Figura 1. Síntesis secuencial del manejo de la nefritis lúpica

CONCLUSIÓN

El Lupus Eritematoso Sistémico (LES) es una compleja enfermedad, en la cual todos los componentes claves del sistema inmunológico están involucrados en la patogenia de esta enfermedad (33). El uso de esteroides e inmunosupresores (ciclofosfamida IV o Micofenolato de mofetilo) deben ser utilizados en el tratamiento inicial. El tratamiento de mantenimiento utiliza la vía oral y comprende los esteroides y los inmunosupresores, fundamentalmente azatioprina y micofenolato de mofetilo. Este tratamiento de mantenimiento puede durar de dos hasta ocho años. Las formas más severas de nefropatía lúpica se tratan de una manera semejante. Se recomienda el uso de IECAS, ARAII, estatinas y si existe un síndrome antifosfolipídico debe ser manejado de forma adecuada en función de la situación clínica.

REFERENCIAS

1. Fakhouri F, Lesavre Ph. Quel traitement pour les néphropathies lupiques en 2008? En: Lesavre P. Drüeke T, Legendre C, Niaudet P, eds.Actualités Néphrologiques Jean Hamburger. Paris, Paris: Médecine-Sciences Flammarion; 2008: 217-227.
2. Weening JJ, D`Agati VD, Schwartz MM et al. The classification of glomerulonephritis in systemic lupus erythematosus revisited. J Am Soc Nephrol 2004; 15 : 241-250.
3. Bujan S, Ordi-Ros J, Paredes J et al.Contribution of the initial features of systemic lupus erythematosus to the clinical evolution and survival of a cohort of Mediterranean patients. Ann Rheum Dis 2003; 62: 859-865.
4. Cervera R, Khamashta MA, Font J et al. Morbidity and mortality in systemic lupus erithematosus during a10-year period: a comparison of early and late manifestations in a cohort of 1000 patients. Medicine 2003; 82: 299-308.
5. Bakir AA, Levy PS, Dunea G. The prognosis of lupus nephritis in African-Americans: a retrospective analysis. Am J Kidney Dis 1994;24:159-71.
6. Houssiau FA, Vasconcelos C, D’Cruz D et al. Immunosupressive therapy in lupus nephritis: the Euro-lupus Nephritis Trial, a randomized trial of low-dose versus high-dose intravenous cyclophosphamide. Arthritis Rheum 2002; 46: 2121-2131.
7. Sloan RP, Schwartz MM, Korbet SM, Borok RZ Long-term outcome in systemic lupus erythematosus membranous glomerulonephritis. Lupus Nephritis Collaborative Study Group. J Am Soc Nephrol 1996 Feb;7: 299-305.
8. Mok CC, Ying KY, Tang S et al.Predictors and outcome of renal flares after successful cyclophosphamide treatment for diffusive proliferativa lupus glomerulohephritis. Arthritis Rheum 2004; 50: 2559-2568.
9. Korbet SM, Lewis EJ, Schwartz MM et al. Factors predictive of outcome in severe lupus nephritis. Lupus Nephritis Collaborative Study Group. Am J Kidney Dis 200; 35: 904-914.
10. Houssiau FA, Vasconcelos C, D’Cruz D et al. Early response to immunosuppressive therapy predicts good renal outcome in lupus nephritis: lessons from long-term follow up of patients in the Euro-Lupus Nephritis Trial. Arthritis Rheum 2004; 50: 3934-3940.
11. Flanc RS, Roberts MA, Strippoli GF et al.Treatment of diffuse proliferativa lupus nephritis: a meta-analysis of randomized controlled trials. Am J Kidney Dis 2004; 43: 197-208.
12. Spetie DN, Tang Y, Rovin BH et al. Mycophenolate therapy of SLE membranous nephropathy. Kidney Int 2004; 66: 2411-2415.
13. Grootscholten C, Ligtenberg G, Hagen EC et al. Azathioprine/methylprednisolone versus cyclophosphamide in proliferativa lupus nephritis. A randomized controlled trial. Kidney Int 2006; 70: 732-742.
14. Grootscholten C, Berden JH. Discontinuation of immunosuppression in proliferativa lupus nephritis: is it possible? Nephrol Dial Transplant 2006; 21: 1465-1469.
15. Mersereau J, Dooley MA. Gonadal failure with cyclophosphamide therapy for lupus nephritis: advances in fertility preservation. Rheum Dis Clin North Am 2010; 36:99-108.
16. Chan TM, Li FK, Tang CS et al. Efficacy of mycophenolate mofetil in patients with diffuse proliferativa lupus nephritis The N Engl J Med 2000; 343: 1655-1162.
17. Ginzler EM, Dooley MA, Aranow C et al. Mycophenolate mofetil or intravenous cyclophosphamide for lupus nephritis. N Engl J Med 2005; 3535: 2219-2228.
18. Kuiper-Geertsma DG, Derksen RH. Newer drugs for the treatment of lupus nephritis. Drugs 2003; 63: 167-180.
19. Sahin GM, Sahin S, Kiziltas S et al. Mycophenolate mofetil versus azathioprine in the maintenance therapy of lupus nephritis. Ren Fail 2008; 30: 865-869.
20. Mak A, Cheak AA, Tan JY et al. Mycophenolate mofetil is as efficacious as, but safer than, cyclophosphamide in the treatment of proliferativa lupus nephritis: a meta-analysys amd meta-regression. Rheumatology (Oxford) 2009; 48:944-952.
21. Elyan M, Ballou S. The effectiveness and safety of mycophenolate mofetil in lupus nephritis. Clin Rheumatol 2009; 28: 835-840.
22. Appel GB, Contreras G, Dooley MA et al. Mycophenolate mofetil versus cyclophosphamide for induction treatment of lupus nephritis. J Am Soc Nephrol 2009; 20: 1103-1112.
23. Chan TM, Tse KC, Tang CS et al. Long-term study of mycophenolate mofetil as continuous induction and maintenance treatment for diffuse proliferativa lupus nephritis. J Am Soc Nephrol 2005; 16: 1076-1084.
24. Looney RJ, Anolik JH, Campbell D et al. B cell depletion as a novel treatment for systemic lupus erythematosus: a phase I/II dose-escalation trial of rituximab Arthritis Rheum. 2004; 50: 2580-2589.
25. Smith KG, Jones RB, Burns SM et al. Long-term comparison of rituximab treatment for refractory systemic lupus erythematosus and vasculitis: remission, relapse, and re-treatment. Arthritis Rheum 2006; 54: 2970-2982.
26. Gunnarsson I, Sundelin B, Jonsdottir T et al. Histopathologic and clinical outcome of rituximab treatment in patients with cyclophosphamide-resistant proliferativa lupus nephritis. Arthritis Rheum 2007; 56: 1263-1272.
27. Tokunaga M, Saito K, Kawabata D et al. Efficacy of rituximab ( anti-CD20) for refractory systemic lupus erythematosus involving the central nervous system. Am Rheum Dis 2007; 66: 470-475.
28. Robak E, Robak T. Monoclonal antibodies in the treatment of systemic lupus erythematosus. Curr Drug Targets 2009; 10: 26-37.
29. Looney RJ. B cell-targeted therapies for systemic lupus eythematosus: an update on clinical trial data. Drugs 2010; 70: 529-540.
30. Looney RJ, Anolik J, Sanz I. A perspective on B-cell-targeting therapy for SLE. Mod Rheumatol 2010; 20: 1-10.
31. Suzuki K, Kameda H, Amano K et al. Single center prospective study of tacrolimus efficacy and safety in the treatment of various manifestations in systemic lupus erythematosus. Rheumatol Int 2010 (en prensa).
32. Shinjo SK, Bonfá E, Woydyla D et al. Antimalarial treatment may have a time-dependent effect on lupus survival: data from a multinacional Latin American inception cohort. Arthritis Rheum 2010; 62: 855-862.
33. Rahman A, Isenberg DA. Systemic lupus erythematosus. N Engl J Med 2008; 358: 929-939.
34. Contreras G, Pardo V, Leclercq B et al. Sequential therapies for proliferative lupus nephritis. N Engl J Med 2004: 350: 971-980.