James E. Balow

The Classification of Glomerulonephritis in Systemic Lupus Erythematosus Revisited

The currently used classification reflects our understanding of the pathogenesis of the various forms of lupus nephritis, but clinicopathologic studies have revealed the need for improved categorization and terminology. Based on the 1982 classification published under the auspices of the World Health Organization (WHO) and subsequent clinicopathologic data, we propose that class I and II be used for purely mesangial involvement (I, mesangial immune deposits without mesangial hypercellularity; II, mesangial immune deposits with mesangial hypercellularity); class III for focal glomerulonephritis (involving <50% of total number of glomeruli) with subdivisions for active and sclerotic lesions; class IV for diffuse glomerulonephritis (involving > or =50% of total number of glomeruli) either with segmental (class IV-S) or global (class IV-G) involvement, and also with subdivisions for active and sclerotic lesions; class V for membranous lupus nephritis; and class VI for advanced sclerosing lesions. Combinations of membranous and proliferative glomerulonephritis (i.e., class III and V or class IV and V) should be reported individually in the diagnostic line. The diagnosis should also include entries for any concomitant vascular or tubulointerstitial lesions. One of the main advantages of the current revised classification is that it provides a clear and unequivocal description of the various lesions and classes of lupus nephritis, allowing a better standardization and lending a basis for further clinicopathologic studies. We hope that this revision, which evolved under the auspices of the International Society of Nephrology and the Renal Pathology Society, will contribute to further advancement of the WHO classification.

Ancient missense mutations in a new member of the RoRet gene family are likely to cause Familial Mediterranean Fever

Familial Mediterranean fever (FMF) is a recessively inherited disorder characterized by dramatic episodes of fever and serosal inflammation. This report describes the cloning of the gene likely to cause FMF from a 115-kb candidate interval on chromosome 16p. Three different missense mutations were identified in affected individuals, but not in normals. Haplotype and mutational analyses disclosed ancestral relationships among carrier chromosomes in populations that have been separated for centuries. The novel gene encodes a 3.7-kb transcript that is almost exclusively expressed in granulocytes. The predicted protein, pyrin, is a member of a family of nuclear factors homologous to the Ro52 autoantigen. The cloning of the FMF gene promises to shed light on the regulation of acute inflammatory responses.Familial Mediterranean fever (FMF) is a recessively inherited disorder characterized by dramatic episodes of fever and serosal inflammation. This report describes the cloning of the gene likely to cause FMF from a 115-kb candidate interval on chromosome 16p. Three different missense mutations were identified in affected individuals, but not in normals. Haplotype and mutational analyses disclosed ancestral relationships among carrier chromosomes in populations that have been separated for centuries. The novel gene encodes a 3.7-kb transcript that is almost exclusively expressed in granulocytes. The predicted protein, pyrin, is a member of a family of nuclear factors homologous to the Ro52 autoantigen. The cloning of the FMF gene promises to shed light on the regulation of acute inflammatory responses.

Therapy of lupus nephritis: controlled trial of prednisone and cytotoxic drugs

We evaluated renal function in 107 patients with active lupus nephritis who participated in long-term randomized therapeutic trials (median follow-up, seven years). For patients taking oral prednisone alone, the probability of renal failure began to increase substantially after five years of observation. Renal function was better preserved in patients who received various cytotoxic-drug therapies, but the difference was statistically significant only for intravenous cyclophosphamide plus low-dose prednisone as compared with high-dose prednisone alone (P = 0.027). The advantage of treatment with intravenous cyclophosphamide over oral prednisone alone was particularly apparent in the high-risk subgroup of patients who had chronic histologic changes on renal biopsy at study entry. Patients treated with intravenous cyclophosphamide have not experienced hemorrhagic cystitis, cancer, or a disproportionate number of major infections. We conclude that, as compared with high-dose oral prednisone alone, treatment of lupus glomerulonephritis with intravenous cyclophosphamide reduces the risk of end-stage renal failure with few serious complications.

Glucocorticosteroid Therapy: Mechanisms of Action and Clinical Considerations

The administration of glucocorticosteroids results in a wide range of effects on inflammatory and immunologically mediated disease processes. Glucocorticosteroids cause neutrophilic leukocytosis together with eosinopenia, monocytopenia, and lymphocytopenia. A principal mechanism whereby corticosteroids suppress inflammation is their impeding the access of neutrophils and monocytes to an inflammatory site. Granulocyte function is relatively refractory, whereas monocyte-macrophage function seems to be particularly sensitive to corticosteroids. Corticosteroid administration causes a transient lymphocytopenia of all detectable lymphocyte subpopulations, particularly the recirculating thymus-derived lymphocyte. The mechanism of this lymphocytopenia is probably a redistribution of circulating cells to other body compartments. There is considerable disagreement about the direct effects of corticosteroid administration on human lymphocyte function. The corticosteroid regimen should be adjusted to attain maximal therapeutic benefit with minimal adverse side effects. Often, alternate-day dosage regimens effectively maintain disease remission with minimization or lack of Cushingoid and infectious complications.

Glucocorticoid Therapy for Immune-Mediated Diseases: Basic and Clinical Correlates

Dr. Dimitrios T. Boumpas (Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], National Institutes of Health [NIH], Bethesda, Maryland): Since 1949, when Hench and colleagues first introduced cortisone for the treatment of rheumatoid arthritis, glucocorticoids have revolutionized the treatment of immunologically mediated diseases. Although substantial complications associated with glucocorticoids have tempered enthusiasm for their use, they have remained the cornerstone of therapy for virtually all immunologically mediated diseases. In recent years, an explosion of new information has occurred relevant to both basic and clinical aspects of glucocorticoid therapy. We describe the molecular mechanisms, sites of action, and effects of glucocorticoids on various cells involved in inflammatory and immunologically mediated reactions. Treatment principles are also provided with examples of specific glucocorticoid regimens in prototypical conditions. We also review selective complications of glucocorticoid therapy and discuss recent information about their pathogenesis and management. Mechanisms of Action Dr. George P. Chrousos (Chief, Pediatric Endocrinology Section, Developmental Endocrinology Branch, National Institute of Child Health and Human Development, NIH, Bethesda, Maryland): Glucocorticoids exert most of their effects through specific, ubiquitously distributed intracellular receptors [1]. The classic model of glucocorticoid action was described more than two decades ago and is briefly updated here (Figure 1, panel A). Glucocorticoids circulate in blood, is either in the free form or in association with cortisol-binding globulin. The free form of the steroid can readily diffuse through the plasma membrane and can bind with high affinity to cytoplasmic glucocorticoid receptors (the role of receptors primarily residing in the nucleus is controversial). The formation of the ligand-receptor complex is followed by its activation (that is, translocation into the nucleus and binding to what are called acceptor sites). The bound complex modulates transcription of specific genes that encode proteins responsible for the action of glucocorticoids. Figure 1. Mechanisms of glucocorticoid action. Panel A. Panel B. Glucocorticoid Receptors In 1985, the complementary DNA of the human glucocorticoid receptor was cloned [2]; it contains three main functional domains Figure 1, panel B): first, the DNA-binding domain in the center of the molecule that recognizes specific sequences of the DNA called hormone-responsive elements; second, the ligand-binding domain in the carboxyl terminal region that interacts with the specific steroid; and third, the immunogenic domain in the amino terminal region. The nonactivated glucocorticoid receptor resides in the cytosol in the form of a hetero-oligomer with other highly conserved proteins [3]. This molecular complex comprises receptor, heat-shock proteins, and immunophilin (Appendix Table 1) [4]. The binding of the receptor to the heat-shock protein 90 facilitates its interaction with the ligand [5]. When the ligand binds, the receptor dissociates from the rest of the hetero-oligomer and translocates into the nucleus. Before or after the translocation, the receptor forms homodimers through sequences present in the DNA and ligand-binding domains [6]. Appendix Table 1. Glossary of Genetic Terms Gene Regulation After specific interaction with pore-associated proteins, the hormone-receptor complexes enter the nucleus through the nuclear pores [7]. The interaction is facilitated by two nuclear localization sequences in the receptor, both in the ligand-binding domain. Inside the nucleus, the hormone-receptor complexes bind to specific glucocorticoid responsive elements within DNA [8]. The complexes modulate the transcription rates of the corresponding glucocorticoid-responsive genes [9], apparently by stabilizing the initiation complex, composed of RNA polymerase II and its ancillary factors A through F. The hormone-receptor complex may interact directly with factor IIB [10], but it also interacts with other nuclear proteins to produce the conditions necessary for effective transcription [11]. These proteins may be able to relax the DNA away from the nucleosome and thus make it easier for the polymerase to exert its effects. In addition, glucocorticoid receptors may interact with DNA-binding proteins that are associated with different regulatory elements of the DNA [12, 13]. At least two such proteins have been described: One is the glucocorticoid modulatory element-binding protein and the other is the CACCC-box-binding protein. Both of these transcription factors potentiate the modulatory effects of glucocorticoids after transcription of specific genes. Transcription appears to be important in the regulation of genes involved in growth and inflammation. Glucocorticoid response elements can act both positively and negatively on transcription, depending on the gene on which the complex acts [14, 15]. One major way by which glucocorticoids exert down-modulatory effects on transcription is through noncovalent interaction of the activated hormone-receptor complex with the c-Jun/c-Fos heterodimer [16-18], which binds to the activator protein (AP)-1 site of genes of several growth factors and cytokines. The glucocorticoid-receptor complex prevents the c-Jun/c-Fos heterodimer from stimulating the transcription of these genes. Another mechanism by which glucocorticoids may suppress gene transcription is by an interaction between the hormone-receptor complex and glucocorticoid response elements that are in close proximity to responsive elements for other transcription factors [19]. Thus, the promoter region of the glycoprotein hormone- subunit, which is stimulated by cyclic AMP through the cyclic AMP-responsive element, contains a glucocorticoid response element in close proximity, so that when the receptor dimer binds to its own element, it hinders the cyclic AMP-binding protein from exerting its stimulatory effect on that gene. Post-Transcriptional Effects In addition to modulating transcription, glucocorticoids also have effects on later cellular events, including RNA translation, protein synthesis, and secretion. They can alter the stability of specific messenger RNAs of several cytokines and other proteins, thereby altering the intracellular steady-state levels of these molecules [20, 21]. This may occur through modulation of transcription of still unknown proteins that bind RNA and alter its translation and degradation rates. Also, glucocorticoids influence the secretion rates of specific proteins through mechanisms that have not yet been defined. Finally, the receptor itself has guanylate cyclase activity, and glucocorticoids can rapidly alter the electrical potential of some cells [22, 23]. Anti-inflammatory and Immunosuppressive Effects Dr. Dimitrios T. Boumpas: Although the cause and pathogenesis of many immunologically mediated diseases are not completely understood, it is known that the localization of leukocytes at sites of inflammation, their subsequent activation, and the generation of secretory products contribute to tissue damage, as shown in Figures 2 and 3 [24-26]. Glucocorticoids inhibit the access of leukocytes to inflammatory sites, interfere with their function and the function of fibroblasts and endothelial cells at those sites, and suppress the production and the effects of humoral factors. In general, leukocyte traffic is more susceptible to alteration by glucocorticoids than is cellular function; in turn, cellular immunity is more susceptible than humoral immunity to these agents. Figure 2. Models of the pathogenesis of inflammation and immune injury. Panel A. Panel B. Figure 3. Cellular adhesion molecules. Even though the effects of glucocorticoids on the different types of inflammatory cells will be discussed separately, each cell type is actually involved in complex interactions with other cells. Glucocorticoids affect many, if not all, the cells and tissues of the body, thus provoking a wide range of changes that involve several cell types concurrently. Effects on Nonlymphoid Inflammatory Cells Dr. Ronald L. Wilder (Chief, Inflammatory Joint Diseases Section, Arthritis and Rheumatism Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland): Glucocorticoids are among the most potent anti-inflammatory agents available in clinical medicine. Pharmacologic doses of glucocorticoids dramatically inhibit exudation of plasma and accumulation of leukocytes at sites of inflammation. Several factors influence the magnitude of these effects, including the dose and route of administration of the glucocorticoids used, as well as the type and differentiation state of the target cell population [27]. Several host variables also modify the anti-inflammatory response to glucocorticoids. For example, some persons (those with active systemic lupus erythematosus) appear to have an accelerated rate of glucocorticoid catabolism [28]. Various levels of target tissue resistance may exist in some patients with systemic lupus erythematosus and rheumatoid arthritis [29]. These factors, alone or in combination, may explain the observation that different patients and diseases have variable therapeutic responses to glucocorticoids [30, 31]. Macrophages Glucocorticoids antagonize macrophage differentiation and inhibit many of their functions [27]. These agents 1) depress myelopoiesis and inhibit expression of class II major histocompatibility complex antigens induced by interferon-; 2) block the release of numerous cytokines, such as interleukin-1, interleukin-6, and tumor necrosis factor-; 3) depress production and release of proinflammatory prostaglandins and leukotrienes; and 4) depress tumoricidal and microbicidal activities of activated macrophages. Neutrophils The major effect of glucocorticoids on neutrophil

Prognostic factors in lupus nephritis: Contribution of renal histologic data

The predictive value of laboratory results and renal histologic data was examined in 102 patients upon entry into prospective, randomized, therapeutic trials of lupus nephritis. Three clinical features at the time of entry into the study were individually associated with increased rates of renal failure: age less than 24 years, male gender, and an elevated serum creatinine level. Subjects with diffuse proliferative or membranoproliferative glomerulonephritis were at a modest but significantly increased risk for the development of end-stage renal disease compared with patients with other classes of lupus nephritis. Semiquantitative scores of histologic features (specified by activity and chronicity indexes) identified subgroups of patients with comparatively high renal failure rates. To address the controversial issue of whether renal histologic data significantly improve the outcome predictions in patients with lupus nephritis, multivariate survival models were generated, permitting simultaneous consideration of multiple prognostic factors. Outcome predictions based on the strongest clinical predictors (age, sex, and serum creatinine level) were significantly enhanced by the addition of activity and chronicity indexes. Only age and chronicity index contributed significantly to the five-variable model and together constituted a two-variable model, the predictions of which were similar to observed outcomes. In the context of the highly significant prognostic indicators (age and chronicity index), immunosuppressive agents appeared to provide a slight therapeutic advantage over oral corticosteroids alone.

Methylprednisolone and Cyclophosphamide, Alone or in Combination, in Patients with Lupus Nephritis: A Randomized, Controlled Trial

Therapy for patients with life-threatening systemic lupus erythematosus has included high doses of corticosteroids and cytotoxic or cytostatic drugs [1-20]. Cyclophosphamide, given in intermittent intravenous boluses, has been widely used to treat renal [1-68, 15, 21] and central nervous system disease [2, 3, 6, 7, 19-21], but this therapy is sometimes withheld in the hope that disease might be controlled with corticosteroids or other immunosuppressive drugs. Moreover, some patients do not respond adequately to therapy with intermittent boluses of cyclophosphamide, and these patients might benefit from more intensive therapy. In a previous study [3], monthly administration of methylprednisolone (1.0 g/m2 body surface area) was less effective than bolus therapy with cyclophosphamide. However, the limited duration of the methylprednisolone regimen [6 months] might have been insufficient to treat lupus nephritis. To address this concern, we evaluated patients receiving methylprednisolone once a month for 1 year; additional boluses were given as needed to control disease. We compared these patients with patients receiving our standard therapy: intermittent boluses of cyclophosphamide. A group of patients randomly assigned to receive both cyclophosphamide and methylprednisolone was also included for three major reasons: 1) some patients with lupus nephritis respond inadequately to boluses of cyclophosphamide, 2) anecdotal experience had suggested that cyclophosphamide therapy might be more effective for all patients when given with substantial doses of corticosteroids, and 3) animal studies had shown the advantage of combined chemotherapy for lupus nephritis [22, 23]. Our study design was modified from previous designs so that therapy could be intensified for patients with refractory or relapsing disease. Methods Patient Selection We enrolled 82 patients with lupus nephritis into this randomized, parallel study at the Clinical Center of the National Institutes of Health (Bethesda, Maryland) between 1986 and 1990. To enter the study, patients had to have both glomerulonephritis and a diagnosis of systemic lupus erythematosus [24]. Glomerulonephritis was defined as a sediment on two or more urinalyses that showed either 10 or more erythrocytes per high-power field or erythrocyte or leukocyte casts (without evidence of infection) or both, plus histologic evidence of active proliferative lupus glomerulonephritis on a renal biopsy specimen obtained within 3 months of study entry (provided that a biopsy could be done safely). Scores for renal histologic activity and chronicity were assessed as reported elsewhere [25]. All eligible patients were invited to participate. Exclusion criteria were 1) receipt of cytotoxic drug treatment for more than 2 weeks during the 6 weeks before study entry or receipt of cyclophosphamide therapy for more than 10 weeks at any time; 2) receipt of pulse therapy with corticosteroids during the 6 weeks before study entry; 3) need [at the time of study entry] for oral corticosteroids in dosages greater than 0.5 mg of a prednisone equivalent per kilogram of body weight per day to control extrarenal disease; 4) active or chronic infection; 5) pregnancy; 6) the presence of only one kidney; 7) insulin-dependent diabetes mellitus; and 8) allergy to methylprednisolone or cyclophosphamide. Study Design The protocol that we used was approved by the NIDDK/NIAMS (National Institute of Diabetes and Digestive and Kidney Diseases/National Institute of Arthritis and Musculoskeletal and Skin Diseases) Institutional Review Board [86-AR-0189]. After giving signed, written informed consent, patients were randomly assigned to one of three treatment groups by drawing from a masked card sequence arranged from a table of random numbers. Each group received one of the following regimens: 1) intravenous methylprednisolone [1 g/m2 body surface area], given as boluses over 60 minutes on 3 consecutive days followed by at least 12 consecutive monthly single infusions; 2) intravenous cyclophosphamide, given as boluses once a month for 6 consecutive months and then once every 3 months for at least 2 more years; and 3) the combination of these two regimens. After a patient completed 1 year of study, a decision about whether therapy would be modified was made on the basis of the patients renal status at that time (Figure 1). In patients receiving methylprednisolone, therapy was discontinued if urine studies showed that renal remission had occurred. Renal remission was defined as the presence of fewer than 10 dysmorphic erythrocytes per high-power field, the absence of cellular casts, and excretion of less than 1 g of protein per day. If a renal remission was not evident, the patient continued to receive methylprednisolone every month for 6 more months. After the additional 6 months, if renal remission was still not evident, the patient received treatment for another 6 months. Therapy with methylprednisolone was limited to a maximum of 36 monthly boluses. Figure 1. Treatment regimens and decision pathways used in this clinical trial for lupus nephritis. At 1 year, patients who had been receiving cyclophosphamide alone or in combination with methylprednisolone continued to receive or began to receive cyclophosphamide alone, once every 3 months, if the results of urine studies were substantially improved. Substantial improvement was defined as a reduction of at least 50% in 1) the number of dysmorphic erythrocytes seen in urine samples, 2) the number of cellular casts, and 3) proteinuria, without a mmol of the serum creatinine level. Quarterly administration of cyclophosphamide was continued for 2 years after renal remission occurred, after which time therapy was stopped. After the first year of the study, patients in any treatment group who were no longer receiving monthly therapy but who had evidence of the reactivation of glomerular disease had their originally assigned regimens reinstituted as if they were beginning therapy from enrollment. Reactivation of glomerular disease was defined as new active nephritis with an increase of at least 50% (relative to the lowest reproducible values obtained during the study) in at least two of the following: number of dysmorphic erythrocytes ( 10 per high-power field), number of cellular casts, proteinuria ( 1 g of protein per day), or serum creatinine level. One year after the reinstitution of therapy, patients were again evaluated for evidence of active glomerulonephritis (as described above). As before, patients could be withdrawn from therapy, could restart treatment, or could continue to receive cyclophosphamide every 3 months. Patients could restart therapy no more than twice; if therapy failed more than three times, patients were declared to be nonresponders. Treatment and Follow-up Cyclophosphamide was infused for 60 minutes at an initial dose of 0.75 g/m2 body surface area. If the leukocyte nadir was greater than 3000 cells/mm3, the cyclophosphamide dose was increased by 25%, to a maximum of 1 g/m2 body surface area. The dose was reduced by 25% for leukocyte counts less than 1500 cells/mm3. Patients with a creatinine clearance of less than 30 mL/min received an initial dose of 0.5 g/m2 body surface area, and subsequent doses were adjusted on the basis of the lowest leukocyte count. Patients treated with cyclophosphamide were hydrated, and diuretics were used to maintain neutral fluid balance. Thiethylperazine, 10 mg, with 25 mg of diphenhydramine or 0.25 mg of lorazepam, was administered orally or intravenously every 6 hours for nausea. After the middle of 1990, patients were treated in a day hospital setting, where they received intravenous saline, 200 mL per hour for 10 hours. Mesna (2-mercaptoethanesulfonate), at 20% of the cyclophosphamide dose, was infused intravenously for 10 minutes before cyclophosphamide was administered and every 3 hours thereafter, for a total of four doses. Ondansetron, 8 mg, was given every 4 hours beginning 4 hours after infusion of cyclophosphamide, for a total of three doses. Dexamethasone, 10 mg, was given 4 hours after administration of cyclophosphamide [26]. Patients were instructed to continue oral hydration after discharge from the day hospital to maintain a dilute and frequent diuresis for at least 24 hours after infusion of cyclophosphamide. All patients were initially given oral prednisone, 0.5 mg/kg per day for 4 weeks. The prednisone dose was then tapered by 5 mg every other day each week to the minimal dose required to control extrarenal disease or 0.25 mg/kg every other day, whichever was greater. For severe extrarenal flares of lupus, patients were permitted to receive prednisone, 1.0 mg/kg per day for 2 weeks. Blood pressure was closely monitored and was maintained within 110 to 130/70 to 85 mm Hg with antihypertensive therapy. The intervals at which patients were followed were dictated by the activity of lupus and nephritis. In general, all patients were seen monthly during the first year of the study and every 3 months thereafter. At each study visit, patients were questioned about and examined for adverse events. Outcome Measures The primary study outcome was the response to the study drugs as defined by 1) the percentage of patients who achieved renal remission, 2) the number of nonresponders (nonresponse was defined as 10 erythrocytes per high-power field, cellular casts, proteinuria [>1 g of protein per day], and doubling of the serum creatinine level), and 3) the percentage of adverse events. The outcome data, with the exception of data on adverse events, were collected in a blinded manner on 1 May 1995, 5 years after the last patient was enrolled in the study. Secondary outcome measures were renal failure that required dialysis (end-stage renal disease), stable doubling of the serum creatinine level, and number of renal relapses (renal relapse was defined as a reactivation of renal disease after 6 or more months of remissio

Risk for Sustained Amenorrhea in Patients with Systemic Lupus Erythematosus Receiving Intermittent Pulse Cyclophosphamide Therapy

Table. Drugs and Abbreviation Ovarian toxicity is an important consideration before the use of cyclophosphamide therapy in premenopausal women [1]. The deleterious effects of cyclophosphamide on ovarian function were noted in patients with rheumatoid arthritis treated with daily oral cyclophosphamide [2]. These preliminary observations have been confirmed and extended by subsequent studies in patients with various immune-mediated diseases including rheumatoid arthritis [3], systemic lupus erythematosus [4-6], renal diseases [3, 4, 6, 7], and multiple sclerosis [8]. In these studies, 50% to 70% of women receiving regimens of daily oral cyclophosphamide for 6 to 48 months developed amenorrhea. Studies mainly in cancer patients have suggested that ovarian toxicity from cyclophosphamide is related to dosage and patient age [9-13]. Intermittent pulse cyclophosphamide is widely used in renal [6, 14-17] and major extrarenal complications of lupus erythematosus [18-20]. Because of its more favorable balance of efficacy and toxicity, intermittent pulse cyclophosphamide therapy is considered an acceptable alternative to daily oral cyclophosphamide for the treatment of proliferative lupus nephritis. In addition to lupus, pulse cyclophosphamide therapy has been used with variable results for the treatment of various immune-mediated rheumatic [21-28], renal [29-31], neurologic [32, 33], and hematologic diseases [34] or their complications (reviewed in [20]). Because pulse cyclophosphamide therapy is used for women of child-bearing age who have immunologically mediated diseases, accurate information about ovarian toxicity rates with this therapy is critical. Even though several studies exist of the gonadal toxicity of alkylating agents in patients with malignancy and autoimmune diseases, the doses and treatment schedules in these studies [3-13] differ from those of pulse cyclophosphamide as currently used in immunologically mediated disorders [14-34]. Moreover, the concomitant use of adjunctive oncologic therapies that may be toxic to the ovaries also limits the applicability of some of these data [9-13] to patients with autoimmune diseases. To address some of these issues more directly, we evaluated the risk for amenorrhea in women with systemic lupus erythematosus treated with pulses of cyclophosphamide according to duration of treatment (number of doses) and the age at the initiation of therapy. Our data suggest that intermittent pulse cyclophosphamide therapy is associated with secondary amenorrhea and that duration of therapy and age are independent risk factors. The toxicity rates provided by our study should be useful to physicians and patients before they decide whether to use pulse cyclophosphamide therapy. Methods Selection of Patients For the purpose of this study, we defined a short course of cyclophosphamide (Cytoxan, Bristol Myers Oncology, Princeton, New Jersey) as 7 monthly pulses of intravenous cyclophosphamide (short-CY) and a long course as 15 or more pulses (long-CY). Criteria for eligibility included women who were 40 years old or younger. Patients with other causes of secondary amenorrhea (including end-stage renal disease) were excluded from the analysis. Amenorrhea was defined as lack of menses for at least 4 months. Sustained amenorrhea was defined as amenorrhea not resolving within 12 months after cessation of pulse cyclophosphamide therapy. Patients included in this analysis participated in two different prospective therapeutic trials for lupus nephritis at the National Institutes of Health from 1973 to 1990 [6, 17] and in a retrospective study for neuropsychiatric lupus [19]. For the first protocol, patients with severe proliferative nephritis [defined as impaired renal function alone, very active renal histology, or both] were randomly assigned to one of the following three treatment groups: 1) methylprednisolone pulses at 1.0 g/m2 of body surface area, monthly for 6 months [total of nine doses, n = 25]; 2) a short course of cyclophosphamide pulses (short-CY) at 0.5 to 1.0 g/m2, monthly for 6 months only [total of seven doses, n = 20]; or 3) a long course of cyclophosphamide pulses (long-CY) given monthly for 6 months followed by quarterly pulses for an additional 2 years (total of 15 doses, n = 20). Sixteen patients from the methylprednisolone (Medrol, The Upjohn Company, Kalamazoo, Michigan) group; 13 patients from the short-CY group; and 14 patients from the long-CY group were eligible by age, sex, and renal function criteria for our analysis. In the second protocol [6], one group of patients with active lupus nephritis was randomly assigned to receive quarterly pulse cyclophosphamide (0.5 to 1.0 g/m2 [n = 20]). Patients from this protocol who received at least 15 doses (range, 15 to 24 doses) of cyclophosphamide were included in our analysis (n = 9). Finally, three patients with neuropsychiatric lupus treated with a short course of cyclophosphamide [19], analogous to the protocol of short-CY for lupus nephritis, were included. Patients were followed for at least 4 years after the cessation of therapy. All patients had a thorough gynecologic evaluation after the occurrence of amenorrhea. Serum gonadotrophin levels were available for 7 of 11 patients who developed sustained amenorrhea. Statistical Analysis The distribution of clinical features among the treatment groups at study entry was analyzed using the Kruskal-Wallis and chi-square tests. Two-tailed tests were used to estimate the P values. The proportion of patients developing sustained amenorrhea was compared according to duration of cyclophosphamide therapy and patient age at study entry. For these comparisons, statistical analysis was done using the Fisher exact test and the chi-square test for trend where appropriate. Results Pertinent data on the patients evaluated for amenorrhea are shown in Table 1. The distributions of demographic and laboratory features were not statistically different among the methylprednisolone and cyclophosphamide treatment groups. Table 1. Characteristics of Patients with Systemic Lupus Erythematosus in this Study The rates of sustained amenorrhea according to age and duration of treatment are shown in Table 2. Eleven patients had sustained (28%) and three patients had temporary (8%) amenorrhea of the 39 patients treated with pulse cyclophosphamide. Patients treated with 15 or more doses of cyclophosphamide (long-CY) were more likely to develop sustained amenorrhea than patients receiving 7 doses (short-CY) (39% compared with 12%) (the Fisher exact test, P = 0.07). No patients treated with methylprednisolone (the control group) had amenorrhea. Seven of 14 patients who developed amenorrhea did so within the first seven doses of pulse cyclophosphamide. Older patients tended to develop amenorrhea earlier. Three patients (all in the Short-CY group) developed temporary amenorrhea that resolved within 12 months after cessation of therapy. Table 2. Rate of Sustained Amenorrhea in Patients Treated with Pulse Cyclophosphamide according to Age and Duration of Therapy In addition to the number of doses, age seemed to contribute to the risk for permanent amenorrhea (Table 2). Of 16 patients younger than 25 years, only 2 developed amenorrhea (12%). Both patients (ages 22 years) belonged to the Long-CY group and had received 20 and 24 doses of cyclophosphamide, respectively. Among the 8 patients who were 31 years old or older, 5 (62%) developed amenorrhea compared with 12% in the youngest age group. Patients who were 26 to 30 years old had an intermediate rate (27%) of amenorrhea (chi-square test for trend, P = 0.04). The risk for sustained amenorrhea among patients treated with Long-CY was most evident in patients older than 25 years (Table 2). Among patients 26 years of age or older, 2 of 12 treated with Short-CY developed sustained amenorrhea, whereas 7 of 11 patients treated with Long-CY developed sustained amenorrhea (the Fisher exact test, P = 0.03). Discussion Patients with systemic lupus erythematosus now survive longer. With the decreased morbidity and longer life expectancy of these patients, gonadal toxicity is becoming a problem. Our study addresses the ovarian toxicity of pulse cyclophosphamide therapy, a commonly used intensive therapy for the major manifestations of lupus and other immune-mediated diseases. Ovarian Toxicity The mechanism of ovarian toxicity from cyclophosphamide has been studied in animal models [35-38]. A single intraperitoneal injection of 100 mg/kg of cyclophosphamide decreases the number of small follicles in ovaries of mice by about 63% [35]. The pool of growing follicles (medium to large) appears to be more vulnerable to the cytotoxic effect of cyclophosphamide than the small follicles [37]. After intraperitoneal injections of cyclophosphamide in immature rats primed with pregnant mare gonadotrophins, serum estradiol levels and the number of granulosa cells expressed from each ovary were decreased [37]. Cross-links in DNA in granulosa cells continue up to and probably beyond 24 hours, suggesting that the effects of cyclophosphamide on granulosa cells are prolonged. In addition to DNA, other macromolecules (enzymes, proteins) in the granulosa cells may be alkylated by cyclophosphamide metabolites. Decreased serum estrogen levels lead to up-regulation of follicle-stimulating hormone secretion, thus accelerating further follicular recruitment into the developing cyclophosphamide-sensitive pool of follicles. This mechanism perpetuates a vicious cycle, whereby cyclophosphamide destroys the developing follicles by attacking rapidly dividing granulosa cells, reducing their steroid secretion, and leading to increased pituitary gonadotrophin production, which enhances further recruitment of follicles into the pool of maturing follicles susceptible to cyclophosphamide [37]. These early events eventually result in accelerated depletion of ovarian follicles as shown in histologic sections from

Acute tumor lysis syndrome: A review of 37 patients with Burkitt's lymphoma

Renal and metabolic complications of tumor lysis during 46 episodes of remission induction chemotherapy were reviewed in 37 patients with American Burkitts lymphoma. Azotemia occurred in 14 patients, preceding chemotherapy in eight. All of these patients had abdominal tumors. Pretreatment azotemia was associated with elevated lactic dehydrogenase (LDH) and uric acid levels, and sometimes extrinsic ureteral obstruction by tumor. Two patients required dialysis for uric acid nephropathy before chemotherapy was initiated. Following chemotherapy, major complications of tumor lysis (hyperuricemia, hyperkalemia and hyperphosphatemia) were associated with very large tumors, high LDH levels and inadequate urinary output. In patients undergoing diuresis and receiving allopurinol, hyperkalemia or hyperuricemia developed infrequently unless concomitant renal failure ensued. Hyperphosphatemia, which occurred only after chemotherapy, developed in 10 of 32 (31 per cent) nonazotemic and in all azotemic patients. Hemodialysis was required in three post-treatment patients for control of azotemia, hyperuricemia, hyperphosphatemia and/or hyperkalemia. Because of the potential for renal failure caused by precipitation of phosphate, severe hyperphosphatemia is an additional criterion for dialysis in patients with acute tumor lysis syndrome.

Tocilizumab in systemic lupus erythematosus: Data on safety, preliminary efficacy, and impact on circulating plasma cells from an open‐label phase I dosage‐escalation study

OBJECTIVE To assess the safety of interleukin-6 receptor inhibition and to collect preliminary data on the clinical and immunologic efficacy of tocilizumab in patients with systemic lupus erythematosus (SLE). METHODS In an open-label phase I dosage-escalation study, 16 patients with mild-to-moderate disease activity were assigned to receive 1 of 3 doses of tocilizumab given intravenously every other week for 12 weeks (total of 7 infusions): 2 mg/kg in 4 patients, 4 mg/kg in 6 patients, or 8 mg/kg in 6 patients. Patients were then monitored for an additional 8 weeks. RESULTS The infusions were well tolerated. Tocilizumab treatment led to dosage-related decreases in the absolute neutrophil count, with a median decrease of 38% in the 4 mg/kg dosage group and 56% in the 8 mg/kg dosage group. Neutrophil counts returned to normal after cessation of treatment. One patient was withdrawn from the study because of neutropenia. Infections occurred in 11 patients; none was associated with neutropenia. Disease activity showed significant improvement, with a decrease of > or =4 points in the modified Safety of Estrogens in Lupus Erythematosus National Assessment version of the Systemic Lupus Erythematosus Disease Activity Index score in 8 of the 15 evaluable patients. Arthritis improved in all 7 patients who had arthritis at baseline and resolved in 4 of them. Levels of anti-double-stranded DNA antibodies decreased by a median of 47% in patients in the 4 mg/kg and 8 mg/kg dosage groups, with a 7.8% decrease in their IgG levels. These changes, together with a significant decrease in the frequency of circulating plasma cells, suggest a specific effect of tocilizumab on autoantibody-producing cells. CONCLUSION Although neutropenia may limit the maximum dosage of tocilizumab in patients with SLE, the observed clinical and serologic responses are promising and warrant further studies to establish the optimal dosing regimen and efficacy.