Short Course of Weekly Low-Dose Intravenous Pulse Cyclophosphamide in the Treatment of Lupus Nephritis: A Preliminary Study

We review our experience with low-dose intravenous pulse cyclophosphamide as treatment of biopsy-proven lupus nephritis. Seventeen patients were treated with 2-4 (mostly 3) weekly low-dose intravenous pulses of cyclophosphamide (500 mg) and moderate doses of prednisolone (0.5mg/kg/day), followed by an oral immunosuppressive drug (either azathioprine or cyclophosphamide). As compared with the classical monthly high-dose cyclophosphamide regimen, this weekly low-dose regimen induced neutropenia in one patient only. The incidence of herpes zoster was very low (6 %). At the end of the follow-up period (15 ± 8 months), two patients required chronic ambulatory peritoneal dialysis. The 14 patients that could be evaluated improved their mean serum albumin from 30 ± 7 to 37.5 ±7 g/l (mean ± SD; P < 0.01) and their mean serum creatinine fell from 125 ± 119 to 101 ± 66 μmol/l (not significant). Mean DNA binding dropped from 71 ± 29 to 26 ± 27 % (P < 0.001) and mean complement fraction C4 levels increased from 14 ± 8 to 28 ± 18 mg/dl (P < 0.05). The mean daily prednisolone dose was dramatically reduced from 26 ± 8 to 10 ± 4 mg (P < 0.001). Although this preliminary and retrospective study clearly needs validation with a larger cohort followed for a longer period, it seems that a treatment combining moderate doses of steroids and 3-4 weekly low-dose intravenous pulses of cyclophosphamide, followed by oral immunosuppression, is well tolerated and beneficial — at least in the short term — for most patients with severe lupus nephritis.