Background/Purpose: The current guidelines from both the American College of Rheumatology and the American Society of Nephrology suggest initiating induction therapy for Class III and Class IV lupus nephritis with cyclophosphamide or mycophenolate mofetil and then starting maintenance therapy, generally mycophenolate mofetil or azathioprine. However, the duration of maintenance therapy is not specified in the guidelines.  Many patients with lupus nephritis take these maintenance medications indefinitely.

Methods: We reviewed the charts of lupus nephritis patients in a rheumatology office practice whose biopsies showed Class III or Class IV lupus nephritis. All had been treated with mycophenolate mofetil or cyclophosphamide and then switched to maintenance therapy.  We describe the course of 6 patients who stopped their immunosuppressive maintenance therapy and 2 patients who never began maintenance immunosuppressive treatment.

Results: 6 patients stopped their maintenance immunosuppressive therapy for Class III or Class IV lupus nephritis. One patient with class III and one patient with class IV lupus nephritis never started it.  All are still doing well without a renal or systemic disease flare up.  The reasons these patients stopped the maintenance therapy included fertility and pregnancy concerns, doubt that continuing maintenance medicine was necessary, and lack of compliance.

Conclusion: Previous studies have shown that patients with class III and IV lupus nephritis, who go into remission with induction therapy, with normalization of creatinine and a significant reduction of proteinuria, are likely to stay in remission. It is unknown whether they need indefinite maintenance therapy. The lupus patients described here were able to discontinue maintenance immunosuppressive therapy, or never began it, and are doing well without relapse of their nephritis. We did not find any Class III or IV lupus nephritis patients who flared after discontinuing immunosuppressive treatment in this small sample.

This study suggests that the duration of treatment with maintenance immunosuppressive therapy should be evaluated and guidelines amended to address the duration of maintenance medication based on patient responses to induction treatment