For children with membranous lupus nephritis, with or without nephrotic syndrome, steroids and nonsteroidal immunosuppressive therapy are the treatments recommended by pediatric rheumatologists and nephrologists, according to recent findings.
In the study, researchers administered an online survey to 272 members of the Childhood Arthritis and Rheumatology Research Alliance and to 507 members of the American Society of Pediatric Nephrology. The survey included questions pertaining to use of steroids, non-steroid immunosuppression (NSI) and renin-angiotensin aldosterone system (RAAS)-inhibiting medication. The questions were presented within the context of two hypothetical cases: one case of pure membranous lupus nephritis (MLN) with nephrotic syndrome (NS); and a case of pure MLN without NS, with proteinuria characterized as less than 1 g per day. A description of the patient with NS detailed “hypoalbuminemia, hyperlipidemia and an abnormal urinalysis (5 g/day of protein, five to 10 red blood cells/high power field).” Neither of these hypothetical patients had significant extrarenal disease. The researchers defined maintenance therapy as treatment that started 4 months to 6 months after start of initial treatment.
The survey elicited 117 responses from physicians, 57 of which were pediatric rheumatologists and 60 were pediatric nephrologists. Respondents represented a range of years in practice, number of patients with lupus at their centers and number of new patients with LN per year at their center.
Most pediatric rheumatologists (98%) and pediatric nephrologists (91%) concurred that systemic steroids should be the initial treatment of pure MLN with NS. Regarding pure MLN without NS, first-line treatment with steroids was recommended by a larger percentage of rheumatologists (93%) vs. nephrologists (60%). Among patients with pure MLN with NS who responded to first-line treatment, the continuation of low-dose maintenance steroids was recommended by 53% of rheumatologists and by 49% of nephrologists. In terms of patients with pure MLN without NS who responded to first-line therapy, a smaller percentage of rheumatologists (30%) and nephrologists (33%) recommended low-dose maintenance steroid treatment prolongation.
Most pediatric rheumatologists (98%) and pediatric nephrologists (83%) supported the use of NSI for patients with pure MLN with NS. The most commonly used first-line NSI for both groups of respondents and for both hypothetical cases was mycophenolate. Some survey responses selected more than one NSI as their first-line choice. In patients with pure MLN with NS who did not respond to first-line therapy, an array of other medications for MSI was recommended, with no evident preference shown.
Among pure MLN patients without NS who were resistant to first-line therapy, 92% of rheumatologists and 91% of nephrologists supported the use of NSI. No clear preference was demonstrated among the alternative agents.
most nephrologists (93%) for pure MLN. In terms of RAAS blockers, 54% of pediatric rheumatologists were recommended by most pediatric nephrologists (93%) and complied with the nephrologists’ judgment in making these decisions.
“The results of our study highlight the empirical character of treatment decisions for pediatric MLN,” the researchers wrote. “Future observational studies are needed to better describe treatment practices and renal outcomes for patients with MLN.” -by Jennifer Byrne
The researchers report no relevant disclosures.