Traitement des glomérulonéphrites lupiques prolifératives. Évolution des idées et situation en 2008

The prevalence of the renal involvement is estimated at 40% during the course of systemic lupus erythematosus. In more than half of cases, the histological evaluation leads to the diagnosis of a severe glomerulonephritis (class III or IV A or A/C of the 2003 ISN/RPS classification) which requires a powerful treatment aiming at the remission of the nephritis, at the prevention of relapses, and at the prevention of chronic renal failure and death, with low toxicity. This review focuses on the most important trials of the last three decades that progressively delineated the treatment regimens used for lupus proliferative glomerulonephritis with active lesions. The treatment should consist in an induction regimen followed by a maintenance regimen. Until now, the standard induction associates corticosteroids and intravenous cyclophosphamide, and the most efficient regimen for maintenance with the best tolerance profile is the association of low dose corticosteroids and azathioprine or mycophenolate mofetil. However, the use of cyclophosphamide is limited by its side effects and its cumulated dose should be reduced as much as possible. When cyclophosphamide is not considered for induction, azathioprine or mycophenolate mofetil associated with steroids may constitute an alternative regimen. However, azathioprine seems less effective than cyclophosphamide to prevent relapses and preserve the renal function on a long-term basis. Preliminary data evaluating induction with mycophenolate mofetil are promising, but ongoing trials are needed to determine if induction with mycophenolate mofetil could reach this goal.