Essentials of Clinical Immunology by Helen Chapel & Mansel Haeney & Siraj Misbah & Neil Snowden

Author:Helen Chapel & Mansel Haeney & Siraj Misbah & Neil Snowden [Chapel, Helen]
Language: eng
Format: azw3
Publisher: Wiley
Published: 2013-12-16T16:00:00+00:00

The prognosis in SLE is not as dismal as was once believed, but the development of renal disease is a strong predictor of ESRF and early mortality. The 10-year survival in patients with all forms of the disease is over 80%. Patients with ESRF are excellent candidates for renal transplantation. Disease activity post transplantation is sporadic and infrequent; recurrence of lupus nephritis is rare.

The major cause of early deaths is active systemic disease – particularly central nervous system, cardiac, thrombotic and renal disease. Late deaths are often caused by disease progression (e.g. ESRF). Infection is an important cause of mortality at all stages of the condition. Overwhelming infection occurs typically in patients treated with high-dose steroids and other immunosuppressive drugs. While aggressive induction treatment reduces renal disease, it may increase susceptibility to infection (Chapter 3).

Most treatment data suggest that WHO class II nephritis has a benign course, and treatment, in the absence of other indications, is not usually needed. The outcome and treatment of class V nephritis is hotly debated. The decision to treat active WHO class III and IV lupus nephritis is less controversial. Systematic review of available trials supports treatment with corticosteroids and an immunosuppressive agent, usually cyclophosphamide or azathioprine. A Cochrane review showed that cyclophosphamide plus steroids slowed progression to ESRF but had no impact on mortality and with a significant risk of ovarian failure. Azathioprine plus steroids reduced the risk of mortality but did not alter renal outcomes. Ciclosporin is an alternative agent, particularly used in children to reduce corticosteroid complications.

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