课件：肾小球疾病的免疫治疗新进展.ppt

Patient Selection ? We recommend that corticosteroid and immunosuppressive therapy be considered only in FSGS pts – Idiopathic – Nephrotic (1C) Treatment of Class I, II LN Corticosteroids and immunosuppressives only as dictated by the extrarenal manifestations of SLE (not graded) If patients have proteinuria ＞ 3 g/d, we suggest treatment with corticosteroids or calcineurin inhibitors as for minimal change disease or focal segmental glomerulosclerosis (2D) Podocytopathies, characterized by diffuse foot process effacement in the absence of glomerular capillary wall IC deposition or endocapillary proliferation may be more common in SLE patients Treatment of Class VI LN Corticosteroids and immunosuppressives only as dictated by the extrarenal manifestations of SLE (2D) As with CKD from any etiology, antiproteinuric, antihypertensive, and renal protective therapies are indicated to preserve residual kidney function and delay ESRD as long as possible * modified 修改的 AZATHIOPRINE -RCT in Europeans AZA + corticosteroids vs. IV-CYC + corticosteroids -2 years-no difference in response rate; fewer AE with AZA -Longer follow-up AZA group had higher relapse rate, greater risk of doubling SCr, more chronicity on repeat biopsy CYCLOSPORINE -Small open label RCT (N=40) of CSA (9 months) vs. IV and PO CYC (atypical regimen) -No difference in response rate at 9 or 18 months TACROLIMUS WITH MMF -Small RCT in China compared tacrolimus (4 mg/d) + MMF (1 g/d) + corticosteroids vs. IV-CYC + corticosteroids for Class IV + V LN -At 6 months there were complete or partial remission in 90% multi-target and 45% CYC (P=0.002) -Not yet evaluated in other ethnic groups * Maintenance Therapy Corticosteroids (≦10 mg/d prednisone equivalent) + MMF (1-3 g/d) (1B) -OR- + AZA (1.5-2.5 mg/kg/d) (1B) -OR- + CNI (if intolerant of MMF/AZA) (2C) After a CR it is suggested that maintenance therapy be continued for at