Rheumatologists use rituximab more often than nephrologists for lupus nephritis in children
Rheumatologists opt for therapy regimens that include rituximab more often than nephrologists in treating refractory lupus nephritis or renal flare in children, according to data published in Pediatric Rheumatology.
“Lupus nephritis is common in childhood-onset [systemic lupus erythematosus], however rare in comparison to the general population,” Mileka Gilbert, MD, PhD, of the Medical University of South Carolina, in Charleston, told Healio Rheumatology. “Thus, adequate clinical trials to evaluate treatment of lupus nephritis in pediatric patients and prevent end-stage renal disease are limited.”
“Consensus treatment plans and guidelines for initial treatment of lupus nephritis in childhood-onset SLE have been published by organizations such as the Childhood Arthritis and Rheumatology Research Alliance (CARRA) and Kidney Disease: Improving Global Outcomes (KDIGO),” she added. “However, it is not clear how to approach therapy for children whose kidney disease is refractory to initial immunosuppressant therapies or in cases where kidney disease flares after response to initial therapies.”
To analyze the current practices of North American rheumatologists and nephrologists in treating lupus nephritis and flare in childhood-onset SLE, Gilbert and colleagues surveyed members of CARRA and the American Society for Pediatric Nephrology (ASPN). Conducted in November 2015, the survey presented two cases. The first case was described as refractory disease after induction treatment with corticosteroids and cyclophosphamide. The second was lupus nephritis flare following initial response to treatment.
Respondents were asked to chose treatments for three follow up scenarios for each case, varying by presentation severity. Treatment options included cyclophosphamide, mycophenolate mofetil, rituximab (Rituxan; Genentech, Biogen) and others, either alone or in combination. A total of 117 individuals responded to the survey, including 76 from ASPN and 41 from CARRA, or about 15% of eligible members from each group.
According to the researchers, treatment choices varied greatly between nephrologists and rheumatologists, with only two of the six follow-up scenarios producing greater than 50% agreement for an individual strategy. For example, 59% of nephrologists, but only 38% of rheumatologists, chose to increase the mycophenolate mofetil dosage in the case of lupus nephritis refractory to induction therapy with proteinuria, hematuria and improved serum creatinine.
In addition, 58% of rheumatologists reached for combination therapy with cyclophosphamide and rituximab in a scenario demonstrating severe renal flare following achieving remission with induction therapy. Meanwhile, the top choice among nephrologists in this scenario was cyclophosphamide alone, but with only 43% agreement.
Rheumatologists, compared with nephrologists, chose more therapy options that included rituximab in all follow-up scenarios except one (P<.05).
“The results show that choices of immunosuppressant therapies are highly variable, and that pediatric rheumatologists in the study chose more therapy options that included rituximab compared to pediatric nephrologists,” Gilbert said. “The reasons for these results are unclear. The study is limited by numbers of participants in the survey — 15% of CARRA and ASPN members — and thus may not be generalizable.”
“The variability among therapy choices highlights the need for pediatric nephrologists and rheumatologists to collaborate on studies to treat lupus nephritis in children,” she added. “Members of CARRA and ASPN have come together to form the Pediatric Nephrology and Rheumatology Collaborative Group to study important research questions and provide hope to children with lupus nephritis.”