Der Nephrologe

, Volume 3, Issue 6, pp 471–475

Die Nierenbeteiligung beim systemischen Lupus erythematodes

Leitthema

Zusammenfassung

Die Nierenbeteiligung beim systemischen Lupus erythematodes (SLE) ist eine schwerwiegende, prognostisch ungünstige Organbeteiligung. Ähnlich der „bunten“ klinischen Allgemeinsymptomatik des SLE bietet auch die Nierenbeteiligung eine breite Palette unterschiedlicher Verlausformen: von der asymptomatischen Mikrohämaturie bis zum rapid-progressiven Nierenversagen. Entsprechend den unterschiedlichen klinisch-nephrologischen Symptomen finden sich auch histologisch verschiedene Ausprägungen der Lupusnephritis, die in 6 Formen klassifiziert wird. Leichte Formen der Lupus-Nephritis erfordern keine immunsuppressive Therapie. Die diffus-proliferative Form hingegen (Typ IV), die aggressivste Form mit der schlechtesten Prognose, erfordert eine unverzügliche Behandlung. Neuere Ansätze zielen auf eine Remission schon in der frühen Induktionsphase bei verringerten Nebenwirkungen (z. B. Low-dose-Cyclophosphamid, Mycophenolat). Innovative Therapiekonzepte versprechen weitere Fortschritte in der Behandlung der Lupus-Nephritis.

Schlüsselwörter

Lupusnephritis Mycophenolatmofetil Induktionstherapie Prognose 

Renal disease in systemic lupus erythematosus

Abstract

Renal involvment in patients with systemic lupus erythematosus displays a broad variety of clinical symptoms ranging from asymptomatic hematuria to rapidly progressing glomerulonephritis. The histopathological findings in renal biopsy are classified in six different forms reflecting this diversity. Mild forms of lupus nephritis do not require immunosuppressive therapy whereas the diffuse-proliferative lupus nephritis (classified as type IV) as the most aggressive form with the worst prognosis demands immediate treatment. Recent approaches aimed to achieve remission in the early induction phase with reduced side effects (e.g. low-dose cyclophosphamide, mycophenolate). Novel therapeutic concepts promise further improvement in lupus nephritis treatment.

Keywords

Lupus nephritis Mycophenolate mofetil Induction therapy Prognosis 

Literatur

  1. 1.
    Cameron JS (1999) Lupus nephritis. J Am Soc Nephrol 10: 413–424PubMedGoogle Scholar
  2. 2.
    Nossent HC, Henzen-Logmans SC, Vroom TM et al. (1990) Contribution of renal biopsy data in predicting outcome in lupus nephritis. Analysis of 116 patients. Arthritis Rheum 33: 970–977PubMedCrossRefGoogle Scholar
  3. 3.
    Weening JJ, D’Agati VD, Schwartz MM et al. (2004) International society of nephrology working group on the classification of lupus nephritis; renal pathology society working group on the classification of lupus nephritis. The classification of glomerulonephritis in systemic lupus erythematosus revisited. Kidney Int 65: 521–530PubMedCrossRefGoogle Scholar
  4. 4.
    Schwartz MM, Lan SP, Bernstein J et al. (1993) Irreproducibility of the activity and chronicity indices limits their utility in the management of lupus nephritis. Lupus Nephritis Collaborative Study Group. Am J Kidney Dis 21: 374–377PubMedGoogle Scholar
  5. 5.
    Glassock RJ (2004) Reclassification of lupus glomerulonephritis: Back to the future. J Am Soc Nephrol 15: 501–503PubMedCrossRefGoogle Scholar
  6. 6.
    Hiramatsu N, Kuroiwa T et al. (2008) Revised classification of lupus nephritis is valuable in predicting renal outcome with an indication of the proportion of glomeruli affected by chronic lesions. Rheumatology 47: 702–707PubMedCrossRefGoogle Scholar
  7. 7.
    Bansal VK, Beto JA (1997) Treatment of lupus nephritis: a meta-analysis of clinical trials. Am J Kid Dis 29: 193–199PubMedCrossRefGoogle Scholar
  8. 8.
    Houssiau FA et al. (2002) Immunosuppressive therapy in lupus nephritis: the Euro-Lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Arthritis Rheum 46: 2121–2131PubMedCrossRefGoogle Scholar
  9. 9.
    Ginzler EM, Dooley MA, Aranow C et al. (2005) Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. N Engl J Med 353: 2219–2228PubMedCrossRefGoogle Scholar
  10. 10.
    Ginzler EM, Appel GB, Dooley MA et al. (2007) Mycophenolate mofetil and intravenous cyclophosphamide in the Aspreva Lupus Management Study. ACR Meeting 2007 Abstract sessionGoogle Scholar
  11. 11.
    Walsh M, James M et al. (2007) Mycophenolate Mofetil for induction therapy of lupus nephritis: a systematic review and meta-analysis. Clin J Am Soc Nephrol 2: 968–975PubMedCrossRefGoogle Scholar
  12. 12.
    Moore RA, Derry S (2006) Systematic review and meta-analysis of randomised trials and cohort studies of mycophenolate mofetil in lupus nephritis. Arthritis Res Ther 8: 182CrossRefGoogle Scholar
  13. 13.
    Grootscholten C, Ligtenberg G, Hagen EC et al. (2006) Azathioprine /methylprednisolone versus cyclophosphamide in proliferative lupus nephritis. A randomized trial. Kidney Int 70: 732PubMedCrossRefGoogle Scholar
  14. 14.
    Houssiau FA, Vasconcelos C, D’Cruz D et al. (2004) Early response to immunosuppressive therapy predicts good renal outcome in lupus nephritis: lessons from long-term follow-up of patients in the Euro-Lupus nephritis trial. Arthritis Rheum 50: 3934PubMedCrossRefGoogle Scholar
  15. 15.
    Korbet SM et al. (2000) Factors predictive of outcome in severe lupus nephritis. Lupus Nephritis Collaborative Study Group. Am J Kidney Dis 35: 904–914PubMedCrossRefGoogle Scholar
  16. 16.
    Contreras G et al. (2004) Sequential therapies for proliferative lupus nephritis. N Engl J Med 350: 971–980PubMedCrossRefGoogle Scholar
  17. 17.
    Leandro MJ et al. (2002) An open study of B lymphocyte depletion in systemic lupus erythematosus. Arthritis Rheum 46: 2673–2677PubMedCrossRefGoogle Scholar
  18. 18.
    Saito K et al. (2003) Successful treatment with anti-CD20 monoclonal antibody (rituximab) of life-threatening refractory systemic lupus erythematosus with renal and central nervous system involvement. Lupus 12: 798–800PubMedCrossRefGoogle Scholar
  19. 19.
    Ng KP, Cambridge G, Leandro MJ et al. (2007) B cell depletion therapy in systemic lupus erythematosus: long-term follow-up and predictors of response. Ann Rheum Dis 66(9): 1259–1262PubMedCrossRefGoogle Scholar
  20. 20.
    Alarcon-Segovia D et al. (2003) LJP 394 for the prevention of renal flare in patients with systemic lupus erythematosus: results from a randomized, double-blind, placebo-controlled study. Arthritis Rheum 48: 442–454PubMedCrossRefGoogle Scholar
  21. 21.
    Strand V et al. (2003) Improvement in health-related quality of life in systemic lupus erythematosus patients enrolled in a randomized clinical trial comparing LJP 394 treatment with placebo. Lupus 12: 677–686PubMedCrossRefGoogle Scholar
  22. 22.
    Aringer M et al. (2004) Safety and efficacy of tumor necrosis factor alpha blockade in systemic lupus erythematosus: an open-label study. Arthritis Rheum 50: 3161–3169PubMedCrossRefGoogle Scholar
  23. 23.
    Charles PJ et al. (2000) Assessment of antibodies to double-stranded DNA induced in rheumatoid arthritis patients following treatment with infliximab, a monoclonal antibody to tumor necrosis factor alpha: findings in open-label and randomized placebo-controlled trials. Arthritis Rheum 43: 2383–2390PubMedCrossRefGoogle Scholar
  24. 24.
    Schwarting A, Paul K, Tschirner S et al. (2005) Interferon-beta: a therapeutic for autoimmune lupus in MRL-Fas lpr mice. J Am Soc Nephrol 16(11): 3264–3272PubMedCrossRefGoogle Scholar
  25. 25.
    Wang Y et al. (1996) Amelioration of lupus-like autoimmune disease in NZB/WF1 mice after treatment with a blocking monoclonal antibody specific for complement component C5. Proc Natl Acad Sci USA 93: 8563–8568PubMedCrossRefGoogle Scholar
  26. 26.
    Hillmen P et al. (2004) Effect of eculizumab on hemolysis and transfusion requirements in patients with paroxysmal nocturnal hemoglobinuria. N Engl J Med 350: 552–559PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2008

Authors and Affiliations

  1. 1.Schwerpunkt Rheumatologie, Nephrologie, klinische Immunologie I. Medizinische Klinik und Poliklinik, Johannes Gutenberg-Universität MainzMainzDeutschland
  2. 2.SANA-Rheumazentrum Reinland-PfalzBad KreuznachDeutschland

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