Rheumatology Advances in Practice | 2021
Efficacy of belimumab monotherapy in high infectious risk patient affected by lupus nephritis
Abstract
DEAR EDITOR, Lupus nephritis (LN) is the most common severe manifestation of Systemic Lupus Erythematosus (SLE). It develops in 40% of SLE patients, and treatment with mycophenolate mofetil (MMF) or cyclophosphamide (CYC) is indicated to induce remission [1]. Belimumab (BEL), a human monoclonal antibody inhibiting B cell activating factor (BAFF) is approved worldwide for the treatment of several SLE manifestations and when added to standard-of-care it may gradually reduce proteinuria and the risk for LN [1]. We herein report the case of a 35-year-old North African woman, who was diagnosed with SLE in 2011, with severe haematological and cutaneous involvement and initially treated with hydroxychloroquine (HCQ) 200 mg twice a day, MMF 1 g twice a day and prednisone 0.5 mg/kg/day. In 2015 she was hospitalized in the intensive care unit owing to severe Cytomegalovirus pneumonia pneumonia. MMF was discontinued, and after recovery, treatment with azathioprine (AZA) 100 mg/ day and intravenous immunoglobulin 25 g/monthly was started on a background of HCQ. In March 2017 at follow-up, because of the evidence of proteinuria (2311 mg/24 h), hypocomplementaemia C3 (12 mg/dl) and a mild increase of serum creatinine (SCr) (1.20 mg/ dl), she underwent a renal needle biopsy. Histology showed stage 4 Glomerulonephritis, characterized by segmental endocapillary proliferation, necrosis and subendothelial deposits (Fig. 1). Induction treatment with methylprednisolone pulses followed by i.v. CYC, 500 mg every 2 weeks for 3 months (Euro-Lupus Regimen), was performed with initial benefit. Maintenance treatment with AZA and HCQ was started. One month later, the patient presented signs of bone marrow toxicity, probably related to AZA, which was then interrupted. A further increase in proteinuria (2670 mg/24 h) and SCr (1.3 mg/ dl) occurred, with a high titre of anti-dsDNA antibodies (ab) (>379 U/ml) and a SLEDAI of 20. In consideration of Key message