purpose of this phase of the project was to formulate CTPs for the maintenance phase (M-Rx) of proliferative LN based on medical evidence and consistent with current clinical practice.

Methods:

Based on extensive literature review, an online Delphi survey addressing various aspects of M-Rx for proliferative LN was sent to 57 members of the CARRA-SLE Committee. A subsequent consensus conference held on June 1, 2011 was attended by 36 CARRA voting members who are experienced in the care of jSLE. The consensus level was set at 80%.

Results:

The response rate to the Delphi survey was 86%. Consensus was reached that the duration of the CPTs for proliferative LN should be 36 months post-kidney biopsy at which time their effectiveness can be assessed (Figure 1). There was consensus that for a patient with substantial response to induction therapy (I-Rx): 1). mycophenolic acid (MMF) or cyclophosphamide (CYC) are the immunosuppressive medications to be used during M-Rx; 2). MMF and CYC dosing should be the same as specified for I-Rx; 3). MMF will be initiated within 2 weeks of the last CYC infusion given for I-Rx; 4). CYC administration, started 3 months after the last infusion of I-Rx will be continued every 3 months; and, 5). combination immunosuppressive therapy will not be used. Concerns about non-adherence, pregnancy, worsening of LN, and drug intolerance may warrant change of the immunosuppressive agent initially chosen for M-Rx; azathioprine use may be considered in these settings. There was consensus to utilize a uniform corticosteroid tapering regimen during M-Rx. Resolution of proteinuria, presence of avascular necrosis, and normalization of complement C3 and C4 levels all influence the decision to discontinue corticosteroid during M-Rx.

Figure 1. Consensus Treatment Plans for Proliferative LN in jSLE

Conclusion:

Consensus was reached about key features of CTPs that are part of the M-Rx of proliferative LN in jSLE. Further efforts are in progress to address issues of partial response and renal flares during M-Rx for proliferative LN.

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, et al; Developing Consensus Treatment Plans for Proliferative Nephritis in Juvenile Systemic Lupus Erythematosus: Maintenance Therapy. [abstract]. Arthritis Rheum 2011;63 Suppl 10 :2624
DOI:

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