Mycophenolate Mofetil is an Effective Induction Therapy Agent in Childhood-onset Pure Membranous Lupus Nephritis

Maria Pereira¹, Eyal Muscal², Marietta DeGuzman³, Anna Carmela Sagcal-Gironella⁴ and Scott E. Wenderfer⁵, ¹Immunology, Allergy & Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, ²Immunology, Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, ³Pediatric Immunology, Allergy and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, ⁴Pediatric Immunology, Allergy, and Rheumatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, ⁵Pediatrics-Renal, Baylor College of Medicine, Texas Children's Hospital, Houston, TX

Meeting: 2017 Pediatric Rheumatology Symposium

Keywords: Lupus nephritis, mycophenolate mofetil and pediatrics

Session Information

Date: Thursday, May 18, 2017

Title: Clinical and Therapeutic Poster Session

Session Type: Abstract Submissions

Session Time: 5:30PM-7:00PM

Background/Purpose:

Treatment guidelines for childhood-onset class V membranous lupus nephritis (MLN) have not yet been established. The addition of mycophenolate mofetil (MMF) has shown improvement in the 5-year renal and patient survival rates in recent studies, but the role of early treatment with MMF remains unclear. We hypothesized that use of MMF as induction therapy in children is associated with good outcomes.

Methods:

We conducted a single-center retrospective observational cohort study of consecutively diagnosed children with pure MLN from 2002 to 2016 after obtaining an IRB approval. Patients treated with MMF on MLN diagnosis were identified. Clinical, laboratory measures, and treatment regimens were analyzed using descriptive statistics. Renal outcomes were documented before and after completion of 6 months of initial treatment. Numerical data was compared using paired t-test. Mean differences and 95% confidence interval were reported. All tests were considered positive with a p value <0.05. Renal response was defined using consensus definitions from the Childhood Arthritis and Rheumatology Research Alliance (CARRA).

Results:

Most patients prior to the year 2000 were treated with glucocorticoids alone. Introduction of MMF in addition to glucocorticoids for MLN patients was first prescribed in 2002, and became a regular practice after 2010. MMF usually started within 2 weeks of kidney biopsy. There was a total of 27 subjects with pure MLN treated with MMF in the cohort (85% females, 40% Hispanic, 37% African-American, 11% Caucasian, and 11% Asian) with a mean age of 14.0 ± 2.5 years and a median follow-up time of 2.8 years (IQR 1.5 – 4.6). Nearly half of the patients had hypocomplementemia (48%) and one-fourth had elevated anti double-stranded DNA (26%) on presentation. Nephrotic syndrome was seen in 81% and acute kidney injury in 11% on initial presentation. Mean initial prednisone dose was 0.5±0.3 mg/kg/day. Efficacy of MMF after 6 months of initial treatment was reflected by improvement in mean urine protein creatinine ratio (p=0.0047), increased serum albumin (p=0.0017), and SLEDAI score drop (p<0.001) (Table 1). Renal response rates at 6 months were: complete response in 31%, moderate in 31%, mild in 23%, and no response in 12% of the cohort. At 24 months, complete response was achieved in 67%, moderate in 5%, mild in 5% and no response in 22% of the patients.

Conclusion:

Favorable outcomes were reported with the early use of MMF on this single-center cohort of childhood-onset pure MLN.

Table 1. Differences in baseline variables before and after 6 months of mycophenolate mofetil treatment
Baseline Variable	Pre-MMF	Post-MMF	Mean difference (95% CI)	p value
Spot uPCR (g/g)	4.3 ± 5.0	1.0 ± 1.3	3.2 ± 4.9 (1.1 to 5.4)	0.0047
Urine protein (g/24h)	4.9 ± 6.5	1.0 ± 1.3	3.9 ± 6.7 (-1.3 to 9.1)	NS
Serum creatinine (mg/dL)	0.5 ± 0.2	0.6 ± 0.1	0.1 ± 0.2 (-0.06 to 0.09)	NS
Serum albumin (g/L)	2.9 ± 0.7	3.8 ± 0.5	-0.9 ± 0.8 ( -1.2 to -0.3)	0.0017
GFR (mL/min/1.73m²)	135 ± 53	129 ± 29	6.2 ± 41 (-11.3 to 23.7)	NS
SLEDAI score (points)	12.8 ± 6.5	6.3 ± 4.4	6.5 ± 5.6 (4.2 to 8.8)	<0.001
uPCR, urine protein creatinine ratio; GFR, glomerular filtration rate;
SLEDAI, systemic lupus erythematosus disease activity index; MMF, mycophenolate mofetil; NS, no statistical significance.

Disclosure: M. Pereira, None; E. Muscal, None; M. DeGuzman, None; A. C. Sagcal-Gironella, None; S. E. Wenderfer, None.

To cite this abstract in AMA style:

Pereira M, Muscal E, DeGuzman M, Sagcal-Gironella AC, Wenderfer SE. Mycophenolate Mofetil is an Effective Induction Therapy Agent in Childhood-onset Pure Membranous Lupus Nephritis [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 4). https://acrabstracts.org/abstract/mycophenolate-mofetil-is-an-effective-induction-therapy-agent-in-childhood-onset-pure-membranous-lupus-nephritis/. Accessed .

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