目的:为狼疮性肾炎(LN)的诊断和治疗制定第二个以证据为基础的巴西风湿病学会共识。
方法:巴西风湿病学会LupusCommittee的两名方法学专家和20名风湿病学家参与了本指南的制定。定义了14个PICO问题,并进行了系统评价。对符合条件的随机对照试验进行了关于肾脏完全缓解的分析,部分肾脏缓解,血清肌酐,蛋白尿,血清肌酐倍增,进展为终末期肾病,肾复发,和严重不良事件(感染和死亡率)。建议评估的分级,使用开发和评估(GRADE)方法来制定这些建议。建议要求≥82%的投票成员同意,并被归类为强烈赞成,微弱地赞成,有条件的,弱反对或强烈反对特定干预。LN管理的其他方面(诊断,治疗的一般原则,合并症和难治性病例的治疗)通过文献回顾和专家意见进行了评估。
结果:所有SLE患者均应接受肌酐和尿液分析检查以评估肾脏受累情况。肾活检被认为是诊断LN的金标准,如果不可用或该程序有禁忌症,治疗决策应基于临床和实验室参数.提出了14项建议。目标肾反应(TRR)定义为肾功能的改善或维持(治疗基线时±10%),并在3个月时24小时蛋白尿或24小时UPCR减少25%。在6个月时减少了50%,12个月时蛋白尿<0.8g/24h。应向所有SLE患者开具羟氯喹处方,除了禁忌症。糖皮质激素应以最低剂量和最短的必要时间使用。在III类或IV类(±V)中,霉酚酸酯(MMF),环磷酰胺,MMF加他克莫司(TAC),MMF加belimumab或TAC可用作诱导疗法。对于维持治疗,MMF或硫唑嘌呤(AZA)是首选,TAC或环孢菌素或来氟米特可用于不能使用MMF或AZA的患者。利妥昔单抗可用于难治性疾病。在未能实现TRR的情况下,评估依从性很重要,免疫抑制剂剂量,辅助治疗,合并症,并考虑活检/再活检。
结论:这一共识提供了基于证据的数据来指导LN的诊断和治疗。支持巴西制定公共和补充卫生政策。
OBJECTIVE: To develop the second evidence-based Brazilian Society of
Rheumatology consensus for diagnosis and treatment of lupus nephritis (LN).
METHODS: Two methodologists and 20 rheumatologists from Lupus Comittee of Brazilian Society of
Rheumatology participate in the development of this
guideline. Fourteen PICO questions were defined and a systematic review was performed. Eligible randomized controlled trials were analyzed regarding complete renal remission, partial renal remission, serum creatinine, proteinuria, serum creatinine doubling, progression to end-stage renal disease, renal relapse, and severe adverse events (infections and mortality). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to develop these recommendations. Recommendations required ≥82% of agreement among the voting members and were classified as strongly in favor, weakly in favor, conditional, weakly against or strongly against a particular intervention. Other aspects of LN management (diagnosis, general principles of treatment, treatment of comorbidities and refractory cases) were evaluated through literature review and expert opinion.
RESULTS: All SLE patients should undergo creatinine and urinalysis tests to assess renal involvement. Kidney biopsy is considered the gold standard for diagnosing LN but, if it is not available or there is a contraindication to the procedure, therapeutic decisions should be based on clinical and laboratory parameters. Fourteen recommendations were developed. Target Renal response (TRR) was defined as improvement or maintenance of renal function (±10% at baseline of treatment) combined with a decrease in 24-h proteinuria or 24-h UPCR of 25% at 3 months, a decrease of 50% at 6 months, and proteinuria < 0.8 g/24 h at 12 months. Hydroxychloroquine should be prescribed to all SLE patients, except in cases of contraindication. Glucocorticoids should be used at the lowest dose and for the minimal necessary period. In class III or IV (±V), mycophenolate (MMF), cyclophosphamide, MMF plus tacrolimus (TAC), MMF plus belimumab or TAC can be used as induction therapy. For maintenance therapy, MMF or azathioprine (AZA) are the first choice and TAC or cyclosporin or leflunomide can be used in patients who cannot use MMF or AZA. Rituximab can be prescribed in cases of refractory disease. In cases of failure in achieving TRR, it is important to assess adherence, immunosuppressant dosage, adjuvant therapy, comorbidities, and consider biopsy/rebiopsy.
CONCLUSIONS: This
consensus provides evidence-based data to guide LN diagnosis and treatment, supporting the development of public and supplementary health policies in Brazil.