Multitarget therapy of mycophenolate mofetil and cyclosporine A for induction treatment of refractory lupus nephritis

Abstract

Standard induction therapy for lupus nephritis (LN) with mycophenolate mofetil (MMF) or cyclophosphamide (CYC) is often ineffective. Evidence on rescue induction regimens is scarce. We analyzed efficacy and tolerability of multitarget immunosuppression with MMF and cyclosporine A (CsA) as induction treatment for LN (class III/IV/V) refractory to CYC and/or MMF. We included all six refractory LN patients (class IV = 3, class V = 2, class III = 1) from our 400-patient tertiary Lupus Clinic observed between 2012 and 2015. Four patients had previously received pulse CYC. All six received MMF as first or second induction therapy and CsA was added once failure to reach remission was established. Daily dose of MMF was 2–3 g and CsA was dosed up to 2.6–3.7 mg/kg/day. Mean proteinuria was reduced from 2407 mg/24 hours at the start of the MMF+CsA regimen to 544 mg/day after six months. The mean prednisolone dose was reduced from 17.5 to 6 mg/day after six months of MMF+CsA. Four patients achieved a complete renal response, one patient had a partial renal response and one failed to respond. None of the patients presented with adverse events. These data suggest that adding CsA to MMF can induce complete remission of refractory LN and is well tolerated.

Keywords

Systemic lupus erythematosus lupus nephritis multitarget therapy

Introduction

Lupus nephritis (LN) is the most frequent major organ involvement in systemic lupus erythematosus (SLE), occurring in about 30%–50% of patients with SLE.^1,2 It is a major cause of morbidity and mortality in SLE. LN is heterogeneous and varies from mild disease to an aggressive condition that may progress to end-stage renal disease in 10%–30% of patients.^1,3

Guidelines from Europe, the United States and Asia recommend either cyclophosphamide (CYC) or mycophenolate mofetil (MMF) in combination with high-dose glucocorticoids as initial therapy for inducing remission of LN.^1,4,5 However, cases of LN refractory to induction treatment with these regimens are common and difficult to manage. A combination of MMF and calcineurin inhibitors (tacrolimus or cyclosporine A (CsA)) is suggested by the American College of Rheumatology (ACR) guidelines but evidence on this strategy is scarce.^4,6–11

Multitarget therapy with MMF and CsA is successfully used as immunosuppression following solid organ transplantation, and these agents have additive inhibitory effects on lymphocytes.¹² MMF is hydrolyzed to the active drug mycophenolic acid, which is a potent inhibitor of T- and B-lymphocyte proliferation via reversible inhibition of inosine 5-monophosphate dehydrogenase.¹³ CsA binds to cyclophilin and inhibits the phosphatase activity of calcineurin, thus blocking the activation of T-cell-specific transcription factors.¹⁴ As a result, T-cell activation and subsequent cytokine production, B-cell activation and immunoglobulin production are reduced.¹⁵ It also stabilizes the podocyte actin cytoskeleton leading to maintenance of the integrity of the glomerular filtration barrier and reducing proteinuria.¹⁶ Furthermore, CsA enhances the effect of glucocorticoids through the inhibition of P-glycoprotein.¹⁷

A systematic review that included two open-label, randomized, and controlled studies and six cohort studies found that CsA may improve renal and/or non-renal disease activity and have a steroid-sparing effect. However, CsA indication in these cases was not for refractory LN induction therapy.¹⁸

Our objective is to analyze the effectiveness and tolerability of multitarget rescue therapy with MMF and CsA for active LN in a series of patients who failed to respond to standard induction.

Methods

This paper is based on retrospective analysis of a monocentric SLE cohort defined according to the ACR-revised and/or the Systemic Lupus International Collaborating Clinics (SLICC) classification criteria for SLE.^19,20 Patients were included from January 1, 2012 to December 31, 2015.

Induction therapy with MMF+CsA was prescribed to patients who presented with: (1) biopsy-confirmed active LN (class III/IV/V, International Society of Nephrology/Renal Pathology Society (ISN/RPS) 2003 classification²¹) and (2) inadequate response to at least one standard regimen (CYC and/or MMF) for six months. All patients received oral prednisolone, hydroxychloroquine, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) during induction. Adequate compliance with treatment was closely checked and confirmed.

Effectiveness and tolerability were assessed at six months. Partial renal response and complete renal response were defined on the basis of European League Against Rheumatism/European Renal Association-European Dialysis and Transplant Association recommendations for LN.¹ Complete renal response was defined as urine protein/creatinine ratio < 50 mg/mmol (proteinuria < 0.5 g/24 hours) and normal or near normal (within 10% of normal glomerular filtration rate (GFR) if previously abnormal) renal function. Partial remission was defined as at least 50% reduction in proteinuria to subnephrotic levels and normal or near-normal renal function. Improvement included any reduction in proteinuria and normalization or stabilization of GFR. Inadequate response to treatment was defined as failure of proteinuria to improve by at least 50% or proteinuria in nephrotic levels or decreasing GFR.

Results

Six patients with LN (100% female, 100% Caucasian, age: 21–51 years) fulfilled the inclusion criteria and were evaluated. All patients fulfilled both the ACR-revised and SLICC classification criteria. Three patients had a history of malar rash (patients 1, 4 and 5), two had oral ulcers (patients 1 and 4), three had arthritis (patients 1, 2 and 3), two had hemolytic anemia (patients 2 and 5), three had thrombocytopenia (patients 1, 3 and 5) and all had leukopenia or lymphopenia. All six patients had a history of positive testing for anti-double-stranded DNA antibodies, one tested positive for anti-Sm antibody (patient 1) and all patients had low serum C3 or C4 levels. Table 1 shows their baseline demographic and renal parameters.

Table 1

Baseline characteristic of patients (at start of cyclosporine A)

Patient	Age	Duration of SLE diagnosis (months)	Lupus nephritis ISN/RPS Class	Previous induction regimen (plus prednisolone and ACEi/ARB)	Duration of previous MMF therapy (months)	Duration of previous complete remission with MMF (months)
1	23	70	IV	CYC; MMF	20	16
2	25	18	IV	MMF	18	13
3	22	106	IV	CYC; MMF	12	0
4	51	216	V	MMF	23	0
5	21	167	III	CYC; MMF	45	0^a
6	36	11	V	CYC; MMF	6	0

ACEi: angiotensin-converting enzyme inhibitor; ARB: Angiotensin receptor blockers; ISN/RNP Class: International Society of Nephrology/Renal Pathology Society Classification 2003 classification of lupus nephritis; MMF: mycophenolate mofetil; SLE: systemic lupus erythematosus.

Partial response.

The LN was class IV in three cases, class V in two and class III in one. Four patients failed to respond to the CYC Eurolupus regimen as first induction regimen and were switched to MMF, and the other two received MMF as first treatment strategy. After failure to achieve response or presenting with a new LN flare while on MMF 2000–3000 mg/day, CsA was added to the MMF. The mean duration of MMF therapy prior to the addition of CsA was 21 months. Two patients had a complete previous response with MMF therapy, one patient had a partial response and three patients failed to respond. Oral prednisolone, hydroxychloroquine and ACE inhibitor or ARB for either hypertension or control of proteinuria were given with all regimens.

Clinical, laboratory and medication parameters at baseline (starting date of MMF+CsA regimen) and at six-month follow-up are shown in Table 2. Mean MMF daily dose was 2250 mg, and CsA was dosed up to a mean of 2.9 mg/kg/day. The mean prednisolone dose was 17.5 mg/day at baseline and reduced to 6 mg/day after six months of MMF+CsA. The mean proteinuria was reduced from 2407 mg/24 hours at baseline to 1484 mg/day and 544 mg/day after three and six months, respectively. Mean serum creatinine levels were 0.53 mg/dl at baseline and 0.68 mg/dl after six months. Four patients achieved complete renal remission with a mean reduction in proteinuria of 1724.9 mg/day, one patient had a 51.2% reduction in proteinuria (reduction in proteinuria of 2945.1 mg/day) and one failed to respond. The mean time to complete remission was five months.

Table 2

Medication and outcome measures at baseline and six-month follow-up data

Patient	MMF dose (mg/day)	CsA dose (mg/kg/day)	Prednisolone dose		Proteinuria (mg/day)^a		Creatinine (mg/dl)		SLEDAI-2K		Time to complete renal remission (months)	Adverse effects
Patient	MMF dose (mg/day)	CsA dose (mg/kg/day)	Baseline	Six months	Baseline	Six months	Baseline	Six months	Baseline	Six months	Time to complete renal remission (months)	Adverse effects
1	2000	2.6	40	10	1052.0	144.0	0.39	0.51	12	10	3	None
2	2500	2.6	10	5	3252.0	261.0	0.58	0.9	5	2	6	None
3	3000	3.2	10	5	1732.5	256.4	0.45	0.51	12	4	3	None
4	2000	2.8	5	5	1047.9	2007.0	0.8	0.86	8	9	Not achieved	None
5	2000	3	20	5	1609.0	84.6	0.41	0.70	8	4	6	None
6	2000	3	20	10	5748.6	2803.5	0.54	0.64	6	8	Not achieved	None

MMF: mycophenolate mofetil; CsA: cyclosporine A; SLEDAI-2K: Systemic Lupus Erythematosus Disease Activity Index 2000.

Proteinuria (mg/day) measured in 24-hour proteinuria or in random urine protein-to-creatinine ratio.

Adverse events

MMF+CsA rescue induction treatment was generally well tolerated. None of the patients developed toxicity requiring suspension of combination therapy up to six months of treatment. There were no severe nephrotoxic adverse effects, though a small increase in serum creatinine was noted in patient 2 (0.58 to 0.9 mg/dl) and patient 5 (0.41 to 0.7 mg/dl).

Discussion

This case series suggests that the addition of CsA to MMF can induce complete remission of LN in patients with refractory disease or loss of response to MMF ≥2000 mg/day. Both patients with previous loss of efficacy to MMF achieved a complete renal response upon addition of CsA and, of the four patients with refractory disease, two presented with a complete renal response, one had a partial response and just one patient failed to respond. None of the ISN class V patients achieved a complete renal response: One patient had a partial response and one patient failed to respond. The addition of CsA to MMF allowed tapering the daily glucocorticoid doses in all responders.

Prior to addition of CsA, all our patients received a full dose of MMF treatment for an extended duration (mean of 21 months) without adequate renal response, so that the probability of an even more delayed response to MMF was judged as very slim. Furthermore, after starting CsA, a complete renal response was achieved after a mean of five months, which in our view is consistent with a therapeutic effect of the multitarget regimen. However, as this was not a controlled study, we cannot objectively ascertain the added therapeutic effect of CsA.

Multitarget immunosuppression with MMF and CsA was previously reported in only one study, of 16 children with severe proliferative LN (World Health Organization class III and IV), using a combination of monthly intravenous methylprednisolone (10–30 mg/kg) up to six doses, MMF (625–1299 mg/m²/day), CsA (3–6 mg/kg/day) and oral glucocorticoids.⁷ In this study, the complete renal remission rate was 44% at six months and 75% at one year, with the rest of the patients achieving partial remission and none failing treatment. In that pediatric study CsA was added to MMF by protocol in all patients who had moderate proteinuria (>1 g/day/1.73 m²) after the first month of induction, so that the value of MMF+CsA as a rescue induction therapy cannot be appreciated.

Recently, the preliminary results of the trial Aurinia Urinary Protein Reduction Active—Lupus With Voclosporin (ClinicalTrial.gov identifier number NCT02141672) were reported. In this study, voclosporin, a novel calcineurin inhibitor, used in combination with MMF as a first induction regimen for LN, showed beneficial effects on the renal remission rate when compared to MMF alone, reinforcing the positive role of MMF and calcineurin inhibitors combination therapy in LN therapy.²² Similar results were reported in a few studies using a combination of MMF and tacrolimus.^6,8–11

Only one case series and one uncontrolled cohort study reported the use of multitarget combination therapy with MMF and a calcineurin inhibitor (tacrolimus) as a rescue induction therapy in LN refractory to MMF: Lanata and colleagues reported the use of combination therapy of MMF and tacrolimus in seven patients with ISN class III–V, with four of them achieving clinical response (one complete remission and three partial remissions) after a mean follow-up of 16 months;⁶ Cortés-Hernández et al. also described a significant reduction of proteinuria after two years of follow-up in 17 patients with ISN class IV and V treated with this MMF and tacrolimus combination (six patients achieved complete remission and another six achieved partial remission).¹¹

To the best of our knowledge, this is the first study reporting on a multitarget combination regimen of MMF and CsA for LN as rescue induction therapy. The combined effect of the MMF, CsA and glucocorticoids results in a mixed humoral and cellular immunosuppression, acting on inflammatory, proliferative, vasculitic and membranous lesions synchronously, suppressing LN activity, decreasing urinary protein excretion and preserving renal function even in glucocorticoid-refractory LN. Compared with tacrolimus, CsA is a less expensive and more widely available drug, and presents a more favorable profile on glucose metabolism.²³

Our study suggests that multitarget therapy with CsA and MMF can be effective and well tolerated as a rescue induction treatment for ISN class III/IV/V LN, deserving consideration as an option for LN that fails to respond to standard therapies. Larger, prospective, randomized and controlled studies are, however, warranted to validate our findings.

Footnotes

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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