Repeated pulses of methyl-prednisolone with reduced doses of prednisone improve the outcome of class III, IV and V lupus nephritis: An observational comparative study of the Lupus-Cruces and lupus-Bordeaux cohorts

ObjectiveTo compare the clinical course of patients with class III, IV and V lupus nephritis (LN) treated at Hospital Universitario Cruces (CC) and at Bordeaux University Hospital (BC).MethodsThe Lupus-Cruces nephritis protocol combines pulses of 125 mg of methyl-prednisolone with each fortnightly pulse of cyclophosphamide and prednisone ≤ 30 mg/day with tapering over 12-14 weeks until 2.5-5 mg/day. The BC followed international lupus nephritis guidelines, combining high-dose prednisone and either mycophenolate mofetil or cyclophosphamide, followed by maintenance therapy with low dose prednisone and immunosuppressive drugs. The main outcomes were complete renal remission (CR) and glucocorticoid toxicity.Results44 patients from BC and 29 from CC were included. The mean maximum prednisone dose was 42.5 (BC) vs. 21 mg/day (CC), p < 0.001. The average 6-month prednisone dose was 21 (BC) vs. 8.3 mg/d (CC), p < 0.001.The mean number of methyl-prednisolone pulses was 3 (BC) vs. 9.3 (CC), p < 0.001. HCQ was used by 64% (BC) vs. 100% (CC), p < 0.001.CR rates were 30% (BC) vs. 69% (CC), p = 0.001, and 42% (BC) vs. 86% (CC), p < 0.001, at 6 and 12 months, respectively. Patients from the CC more frequently achieved CR (adjusted HR 3.8, 95%CI 2.05-7-09). The number of pulses of methyl-prednisolone were associated with CR (adjusted HR 1.09, 95%CI 1.03-1.15). Patients in the CC had a lower risk of GC-related side effects (adjusted HR 0.19, 95%CI 0.04-0.89).ConclusionThe Lupus-Cruces nephritis protocol improves the outcome of LN. Repeated methyl-prednisolone pulses help reduce the dose of oral glucocorticoids and enhance clinical response.