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Lupus und Nierenbeteiligung

Lupus and renal involvement

  • Leitthema
  • Published:
Der Nephrologe Aims and scope

Zusammenfassung

Hintergrund

Der systemische Lupus erythematodes (SLE) und insbesondere die Lupusnephritis (LN) stellen weiterhin eine therapeutische Herausforderung dar, auch wenn durch die Zulassung neuer Therapeutika in den letzten Jahren Erfolge zu verzeichnen sind.

Ziel

Überblick über die aktuellen Empfehlungen und Möglichkeiten der Therapie der LN.

Material und Methoden

Kritische Bewertung der aktuellen Guidelines (EULAR [European League Against Rheumatism], ERA-EDTA [European Renal Association – European Dialysis And Transplant Association]) sowie klinischer Studien zur LN.

Ergebnisse

Mit Mycophenolat-Mofetil (MMF) steht ein wirksames Medikament sowohl zur Induktions- und Erhaltungstherapie bei der LN der Klassen III und IV (± V) sowie für die Klasse V zur Verfügung. Alternativen sind bei Klasse III und IV Cyclophosphamid (CYC) und Rituximab (RTX) sowie bei Klasse V Ciclosporin (CSA), CYC und RTX. Belimumab (BEL) sollte bei persistierender extrarenaler Aktivität „add-on“ gegeben werden. Die Kombination von Voclosporin (VOC) mit MMF und Steroiden bei der LN der Klassen III und IV verspricht weitere Vorteile. Reserveoptionen für therapierefraktäre oder lebensbedrohliche Verläufe sind derzeit Daratumumab, Bortezomib sowie die autologe Stammzell- oder die allogene Transplantation von mesenchymalen Stammzellen. Eine präemptive Nierentransplantation sollte wegen des guten Outcome bei SLE mit terminaler Niereninsuffizienz frühzeitig angedacht werden.

Schlussfolgerung

Neue Medikamente wie BEL und VOC sowie in Erprobung befindliche Substanzen wie Anifrolumab und Obinutuzumab versprechen neue Optionen für die Therapie der LN. Jedoch besteht weiterer Bedarf an Optionen für therapierefraktäre und/oder lebensbedrohliche Verläufe. Die Rolle von Kontrollbiopsien vor Absetzen der Immunmodulation muss noch abschließend geklärt werden.

Abstract

Background

Despite recent improvements in clinical outcomes through newly approved drugs, systemic lupus erythematosus (SLE) and especially lupus nephritis (LN) are still a therapeutic challenge.

Aim

Overview of the current recommendations and options in the treatment of LN.

Material and methods

Critical appraisal of the current recommendations by the European League Against Rheumatism (EULAR), the European Renal Association—European Dialysis and Transplant Association (ERA-EDTA) and clinical studies on LN.

Results

Mycophenolate-mofetil (MMF) is an effective drug for induction and maintenance therapy of LN classes III and IV (± V) as well as for class V. Alternatives for classes III and IV include cyclophosphamide (CYC) and rituximab (RTX) and for class V cyclosporine (CSA), CYC and RTX. Belimumab (BEL) should be used as an add-on in cases of persisting extrarenal activity. The combination of voclosporin (VOC) with MMF and steroids promises further advantages in LN classes III and IV. Further options for treatment refractory or life-threatening courses are currently daratumumab, bortezomib and autologous stem cell transplantation or allogeneic mesenchymal stem cell transplantation. Due to excellent outcomes pre-emptive kidney transplantation should be considered early in SLE with terminal kidney insufficiency.

Conclusion

New drugs, such as BEL and VOC as well as substances currently undergoing trials, such as anifrolumab and obinutuzumab, present promising new options for treatment of LN; however, there is a further need of options for treatment refractory and/or life-threatening courses. The role of regular control biopsies prior to discontinuation of immunomodulation must be finally clarified.

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Authors and Affiliations

  1. Sektion Rheumatologie, Abteilung für Nephrologie, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, München, Deutschland

    Georg Lorenz &  Ariane Hammitzsch

  2. Abteilung für Nephrologie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland

    Uwe Heemann

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  1. Georg Lorenz
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Correspondence to Ariane Hammitzsch.

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G. Lorenz, U. Heemann und A. Hammitzsch geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Uwe Heemann, München

Hans-Joachim Anders, München

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Lorenz, G., Heemann, U. & Hammitzsch, A. Lupus und Nierenbeteiligung. Nephrologe 16, 372–379 (2021). https://doi.org/10.1007/s11560-021-00523-0

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