Question

A 21-year-old woman had grade IV lupus nephritis 5 years ago, with an excellent response to pulse cyclophosphamide and steroid. Now she has cerebritis and renal failure requiring hemodialysis. Is there any benefit to cyclophosphamide?

Saleh Hamad, MD

Response from Arthur Kavanaugh, MD

An important feature of this case is that the patient now is in renal failure, requiring dialysis. One of the most important factors that would affect my therapeutic decision would be the potential reversibility of the renal disease. For example, if the patient had scarred glomeruli, without much active inflammation, then based only on the kidneys, there would seem to be little potential benefit from aggressive therapy. On the other hand, if the renal lesion was active and had little chronic change or damage, the kidneys might be saved with aggressive therapy. In cases such as this, I think renal biopsy, in the context of the other clinical information, can be helpful in guiding therapy. Complicating this case is the presence of cerebritis. Although large controlled trials on this subject have not been conducted, I believe many rheumatologists would favor the use of aggressive therapies, such as pulse cyclophosphamide, for patients with severe central nervous system disease. Of course, because the active metabolites of cyclophosphamide are largely eliminated by the kidney, the doses must be adjusted in patients with renal insufficiency.

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