• Lorna K Henderson, Philip Masson, Jonathan C Craig, Matthew A Roberts, Robert S Flanc, Giovanni F M Strippoli, and Angela C Webster.
• Cochrane Renal Group, Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia. lorna.k.henderson@gmail.com
• Am. J. Kidney Dis. 2013 Jan 1; 61 (1): 74-87.

BackgroundLupus nephritis accounts for ~1% of patients starting dialysis therapy. Treatment regimens combining cyclophosphamide with steroids preserve kidney function but have significant side effects. Newer immunosuppressive agents may have improved toxicity profiles.Study DesignSystematic review and random-effects meta-analysis, searching MEDLINE (1966 to April 2012), EMBASE (1988-2011), and the Cochrane Renal Group Specialised Register.Setting & PopulationPatients with biopsy-proven proliferative lupus nephritis (classes III, IV, V+III, and V+IV).Selection CriteriaRandomized controlled trials.InterventionImmunosuppressive treatment regimens used for induction and maintenance therapy of lupus nephritis.OutcomesMortality, renal remission and relapse, doubling of creatinine level, proteinuria, incidence of end-stage kidney disease, ovarian failure, alopecia, leukopenia, infections, diarrhea, vomiting, malignancy, and bladder toxicity.Results45 trials (2,559 participants) of induction therapy and 6 (514 participants) of maintenance therapy were included. In induction regimens comparing mycophenolate mofetil (MMF) with intravenous cyclophosphamide, there was no significant difference in mortality (7 studies, 710 patients; risk ratio [RR], 1.02; 95% CI, 0.52-1.98), incidence of end-stage kidney disease (3 studies, 231 patients; RR, 0.71; 95% CI, 0.27-1.84), complete renal remission (6 studies, 686 patients; RR, 1.39; 95% CI, 0.99-1.95), and renal relapse (1 study, 140 patients; RR, 0.97; 95% CI, 0.39-2.44). MMF-treated patients had significantly lower risks of ovarian failure (2 studies, 498 patients; RR, 0.15; 95% CI, 0.03-0.80) and alopecia (2 studies, 522 patients; RR, 0.22; 95% CI, 0.06-0.86). In maintenance therapy comparing azathioprine with MMF, the risk of renal relapse was significantly higher (3 studies, 371 patients; RR, 1.83; 95% CI, 1.24-2.71).LimitationsHeterogeneity in interventions and definitions of remission and lack of long-term outcome reporting.ConclusionsMMF is as effective as cyclophosphamide in achieving remission in lupus nephritis, but is safer, with a lower risk of ovarian failure. MMF is more effective than azathioprine in maintenance therapy for preventing relapse, with no difference in clinically important side effects.Copyright © 2012 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.

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